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Objective: The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in hospital resource utilization and the need to defer nonurgent cardiac surgery procedures. The present study aims to report the regional variations of North American adult cardiac surgical case volume and case mix through the first wave of the COVID-19 pandemic.Methods: A survey was sent to recruit participating adult cardiac surgery centers in North America. Data in regard to changes in institutional and regional cardiac surgical case volume and mix were analyzed.Results: Our study comprises 67 adult cardiac surgery institutions with diverse geographic distribution across North America, representing annualized case volumes of 60,452 in 2019. Nonurgent surgery was stopped during the month of March 2020 in the majority of centers (96%), resulting in a decline to 45% of baseline with significant regional variation. Hospitals with a high burden of hospitalized patients with COVID-19 demonstrated similar trends of decline in total volume as centers in low burden areas. As a proportion of total surgical volume, there was a relative increase of coronary artery bypass grafting surgery (high þ7.2% vs low þ4.2%, P ¼ .550), extracorporeal membrane oxygenation (high þ2.5% vs low 0.4%, P ¼ .328), and heart transplantation (high þ2.7% vs low 0.4%, P ¼ .090), and decline in valvular cases (high -7.6% vs low -2.6%, P ¼ .195). Conclusions:The present study demonstrates the impact of COVID-19 on North American cardiac surgery institutions as well as helps associate region and COVID-19 burden with the impact on cardiac surgery volumes and case mix. (J

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Extracorporeal membrane oxygenation (ECMO) contributes to coagulopathy, necessitating systemic anticoagulation to prevent thrombosis. Traditionally, unfractionated heparin (UFH) has been the anticoagulant of choice, however, due to many inadequacies new evidence suggests benefit with the use of direct thrombin inhibitors. This retrospective cohort sought to evaluate the safety and efficacy of bivalirudin compared to UFH in ECMO patients. Primary endpoints included incidence of bleeding and thrombosis. Percent time in therapeutic range (TR), time to achieve TR and number of dose titrations required to maintain TR were calculated to assess efficacy of institutional protocols. Overall incidence of thrombosis was low, with one event in the bivalirudin group and no events in the UFH group. No difference was found in rates of bleeding between groups (6% vs. 10%, P = 0.44). Bivalirudin yielded higher percent time in TR (86% vs. 33%, P < 0.001), faster time to TR (2 vs. 18 hr, P < 0.001) and required fewer dose adjustments to maintain TR (2 vs. 11, P < 0.001) compared to UFH. These results suggest bivalirudin and UFH are associated with similar rates of bleeding and thrombosis in patients requiring ECMO support. Our results demonstrate the favorable pharmacokinetic profile of bivalirudin, and its ability to consistently maintain TR when compared to UFH.

There has been a dramatic increase in intravenous drug abuse (IVDA)-related deaths in midlife Americans. Nowhere is this more profound than in rural Appalachia, with Kentucky in the midst of the epidemic. The causes of this finding are multifactorial and likely related to social, economic, legal, and population factors. Evidence suggests that the economic middle class is shrinking. The traditionally white midlife demographic that used to comprise more than 80% of the US middle class now accounts for less than 60%. Along with this shrinking middle class come the inevitable trappings of poverty, including drug abuse. Population-based data reveal that the shrinking middle class is associated with a significant rise in drug abuse in the population that traditionally made up the middle class; that is, white, midlife Americans. In Kentucky, the drug of choice for abuse has changed during the past 2 decades, largely related to law enforcement and political efforts. Efforts to control drug abuse have, however, suppressed availability and use of 1 substance only to have another move to the forefront. For example, during this time abuse has shifted from methamphetamine at the turn of the century to narcotic pills during the early 2000s to intravenous injection of heroin beginning around 2010. Along with this shift in the drug of choice for abuse came an alarming trend in mortality associated with IVDA, both in Kentucky and nationally, including the need for surgical correction of IVDA-related endocarditis. Thoracic surgeons have tended to avoid or ignore the greater problems that caused the epidemic of IVDA-related endocarditis. Perhaps it is time for thoracic surgeons to give a stronger voice to the societal issues that loom in the background of this epidemic.