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Ann Thorac Surg 2006;82:1611-1620
© 2006 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, New York University, New York, New York
b Divisions of Cardiology, Cardiac Anesthesiology, Biostatistics and Data Management Core, and Cardiothoracic Surgery, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
Accepted for publication May 22, 2006.
* Address correspondence to Dr Gaynor, Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Suite 8527, Philadelphia, PA 19104 (Email: gaynor{at}email.chop.edu).
Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 2, 2006.
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Abstract |
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METHODS: We performed a review of patients undergoing the Fontan procedure between January 1, 2000 and December 31, 2004.
RESULTS: The Fontan procedure was performed in 160 patients. The median age was 2.2 years (range, 1.0 to 29.1 years). Hypoplastic left heart syndrome or a variant was present in 114 patients (71%), and heterotaxy was present in 19 (12%). CPB and modified ultrafiltration were used in all patients. Aortic cross-clamping was used in 154 (96%) of 160 patients and deep hypothermic circulatory arrest (DHCA) in 132 (83%). A lateral tunnel Fontan was performed in 69 patients (43%) and an extracardiac Fontan in 91 (57%). A fenestration was created in 144 patients (90%). Two patients died. Freedom from death or takedown was 98% (157/160). Median duration of pleural drainage was 2 days (range, 1 to 44 days) and was more than 14 days in 16 patients. Median duration of hospitalization was 6 days (range, 3 to 55 days). The small number of deaths precluded assessment of risk factors for mortality. By multivariable analysis, risk factors for pleural drainage longer than 3 days were extracardiac connection (p < 0.001) and increasing mean pulmonary artery pressure before the Fontan procedure (p = 0.033). By multivariable analysis, risk factors for hospitalization for more than 7 days were extracardiac connection (p = 0.003), increasing duration of total support (CPB and DHCA, p = 0.027), and decreasing systemic oxygen saturation before the Fontan procedure (p = 0.048).
CONCLUSIONS: The Fontan procedure can be performed using CPB and aortic cross-clamping with low morbidity and mortality.
During the last three decades, improvements in perioperative care have reduced morbidity and mortality for the Fontan significantly [1], even for patients with hypoplastic left heart syndrome (HLHS) [2–4]. Questions remain, however, about the optimal management strategy. Both lateral tunnel (LT) and extracardiac (EC) connections are widely used. Recent reports have advocated avoidance of cardiopulmonary bypass (CPB) and aortic cross-clamping for the theoretic benefit of avoiding the inflammatory consequences of CPB and the potential for perioperative myocardial dysfunction [5–8]. Thus far, no single approach has been shown to be superior. We continue to use CPB and aortic cross-clamping, as well as both EC and LT reconstruction. The present study was undertaken to evaluate the early outcome of all patients undergoing the modified Fontan procedure at our institution from January 1, 2000 to December 31, 2004.
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Material and Methods |
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Perioperative Data Acquisition
Preoperative variables
Table 1
lists the variables recorded. Patients were assigned to one of the diagnostic groups on the basis of cardiac anatomy. The presence of heterotaxy was recorded. Morphology and regurgitation of the atrioventricular (AV) valve were determined from the preoperative echocardiogram. Hemodynamic values were obtained from the pre-Fontan catheterization (n = 140). For purposes of this study, the viral respiratory season was defined as November to March.
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Postoperative variables
Table 1 lists the post-procedure variables that were recorded. Duration of pleural drainage was defined as beginning at the time of surgery and ending with the removal of the final drain or the final thoracentesis, whether performed during the initial admission or a readmission within 30 days after surgery.
Statistical Analysis
Data analysis occurred in three phases. Phase I consisted of obtaining measures of central tendency, variability, and association for all variables in the data set, with special attention given to patient-related, operative, and early failure outcomes.
In phase II, the modeling phase, three different sets of single-covariate logistic regression models were specified and tested using the three distinct outcomes of pleural drainage, length of hospitalization, and readmission. Operation during the viral season (November to March) was tested as a risk factor for the three outcomes. Pleural drainage and length of hospitalization were analyzed for survivors and dichotomized for analysis because of the skewed nature of the distributions and to avoid transformations that did not lend themselves to meaningful interpretation. Pleural drainage was dichotomized in two ways, at 3 days (
3 days, 3+ days) and at 14 days (14 days, 14+ days). Length of hospital stay was dichotomized at 7 days (7 days, 7+ days). A total of 23 single-covariate logit models were tested for each outcome, with 
= 0.05 as the criterion for statistical significance.
In phase III, multiple covariate models were specified and tested using variables from the single covariate models with p < 0.10 and clinical criteria.
Finally, owing to the potential for use of LT or EC with different types of patient populations, additional descriptive comparisons between LT and EC groups were conducted. All data were analyzed using SPSS 13 (SPSS Inc, Chicago, IL) and STATA 9 (STATA Corp, College Station, TX).
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Results |
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Early Failure
Two patients (1.3%) died. One patient had a single right ventricle and moderate AV valve regurgitation and died despite Fontan takedown and extracorporeal membrane oxygenation (ECMO). The other patient had HLHS and severe AV valve regurgitation and had not had a previous superior cavopulmonary connection because of venous thrombosis after ECMO in the newborn period. The small number of deaths in this study precluded meaningful statistical analysis of risk factors for death.
An additional patient required a Fontan takedown to bidirectional Glenn but survived to hospital discharge. This patient had upstairs-downstairs ventricle and dextrocardia. Fontan takedown and ECMO were required for persistent malignant tachyarrhythmias.
No patient required transplantation within the first 30 days after the Fontan. Early failure (death, Fontan takedown, or transplantation within 30 days postoperatively) occurred in 3 (1.9%) of 160 patients and in 2 (1.8%) of 114 patients with single right ventricle. Two of the early failures occurred during the viral season. As with mortality, the small number of early failures precluded meaningful modeling of risk factors.
Morbidity
Operative complications are listed in Table 3. Three patients required ECMO, including the 2 described previously and an additional patient who survived without takedown of the Fontan. Tachyarrhythmias requiring medical therapy occurred in 15 patients (9.4%), and pacemakers were required in 5 (3%). Reoperation within the same hospitalization as the Fontan procedure was necessary in 23 patients (14%), most commonly for reexploration for bleeding in 7, placement of a pacemaker in 5, and institution of ECMO in 3. The median duration of mechanical ventilation was 5 hours (range, 0 to 216 hours), and 12 patients (7.5%) required reintubation.
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The median duration of hospitalization among survivors was 6 days (range, 3 to 55 days), and the mean was 8.2 ± 7.1 days. One third of the patients required hospitalization for more than 7 days, and less than 10% required hospitalization for more than 14 days. Multiple covariate models revealed only EC (p = 0.003), increasing total support time (p = 0.025), and decreased preoperative systemic oxygen saturation (p = 0.043) as risk factors for prolonged hospitalization when dichotomizing it at 7 days (Table 4). Ventricular morphology did not impact length of hospitalization in the current study. Increased duration of aortic cross-clamping was not associated with increased duration of pleural drainage or longer hospitalization for either of the multiple covariate models.
Readmission to our institution was required in 23 patients (15%), most commonly for pleural effusion. Single and multiple covariate models failed to demonstrate any statistically significant risk factors for readmission. It is possible that an occasional patient might have been readmitted to another institution and would not have been included.
Season of Operation
Fontan operations were performed on 32 patients (20%) during the viral respiratory season. Patients undergoing surgery during the viral season were younger than those undergoing surgery during the rest of the year (median, 2.0 years; range, 1.0 to 10.9 versus median, 2.2 years; range, 1.2 to 29.1; p = 0.009). The viral season cohort also had slightly lower preoperative oxygen saturation (82% ± 4% versus 84% ± 5%, p = 0.008) and slightly higher atrial pressure (7.6 ± 2.6 mm Hg versus 6.4 ± 2.1 mm Hg, p = 0.024). By multivariable analysis, season of operation was not a risk factor for prolonged pleural drainage, for thoracentesis or chest tube placement, or for prolonged hospitalization.
Extracardiac Versus Lateral Tunnel
Table 2 lists the characteristics of the LT and EC groups. The 91 extracardiac patients were older (p = 0.001), less likely to undergo fenestration (p = 0.014), and more likely to have heterotaxy (p < 0.001) and a common AV valve (p < 0.001). Median pleural drainage was 2 days longer with EC (1 day versus 3 days, p < 0.001; Table 3). The mean duration of pleural drainage for EC patients was 7.1 ± 9.0 days (p < 0.001), and the mean duration of pleural drainage for LT patients was 3.1 ± 5.3 days. Extracardiac patients were more likely to have duration of pleural drainage of more than 3 days (Fig 2;
p < 0.001). Median hospitalization was also 2 days longer with EC (5 days versus 7 days, p < 0.001; Table 3). The mean duration of hospitalization for EC patients was 10.2 ± 8.7 days, and the mean duration of hospitalization for LT patients was 5.6 ± 2.8 days. The 5 patients who required pacemaker placement were in the LT group.
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Operative mortality in our series was 1.2% and for patients with a single right ventricle, 1.8%. The overall early failure rate (death, Fontan takedown, or transplantation) was 1.9%. These data compare favorably with previous reports, particularly for patients with HLHS and a single right ventricle. Early reports of outcome for the Fontan operation had mortality and failure rates approaching 20%, and for HLHS patients, the rates approached 40% [16].
Our institution reported the outcomes of the Fontan operation performed from 1992 to 2000 [2]. In that cohort comprised predominantly of LT reconstructions, the mortality rate was 6.6%, with most of the deaths occurring in the first 2 years of the study period. Right ventricular morphology was not a risk factor for death in that cohort. Other institutions reported similar mortality and failure rates. [1, 3, 4, 9, 17] The mortality rate in the current study reflects the continued improvement in outcome. Heterotaxy syndrome, formerly considered a risk factor [18, 19], was not associated with increased mortality in the current study.
Morbidity after the Fontan operation continues to decrease. The median duration of pleural drainage in this cohort was 2 days, and the median hospitalization was 6 days. These values also compare favorably with previous series from our own institution and others in which the median duration of pleural drainage was as long as 10 days, and median hospitalization was 9 to 13 days [2, 10, 20]. The multiple covariate risk factor models for morbidity reported here are generally consistent with previous reports. Increased morbidity had been previously demonstrated with increased total support time as well as with elevated pulmonary artery pressure and decreased preoperative systemic oxygen saturation, both markers of increased pulmonary vascular resistance [10, 16, 21].
In contrast with the previous report from our institution and reports from other institutions [2, 22, 23], right ventricular morphology was not associated with increased pleural drainage or hospitalization in the current study. Also in contrast with previous reports [18, 19], heterotaxy syndrome was not associated with increased mortality or morbidity. In addition, fears of significant perioperative myocardial dysfunction and subsequent increased morbidity from aortic cross-clamping were not realized in this cohort of patients.
Previous reports have suggested increased mortality and pleural drainage for patients undergoing the Fontan operation during the viral respiratory season. Nicolas and associates [24] reviewed a cohort of 2700 patients from a multiinstitution registry who underwent the Fontan operation from 1982 to 2000 and found mortality during the viral season was 14% compared with 11% during other seasons. Fedderly and associates [25] reported a statistically significant increase in the amount and duration of chest tube drainage during the viral respiratory season. In addition, the mean duration of hospitalization increased from 16 to 22.5 days during the viral season.
We have avoided performing the Fontan during the viral season unless the patient's clinical status prevented postponing the surgery. This bias is reflected in the higher risk profile of the viral season cohort: younger age, higher preoperative atrial pressure, and lower preoperative oxygen saturation. In the current study, however, operation in the viral season was not associated with increased pleural drainage or duration or hospitalization.
Recent articles have advocated performing the Fontan procedure without CPB and aortic cross-clamping to avoid potential increased morbidity from inflammatory insult and myocardial dysfunction; however, reports on the outcome of patients treated with this strategy are limited. Petrossian and associates [13] reported an overall mortality of 1% in a cohort of 256 patients, in which 42 (median age, 4.5 years; range, 1.4 to 43) underwent EC Fontan without CPB. In addition, systemic venous and common atrial pressures were slightly reduced and the transpulmonary gradient in the off-pump group was lower. The differences were less than 2 mm Hg in each case, however, and the impact of these differences on morbidity and mortality is not reported. For the entire cohort of 256 patients, the median chest tube duration was 8 days, and the median hospitalization was 11 days, both significantly longer than for patients in the current study, even for the EC subgroup. Fenestration was used in 19% of patients. The duration of pleural drainage and hospitalization for the off-pump subgroup was not reported.
Yeoman and associates [14] reported no early mortality in 24 patients (mean age, 5.9 ± 2.9 years) undergoing EC without CPB. Three patients (7%) required reoperation for pleural drainage, and the mean hospital stay was 16 days. Fenestration was not routinely used in this cohort. Xu and associates [15] had an early mortality of 13% in 16 patients with a mean age 9.8 ± 6.2 years.
Additional points of caution with an off-pump strategy can be raised. The patients in these series were noticeably older than the cohort reported in the current study. Potential benefits of the off-pump strategy might be negated by the need to wait until the patients are 4 or 5 years old. Stenbog and colleagues [26] reported results in 20 patients undergoing Fontan and observed accelerated somatic growth after these procedures if the surgery was done before 5 years of age. Ovroutski and colleagues [27] observed the growth of 51 children for a mean period of nearly 5 years after extracardiac Fontan. Accelerated growth from the 10th percentile up as high as the 50th percentile was observed in patients younger than 4 years of age at the time of Fontan but not in the patients older than 4 years of age (p < 0.05).
The EC and LT reconstructions were both used in the current study cohort, and each technique has potential advantages. The outcomes were excellent for both approaches, and further investigations will be required to determine which reconstruction is optimal for a particular patient.
The EC reconstruction has fewer atrial suture lines and protects the atrium from exposure to high pressures, possibly reducing the propensity toward arrhythmias in this patient population [10, 28]. Disadvantages for the EC approach include its limited growth potential and the relative difficulty in performing fenestration, particularly if the operation is done without CPB.
Conversely, the LT reconstruction has growth potential and is relatively simple to fenestrate. Although the long-term consequences of routine fenestration have not been fully elucidated, there is evidence that short-term outcomes are impacted favorably by its use [29, 30]. Potential disadvantages for the LT approach include the atrial suture lines and the exposure of a portion of the atrium to increased venous pressure. In the current study, LT reconstruction was associated with reduced pleural drainage and hospitalization.
This study is limited by its retrospective design and by the lack of randomization of the choice of reconstruction. Multivariable analyses demonstrated significantly reduced morbidity for the LT group, but interpretation of these data is confounded by lack of randomization of patients and because the EC and LT groups differed in many important ways. However, the major dissimilarities between the groups, including heterotaxy, common AV valve, and ventricular morphology, were not associated with increased risk in multivariable analyses. Longer-term analyses will be needed.
Importantly, and despite the increased use of EC in this cohort, the overall morbidity was improved compared with our previous report. Longer-term analyses will be needed to assess fully the impact of the use of circulatory arrest on the subsequent neurologic development of the patient. Such investigation is ongoing at our institution.
The current study demonstrates that the short-term results of the Fontan operation performed with a strategy using CPB, aortic cross-clamping, DHCA, routine fenestration, and modified ultrafiltration are excellent. The rate of mortality, the duration of pleural drainage, and the duration of hospitalization compare favorably with the limited data available on the results of the Fontan performed without CPB. Longer-term studies will be required, however, to evaluate if CPB, aortic cross-clamping, and the type of reconstruction impact the subsequent neurologic development of the patient and the incidence of long-term Fontan sequelae such as protein-losing enteropathy and arrhythmias.
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Discussion |
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DR SPRAY: Basically, for those rare patients, we still use cross-clamp, for the most part, at the Fontan, certainly. We rarely choose the hemi-Fontan.
DR GERHARD ZIEMER (Tuebingen, Germany): This is a great study. My team and myself just seem to do something wrong, because we have our chest tubes in for about 2 weeks on average. So my question is, what is the cutoff point? When are you saying now I can pull the chest tube? Maybe one of the problems of people like myself is that we're just not there to pull the tube at a certain point, and then at some point just the tube is the only reason for having more effusion. So is there something like a rule of thumb, or do you really calculate? I assume the drainage has not completely stopped when you remove the chest drains.
DR MEYER: That is accurate. We certainly have discussed the possibility that placing pleural tubes, which we did not routinely do, results in their staying for a prolonged period, as they may drain what the pleural surface might otherwise be able to absorb.
DR ZIEMER: So what is the secret about when you pull it?
DR MEYER: There is no specific cutoff.
DR ZIEMER: Well, I mean, this is a problem then in comparing different studies. Some have chest tubes in for 2 days and others for 5 or 8 days. Or differently phrased, if you're chicken, you have it in for 2 weeks. The tough guys, however, pull it after 2 days. But maybe everybody could pull it at 2 days. So there is no science to it?
DR MEYER: Generally if the mediastinal tube is draining, we wouldn't take it out. Usually, in fact, they are fairly dry when removed.
DR ZIEMER: But then there is different patient size also.
DR MEYER: Fortunately, only about 22% of patients required placement of a pleural drain after removal of the initial chest tube.
DR HENRY L. WALTERS III (Detroit, MI): From your data, I believe I agree with you that there is no compelling reason to move towards the elimination of cardiopulmonary bypass and cross-clamping for performing Fontan procedures. I believe that in hypoplastic left heart syndrome, it is a good idea to use bypass and aortic cross-clamping for technical reasons.
However, in addition to using cardiopulmonary bypass and cross-clamping, you also used deep hypothermic circulatory arrest in 83% of your patients. Do you find the frequent use of total circulatory arrest to be an important part of your technique? If so, then why do you find it to be so important and do you plan on continuing that particular practice? Do you really think that the use of total circulatory arrest is a necessary part of the algorithm of performing a good Fontan?
DR MEYER: To answer the last part first, I think that we do plan to continue to use it. We believe that the data demonstrates this strategy to be safe. It facilitates the operation and might in fact make the overall pump time shorter. However, we are actively investigating the long-term impact of circulatory arrest on neurological outcome and on other outcome measures. But for the moment, we do continue to use it.
DR CARLO F. MARCELLETTI (Palermo, Italy): If I understand correctly the numbers, basically all patients, except 4, were staged; is that correct?
DR MEYER: Correct.
DR MARCELLETTI: Now, I think the answer about pleural effusion is there. I mean, most of the patients have been used for some time to a superior vena cava-to-pulmonary artery anastomosis or hemi-Fontan. So those patients, indeed, also in our experience, they tend to drain very little. Because I think that if you do a primary Fontan, you are very likely to expect prolonged effusion because the SVC system has to get adapted to a sudden change in hemodynamics. So I think that, if you agree, this could be an answer. And then, of course, I've always thought that all Fontans should be staged, and I think this is a good procedure.
The other observation that I would make is that actually cardiopulmonary bypass is very useful. What can be easily avoided is cross-clamping. We perform all our extracardiac Fontan without cross-clamping. We put a vent in the root of the aorta, because at the time you transect the inferior vena cava and remove the rest of the septum, you could get air if the heart is beating. But if you take the precaution of venting the aortic root, the operation can be performed without cross-clamping.
DR CHRISTOPHER KNOTT-CRAIG (Oklahoma City, OK). What we frequently find is that patients go home in 4 to 5 days without effusions; they then follow up with a cardiologist 8 or 10 days later and have a small pleural effusion, which doesn't seem to be bothering them. However, a pleural drain gets placed, and from then it's a spiral of effusions and drains which persist for many days. My questions therefore are (A) what is your strategy for these patients? and (B) do you discharge your patients on a restrictive diet, a low-fat or low-salt diet? Do you think this has merit? Finally, what is your policy in terms of ACE inhibitors in the postoperative period? Do you think they play any part in the presence or absence of effusions?
DR MEYER: The diet is not restricted. I think they are encouraged to eat whatever they want. We are generally not very aggressive in draining small effusions that are not bothering the patients. This strategy might help avoid the spiral that you describe. Most of our patients are receiving ACE inhibitors.
DR SHAUN SETTY (Minneapolis, MN): Do you anticoagulate your patients? And if so, which patients do you anticoagulate?
DR MEYER: They are not routinely anticoagulated.
DR CARL L. BACKER (Chicago, IL): I have a comment and a question. The comment is that this is a classic example of how surgeons using vastly different techniques can have similarly excellent results—crossclamp versus no crossclamp, fenestration versus no fenestration, cardiopulmonary bypass with circulatory arrest versus the West Coast approach with no bypass! Similarly excellent results with quite different techniques.
The question relates to a critical evaluation of your data. You indicated that the better outcomes regarding pleural effusions and length of stay are with the lateral tunnel with fenestration. Yet one of your first slides showed that as the study progressed, you have been switching from a preference for the lateral tunnel to a preference for the extracardiac Fontan. Why that shift in your strategy to the extracardiac technique when your data would suggest that you have better results with the lateral tunnel technique?
DR MEYER: Well, to some degree the data was a little bit surprising. The difference between the two groups was more than was anticipated. Although it did confirm the bias of some of the surgeons in the institution, and the lateral tunnel has made a comeback over the last year and a half.
DR SCOTT M. BRADLEY (Charleston, SC): With regard to the pleural effusion data, what is your institutional approach to aortopulmonary collaterals at the preoperative cath? How often are they sought? In what percentage of these patients were collaterals coil-occluded preoperatively?
DR MEYER: I think they're coil occluded in many cases. But frequently the caths are at outside institutions and things are coil-occluded that we might not coil-occlude at our institution. But significant ones are occluded.
DR BRADLEY: So do your own cardiologists actively go after collaterals at the preoperative cath, or ignore them?
DR SPRAY: The question you're asking really is prior to the Fontan operation?
DR BRADLEY: Yes, prior to the Fontan.
DR SPRAY: Significant aortopulmonary collateral prior to the Fontan we would coil. The issue comes up very infrequently, because almost always that issue is really coming up at the time of the secondary stage operation where the patient shows up prior to a bidirectional Glenn or hemi-Fontan and they have a lot of collaterals from the mammary, arteries, as they all do, and they end up with a series of collaterals to the right mammary, which I think is no benefit. But prior to the Fontan surgery, if they have significant aortopulmonary collaterals, they would be addressed.
DR BRADLEY: And just another comment, maybe an observation more than a question. Many of your patients underwent Fontan procedures utilizing circulatory arrest. I wonder if that is actually a marker for something else, such as decreased mediastinal dissection during the operation, which might result in less severing of lymphatics, and consequently less pleural effusion drainage postoperatively. Any thoughts?
DR MEYER: The dissection is really the same for the patients that get circulatory arrest and do not get circulatory arrest.
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Requirements for Recertification/Maintenance of Certification in 2007 |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionRequirements for...AcknowledgmentsReferences |
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The American Board of Thoracic Surgery will no longer publish the names of individuals who have not recertified in the American Board of Medical Specialties directories. The Diplomate's name will be published upon successful completion of the recertification/maintenance of certification process.
The CME requirements are 70 Category I credits in either cardiothoracic surgery or general surgery earned during the 2 years prior to application. SESATS and SESAPS are the only self-instructional materials allowed for credit. Category II credits are not allowed. The Physicians Recognition Award for recertifying in general surgery is not allowed in fulfillment of the CME requirements. Interested individuals should refer to the Booklet of Information for a complete description of acceptable CME credits.
Diplomates should maintain a documented list of their major cases performed during the year prior to application for recertification. This practice review should consist of 1 year's consecutive major operative experiences. If more than 100 cases occur in 1 year, only 100 should be listed.
Candidates for recertification/maintenance of certification will be required to complete all sections of the SESATS self-assessment examination. It is not necessary for candidates to purchase SESATS individually because it will be sent to candidates after their application has been approved.
Diplomates may recertify the year their certificate expires, or if they wish to do so, they may recertify up to two years before it expires. However, the new certificate will be dated 10 years from the date of expiration of their original certificate or most recent recertification certificate. In other words, recertifying early does not alter the 10-year validation.
Recertification/maintenance of certification is also open to Diplomates with an unlimited certificate and will in no way affect the validity of their original certificate.
The deadline for submission of applications for the recertification/maintenance of certification process is May 10 each year. A brochure outlining the rules and requirements for recertification/maintenance of certification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, 633 N St. Clair St, Suite 2320, Chicago, IL 60611; telephone: (312) 202-5900; fax: (312) 202-5960; e-mail: info{at}abts.org. This booklet is also published on the website: www.abts.org.
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