Background: Institutional factors have been shown to impact outcomes following orthotopic heart transplantation (OHT). This study evaluated center variability in the utilization of induction therapy for OHT and its implications on clinical outcomes. Methods: Adult OHT patients between 2010 and 2018 were identified from the UNOS registry. Transplant centers were stratified based on their rates of induction therapy utilization. Mixed-effects logistic regression models were created with drug-treated rejection within 1-year as primary endpoint and individual centers as random parameter. Risk-adjusted Cox regression was used to evaluate patient-level mortality outcomes. Results: In 17,524 OHTs performed at 100 centers, induction therapy was utilized in 48.6% (n=8411) with substantial variability between centers (IQR 21.4 – 79.1%).There were 36, 30, and 34 centers in the low (<29%), intermediate (29-66%), and high (>67%) induction utilization terciles groups, respectively. Induction therapy did not account for the observed variability in the treated rejection rate at 1-year among centers after adjusting for donor and recipient factors (p=0.20). No differences were observed in postoperative outcomes among induction utilization centers groups (all, p>0.05). Furthermore, there was a weak correlation between the percentage of induction therapy utilization at the center-level and recipients found to have moderate (r=0.03) or high (r=0.04) baseline risks for acute rejection at 1-year. Conclusions: This analysis demonstrates there is substantial variability in the use of induction therapy among OHT centers. In addition, there was a minimal correlation with baseline recipient risk or 1-year rejection rates, suggesting a need for better-standardized practices for induction therapy use in OHT.

Objectives: Though guidelines are set by the American Board of Thoracic Surgery for the operative cases that cardiothoracic surgery residents must perform to be board-eligible, no such recommendations exist to assess competency for the wide range of high-risk bedside procedures. Our department created and implemented a multi-disciplinary developed course designed to standardize common high-risk bedside procedures and credential our residents. The aim of this study was to survey the attitudes of residents to and query the efficacy of such a course. Methods: The course was designed with the goal of standardizing endotracheal intubation, arterial line insertion (radial and femoral), central venous line insertion, pigtail tube thoracostomy and nasogastric tube placement. The course consisted of an online module followed by a 4-hour hands on simulation session. Knowledge based pre and post evaluations were administered as well as Likert based survey regarding multiple aspects of the residents’ perceptions of the course and the procedures. Results: Twenty-three (7 traditional and 16 integrated) cardiothoracic surgical residents participated in the course. Residents reported that 48% of the time, bedside procedures were historically taught by other trainees rather than faculty. All residents endorsed increased standardization of all procedures after the course. Likewise, residents showed increased confidence in all procedures except for pigtail and thoracentesis as well as nasogastric tube placement. 43.5% of the participants demonstrated improvement in the pre and post-test knowledge-based evaluations. ConclusionCardiothoracic residents have favorable attitudes towards standardization and credentialing for high risk bedside procedures and utilizing such courses may help standardize procedural techniques.

Coronary artery aneurysms are exceedingly rare and tend to be found incidentally on angiography. We present the case of a 6cm giant coronary artery aneurysm discovered in a 25 year old man. Subsequent workup included cardiac gated MRI, CT angiography and left heart catheterization. Imaging revealed a 6.7 x 6.2 x 6.0 cm aneurysm involving the mid LAD subsequent to the takeoff of a large septal perforator. He was taken electively for operative repair during which the aneurysm was opened, unroofed and ligated at the ostium while taking care to ensuring normal flow in the septal perforator that supplied multiple small collaterals. In this unique case, a coronary artery aneurysm of considerable size was encountered in the LAD of a healthy young adult in which the size of the aneurysm precluded distal revascularization via bypass grafting. Multiple imaging modalities were used to characterize this finding and aid in surgical planning.