Postdoctoral National Institutes of Health F32 Grants: Broken Pipeline in the Development of Surgeon-Scientists.

Objective: We examined trainees in surgery and internal medicine who received National Institutes of Health (NIH) F32 postdoctoral awards to determine their success rates in obtaining future NIH funding.

Background: Trainees participate in dedicated research years during residency (surgery) and fellowship (internal medicine). They can obtain an NIH F32 grant to fund their research time and have structured mentorship.

Reduced-flow ex vivo lung perfusion to rehabilitate lungs donated after circulatory death.

Background: Current ex vivo lung perfusion (EVLP) protocols aim to achieve perfusion flows of 40% of cardiac output or more. We hypothesized that a lower target flow rate during EVLP would improve graft function and decrease inflammation of donation after circulatory death (DCD) lungs.

Methods: A porcine DCD and EVLP model was utilized.

Comprehensive National Institutes of Health funding analysis of academic cardiac surgeons.

Objective: To determine trends in National Institutes of Health (NIH) funding for cardiac surgeons, hypothesizing they are at a disadvantage in obtaining funding owing to intensive clinical demands.

Methods: Cardiac surgeons (adult/congenital) currently at the top 141 NIH-funded institutions were identified using institutional websites. The NIH funding history for each cardiac surgeon was queried using the NIH Research Portfolio Online Reporting Tools Expenditures and Results (RePORTER).

Are You Making Yourself Clear? You Can't Communicate, or Think, Effectively If You Can't Write Clearly.

In the not too distant past, illegible handwriting was considered to be the biggest problem with medical record keeping. Now the primary problem with medical records is that they are disorganized, and usually undigested, data dumps. A solution to at least part of this problem lies in utilizing the principles of the problem-oriented record.

Adenosine 2A Receptor Activation Attenuates Ischemia Reperfusion Injury During Extracorporeal Cardiopulmonary Resuscitation.

Objective: We tested the hypothesis that systemic administration of an A2AR agonist will reduce multiorgan IRI in a porcine model of ECPR.

Summary Background Data: Advances in ECPR have decreased mortality after cardiac arrest; however, subsequent IRI contributes to late multisystem organ failure. Attenuation of IRI has been reported with the use of an A2AR agonist.

Preparing for the Lurch into a Surgery Clerkship.

Over our combined nearly 50 years as surgical educators, we have been asked many times by medical students how they should prepare for and function in a Surgery Clerkship. It is still easy for me (C.G.

Can Lung Transplant Surgeons Still Be Scientists? High Productivity Despite Competitive Funding.

Background: Today's declining federal budget for scientific research is making it consistently more difficult to become federally funded. We hypothesized that even in this difficult era, surgeon-scientists have remained among the most productive and impactful researchers in lung transplantation.

Methods: Grants awarded by the NIH for the study of lung transplantation between 1985 and 2015 were identified by searching NIH RePORTER for 5 lung transplantation research areas.

String Music: Creating Coronary Artery and other Vascular Anastomoses.

The initial version of this treatise was written as I (Curt Tribble) was learning to do coronary anastomoses over 30 years ago, and I worried that I was not being taught very well how to go about doing them. It seemed to me that my teachers were channeling Dr. Alain Carpentier, who often answered questions about his mitral valve repair techniques by saying, "Oh, you just know.

Ex Vivo Assessment of Porcine Donation After Circulatory Death Lungs That Undergo Increasing Warm Ischemia Times.

Background: Increased utilization of donation after circulatory death (DCD) lungs may help alleviate the supply/demand mismatch between available donor organs and lung transplant candidates. Using an established porcine DCD model, we sought to determine the effect of increasing warm ischemia time (WIT) after circulatory arrest on lung function during ex vivo lung perfusion (EVLP).

Methods: Porcine donors (n = 15) underwent hypoxic cardiac arrest, followed by 60, 90, or 120 minutes of WIT before procurement and 4 hours of normothermic EVLP.

On Becoming a Surgical Intern: Navigating the Lurch from Medical School to Internship.

There are three major transitions in the educational trajectory of those heading into a career in surgery. The first transition is from the first year or two of medical school to the clerkships of the third year.  The second is the transition from medical school into the first postgraduate year of residency training.

Reoperative Cardiac Surgery - Part II.

The preparation for a reoperative cardiac surgical case was covered in Part I of this two part review [Tribble 2018]. Part II will cover primarily intraoperative strategies and techniques.  As noted in Part I, there has been surprisingly little written about the strategies and techniques of reoperative cardiac surgery.

Cardiothoracic and Vascular Surgeons Achieve High Rates of K Award Conversion Into R01 Funding.

Background: Obtaining National Institutes of Health (NIH) R01 funding remains extremely difficult. The utility of career development grants (K awards) for achieving the goal of R01 funding remains debated, particularly for surgeon-scientists. We examined the success rate for cardiothoracic and vascular (CTV) surgeons compared with other specialties in converting K-level grants into R01 equivalents.

Expanding the donor lung pool: how many donations after circulatory death organs are we missing?

Background: The number of patients with end-stage pulmonary disease awaiting lung transplantation is at an all-time high, while the supply of available organs remains stagnant. Utilizing donation after circulatory death (DCD) donors may help to address the supply-demand mismatch. The objective of this study is to determine the potential donor pool expansion with increased procurement of DCD organs from patients who die at hospitals.

Cardiothoracic surgery training grants provide protected research time vital to the development of academic surgeons.

Background: The Ruth L. Kirschstein Institutional National Research Service Award (T32) provides institutions with financial support to prepare trainees for careers in academic medicine. In 1990, the Cardiac Surgery Branch of the National Heart, Lung and Blood Institute (NHLBI) was replaced by T32 training grants, which became crucial sources of funding for cardiothoracic (CT) surgical research.

Give My Poor Heart Ease.

We came to The University of Virginia (UVA) within a year of each other nearly four decades ago: one (DN) to join the UVA basketball team during four of the best years of UVA basketball, and to earn 2 degrees, first in English and then in Sports Psychology; and the other (CT) to begin 7 years of training in general, vascular, thoracic, and cardiac surgery, which culminated with a faculty appointment in the UVA Department of Surgery, with part of the charge being to organize most of the Department's educational programs. Realizing that the education and training of medical students and surgical residents would require knowledge, skills, and understanding above and beyond the usual training of a resident in surgery, I (CT) started an informal, though enriching, attempt to find those on the grounds of the University who might share ideas and insights that could enhance the educational programs in the Department. This process embodied the vision of the founders of the University to create an "academical village.

In vivo lung perfusion rehabilitates sepsis-induced lung injury.

Background: Sepsis is the leading cause of lung injury in adults and can lead to acute respiratory distress syndrome (ARDS). Using a novel technique of isolated in vivo lung perfusion (IVLP), we hypothesized that normothermic IVLP will improve oxygenation and compliance in a porcine model of sepsis-induced lung injury.

Methods: Mature adult swine (n = 8) were administered lipopolysaccharide (LPS; 50 μg/kg over 2 hours) via the external jugular vein, followed by sternotomy and central extracorporeal membrane oxygenation (ECMO) cannulation (right atrium to ascending aorta).

The Skeleton in the Closet: Harvesting a Skeletonized IMA.

There is a considerable amount of data that using more than one arterial graft provides a survival advantage for patients undergoing coronary bypass operations. The Society of Thoracic Surgeons has a set of official guidelines for the use of arterial grafts which include the following recommendations:Internal mammary arteries (IMA's) should be used to bypass the left anterior descending (LAD) artery when bypass of the LAD is indicated.As an adjunct to left internal mammary artery (LIMA), a second arterial graft (right IMA or radial artery [RA]) should be considered in appropriate patients.

Median Sternotomy for Lung Transplantation: Techniques and Advantages.

Lung transplantation is traditionally performed with a clamshell thoracotomy or bilateral anterior thoracotomy incisions. We have performed 121 lung transplants with a median sternotomy incision from 2013-2017. We present our technique for lung transplantation utilizing cardiopulmonary bypass with a median sternotomy, and discuss the potential advantages of this technique.

Lungs donated after circulatory death and prolonged warm ischemia are transplanted successfully after enhanced ex vivo lung perfusion using adenosine A2B receptor antagonism.

Objective: The current supply of acceptable donor lungs is not sufficient for the number of patients awaiting transplantation. We hypothesized that ex vivo lung perfusion (EVLP) with targeted drug therapy would allow successful rehabilitation and transplantation of donation after circulatory death lungs exposed to 2 hours of warm ischemia.

Methods: Donor porcine lungs were procured after 2 hours of warm ischemia postcardiac arrest and subjected to 4 hours of cold preservation or EVLP.

Ex Vivo Lung Perfusion Rehabilitates Sepsis-Induced Lung Injury.

Background: Sepsis is the number one cause of lung injury in adults. Ex vivo lung perfusion (EVLP) is gaining clinical acceptance for donor lung evaluation and rehabilitation and may expand the use of marginal organs for transplantation. We hypothesized that 4 hours of normothermic EVLP would improve compliance and oxygenation in a porcine model of sepsis-induced lung injury.

Outcomes of Trainees Performing Coronary Artery Bypass Grafting: Does Resident Experience Matter?

Background: Outcomes after coronary artery bypass graft surgery (CABG) are known to be dependent on attending surgeon volume, but the impact of resident experience is unknown. Our objective was to assess the influence of resident experience to understand the learning curve for CABG.

Methods: From 2008 to 2014, all isolated on-pump CABG (n = 1,668) during which a resident performed the entire operation (including sternotomy, mammary artery harvest, coronary anastomoses, and closure) were reviewed.

Massive Pulmonary Embolism Treated with Catheter Therapy and Extracorporeal Membrane Oxygenation.

Massive pulmonary embolism (PE) is associated with significant morbidity and mortality.  Treatment for massive PE can include systemic thrombolysis and catheter-directed therapy. We present the case of a patient with massive PE successfully treated with catheter-directed therapy, using extracorporeal membrane oxygenation for hemodynamic support, and discuss some of the potential complications associated with this therapy.

Always Keep Your Clothes in the Car.

In helping to organize many different educational environments in the School of Medicine and the Department of Surgery at the University of Virginia over the last 30 years, my colleagues and I have long recognized that our students and trainees, while uniformly well prepared academically for their respective missions, often take inadequate care of themselves. Everyone who has flown on a plane will recall that the flight attendants always tell passengers that, if oxygen is needed, one must put one's own mask on first, before helping others put their masks on. And the obvious reason for that admonition is that you cannot help others if you, yourself, are impaired.

Airway pressure release ventilation during ex vivo lung perfusion attenuates injury.

Objective: Critical organ shortages have resulted in ex vivo lung perfusion gaining clinical acceptance for lung evaluation and rehabilitation to expand the use of donation after circulatory death organs for lung transplantation. We hypothesized that an innovative use of airway pressure release ventilation during ex vivo lung perfusion improves lung function after transplantation.

Methods: Two groups (n = 4 animals/group) of porcine donation after circulatory death donor lungs were procured after hypoxic cardiac arrest and a 2-hour period of warm ischemia, followed by a 4-hour period of ex vivo lung perfusion rehabilitation with standard conventional volume-based ventilation or pressure-based airway pressure release ventilation.