Reid Dale
Postdoctoral Scholar, Cardiothoracic Surgery
All Publications
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Consensus operational definitions of surgical meta-competencies for computer vision-driven performance assessment: a multi-institutional Delphi study.
Surgical endoscopy
2026
Abstract
Operative video is increasingly used to evaluate surgical skills. However, existing assessment frameworks rely on subjective constructs or ordinal scales that are poorly suited for consistent annotation or computational analysis. Artificial intelligence (AI) and computer vision can enable automated and scalable performance assessment but require clearly defined, observable performance domains. We aimed to establish expert consensus on video-native surgical meta-competencies with definitions optimized for computer vision-driven assessment of operative performance.We conducted an international, two-round modified Delphi study involving surgeons with expertise in surgical education. Five candidate meta-competencies-tissue handling, psychomotor skills, progress, dissection quality, and exposure quality-were defined using binary adequacy-based criteria. Participants rated each definition on discrimination and operationality using five-point Likert scales. Definitions were iteratively refined until consensus (≥ 80%) was achieved.Twenty experts from 14 institutions across seven countries participated (34% response rate). After Round 2, all five meta-competencies reached consensus, with mean discrimination scores ranging from 4.33 to 4.67 and operationality scores from 4.28 to 4.56. Progress demonstrated the highest discrimination, indicating strong ability to distinguish adequate from inadequate performance, whereas Dissection Quality demonstrated the highest operationality, suggesting that experts considered it the most readily assessable using video. Participants noted that visually identifiable features, such as effective tissue planes, together with binary adequacy criteria, improved confidence in applying the definitions during video review.We established consensus-based, video-native surgical meta-competencies that provide a standardized framework for computer vision-driven video review. By defining performance using observable constructs designed for consistent annotation across procedural hierarchies, this framework provides a starting point for scalable automated evaluation, pending empirical validation on operative video, to support surgical training and performance assessment.
View details for DOI 10.1007/s00464-026-13373-5
View details for PubMedID 42806083
View details for PubMedCentralID 11260519
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Causal nonlinear dose response analysis of donor-recipient predicted heart mass ratio.
JHLT open
2026; 11: 100418
Abstract
Size-matching in heart transplantation is performed using Predicted Heart Mass (PHM). It is common to regard a Donor-Recipient PHM Ratio smaller than 0.86 to be undersized. Novel applications of nonlinear models to estimate the dose-response effect of heart size mismatching can better calibrate postoperative risk.Patients receiving an isolated heart transplant ages 18 and older between 2000 and 2022 were included. Donor-Recipient PHM Ratio was continuously weighted using Tübbicke's entropy balance method. A Cox proportional hazards model was applied to the weighted sample. We fit penalized smoothing splines to estimate the continuous effect size of Donor-Recipient PHM Ratio on survival. Significance of the nonlinear spline terms was assessed and confidence bands for effect size were constructed.A total of 47,942 patients met inclusion criteria. The nonlinear spline terms for Donor-Recipient PHM Ratio were significantly associated with survival (p = 0.004). The effect of Donor-Recipient PHM Ratio was approximately flat between 0.9 and 1.2. Hazard grew approximately linearly below 0.9. At 0.86, the effect was estimated to be HR = 1.05 (95% CI: 1.02, 1.09). At 0.8, the effect was estimated to be HR = 1.13 (95% CI: 1.06, 1.20).Accurately modeling the effect of donor-recipient heart size matching is necessary to inform the decision of whether to accept or reject a donor organ. We found that heart undersizing confers an increased risk of mortality. We fail to find large changes in the slope of the effect at any particular PHM ratio cutoff.
View details for DOI 10.1016/j.jhlto.2025.100418
View details for PubMedID 41312403
View details for PubMedCentralID PMC12651732
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History and challenges of multi-organ allocation in the United States: A systematic review.
Transplantation reviews (Orlando, Fla.)
2025; 40 (1): 100988
Abstract
Current multi-organ candidates are prioritized primarily based on single-organ risk scores. Once the primary organ is allocated, the secondary organ follows to the same recipient, resulting in waitlisted single-organ candidates being skipped in allocation. Our previous work examined the ethical and statistical alignment of single-organ risk scores. Here, we aim to extend our analysis to multi-organ transplantation policies in the United States, surveying the current state of multi-organ candidate prioritization and the challenges of conducting high-quality research in multi-organ transplantation. We systematically searched PubMed for published literature on the allocation of all multi-organ pairs involving the liver, kidney, lungs, and heart. After screening based on our inclusion and exclusion criteria, we identified 126 articles to include in this review. These include 31 articles for Heart-Lung, 24 for Heart-Kidney, 52 for Liver-Kidney, and 19 for Liver-Heart transplantation. We did not discuss the remaining organ pairs due to insufficient literature to provide a balanced analysis. Provider-, center-, and region-dependent variations exist in multi-organ practices due to evolving national guidelines and a lack of standardized institutional protocols for candidate evaluation and listing. The use of single-organ risk scores in multi-organ allocation has not been statistically validated, therefore raising concerns about applicability. Multi-organ transplant research relies heavily on single-center reports, case studies, and registry-based analyses. The frequent re-use of national registry data limits the novelty and reliability of multi-organ research. We encourage future efforts to consider exploratory, prospective, and perhaps randomized-controlled trials to advance understanding and strengthen the evidence base in multi-organ transplantation.
View details for DOI 10.1016/j.trre.2025.100988
View details for PubMedID 41435721
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Novel Strategies for Inferential Error Management in Reused Clinical Datasets
LIPPINCOTT WILLIAMS & WILKINS. 2025: A4370544
View details for DOI 10.1161/circ.152.suppl_3.4370544
View details for Web of Science ID 001613785100022
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Induction therapy confers survival advantage in mechanically supported patients regardless of peak CPRA in heart transplantation.
JHLT open
2025; 8: 100246
Abstract
There is no consensus regarding induction therapy in patients on mechanically circulatory support (MCS) listed for heart transplantation. We sought to elucidate differences in outcomes between no induction and induction.A total of 3,987 patients were analyzed from the UNOS database from January 2018 through December 2022. Patients on Extracorporeal Membrane Oxygenation (ECMO), HeartMate 3, Impella 5.0 or 5.5, and intra-aortic balloon pump (IABP) and receiving no induction, anti-IL2R antibodies, or T cell depleting agent (TCDA) were included.Of 3,987 patients, 1,288 (32.3%) received no induction, 1,566 (39.3%) received anti-IL2R antibodies, and 1,133 (28.4%) received TCDA. A total of 1,895 (47.5%) were supported with IABP; 1,098 (27.5%) with HeartMate 3; 489 (12.3%) with Impella 5.0 or 5.5; 351 (8.8%) with ECMO; and 154 (3.9%) with combination of the above devices. Comparison of 1-year survival between no induction, anti-IL2R, and TCDA groups in all MCS patients revealed significantly worse survival among those receiving no induction (p<0.0001). Subgroup analysis of peak CPRA 0% patients revealed that no induction had significantly worse survival at 1 year (p=0.002). Analysis of acute rejection at 1 year showed a significantly decreased number of rejection episodes in the TCDA group compared to no induction (OR 0.65, CI 0.47-0.88, p=0.006).Patients requiring MCS prior to heart transplantation have significantly improved post-transplant survival with induction therapy, regardless of their peak CPRA. TCDA confers decreased number of acute rejection episodes at 1 year in this patient population.
View details for DOI 10.1016/j.jhlto.2025.100246
View details for PubMedID 40330664
View details for PubMedCentralID PMC12051702
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Nonlinear effect of body mass index on postoperative survival following isolated heart transplantation.
JHLT open
2025; 7: 100172
Abstract
Guidelines regarding recipient's body mass index (BMI) for heart transplant are evolving with variable cutoffs depending on the country and institution. It is imperative to provide updated nonlinear estimates of postoperative risk attributable to a recipient's BMI to evaluate the relevance of existing cutoffs.A total of 30,787 patients were analyzed from the United Network for Organ Sharing (UNOS) database. Patients receiving an isolated heart transplant ages 18 and older since 2010 were included. Overall survival was the primary outcome. A multivariate Cox proportional hazards model was applied and included a penalized smoothing spline term for recipient BMI and risk factors such as diabetes. We assessed the overall significance of the nonlinear penalized spline terms using an asymptotic Wald test.The cohort consisted of 662 (2.2%) BMI <18.5, 9,359 (30%) BMI 18.5 to 24.9, 10,997 (36%) BMI 25 to 29.9, 9,550 (31%) BMI 30 to 39.9, and 206 (0.7%) BMI ≥40 patients. The nonlinear spline terms for recipient BMI were statistically significant (p < 0.01). The hazard ratio (HR) appeared to grow linearly in BMI at an inflection point of BMI = 26. No inflection point was observed at either of the International Society for Heart and Lung Transplantation recommended cutoffs of BMI = 30 (HR 1.11, confidence interval [CI] 1.07-1.15) or BMI = 35 (HR 1.29, CI 1.24-1.37).After multivariable adjustment, there is no sharp cutoff in survival risk at either BMI = 30 or BMI = 35. Unlike previously reported, postoperative survival risk grows approximately linearly in the BMI range from 26 to 40.
View details for DOI 10.1016/j.jhlto.2024.100172
View details for PubMedID 40144853
View details for PubMedCentralID PMC11935512
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Sex-mismatching in isolated heart transplantation confers no postoperative risk.
JHLT open
2024; 6: 100158
Abstract
For heart transplantation, optimal donor-recipient matching is an important factor in the ongoing development of the United Network for Organ Sharing (UNOS) continuous distribution framework. Donor-recipient sex-mismatch has decreased since the 1990s, but this may be related to the risk posed by size mismatching, particularly when donor hearts are undersized. Thus, the impact of sex-mismatching, controlling for other factors including size mismatch, is uncertain.Adult first-time, isolated heart transplant patients from the UNOS database between October 1, 1987 and December 31, 2022 were analyzed. Cohorts were separated into male and female recipients. Propensity score matching on known preoperative risk factors was performed. Equivalence testing via Two One-Sided Testing (TOST) was performed to assess between-arm equivalence in postoperative outcomes. Survival differences were measured by the between-arm ratio of restricted mean survival time and binary outcome differences by the odds ratio.In the propensity-matched cohort, we found significant equivalence between arms in both male (TOST p < 0.001) and female (TOST p < 0.001) recipients for overall survival at all temporal end-points, postoperative treatment for rejection within 1 year, and predischarge dialysis.Sex-mismatch in isolated heart transplantation confers no additional risk to postoperative outcomes when controlling for other factors, including size mismatch. Consequently, sex-mismatch should not factor into individual assessments of organ acceptance or be incorporated into any national organ allocation policy. Increasing the acceptance of sex-mismatched donors has the potential to expand the donor pool and increase female donor utilization.
View details for DOI 10.1016/j.jhlto.2024.100158
View details for PubMedID 40145045
View details for PubMedCentralID PMC11935461
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Inconsistent values and algorithmic fairness: a review of organ allocation priority systems in the United States.
BMC medical ethics
2024; 25 (1): 115
Abstract
BACKGROUND: The Organ Procurement and Transplant Network (OPTN) Final Rule guides national organ transplantation policies, mandating equitable organ allocation and organ-specific priority stratification systems. Current allocation scores rely on mortality predictions.METHODS: We examined the alignment between the ethical priorities across organ prioritization systems and the statistical design of the risk models in question. We searched PubMed for literature on organ allocation history, policy, and ethics in the United States.RESULTS: We identified 127 relevant articles, covering kidney (19), liver (60), lung (24), and heart transplants (23), and transplant accessibility (1). Current risk scores emphasize model performance and overlook ethical concerns in variable selection. The inclusion of race, sex, and geographical limits as categorical variables lacks biological basis; therefore, blurring the line between evidence-based models and discrimination. Comprehensive ethical and equity evaluation of risk scores is lacking, with only limited discussion of the algorithmic fairness of the Model for End-Stage Liver Disease (MELD) and the Kidney Donor Risk Index (KDRI) in some literature. We uncovered the inconsistent ethical standards underlying organ allocation scores in the United States. Specifically, we highlighted the exception points in MELD, the inclusion of race in KDRI, the geographical limit in the Lung Allocation Score, and the inadequacy of risk stratification in the Heart Tier system, creating obstacles for medically underserved populations.CONCLUSIONS: We encourage efforts to address statistical and ethical concerns in organ allocation models and urge standardization and transparency in policy development to ensure fairness, equitability, and evidence-based risk predictions.
View details for DOI 10.1186/s12910-024-01116-x
View details for PubMedID 39420378
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Impacts of Positive Margins and Surgical Extent on Outcomes after Early-Stage Lung Cancer Resection.
The Annals of thoracic surgery
2024
Abstract
Sublobar resection of early-stage non-small cell lung cancer (NSCLC) is increasingly considered appropriate but may compromise margins compared to lobectomy. This study evaluated resection extent, margin status, and survival for clinical stage I NSCLC patients.Clinical T1-2N0M0 NSCLC patients in the National Cancer Database (2006-2020) treated with primary surgery were compared stratified by margin status. The potential benefit of radiation was explored in subgroup analysis of sublobar resection patients with positive margins.Positive margins occurred in 5,089 (2.8%) of 181,824 patients and were more common in sublobar resections compared to lobectomy (4.3% vs 2.4%,p<0.001). Sublobar resection had the strongest association with positive margins in multivariable analysis (OR 2.06 [95% CI 1.91-2.23],p<0.001). Patients with positive margins were more likely to undergo both adjuvant chemotherapy (16% vs 13%,p<0.001) and radiation (17% vs 1%,p<0.001) but had worse survival in univariate (44.0% 5-year OS vs 69.2%,p<0.001) and multivariable Cox analysis (HR 1.71 [95% CI 1.63-1.78, p<0.001) in the entire cohort, as well as in univariate subset analysis of lobectomy (46.9% vs 70.4%, p<0.001) and sublobar (37.5% vs 64.1%,p<0.001). Postoperative radiation for sublobar patients with positive margins did not improve 5-year OS (36.3% for irradiated patients vs 38.3% for non-irradiated patients,p=0.57), and positive margin sublobar patients treated with radiation had inferior survival to negative margin lobectomy patients.Positive margins occur more frequently after sublobar resection of clinical stage I NSCLC compared to lobectomy. Patients with positive margins have worse survival than complete resection patients and are not rescued by post-operative radiation.
View details for DOI 10.1016/j.athoracsur.2024.05.032
View details for PubMedID 38866199
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Four Decades of Progress in Heart-Lung Transplantation: 271 Cases at a Single Institution.
The Journal of thoracic and cardiovascular surgery
2024
Abstract
OBJECTIVE: The objective of this study is to evaluate survival for combined heart-lung transplant (HLTx) recipients across four decades at a single institution. We aim to summarize our contemporary practice based upon more than 271 HLTx over 40 years.METHODS: Data were collected from a departmental database and the United Network for Organ Sharing (UNOS). Recipients <18y, those undergoing redo HLTx , or triple-organ system transplantation were excluded, leaving 271 patients for analysis. The Pioneering Era was defined by date of transplant between 1981-2000 (N=155), and the Modern Era between 2001-2022 (N=116). Survival analysis was performed using cardinality matching of populations based on donor and recipient age, donor and recipient sex, ischemic time, and sex-matching.RESULTS: Between 1981-2022, 271 HLTx were performed at a single institution. Recipients in the Modern Era were older (42 vs 34y, P<0.001) and had shorter waitlist times (78 vs 234d, P<0.001). Allografts from female donors were more common in the Modern Era (59% vs 39%, P=0.002). In the matched survival analysis, 30-day survival (97% vs 84%, P=0.005), 1-year survival (89% vs 77%, P=0.041), and 10-year survival (53% vs 26%, P=0.012) significantly improved in the Modern Era relative to the Pioneering Era, respectively.CONCLUSIONS: Long-term survival in HLTx is achievable with institutional experience and may continue to improve in the coming decades. Advances in mechanical circulatory support, improved maintenance immunosuppression, and early recognition and management of acute complications such as primary graft dysfunction and acute rejection have dramatically improved the prognosis for HLTx recipients in our contemporary institutional experience.
View details for DOI 10.1016/j.jtcvs.2024.01.042
View details for PubMedID 38320627
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Trends in the Use of Exception Status since Implementation of 2018 United Network for Organ Sharing Single-Organ Adult Heart Transplant and Its Relation to Postoperative Survival Outcomes
LIPPINCOTT WILLIAMS & WILKINS. 2023: S65-S66
View details for Web of Science ID 001094086300118