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Objective Although an ultrasonic harmonic scalpel (HS) has been used to harvest the internal mammary artery (IMA) for coronary artery bypass grafting, the benefits and risks compared to conventional electrocautery (EC) are not clear. We aimed to compare the outcomes of HS versus EC for IMA harvesting. Methods An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. Results This meta-analysis included 12 studies. Pooled analyses demonstrated that both groups had comparable preoperative baseline characteristics including age, gender, and left ventricular ejection fraction. HS included more diabetic patients [33% (95% CI 30, 35) vs. 27% (23, 31), p  = 0.01]. Harvest time for unilateral IMA was significantly longer with HS than EC [39 (31, 47) minutes vs. 25 (17, 33) minutes, p  < 0.01]. However, the rate of pedicled unilateral IMA was significantly higher for EC compared with HS [20% (17, 24) vs. 8% (7, 9), p  < 0.01]. The rate of intact endothelium was significantly higher with HS than EC [95% (88, 98) vs. 81% (68, 89), p  < 0.01). There was no significant difference in postoperative outcomes including bleeding [3% (2, 4)], sternal infection [3% (2, 4)], and operative/30-day mortality [3% (2, 4)]. Conclusions HS required longer IMA harvest times which could be partially attributed to a higher skeletonization rate in this category. HS may cause less endothelial injury than EC; however, no significant differences in postoperative outcomes were seen between the groups.

Background While the effect of pre-transplant weight on patient outcomes following heart transplantation (HTx) has previously been studied, data regarding the impact of dynamic weight change prior to HTx are extremely limited. Objectives We sought to elucidate the interaction between HTx listing weight and weight change while waitlisted, and explore how that interaction impacts post-HTx survival in a continuous manner. Methods Adult patients listed for HTx from 1987 to 2020 were identified from UNOS database. Three-dimensional restricted cubic spline analysis explored post-HTx survival relative to both changes in BMI/weight and BMI at time of HTx listing. Continuous predictor variables were analyzed with Cox proportional hazards method. Results 9,628 included patients underwent HTx. Median recipient age was 55 [IQR 46–62] years, and 21% were females. 53% of patients lost while 47% gained weight on the waitlist. Median BMI (27.6 kg/m 2 [24.3–31.3] vs. 27.4 kg/m 2 [24.2–30.9], paired p  < 0.001) and weight (84.8 kg [73.0–98.0] kg vs. 84.4 kg [72.6–96.6], p  < 0.001) were similar at listing and transplant. One-year survival was 89.3%. Weight loss over 3 BMI points or 10 kg was associated with higher hazard of death irrespective of listing BMI. In non-obese patients, some weight gain (1–4 BMI points or 5–15 kg) was associated with improved survival. In cachectic patients (BMI < 18.5), failure to gain weight was associated with worse survival. Conclusions Impact of weight change varies depending on listing BMI. While a survival benefit is seen in non-obese patients who gain some weight, significant weight loss is associated with poorer survival.

René Gerónimo Favaloro prided himself on being a “simple country doctor.” Born in La Plata, Argentina, Dr. Favaloro had an interest in Argentina's sociopolitical and healthcare systems beginning at a young age. He began his medical education at La Universidad Nacional de La Plata, graduating in 1949 with plans to continue his medical education in the field of surgery; however, in 1950, Dr. Favaloro temporarily resigned from his position as a surgeon to work as a country doctor in a small province of La Pampa, Argentina. It was during this time that Dr. Favaloro became acutely aware of the overwhelmingly poor state of the healthcare system in Argentina. In 1962, Dr. Favaloro redirected his focus back to his surgical interests and moved to the United States to work at the Cleveland Clinic, where he discovered the use of the saphenous vein graft for revascularization of the coronary arteries. Despite a productive medical career in the United States, Dr. Favaloro eventually brought his work back to Argentina, where his heart had always remained. Throughout the incredible milestones of his life, Dr. René Gerónimo Favaloro consistently remained a humble, gracious, and simple country doctor.

Treatment of giant cell myocarditis (GCM) can require bridging to orthotopic heart transplantation (OHT) or recovery with mechanical circulatory support (MCS). Since the roles of MCS and immunotherapy are not well-defined in GCM, we sought to analyze outcomes of patients with GCM who required MCS. A systematic search was performed in June 2019 to identify all studies of biopsy-proven GCM requiring MCS after 2009. We identified 27 studies with 43 patients. Patient-level data were extracted for analysis. Median patient age was 45 (interquartile range (IQR): 32–57) years. 42.1% (16/38) were female. 34.9% (15/43) presented in acute heart failure. 20.9% (9/43) presented in cardiogenic shock. Biventricular (BiVAD) MCS was required in 76.7% (33/43) of cases. Of the 62.8% (27/43) of patients who received immunotherapy, 81.5% (22/27) used steroids combined with at least one other immunosuppressant. Cyclosporine was the most common non-steroidal agent, used in 40.7% (11/27) of regimens. Immunosuppression was initiated before MCS in 59.3% (16/27) of cases, after MCS in 29.6% (8/27), and not specified in 11.1% (3/27). Immunosuppression started prior to MCS was associated with significantly better survival than MCS alone (p = 0.006); 60.5% (26/43) of patients received bridge-to-transplant MCS; 39.5% (17/43) received bridge-to-recovery MCS; 58.5% (24/41) underwent OHT a median of 104 (58–255) days from diagnosis. GCM recurrence after OHT was reported in 8.3% (2/24) of transplanted cases. BiVAD predominates in mechanically supported patients with GCM. Survival and bridge to recovery appear better in patients on immunosuppression, especially if initiated before MCS.

PurposeA body mass index (BMI) > 35 kg/m2 is a relative contraindication to heart transplantation in patients with end-stage heart failure. Bariatric surgery can be considered either concomitantly with continuous-flow left ventricular assist device (CF-LVAD) placement, or staged after CF-LVAD has been placed. We sought to evaluate the outcomes of these approaches.Materials and MethodsAn electronic search was performed to identify all relevant studies. After assessment for inclusion and exclusion criteria, eight studies were pooled for systematic review and metaanalysis.ResultsOverall, of 59 patients, 22 (37%) underwent simultaneous sleeve gastrectomy with CF-LVAD implantation while 37 (63%) underwent staged sleeve gastrectomy after CF-LVAD. The mean age of patients was 46 years (95% CI: 39–53) with 40% females. Mean BMI at most recent follow-up (33.4 kg/m2, 95% CI: 30.2–36.6) was significantly lower compared with mean preoperative BMI (46.7 kg/m2, 95% CI: 42.9–50.6) (p < 0.01). There was no significant difference in total incidence of postoperative complications (simultaneous, 16% (95% CI: 1–87%) versus staged, 23% (95% CI: 7–53%)) or in overall survival (simultaneous, 93% (95% CI: 72–99%) versus staged, 79% (95% CI: 60–90%), p = 0.17) for average follow-up time of 12.7 months. Bariatric surgery resulted in 66% of patients (95% CI: 51–79) to be listed for heart transplantation, including 33% (95% CI: 22–47) who were transplanted.ConclusionsBoth simultaneous and staged bariatric surgeries with CF-LVAD placement have comparable outcomes and significantly reduce BMI. This can allow previously ineligible patients to undergo heart transplantation.

Synovial sarcomas are a distinct clinical entity occurring most often in the lower extremities. They account for 10–14% of all soft tissue sarcomas. Pulmonary synovial sarcomas are quite rare and account for less than 0.5% of all intra-thoracic neoplasms. We present the first reported case of primary pulmonary synovial sarcoma with intra cardiac extension in a 53-year-old male who presented with chronic cough. Imaging revealed a large right upper lobe mass extending through the superior pulmonary veins into the left atrium. The patient underwent a right total pneumonectomy with extraction of the left atrial mass and left atrial reconstruction. Pathology and immunohistochemistry was diagnostic of primary pulmonary synovial sarcoma positive for SYT-SSX1 gene fusion transcription.

The management of patients with ischemic cardiomyopathy involves evaluation of the relative benefits of revascularization versus medical management, or the referral for advanced heart failure therapies. While the decision to proceed with revascularization may be straight-forward in patients with severe angina or important stenosis of the left main coronary artery, many patients have less clear indications for revascularization and require additional evaluation. Viability testing, assessment of hemodynamics or evaluation of mechanical dyssynchrony can provide information that may help define the relative risks of revascularization and medical management. Even in the situation where the operative risk is elevated, it may still be less than the risk of non-operative therapy. When faced with a patient with very high operative risk, one should consider alternative approaches such as cardiac transplantation or the use of long-term ventricular assist devices.

An immunosuppressive tumour microenvironment is a major obstacle in the control of pancreatic and other solid cancers 1 – 3 . Agonists of the stimulator of interferon g enes (STING) protein trigger inflammatory innate immune responses to potentially overcome tumour immunosuppression 4 . Although these agonists hold promise as potential cancer therapies 5 , tumour resistance to STING monotherapy has emerged in clinical trials and the mechanism(s) is unclear 5 – 7 . Here we show that the administration of five distinct STING agonists, including cGAMP, results in an expansion of human and mouse interleukin (IL)-35 + regulatory B cells in pancreatic cancer. Mechanistically, cGAMP drives expression of IL-35 by B cells in an IRF3-dependent but type I interferon-independent manner. In several preclinical cancer models, the loss of STING signalling in B cells increases tumour control. Furthermore, anti-IL-35 blockade or genetic ablation of IL-35 in B cells also reduces tumour growth. Unexpectedly, the STING–IL-35 axis in B cells reduces proliferation of natural killer (NK) cells and attenuates the NK-driven anti-tumour response. These findings reveal an intrinsic barrier to systemic STING agonist monotherapy and provide a combinatorial strategy to overcome immunosuppression in tumours. Systemic treatment of pancreatic cancer with STING agonist stimulates regulatory B cells to express immunosuppressive cytokine IL-35, which weakens the anti-tumour function of natural killer cells.

The NOAA Hazardous Weather Testbed (HWT) conducts annual spring forecasting experiments organized by the Storm Prediction Center and National Severe Storms Laboratory to test and evaluate emerging scientific concepts and technologies for improved analysis and prediction of hazardous mesoscale weather. A primary goal is to accelerate the transfer of promising new scientific concepts and tools from research to operations through the use of intensive real-time experimental forecasting and evaluation activities conducted during the spring and early summer convective storm period. The 2010 NOAA/HWT Spring Forecasting Experiment (SE2010), conducted 17 May through 18 June, had a broad focus, with emphases on heavy rainfall and aviation weather, through collaboration with the Hydrometeorological Prediction Center (HPC) and the Aviation Weather Center (AWC), respectively. In addition, using the computing resources of the National Institute for Computational Sciences at the University of Tennessee, the Center for Analysis and Prediction of Storms at the University of Oklahoma provided unprecedented real-time conterminous United States (CONUS) forecasts from a multimodel Storm-Scale Ensemble Forecast (SSEF) system with 4-km grid spacing and 26 members and from a 1-km grid spacing configuration of the Weather Research and Forecasting model. Several other organizations provided additional experimental high-resolution model output. This article summarizes the activities, insights, and preliminary findings from SE2010, emphasizing the use of the SSEF system and the successful collaboration with the HPC and AWC.