A competency framework in cardiothoracic surgery for training and revalidation — an international comparison

The conventional methods of education, certification and recertification in cardiothoracic surgery face a paradigm shift in line with recent innovations in diagnostics and therapeutics. The attributes of a competent clinician entail proficiency in knowledge, communication, teamwork, management, health advocacy, professionalism and technical skills. This article investigates the skills required for a cardiothoracic surgeon to be competent. The relevant practice of certification and recertification across various regions has also been explored. Validated and competency-based curricula should be designed to develop core competencies to successfully integrate them into practice. Challenges to the implementation of such curricula and potential solutions are explored. Patient safety remains the ultimate aim to ensure excellence of both competency and performance.     

Isthmus flap aortoplasty: an alternative to subclavian flap aortoplasty for long-segment coarctation of the aorta in infants

The ideal operation for infants with coarctation of the aorta remains controversial. Subclavian flap aortoplasty is the most popular technique for this age group. The 5 to 20% recurrence rate is attributed to regrowth of the coarctation web or inadequate length of the subclavian flap, particularly when the aortic isthmus is long and narrow. Severe arm ischemia following subclavian flap aortoplasty, although rare, is a disturbing complication. The purpose of this study is to report the results with a new technique we call isthmus flap aortoplasty for coarctation of a long segment of the aorta in infants. This technique avoids the limitations of subclavian flap aortoplasty. A short segment of aorta, including the ductal entrance and coarctation web, was resected in 4 infants (mean age, 35.5 days) with long-segment coarctation. The posterior wall of the long isthmus was opened longitudinally to the level of the transverse aortic arch. The descending aorta was mobilized and advanced to the level of the aortic arch where the posterior half was sutured. The anterior flap of attached isthmus was then sewn into a longitudinal incision made in the anterior wall of the descending aorta. All infants survived this procedure and had no gradient at completion of the repair. The mean transconduit gradient at rest was zero and rose to 7.0 +/- 0.93 mm Hg after angiography at a mean follow-up of 42 months. Aortograms demonstrated that the reconstructed area had grown in girth and attained a normal caliber in each child.(ABSTRACT TRUNCATED AT 250 WORDS)     

A Method of Enlarging the Distal Transverse Arch in Infants with Hypoplasia and Coarctation of the Aorta

Immediate operation in infants suffering from severe congestive heart failure and coarctation of the aorta associated with hypoplasia of the distal transverse aortic arch often poses a difficult technical problem. Frequently the anastomosis between the hypoplastic arch and the descending thoracic aorta fails to relieve the gradient across the hypoplastic segment appreciably. A technique of enlarging the lumen of the distal arch and thereby further lowering the gradient has been found effective and is presented.     

Porcine Valve Bioprosthesis: Early Thrombosis with Systemic Emboli

We report the case of a patient who had early postoperative thrombosis, with systemic emboli, of an aortic Hancock porcine valve bioprosthesis. Anticoagulants were not used postoperatively because the patient had a history of epistaxis. Progressive symptoms and a 57 mm Hg transvalvular gradient prompted reoperation at six months. Thrombosis of the valve may have been related to postoperative low cardiac output, prolonged dysrhythmias, or lack of anticoagulants.     

Predictors of outcome in early revascularization after acute myocardial infarction

We have reviewed 44 consecutive patients undergoing myocardial revascularization from 1 to 42 days after myocardial infarction. Operation within 12 days of transmural myocardial infarction carried a substantially high risk, particularly in patients with poor ventricular function. Patients with subendocardial infarction may be safely operated on shortly after infarction has occurred. In those with transmural infarcts, it may be advantageous to delay operation if early and aggressive medical therapy can effectively control the symptoms. This has to be counterbalanced, however, by the realization that the situation should not be allowed to slide into one of irreparable ventricular damage from infarct extension.     

Experimental evaluation of reexpansion pulmonary edema

Reexpansion pulmonary edema following pneumothorax is clinically uncommon but occasionally life threatening. This study documents the functional and anatomical abnormalities that occur when a collapsed lung is reexpanded. Right pneumothorax was created through open tube thoracostomy in 30 goats. The animals were divided into six groups by duration of pneumothorax (24, 48, or 72 hours) and technique of reexpansion (waterseal vs 10 cm H2O suction). Arterial blood gases and alveolar-arterial oxygen tension difference (A-aDO2) were analyzed before pneumothorax and after reexpansion. Each lung was reexpanded for 2 hours, chest roentgenograms were obtained, and both lungs were removed. The left lung served as the control. Both lungs were checked for surfactant activity and pulmonary extravascular water volume (PEWY). Light and electron microscopy were also performed. Anatomical and functional changes were present in the reexpanded lung after relief of pneumothorax. Both increased time of collapse and suction reexpansion tended to correlate with increased PEWV, decreased surfactant and arterial PO2, and increased A-aDO2.     

Toward totally endoscopic coronary artery surgery

Background: Here we explore a method of using robotics to reduce morbidity and mortality in conventional coronary surgery. Methods: Using a robotic surgical system two surgeons completed five steps: (1) 80 synthetic suture exercises; (2) 76 left internal thoracic artery to left anterior descending (LIMA-to-LAD) on porcine hearts; (3) cadaveric port placement for assessing optimal access; (4) endoscopic stabilization in the live porcine model; and, finally (5) eight clinical LIMA-to-LADs performed robotically. Results: After 70 hours training, mean dry lab times fell from 7.0 and 5.8 min to 5.7 and 5.1 min in the two surgeonstab series. Wet lab times fell from 40.1 and 28.5 min to 28.8 and 19.2 min. In the clinical series of eight patients there were no mortalities; all had uncomplicated postoperative recovery and all were angina free at 6-week follow-up. Conclusion: The learning curve for robotic training is short, and reproducible results can be achieved clinically, after appropriate training, resulting in real patient benefit.     

心胸外科86例下呼吸道感染危险因素分析及护理干预

目的探讨心胸外科下呼吸道感染的相关危险因素及护理干预。方法对心胸外科发生下呼吸道感染患者的临床资料进行前瞻性和回顾性调查。结果心胸外科86例患者下呼吸道感染的主要危险因素有侵入性操作、60岁高龄患者、不合理使用抗菌药物、恶性肿瘤等。结论对术后呼吸道感染的预防要针对其危险因素,采取相应的护理干预。