Outcomes of lung transplantation from donors with a history of substance abuse

ObjectiveThe study objective was to determine whether donor substance abuse (opioid overdose death, opioid use, cigarette or marijuana smoking) impacts lung acceptance and recipient outcomes.MethodsDonor offers to a single center from 2013 to 2019 were reviewed to determine if lung acceptance rates and recipient outcomes were affected by donor substance abuse.ResultsThere were 3515 donor offers over the study period. A total of 154 offers (4.4%) were opioid use and 117 (3.3%) were opioid overdose deaths. A total of 1744 donors (65.0%) smoked cigarettes and 69 donors (2.6%) smoked marijuana. Of smokers, 601 (35.0%) had less than 20 pack-year history and 1117 (65.0%) had more than 20 pack-year history. Substance abuse donors were younger (51.5 vs 55.2 P < .001), more often male (65.6 vs 54.8%, P < .001), more often White (86.2 vs 68.7%, P < .001), and had hepatitis C (8.3 vs 0.8%, P < .001). Donor acceptance was significantly associated with brain dead donors (odds ratio, 1.56, P < .001), donor smoking history (odds ratio, 0.56, P < .001), hepatitis C (odds ratio, 0.35, P < .001), younger age (odds ratio, 0.98, P < .001), male gender (odds ratio, 0.74, P = .004), and any substance abuse history (odds ratio, 0.50, P < .001), but not opioid use, opioid overdose death, or marijuana use. Recipient survival was equivalent when using lungs from donors who had opioid overdose death, who smoked marijuana, or who smoked cigarettes for less than 20 patient-years or more than 20 patient-years, and significantly longer in recipients of opioid use lungs. There was no significant difference in time to chronic lung allograft dysfunction for recipients who received lungs from opioid overdose death or with a history of opioid use, marijuana smoking, or cigarette smoking.ConclusionsDonor acceptance was impacted by cigarette smoking but not opioid use, opioid overdose death, or marijuana use. Graft outcomes and recipient survival were similar for recipients of lungs from donors who abused substances.     

Deceased-donor lobar lung transplant: A successful strategy for small-sized recipients

ObjectivesLobar lung transplantation (LLTx) from deceased donors is a potential solution for donor–recipient size mismatch for small sized recipients. We reviewed our institutional experience to compare outcomes after LLTx to standard lung transplantation (LTx).MethodsWe retrospectively reviewed transplants in our institution from January 2000 to December 2017. LLTx early- and long-term outcomes were compared with LTx. Additional analysis of outcomes was performed after dividing the cohort into 2 eras (era 1, 2000-2012; era 2, 2013-2017).ResultsAmong the entire cohort (1665), 75 were LLTx (4.5%). Compared with LTx, LLTx were more frequently bridged to transplant with extracorporeal life support or mechanical ventilation and were transplanted in a rapidly deteriorating status (respectively, 20% vs 4.4%, P = .001; 22.7% vs 7.9, P < .001; and 41.3% vs 26.5%, P = .013). LLTx had longer intensive care unit and hospital lengths of stay (respectively, median 17 vs 4 days, and 45 vs 23, both P < .001), and greater 30-day mortality (13.3% vs 4.3%, P = .001) and 90-day mortality (17.3% vs 7.2%, P = .003). In era 2, despite a significantly greater 30-day mortality (10.8% vs 2.8%, P = .026), there was no significant difference in 90-day mortality between LLTx and LTx (13.5% vs 5.1%, P = .070). Overall survival at 1, 3, and 5 years was not significantly different between LLTx and LTx (73.2% vs 84.4%, 56.9% vs 68.4% and 50.4% vs 55.8, P = .088).ConclusionsAlthough LLTx is a high-risk procedure, both mid- and long-term survival are comparable with LTx in all cohorts in the modern era. LLTx therefore represents a valuable surgical option for small-sized recipients.     

The use of blood and blood products in aortic surgery is associated with adverse outcomes

ObjectiveTo report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products.MethodsAll patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival.ResultsA total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001).ConclusionsIn patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.     

The fate of aortic root and aortic regurgitation after supracoronary ascending aortic replacement for acute type A aortic dissection

BackgroundThe aim of this study was to evaluate the fate of the preserved aortic root after supracoronary aortic replacement for acute type A aortic dissection.MethodsBetween October 1999 and March 2018, 339 patients underwent supracoronary aortic replacement for acute type A aortic dissection at our institution. Late outcomes were evaluated, including overall survival, aortic-related death, and aortic root–related reoperation. The median follow-up was 3.7 years (1.4-8.4 years).ResultsOperative mortality was 46 patients (13.6%). The cumulative incidences at 5 years for aortic root–related reoperation, aortic-related death, and non–aortic related death were 2.5%, 14.5% and 12.4%, respectively. Multivariable Cox hazard regression analysis demonstrated greater sinus of Valsalva diameter and number of commissural detachments to be significant risk factors for a composite outcome consisting of aortic-related death or aortic root–related reoperation. Mixed-effects regression demonstrated that sinus of Valsalva diameter significantly increased with time (P < .001), and aortic regurgitation significantly worsened (P < .001).ConclusionsSinus of Valsalva diameter and commissural detachment were independent predictors of unfavorable outcomes after supracoronary aortic replacement. Close follow-up is particularly necessary for these patients, and aortic root replacement at the time of initial operation may lead to more favorable late outcomes.     

Tracheobronchoplasty yields long-term anatomy,function, and quality of life improvement for patients with severe excessive central airway collapse

ObjectivesThis study examines the long-term anatomic and clinical effects of tracheobronchoplasty in severe excessive central airway collapse.MethodsIncluded patients underwent tracheobronchoplasty for excessive central airway collapse (2002-2016). The cross-sectional area of main airways on dynamic airway computed tomography was measured before and after tracheobronchoplasty. Expiratory collapse was calculated as the difference between inspiratory and expiratory cross-sectional area divided by inspiratory cross-sectional area ×100. The primary outcome was improvement in the percentage of expiratory collapse in years 1, 2, and 5 post-tracheobronchoplasty. Secondary outcomes included mean response profile for the 6-minute walk test, Cough-Specific Quality of Life Questionnaire, Karnofsky Performance Status score, and St George Respiratory Questionnaire. Repeated-measures analysis of variance was used for statistical analyses.ResultsThe cohort included 61 patients with complete radiological follow-up at years 1, 2, and 5 post-tracheobronchoplasty. A significant linear decrease in the percentage of expiratory collapsibility of the central airways after tracheobronchoplasty was present. Anatomic repair durability was preserved 5 years after tracheobronchoplasty, with decrease in percentage of expiratory airway collapse up to 40% and 30% at years 1 and 2, respectively. The St George Respiratory Questionnaire (74.7 vs 41.8%, P < .001) and Cough-Specific Quality of Life Questionnaire (78 vs 47, P < .001) demonstrated significant improvement at year 5 compared with baseline. Similar results were observed in the 6-minute walk test (1079 vs 1268 ft, P < .001) and Karnofsky score (57 vs 82, P < .001).ConclusionsTracheobronchoplasty has durable effects on airway anatomy, functional status, and quality of life in carefully selected patients with severe excessive central airway collapse.     

Primary heart dysfunction is greater with combined heart and lung compared with isolated heart procurement

ObjectiveCombined heart and lungs (CHL) procurement differs from isolated heart (IH) procurement in several aspects, including lung recruitment, cannulation, and preservation requirements. We aimed to investigate whether CHL versus IH procurement contributes to the development of primary graft dysfunction (PGD) after heart transplantation (HT).MethodsBetween 1999 and 2019, we assessed 175 patients undergoing HT at a single center. Patients were divided into IH (n = 61) or CHL (n = 114) procurement groups. End points included PGD (defined according to the International Society for Heart and Lung Transplantation consensus statement) and long-term survival.ResultsThe incidence of PGD was significantly greater in CHL recipients compared with IH recipients (53.5% vs 16.4%, P < .001). Multivariable analysis showed that CHL procurement was independently associated with a significant 4.6-fold increased risk for PGD (95% confidence interval, 2.1-11, P < .001). Univariable and multivariable analyses showed that the overall survival was not significantly affected by the procurement group (log-rank P = .150, hazard ratio, 1.13; 95% confidence interval, 0.68-1.88, P = .646). The simultaneous procurement of abdominal organs was not associated with an increased risk of PGD in HT recipients. These results remained consistent in a propensity-matched analysis.ConclusionsCombined procurement of heart and lungs is independently associated with an increased risk of PGD. Further prospective studies are needed to validate this hypothesis-generating study.     

Percutaneous coronary intervention versus coronary artery bypass grafting in patients with reduced ejection fraction

ObjectiveThe aim of this study was to evaluate comparative outcomes for percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with reduced ejection fraction.MethodsAll patients from the University of Pittsburgh Medical Center from 2011 to 2018 who had reduced preoperative ejection fraction (<50%) and underwent CABG or PCI for coronary revascularization were included in this study. Patients were risk-adjusted with propensity matching (1:1) and primary outcomes included long-term survival, readmission, and major adverse cardiac and cerebrovascular events (MACCE).ResultsA total of 2000 patients were included in the current study, consisting of CABG (n = 1553) and PCI (n = 447) cohorts with a mean ejection fraction of 35% ± 9.53%. Propensity matching yielded a 1:1 match with 324 patients in each cohort, controlling for all baseline characteristics. Thirty-day mortality was similar for PCI versus CABG (6.2% vs 4.9%; P = .49). Overall mortality over the study follow-up period (median, 3.23 years; range, 1.83-4.98 years) was significantly higher for the PCI cohort (37.4% vs 21.3%; P < .001). Total hospital readmissions (24.1% vs 12.9%; P = .001), cardiac readmissions (20.4% vs 11.1%; P = .001), myocardial infarction event (7.7% vs 1.8%; P = .001), MACCE (41.4% vs 23.8%; P < .001), and repeat revascularization (6.5% vs 2.6%; P = .02) occurred more frequently in the PCI cohort. Freedom from MACCE at 1 year (74.4% vs 87.0%; P < .001) and 5 years (54.5% vs 74.0%; P < .001) was significantly lower for the PCI cohort. On multivariable cox regression analysis, CABG (hazard ratio, 0.57; 95% confidence interval, 0.44-0.73; P < .001) was significantly associated with improved survival. Prior liver disease, dialysis, diabetes, and peripheral artery disease were the most significant predictors of mortality. The cumulative incidence of hospital readmission was lower for the CABG cohort (hazard ratio, 0.51; 95% confidence interval, 0.37-0.71; P < .001). Multivariable cox regression for MACCE (hazard ratio, 0.48; 95% confidence interval, 0.39-0.58; P < .001) showed significantly fewer events for the CABG cohort.ConclusionsPatients with reduced ejection fraction who underwent CABG had significantly improved survival, lower MACCE, and fewer repeat revascularization procedures compared with patients who underwent PCI.     

Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection

BackgroundThe strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit.MethodsSurgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion.ResultsA total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits, and 2040 (84.9%) patients had no neurologic deficits at presentation. Patients with CM were more less likely to present with chest pain (66% vs 86.5%; P < .001) and back pain (35.9% vs 44.4%; P = .008). Patients with CM were more likely to present with syncope (48.4% vs 10.1%; P < .001), peripheral malperfusion (52.7% vs 38.0%; P < .001), and shock (16.2% vs 4.1%; P < .001). There was no difference in the incidence of Marfan syndrome (2.8% vs 3.0%; P = .870) or history of known aortic aneurysm (11.7% vs 13.9%; P = .296). Patients with CM were more likely to have a DeBakey I (63.8% vs 47.1%; P < .001) and a pericardial effusion (53.8% vs 40.6; P < .001) on presentation. There was no difference in total arch replacement (21.3% for CM vs 19.5% for no CM; P = .473). Patients with CM had an increased incidence of postoperative cerebrovascular accident (17.5% vs 7.2%; P < .001) and acute kidney injury (28.3% vs 18.1%; P < .001). In-hospital mortality was greater in patients with CM (25.7% vs 12.0%; P < .001).ConclusionsFifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.     

Assessing donor organ quality according to recipient characteristics in lung transplantation

ObjectiveThere is a shortage of donor lungs relative to need, but overall donor organ utilization remains low. The most common reason for refusal is organ quality, but the standards applied to selection vary. In this study we sought to characterize differences in lung utilization according to quality across several clinically distinct recipient pools.MethodsData on donor lungs recovered (April 2006 to September 2019) were extracted from the Scientific Registry of Transplant Recipients database. Organs were classified as ideal, standard, or extended quality according to their poorest metric among selected parameters. Subanalyses were performed on the basis of procedure type, age, lung allocation score, era, and alternative definitions of extended quality. Recipient traits and survival according to organ quality were assessed.ResultsOf 156,022 lungs analyzed during the study period, 25,777 (16.5%) were transplanted. There was no difference in quality distribution for single and bilateral transplants. Young candidates were more likely to receive ideal (14.7% vs 12.3%) or standard (9.5% vs 8.2%) lungs, but not extended lungs (75.9% vs 79.5%; all P < .01). Absolute differences in distribution according to lung allocation score quartile were small (<2%). Extended quality donor utilization increased over time. Survival according to donor category was similar at 1 and 3 years post transplant in unadjusted and Cox regression analyses.ConclusionsExtended quality lungs comprise an increasing share of transplants in a national sample. Organ selection varies according to recipient age and lung allocation score. However, absolute differences in quality distribution are small, and adverse effects on outcomes are limited to organs with multiple extended qualifying characteristics.     

Aortic balloon occlusion technique versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in total arch replacement and frozen elephant trunk for acute type A aortic dissection

BackgroundModerate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) is safe and efficient in total arch replacement (TAR) and frozen elephant trunk (FET) for acute type A aortic dissection (ATAAD). Complications related to hypothermia and ischemia are inevitable, however. The aortic balloon occlusion (ABO) technique is performed to elevate the lowest nasopharyngeal temperature to 28°C and shorten the circulatory arrest time. In this study, we aimed to evaluate the efficacy of this new technique.MethodsWe reviewed the clinical data of patients with ATAAD who underwent TAR and FET, including 79 who underwent ABO and 109 who underwent MHCA/ACP.ResultsCirculatory arrest time was significantly lower in the ABO group compared with the MHCA/ACP group (mean, 4.8 ± 1.2 minutes vs 18.4 ± 3.1 minutes; P < .001). The composite endpoint was comparable in the 2 groups (11.4% for ABO vs 13.8% for MHCA/ACP; P = .631). Fewer patients in the ABO group developed high-grade acute kidney injury (AKI) according to a modified RIFLE criterion (22.8% vs 36.7%; P = .041), and the rate of hepatic dysfunction was lower in the ABO group (11.4% vs 28.4%; P = .005). Multivariable logistic analysis showed that the ABO technique is protective against duration of ventilation >24 hours (odds ratio [OR], 0.455; 95% confidence interval [CI], 0.234-0.887; P = .021), hepatic dysfunction (OR, 0.218; 95% CI, 0.084-0.561; P = .002), and grade II-III AKI (OR, 0.432; 95% CI, 0.204-0.915; P = .028).ConclusionsThe ABO technique significantly shortens the circulatory arrest time in TAR and FET. Available clinical data suggest that it has a certain protective effect on the liver and kidney. Future large-sample studies are warranted to thoroughly evaluate this new technique.     

Impact of staff turnover during cardiac surgical procedures

ObjectiveThe impact of staff turnover during cardiac procedures is unknown. Accurate inventory of sharps (needles/blades) requires attention by surgical teams, and sharp count errors result in delays, can lead to retained foreign objects, and may signify communication breakdown. We hypothesized that increased team turnover raises the likelihood of sharp count errors and may negatively affect patient outcomes.MethodsAll cardiac operations performed at our institution from May 2011 to March 2016 were reviewed for sharp count errors from a prospectively maintained database. Univariate and multivariable analyses were performed.ResultsAmong 7264 consecutive cardiac operations, sharp count errors occurred in 723 cases (10%). There were no retained sharps detected by x-ray in our series. Sharp count errors were lower on first start cases (7.7% vs 10.7%, P < .001). Cases with sharp count errors were longer than those without (7 vs 5.7 hours, P < .001). In multivariable analysis, factors associated with an increase in sharp count errors were non–first start cases (odds ratio [OR], 1.3; P = .006), weekend cases (OR, 1.6; P < .004), more than 2 scrub personnel (3 scrubs: OR, 1.3; P = .032; 4 scrubs: OR, 2; P < .001; 5 scrubs: OR, 2.4; P = .004), and more than 1 circulating nurse (2 nurses: OR, 1.9; P < .001; 3 nurses: OR, 2; P < .001; 4 nurses: OR, 2.4; P < .001; 5 nurses: OR, 3.1; P < .001). Sharp count errors were associated with higher rates of in-hospital mortality (OR, 1.9; P = .038).ConclusionsSharp count errors are more prevalent with increased team turnover and during non–first start cases or weekends. Sharp count errors may be a surrogate marker for other errors and thus increased mortality. Reducing intraoperative team turnover or optimizing hand-offs may reduce sharp count errors.     

Prognostic value of recurrence pattern in locally advanced esophageal squamous cell carcinoma: Results from the phase III trial NEOCRTEC5010

ObjectivesThe prognosis of patients with locally advanced esophageal squamous cell carcinoma with different recurrence backgrounds is highly heterogeneous. This study aims to explore the effects of recurrence patterns on prognosis.MethodsThe phase III, multicenter, prospective NEOCRTEC5010 trial enrolled 451 patients with stage IIB-III esophageal squamous cell carcinoma randomly assigned to neoadjuvant chemoradiotherapy combined with surgery (NCRT group) or surgery alone (S group) and followed them long-term. We investigated the effects of recurrence patterns on survival in patients undergoing radical esophagectomy.ResultsIn total, 353 patients were included in the study. The 5-year overall survival of patients with different recurrence patterns was significantly different: recurrence versus recurrence-free (17.8% vs 89.2%; P < .001), early recurrence versus late recurrence (4.6% vs 51.2%; P < .001), and distant metastasis versus locoregional recurrence (17.0% vs 20.0%; P = .666). Patients with early recurrence had significantly shorter survival after recurrence than those with late recurrence (hazard ratio, 1.541; 95% confidence interval, 1.047-2.268, P = .028). There was no significant difference in postrecurrence survival between patients with distant metastasis and locoregional recurrence (hazard ratio, 1.181; 95% confidence interval, 0.804-1.734; P = .396). Multivariate logistic analysis showed that pN1 stage, lymph node dissection <20, and lack of response to NCRT were independent risk factors for postoperative early recurrence. Multivariate Cox regression suggested that NCRT, age ≥60 years, early recurrence, and the pN1 stage were independent risk factors for shortened survival after recurrence.ConclusionsPrerecurrence primary tumor stage is inaccurate in predicting postrecurrence survival. In contrast, recurrence patterns can guide follow-up while also predicting postrecurrence survival. NCRT prolongs disease-free survival but is associated with a worse prognosis in patients with recurrence, especially early recurrence.     

Cardiac-type total anomalous pulmonary venous return is not benign

ObjectiveThe objective of this study was to investigate the association between morphological variation and postsurgical pulmonary vein (PV) stenosis (PPVS) in patients with cardiac total anomalous pulmonary venous connection (TAPVC).MethodsThis single-center, retrospective study included 168 pediatric patients who underwent surgical repair of cardiac TAPVC from 2013 to 2019 (connection to the coronary sinus [CS], n = 136; connection directly to the right atrium [RA], n = 32). Three-dimensional computed tomography modeling and geometric analysis were performed to investigate the morphological features; their relevance to the PPVS was examined.ResultsThe connection type had no association with PPVS (CS type: 18% vs right atrial type: 19%; P = .89) but there was a higher incidence of PPVS in patients with a single PV orifice than > 1 orifice (P < .001). Confluence-to-total PV area ratio (hazard ratio, 4.78, 95% CI, 1.86-12.32; P = .001) and length of drainage route (hazard ratio, 1.22; 95% CI, 1.14-1.31; P < .001) had a 4- and 1-fold increase in the risk for PPVS in the CS type after adjustment for age and preoperative pulmonary venous obstruction. In the right atrial type, those with anomalous PV return to the RA roof were more likely to develop PPVS than to the posterior wall of the RA (P < .001).ConclusionsThe number of inter-junction PV orifice correlated with PPVS development in cardiac TAPVC. The confluence-to-total PV ratio, length of drainage route, and anomalous PV return to the RA roof are important predictors for PPVS. Morphological subcategorization in this clinical setting can potentially assist in surgical decision-making.     

Three-dimensional geometry of coronary arteries after arterial switch operation for transposition of the great arteries and late coronary events

ObjectiveUsing 3-dimensional (3D) modeling to predict late coronary events after the arterial switch operation (ASO) for transposition of the great arteries (TGA).MethodWe reviewed 100 coronary computed tomography scans performed after ASO randomly selected from free-from-coronary-event patients and 21 coronary computed tomography scans from patients who had a coronary event later than 3 years after ASO. Using 3D modeling software, we defined and measured 6 geometric criteria for each coronary artery: Clockwise position of coronary ostium, First centimeter angle defined as the angle between of the coronary artery ostium and the first centimeter of the vessel, Minimal 3D angle between the coronary first centimeter and the aortic wall, ostium height defined as the distance between the ostium and the aortic valve, distance between the coronary ostium and the pulmonary artery, and distance between the coronary first centimeter and the pulmonary artery.ResultsNone of the right ostium geometric parameters were associated with coronary events. Four out of 6 criteria of left coronary artery geometry were associated to coronary events: Clockwise position of the left ostium >67° (P < .001), First centimeter angle >62° (P < .01), minimal 3D angle <39° (P = .003), distance between the coronary ostium and the pulmonary artery <1 mm/mm (P = .03). The association of first centimeter angle >62° and minimal angle in 3D <39° had a 88% sensitivity and a 81% specificity to predict coronary events (receiver operator characteristics curve, 0.847; 95% confidence interval, 0.745-0.949; P < .001).ConclusionsThe acquired geometric characteristics of the transferred left coronary artery are associated with coronary events. Imaging coronary arteries after ASO might be useful to select patients at higher risk of coronary events and to tailor surveillance.     

Ex vivo lung evaluation of single donor lungs when the contralateral lung is rejected increases safe use

ObjectiveThe decision to perform a single-lung transplant (SLT) when the contralateral donor lung is rejected is a challenging scenario. The introduction of ex vivo lung perfusion (EVLP) has improved donor lung assessment, and we hypothesize that it has improved SLT outcomes in this setting.MethodsA retrospective single-center review of all SLTs performed between 2000 and 2017 was performed in which the years 2000 to 2008 were considered the “pre-EVLP era” and 2009 to 2017 the “EVLP era.” Recipients of SLT lungs when the contralateral lung was declined were classified into 3 groups: (1) Pre-EVLP era, (2a) EVLP era but EVLP not used, and (2b) EVLP era and EVLP used. The outcomes of interest were survival, time-to-extubation, and intensive care unit and hospital stay.ResultsAmong 1692 transplants between 2000 and 2017, 244 (14%) were SLT. SLT rate was similar between eras (pre-EVLP 16% vs EVLP 15%), but more SLTs were performed where the contralateral lung was declined in the EVLP era (pre-EVLP 32% vs EVLP 45%, P = .04). Lungs evaluated on EVLP had lower procurement partial pressure of oxygen and were more often from donation after cardiac death donors. Recipients were generally also sicker, with a greater proportion of rapidly deteriorating recipients. Despite this, outcomes were similar between eras with a trend towards lower 30-day mortality in the EVLP era.ConclusionsThe availability of EVLP allowed for better evaluation of marginal single lungs when the contralateral was declined. This has led to increased use rates with preserved outcomes despite use of more extended criteria organs.     

Reintervention rates after bioprosthetic pulmonary valve replacement in patients younger than 30 years of age: A multicenter analysis

ObjectivesTo assess the difference in time to and predictors of reintervention according to valve type in surgical bioprosthetic pulmonary valve replacement (PVR) in patients younger than 30 years of age from multiple centers.MethodsData were retrospectively collected for 1278 patients <30 years of age undergoing PVR at 8 centers between 1996 and 2015.ResultsMean age at PVR was 19.3 ± 12.8 years, with 719 (56.3%) patients ≤18 years of age. Diagnosis was tetralogy of Fallot in 626 patients (50.5%) and 165 (12.9%) had previous PVR. Median follow-up was 3.9 years (interquartile range, 1.2, 6.4). Multiple valve types were used, most commonly CE PERIMOUNT, 488 (38.2%), CE Magna/Magna Ease, 361 (28.2%), and Sorin Mitroflow 322 (25.2). Reintervention occurred in 12.7% and was most commonly due to pulmonary stenosis (68.8%), with most reinterventions occurring in children (85.2%) and with smaller valve sizes (P < .001) Among adults aged 18 to 30 years, younger age was not a significant risk factor for reintervention. Surgical indication of isolated pulmonary regurgitation was associated with a lower risk of reintervention (P < .001). Overall, 1-, 3-, 5-, and 10-year freedom from reintervention rates were 99%, 97%, 92%, and 65%. The only independent risk factors for reintervention after controlling for age and valve size were lack of a concomitant tricuspid valve procedure (P = .02) and valve type (P < .001); Sorin and St Jude valves were associated with similar time to reintervention, and deteriorated more rapidly than other valve types.ConclusionsIn this large multicenter study, 8% of patients have undergone reintervention by 5 years. Importantly, independent of age and valve size, reintervention rates vary by valve type.     

Timing of reintervention influences survival and resource utilization following first-stage palliation of single ventricle heart disease

ObjectiveOutcomes after first-stage palliation of single-ventricle heart disease are influenced by many factors, including the presence of residual lesions requiring reintervention. However, there is a dearth of information regarding the optimal timing of reintervention. We assessed if earlier reintervention would be favorably associated with in-hospital outcomes among patients requiring unplanned reinterventions after the Norwood operation.MethodsThis was a single-center, retrospective review of all patients who underwent the Norwood procedure from January 1997 to November 2017 and required a predischarge unplanned surgical or transcatheter reintervention on 1 or more subcomponent areas repaired at the index operation. Outcomes of interest included in-hospital mortality or transplant, postoperative hospital length of stay, and inpatient cost. Associations between timing of reintervention and outcomes were assessed using logistic regression (mortality or transplant) or generalized linear models (postoperative hospital length of stay and cost), adjusting for baseline patient-related and procedural factors.ResultsOf 500 patients who underwent the Norwood operation, 92 (18.4%) required an unplanned reintervention. Median time to reintervention was 12 days (interquartile range, 5-35 days). There were 31 (33.7%) deaths or transplants, median postoperative hospital length of stay was 49 days (interquartile range, 32-87 days), and median cost was $328,000 (interquartile range, $204,000-$464,000). On multivariable analysis, each 5-day increase in time to reintervention increased the odds of mortality or transplant by 20% (odds ratio, 1.2; 95% confidence interval, 1.1-1.3; P = .004). Longer time to reintervention was also significantly associated with greater postoperative hospital length of stay (P < .001) and higher cost (P < .001).ConclusionsFor patients requiring predischarge unplanned reinterventions after the Norwood operation, earlier reintervention is associated with improved in-hospital transplant-free survival and resource use.     

Significant reduction of postoperative pain and opioid analgesics requirement with an Enhanced Recovery After Thoracic Surgery protocol

ObjectiveTo evaluate differences in postoperative pain control and opioids requirement in thoracic surgical patients following implementation of an Enhanced Recovery after Thoracic Surgery protocol with a comprehensive postoperative pain management strategy.Material and MethodsA retrospective analysis of a prospectively maintained database of patients undergoing pulmonary resections by robotic thoracoscopy or thoracotomy from January 1, 2017, to January 31, 2019, was conducted. Multimodal pain management strategy (opioid-sparing analgesics, infiltration of liposomal bupivacaine to intercostal spaces and surgical sites, and elimination of thoracic epidural analgesia use in thoracotomy patients) was implemented as part of Enhanced Recovery after Thoracic Surgery on February 1, 2018. Outcome metrics including patient-reported pain levels, in-hospital and postdischarge opioids use, postoperative complications, and length of stay were compared before and after protocol implementation.ResultsIn total, 310 robotic thoracoscopy and 62 thoracotomy patients met the inclusion criteria. This pain management strategy was associated with significant reduction of postoperative pain in both groups with an overall reduction of postoperative opioids requirement. Median in-hospital opioids use (morphine milligram equivalent per day) was reduced from 30 to 18.36 (P = .009) for the robotic thoracoscopy group and slightly increased from 15.48 to 21.0 (P = .27) in the thoracotomy group. More importantly, median postdischarge opioids prescribed (total morphine milligram equivalent) was significantly reduced from 480.0 to 150.0 (P < .001) and 887.5 to 150.0 (P < .001) for the thoracoscopy and thoracotomy groups, respectively. Similar short-term perioperative outcomes were observed in both groups before and following protocol implementation.ConclusionsImplementation of Enhanced Recovery after Thoracic Surgery allows safe elimination of epidural use, better pain control, and less postoperative opioids use, especially a drastic reduction of postdischarge opioid need, without adversely affecting outcomes.     

Aortic growth and development of partial false lumen thrombosis are associated with late adverse events in type B aortic dissection

BackgroundPatients with medically treated type B aortic dissection (TBAD) remain at significant risk for late adverse events (LAEs). We hypothesize that not only initial morphological features, but also their change over time at follow-up are associated with LAEs.Materials and MethodsBaseline and 188 follow-up computed tomography (CT) scans with a median follow-up time of 4 years (range, 10 days to 12.7 years) of 47 patients with acute uncomplicated TBAD were retrospectively reviewed. Morphological features (n = 8) were quantified at baseline and each follow-up. Medical records were reviewed for LAEs, which were defined according to current guidelines. To assess the effects of changes of morphological features over time, the linear mixed effects models were combined with Cox proportional hazards regression for the time-to-event outcome using a joint modeling approach.ResultsLAEs occurred in 21 of 47 patients at a median of 6.6 years (95% confidence interval [CI], 5.1-11.2 years). Among the 8 investigated morphological features, the following 3 features showed strong association with LAEs: increase in partial false lumen thrombosis area (hazard ratio [HR], 1.39; 95% CI, 1.18-1.66 per cm² increase; P < .001), increase of major aortic diameter (HR, 1.24; 95% CI, 1.13-1.37 per mm increase; P < .001), and increase in the circumferential extent of false lumen (HR, 1.05; 95% CI, 1.01-1.10 per degree increase; P < .001).ConclusionsIn medically treated TBAD, increases in aortic diameter, new or increased partial false lumen thrombosis area, and increases of circumferential extent of the false lumen are strongly associated with LAEs.     

Deep Sternal Wound Infection and Mortality in Cardiac Surgery: A Meta-analysis

BackgroundDeep sternal wound infection (DSWI) is a rare but severe complication after cardiac surgical procedures and has been associated with increased early morbidity and mortality. Studies reporting long-term outcomes in patients with DSWI have shown contradictory results. We performed a study-level meta-analysis evaluating the impact of DSWI on short- and long-term clinical outcomes.MethodsA systematic literature search was conducted to identify studies comparing short- and long-term outcomes of patients submitted to cardiac surgical procedures who developed DSWI and patients who did not. The primary outcome was overall mortality. Secondary outcomes were in-hospital mortality, follow-up mortality, major adverse cardiovascular events, myocardial infarction, and repeat revascularization. Postoperative outcomes were also investigated.ResultsTwenty-four studies totaling 407 829 patients were included. Overall, 6437 (1.6%) patients developed DSWI. Mean follow-up was 3.5 years. DSWI was associated with higher overall mortality (incidence rate ratio [IRR], 1.99; 95% CI, 1.66-2.38; P < .001), in-hospital mortality (odds ratio, 3.30; 95% CI, 1.88-5.81; P < .001), follow-up mortality (IRR, 2.02; 95% CI, 1.39-2.94; P = .001), and major adverse cardiovascular events (IRR, 2.04; 95% CI, 1.60-2.59; P < .001). No differences in myocardial infarction and repeat revascularization were found, but limited studies reported those outcomes. DSWI was associated with longer postoperative hospitalization, stroke, myocardial infarction, and respiratory and renal failure. Sensitivity analyses on isolated coronary artery bypass grafting studies and by adjustment method were consistent with the main analysis.ConclusionsCompared with patients who did not develop DSWI, patients with DSWI after cardiac surgical procedures had increased risk of death as well as short- and long-term adverse clinical outcomes.