NewYork–Presbyterian Hospital

To investigate longitudinal trends in the American Board of Emergency Medicine (ABEM) Qualifying Examination (QE) performance, identify statistically significant inflection points in pass rates, and determine factors associated with the recent decline observed in 2022. This was a retrospective, observational study conducted in 2 phases. Phase 1 analyzed all QE attempts from 1980 to 2024 (n = 83,254) to identify changepoints using segmented regression and Bayes factor comparisons. Phase 2 focused on QE attempts surrounding the most recent changepoint from 2016 to 2024 (n = 23,784) and used multilevel nonlinear piecewise growth models to examine the association between physician characteristics and QE pass rates before and after the 2022 changepoint. Three statistically significant changepoints were identified: 1988, 2003, and 2022. Although increases in pass rates were noted in 1988 and 2003, 2022 was marked by a decline in pass rates with a steeper drop post-2022 (slope from 2016 to 2022 = -0.17 vs slope 2022 to 2024 = -0.67). From 2016 to 2022, MD graduates had a lesser decline in performance compared with non-MD peers. After 2022, those trained during the COVID pandemic also experienced a lesser decline. ABEM QE pass rates experienced 3 major inflection points since 1980, with the most recent occurring in 2022 and representing a meaningful decline. Physician-level characteristics, particularly medical school degree type and COVID-era training, were significantly associated with this trend.

Moderate and severe tricuspid regurgitation (TR) is associated with poor outcomes, yet current grading systems do not fully capture circulatory heterogeneity. We investigate the relationship of cardiac index (CI) with rest-exercise hemodynamics, metabolic and inflammatory profiles, and clinical outcomes in moderate and severe TR. We prospectively enrolled 300 outpatients with atrial secondary, nonatrial secondary, and lead-associated moderate and severe TRs without ≥moderate left-sided valve disease. All underwent comprehensive laboratory profiling and ultrasound evaluation at rest and during cardiopulmonary exercise. Patients were stratified by CI tertiles and followed clinically (primary end point: all-cause mortality or heart failure hospitalization). CI decreased with TR severity but showed wide interindividual variability. In patients with low CI, severe forward flow limitation was associated with more advanced right ventricle-pulmonary arterial uncoupling and biatrial dysfunction (P<0.05 versus the other tertiles), identifying a hypodynamic-uncoupled profile. Conversely, high CI identified a hyperdynamic-congestive phenotype characterized by advanced congestion, reduced systemic vascular resistance, and heightened systemic inflammation, metabolic-nutritional derangements, and mitochondrial dysfunction (P<0.05 versus the other tertiles). Intermediate CI showed the most favorable hemodynamic and laboratory profile. A U-shaped relationship between CI and adverse outcomes was observed, with the lowest risk at intermediate values. This pattern persisted across TR severity, cause, staging systems, and adiposity categories (P<0.05 for all). In moderate and severe TRs, CI profiling captures cardiac and extracardiac determinants of flow and independently predicts outcomes beyond conventional TR grading and staging. Both low and high CIs identify high-risk patients, while an intermediate CI indicates a balanced, prognostically favorable state. CI profiling may refine risk stratification, guide individualized treatment strategies, and optimize patient selection and timing for tricuspid valve interventions.

Haemorrhage and blood product usage are common in venoarterial extracorporeal membrane oxygenation (VA ECMO) and associated with increased mortality. A prospective, investigator-initiated, longitudinal observational cohort study on major haemorrhagic events in 12 ECMO centres from 3 continents for three predefined subgroups (VA ECMO initiated during cardio-pulmonary resuscitation (ECPR), after cardiothoracic surgery (CTS), for cardiogenic shock (CS)). The aim was to describe haemorrhagic complications as well as transfusion practice and anticoagulation for the whole population as well as the subgroups. In addition, independent baseline predictors for red blood cell (RBC) transfusions were evaluated. 545 prospective patients were included between 2019 and 2022 (ECPR 149, CTS 169, CS 227). Hospital mortality was 46%. Over 2796 days 406 major haemorrhage events in 286 (52%) patients were recorded. CTS and ECPR patients had more frequent events occurring earlier in their course. 88% received RBC transfusions (1.27 (95%CI 1.22 – 1.31) units/day) with significantly more transfusions for CTS and ECPR patients. Platelet transfusion rates were highest in the CTS group (0.58 (95%CI 0.53–0.64) units/day). Haemoglobin and platelet count prior to transfusion were independent of subgroups and averaged (78 g/L (IQR 73, 84), 58 × 10^9/L (IQR 37, 85), respectively). However, platelet count prior transfusion was only marginally higher on days with major haemorrhage (74 × 10^9/L (IQR 50, 104). Systemic anticoagulation was started within the first 24 h in 83% (95% CI 80–87%) of patients, most frequently in CS patients (90%, CI 85–95%). Independent baseline predictors for RBC transfusion were ECPR (IRR 1.50, 95%CI 1.19–1.89) and prior use of antiplatelets (IRR: 1.43, 95%CI 1.13–1.80). Myocarditis and pulmonary embolism were associated with a lower rate of transfusion when compared to myocardial infarct (IRR: 0.57 (0.37–0.89), IRR: 0.67 (0.45–1.00, respectively). Haemorrhagic complications differ in clinical subgroups and RBC transfusion exposure is by far higher than in other critically unwell populations. We identified ECPR and antiplatelet therapy as additional predictors. Transfusion practice for RBC and platelets is variable and does not always follow international guidelines.

Mitral valve replacement (MVR) in patients with complex mitral valve (MV) pathology often necessitates excision of the anterior mitral leaflet (AML), potentially compromising left ventricular (LV) geometry and function. We describe a customised full chordal-sparing mitral valve replacement (FCS-MVRpl) technique that preserves the AML and subvalvular apparatus, aiming to maintain LV architecture and improve postoperative outcomes in patients unsuitable for MV repair. Between 2014 and 2023, 161 consecutive patients underwent FCS-MVRpl. MV pathology included degenerative (n = 94, 57.1%), functional (n = 58, 36.0%), infective (n = 9, 5.6%), and rheumatic (n = 2, 1.2%) disease. Among these, 93 patients (57.8%) exhibited complex MV pathology: massive annular calcification (n = 59, 36.6%), mitral annular disjunction (MAD; n = 25, 15.5%), and posterior annular abscesses due to endocarditis (n = 9, 5.6%). The AML was fully mobilised and translocated, preserving the entire chordal apparatus. In cases with excess leaflet tissue, partial excision of the free edge was performed to facilitate prosthesis seating while maintaining chordal integrity. At 12 months, freedom from procedural complications was 98.6% ± 0.97%, with only two adverse events (1.2%) directly attributable to the technique. Freedom from heart failure-related rehospitalisation was 94.2% ± 1.9%. Multivariable Cox regression identified reduced preoperative left ventricular ejection fraction (LVEF) as a predictor of treatment failure (HR: 0.95; 95% CI: 0.92–0.99; p = 0.015). NYHA functional class improved in the majority of patients: 112 (81.2%) were classified as Class I at follow-up, while 11 (8.0%) experienced deterioration. FCS-MVRpl is a safe and effective alternative for patients with complex MV pathology who are not candidates for repair. Preservation of the AML and subvalvular apparatus supports LV geometry and functional recovery. The technique is particularly beneficial in cases of posterior annular calcification, Barlow disease with excess leaflet tissue, and infective endocarditis involving the posterior annulus. However, it is contraindicated in cases of circumferential MV calcification. Further prospective studies are warranted to validate long-term outcomes and broader applicability.

To evaluate outcomes of proximal humerus fractures (PHFs) treated with locked plating constructs and assess association between fracture reduction and outcome. Retrospective cohort study. Academic tertiary care hospital and affiliated level 1 Trauma Center. All patients treated with proximal humerus locked plating for PHFs (OTA/AO 11A/B/C) by 3 fellowship-trained orthopaedic traumatologists from 2008 to 2020 were screened. Patients were excluded for <12-month follow-up, lack of preoperative radiographic imaging, segmental fracture, isolated tuberosity fracture, humeral nailing, and revision surgery as initial procedure at the study institution. Fracture pattern, reduction, fixation characteristics, and failure were radiographically evaluated. Functional outcomes were assessed using range of motion, American Shoulder and Elbow Surgeons score, QuickDASH, Constant score, and SF-12. Survivorship was calculated using the Kaplan-Meier method. Association of variables with failure was assessed. Among 153 patients treated for PHFs with proximal humerus locked plating, there were 23 OTA/AO A-type, 40 B-type, and 90 C-type fractures. Mean follow-up was 66 months, and mean age 59 ± 15 years (68% female). Mean postoperative coronal alignment was 135 degrees, 91% were fixed within 120-150 degrees, and 53% within 130-140 degrees. Sagittal reduction was neutral in 94%. Medial column restoration was achieved in 80%. Survivorship free from revision surgery was 89% at 5 years. Reduction with coronal alignment outside all neutral reduction ranges (120-150 degrees, 125-145 degrees, 130-140 degrees) and sagittal alignment outside neutral were associated with both radiographic failure and revision surgery ( P < 0.05). Preoperative factors associated with failure included female sex, number of fragments, head-split, fracture-dislocation, valgus coronal alignment, and medial calcar displacement ( P < 0.05). Functional outcomes included overall mean American Shoulder and Elbow Surgeons score of 81 ± 21, QuickDASH 16 ± 19, Constant 80 ± 18, SF-12 Physical 50 ± 9, SF-12 Mental 53 ± 8, active forward flexion 145 ± 33 degrees, active abduction 140 ± 35 degrees, active external rotation 73 ± 24 degrees. Proximal humerus locked plating demonstrated a survivorship free from revision surgery of 89% free at 5 years and favorable functional outcomes including mean Constant scores of 80. Fracture reduction was associated with outcome. Reduction with coronal and sagittal alignment outside of neutral were associated with radiographic failure and revision surgery. These findings highlight that favorable functional outcomes can be achieved with restoration of the proximal humerus anatomy. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.