Determining Risk Factors for Endovenous Heat-induced Thrombosis after Radiofrequency Ablation.

BACKGROUND: The objective of this study was to evaluate risk factors, incidence, management, and outcome of endovenous heat-induced thrombosis (EHIT) related to radiofrequency ablation (RFA). METHODS: This was a single-center retrospective analysis of patients over the age of 18 who underwent RFA between 2016 and 2019. Demographics, comorbidities, medications, severity scores, vascular anatomy, procedural details, and outcome data were collected. EHIT-related data included occurrence, grade, laterality, management, and outcome. RESULTS: During the study period, 672 RFA procedures were performed at our institution. Of these, 642 (median age 57 (21-93), 62.3% female) met study inclusion criteria. EHIT was observed in 43 (6.6%) cases. Concurrent left common femoral vein (CFV) or right femoral vein (FV) incompetence was found to be more prevalent in the EHIT group (P = 0.024 and P = 0.011, respectively). Compared with performing RFA alone, concurrent performance of stab phlebectomy and sclerotherapy with RFA on the left side was found to be associated with possible increased risk for EHIT (P = 0.021). Furthermore, patients with diabetes mellitus (DM) (P = 0.05) and those with median diameter of the treated left vein of 1.2 cm (P = 0.02) were more likely to have a higher EHIT grade (III and IV) than those without DM and those with smaller vein diameter, respectively. Management included aspirin (44%), anticoagulant (28%), both (10%), or neither (18%). EHIT either resolved or regressed (64%), did not change (5%), or propagated (8%) at follow-up. CONCLUSIONS: Left CFV or right FV incompetence was found to be more prevalent in the total EHIT group. Furthermore, DM and the median size of the treated vein on the left (1.2 cm) were more prevalent in the high (III-IV) versus low grade (I-II) EHIT group. More than 50% of EHIT improved (regressed or resolved) at follow-up regardless of the management option. Further analysis with larger patient samples are needed to confirm the association between these variables and the development of EHIT.

Trends of vascular surgery procedures in Marfan syndrome and Ehlers-Danlos syndrome.

OBJECTIVES: Marfan syndrome and Ehlers-Danlos syndrome represent two connective tissue vascular diseases requiring unique consideration in their vascular surgical care. A comprehensive national review encompassing all hospitalizations for the Marfan Syndrome and Ehlers-Danlos syndrome patient population is lacking. METHODS: The National (Nationwide) Inpatient Sample from 2010 to 2014 was reviewed for all inpatient vascular surgery procedures including those with a diagnosis of Marfan syndrome and Ehlers-Danlos syndrome. National estimates of vascular surgery rates were generated from provided weights. Patient demographics, procedure type, and outcomes were assessed. RESULTS: There were 3103 Marfan syndrome and 476 Ehlers-Danlos syndrome vascular procedures identified as well as 3,895,381 vascular procedures in the remainder of population (control group). The percent of aortic procedures from all vascular procedures in Marfan syndrome (23.5%) and Ehlers-Danlos syndrome (23.5%) were 2.5-fold higher than controls (9.1%), p < 0.0001. Open aortic aneurysm repair was also significantly greater in both Marfan syndrome (16.8%) and Ehlers-Danlos syndrome (11.2%) compared to controls (4.4%), p < 0.0001. Endovascular aortic repair (p < 0.2302) was similar among the groups. Marfan syndrome (7.7%) and Ehlers-Danlos syndrome (5.1%) had more thoracic endovascular aortic repair performed than controls (0.7%), p < 0.0001. Percutaneous procedures were fewer in Marfan syndrome (6.3%) than controls (31.3%) and Ehlers-Danlos syndrome (26.3%), p < 0.0001, while repair of peripheral arteries was greater in Marfan syndrome (5.9%) and Ehlers-Danlos syndrome (4.1%) than controls (1.5%), p < 0.0001. For total aortic procedures, the mean age of aortic procedures was 68.2 years in controls vs 45.8 years in Marfan syndrome and 55.3 years in Ehlers-Danlos syndrome, p < 0.0001. Marfan syndrome and Ehlers-Danlos syndrome had fewer comorbidities overall, while controls had significantly higher rates of coronary artery disease (controls 39.9% vs Marfan syndrome 8.3% and Ehlers-Danlos syndrome 13.0%, p < 0.0001), peripheral vascular disease (controls 34.5% vs Marfan syndrome 4.2% and Ehlers-Danlos syndrome 8.7%, p < 0.0001), and diabetes (controls 20.6% vs Marfan syndrome 6.6 and Ehlers-Danlos syndrome 4.4%, p < 0.0001). Marfan syndrome and Ehlers-Danlos syndrome had higher overall complication rate (65.5% and 52.2%) compared to controls (44.6%), p < 0.0001. Postoperative hemorrhage was more likely in Marfan syndrome (42.9%) and Ehlers-Danlos syndrome (39.1%) than controls (22.2%), p < 0.0001. Increased respiratory failure was noted in Marfan syndrome (20.2%) vs controls (10.7%) and Ehlers-Danlos syndrome (8.7%), p = .0003. Finally, length of stay was increased in Marfan syndrome 12.5 days vs Ehlers-Danlos syndrome 7.4 days and controls 7.2 days (p < 0.0001) as well as a higher median costs of index hospitalization in Marfan syndrome ($57,084 vs Ehlers-Danlos syndrome $22,032 and controls $26,520, p < 0.0001). CONCLUSIONS: Patients with Marfan syndrome and Ehlers-Danlos syndrome differ from other patients undergoing vascular surgical procedures, with a significantly higher proportion of aortic procedures including open aneurysm repair and thoracic endovascular aortic repair. While they are younger with fewer comorbidities, due to the unique pathogenesis of their underlying connective tissue disorder, there is an overall higher rate of procedural complications and increased length of stay and cost for Marfan syndrome patients undergoing aortic surgery.

Successful left gonadal vein to inferior vena cava bypass for symptomatic May-Thurner syndrome.

We report the management of symptomatic May-Thurner syndrome refractory to endovascular techniques with left gonadal vein to inferior vena cava bypass. The patient's presentation was exceptional-a young individual with end-stage renal disease status post four failed kidney transplants, dwindling options for dialysis access, and an unusable left thigh arteriovenous graft owing to severe lower extremity edema secondary to common iliac vein compression. Postoperatively, swelling was markedly alleviated and the thigh graft was functional. Discussed are endovascular and venous bypass techniques for management of May-Thurner-associated lesions, as well as approaches to end-stage hemodialysis access salvage.

Physical therapy management, surgical treatment, and patient-reported outcomes measures in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome.

OBJECTIVE: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures. METHODS: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and χ2 analyses. Follow-up results were assessed by changes in 11-item version of Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and patient-rated outcomes. RESULTS: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean ± standard error degree of local tenderness to palpation (1.7 ± 0.1 vs 2.0 ± 0.1; P = .032), the number of positive clinical diagnostic criteria (9.0 ± 0.3 vs 10.1 ± 0.1; P = .001), Cervical-Brachial Symptom Questionnaire scores (68.0 ± 4.1 vs 78.0 ± 2.7; P = .045), and Short-Form 12-item physical quality-of-life scores (35.6 ± 1.5 vs 32.0 ± 0.8; P = .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was -15.6 ± 3.0 (-29.5% ± 5.7%) compared with -29.8 ± 2.4 (-47.9% ± 3.6%) for surgery (P = .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P < .0001). CONCLUSIONS: The present study has demonstrated contemporary outcomes for physical therapy and surgery in a well-studied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for ∼90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery.

Influence of Body Weight on Surgical Treatment for Neurogenic Thoracic Outlet Syndrome.

BACKGROUND: Body weight affects outcomes of surgical treatment for various conditions, but its effects on the treatment of neurogenic thoracic outlet syndrome (NTOS) are unknown. The purpose of this study was to evaluate the influence of body weight on technical and functional outcomes of surgical treatment for NTOS. METHODS: A retrospective review of prospectively collected data was conducted for 265 patients who underwent supraclavicular decompression for NTOS between January 1, 2014 and March 31, 2016. Patients were grouped according to 6 standard body mass index (BMI) categories. The influence of BMI on measures of surgical outcome was analyzed using Pearson correlation statistics, analysis of variance (ANOVA), and multivariate logistic regression. RESULTS: Mean patient age was 33.3 ± 0.7 years (range, 12-70), and 208 (78%) patients were women. Mean BMI was 27.2 ± 0.4 (range 16.8-49.9), with 7 underweight (3%), 95 normal (36%), 84 overweight (32%), 47 obese-I (18%), 15 obese-II (6%), and 17 obese-III (6%). There was a slight but significant association between BMI and age (Pearson P < 0.0001, r = 0.264; ANOVA P = 0.0002), but no correlations between BMI and other preoperative variables. There were no differences between BMI groups for intraoperative, immediate postoperative, or 3-month outcomes. Multivariate logistic regression demonstrated that BMI had no significant effect on functional outcome as measured by the extent of improvement in Disability of the Arm, Shoulder, and Hand score at 3 months (P = 0.429). CONCLUSIONS: There was no substantive influence of BMI on preoperative characteristics or intraoperative, postoperative, or 3-month outcomes for patients with NTOS, and no indication of an "obesity paradox" for this condition. Supraclavicular decompression for NTOS achieves similar outcomes across the BMI spectrum.

Axillary Artery Access for Combined Endoaortic Balloon Occlusion and Perfusion During Robotic Mitral Valve Surgery.

We aimed to develop a method that provides an alternative cannulation site in robotic mitral valve surgery that allows simultaneous endo-occlusion and antegrade perfusion. A 71-year-old man with severe mitral regurgitation and history of coronary artery bypass grafting underwent totally endoscopic robotic mitral valve repair. A 23-mm endoreturn cannula was placed through a 10-mm graft that was sewn to the left axillary artery. An endoballoon was passed through the Dacron/cannula complex and into the ascending aorta. This complex was used for simultaneous antegrade perfusion, endoballoon occlusion, and antegrade cardioplegia. Completion transesophageal echocardiography showed no evidence of mitral regurgitation. The patient had an uneventful postoperative course and was doing well at his 2-month follow-up appointment. The left axillary artery is a viable option for simultaneous endoballoon occlusion, antegrade perfusion, and antegrade cardioplegia in robotic mitral valve surgery. This has the potential benefit of providing antegrade perfusion, which some studies have shown to be associated with a decreased risk of complications when compared with retrograde perfusion specifically in patients with severe peripheral vascular disease.

Noncardiac Surgical Procedures After Left Ventricular Assist Device Implantation.

As left ventricular assist devices (LVADs) are increasingly used for patients with end-stage heart failure, the need for noncardiac surgical procedures (NCSs) in these patients will continue to rise. We examined the various types of NCS required and its outcomes in LVAD patients requiring NCS. The National Inpatient Sample Database was examined for all patients implanted with an LVAD from 2007 to 2010. Patients requiring NCS after LVAD implantation were compared to all other patients receiving an LVAD. There were 1,397 patients undergoing LVAD implantation. Of these, 298 (21.3%) required 459 NCS after LVAD implantation. There were 153 (33.3%) general surgery procedures, with abdominal/bowel procedures (n = 76, 16.6%) being most common. Thoracic (n = 141, 30.7%) and vascular (n = 140, 30.5%) procedures were also common. Patients requiring NCS developed more wound infections (9.1 vs. 4.6%, p = 0.004), greater bleeding complications (44.0 vs. 24.8%, p < 0.001) and were more likely to develop any complication (87.2 vs. 82.0%, p = 0.001). On multivariate analysis, the requirement of NCSs (odds ratio: 1.45, 95% confidence interval: 0.95-2.20, p = 0.08) was not associated with mortality. Noncardiac surgical procedures are commonly required after LVAD implantation, and the incidence of complications after NCS is high. This suggests that patients undergoing even low-risk NCS should be cared at centers with treating surgeons and LVAD specialists.

Spindle cell carcinoma of the breast: a comprehensive analysis.

BACKGROUND: Breast spindle cell malignancies are rare. No standard treatment exists. METHODS: The Surveillance, Epidemiology, and End Results database was used to identify patients with breast spindle cell malignancies, 1992 to 2011. Descriptive statistical analysis and survival analysis were performed. RESULTS: A total of 286 patients were identified (98.6% female). Approximately, 15% had estrogen receptor-positive tumors and 12.5% had progesterone receptor-positive tumors. Nearly 38% underwent partial mastectomy, whereas 55.5% underwent mastectomy. The frequency of partial mastectomy has increased in more recent years. One-third received radiation. Lymph node metastases were infrequent (9.3%) and distant metastases were uncommon (6.1%). Ten-year survival rates for patients with early-stage (I and II) disease were 83.9% after partial mastectomy, 86.7% after partial mastectomy plus radiation, and 71.6% after complete mastectomy. Three-year survival rates for patients with late-stage (III and IV) disease were low with 40.0% after complete mastectomy and 0% after complete mastectomy plus radiation. CONCLUSIONS: This nationally representative analysis demonstrates that early-stage spindle cell carcinoma of the breast is adequately treated by partial mastectomy. Radiation may be considered for small, potentially early survival benefit. For late stage disease, complete mastectomy is appropriate; however, survival is poor, and radiation contributes no significant additional benefit.

Right ventricular assist device results in worse post-transplant survival.

BACKGROUND: To our knowledge, how the need for a right ventricular assist device (RVAD) with a left ventricular assist device (LVAD) affects outcomes after orthotopic heart transplantation has not been studied in a multi-institutional database. METHODS: The United Network for Organ Sharing (UNOS) database was queried for all adult orthotopic heart transplantations from the period 2005-2012. Patients requiring a RVAD + LVAD as a bridge to transplant were compared with patients requiring a LVAD only and patients requiring no ventricular assist device (VAD). RESULTS: During the study period, 16,955 orthotopic heart transplantations were performed. Of these, 13,209 (77.9%) patients did not require a VAD, 3,270 (19.3%) required a LVAD only, and 457 (2.7%) required a RVAD + LVAD. The RVAD + LVAD group had the longest length of stay (25.7 days) compared with the no VAD group (20.8 days) and the LVAD-only group (21.1 days) (p < 0.001). On multivariate analysis, requirement of a RVAD + LVAD before transplantation was independently associated with post-transplant mortality (hazard ratio 1.22, 95% confidence interval 1.01-1.49, p = 0.04). Other variables associated with mortality included donor age, pulsatile flow LVAD as a bridge to transplant, prolonged ischemic time, worsening renal function, black race, history of diabetes in recipient, class II panel-reactive antibody >10%, sex mismatch, and extracorporeal membrane oxygenation or mechanical ventilation as a bridge to transplant. CONCLUSIONS: The requirement of a RVAD in addition to a LVAD before orthotopic heart transplantation is associated with worse post-transplant outcomes and increased mortality.

Examining Noncardiac Surgical Procedures in Patients on Extracorporeal Membrane Oxygenation.

As extracorporeal membrane oxygenation (ECMO) is increasingly used for patients with cardiac and/or pulmonary failure, the need for noncardiac surgical procedures (NCSPs) in these patients will continue to increase. This study examined the NCSP required in patients supported with ECMO and determined which variables affect outcomes. The National Inpatient Sample Database was examined for patients supported with ECMO from 2007 to 2010. There were 563 patients requiring ECMO during the study period. Of these, 269 (47.8%) required 380 NCSPs. There were 149 (39.2%) general surgical procedures, with abdominal exploration/bowel resection (18.2%) being most common. Vascular (29.5%) and thoracic procedures (23.4%) were also common. Patients requiring NCSP had longer median length of stay (15.5 vs. 9.2 days, p = 0.001), more wound infections (7.4% vs. 3.7%, p = 0.02), and more bleeding complications (27.9% vs. 17.3%, p = 0.01). The incidences of other complications and inpatient mortality (54.3% vs. 58.2%, p = 0.54) were similar. On logistic regression, the requirement of NCSPs was not associated with mortality (odds ratio [OR]: 0.91, 95% confidence interval [CI]: 0.68-1.23, p = 0.17). However, requirement of blood transfusion was associated with mortality (OR: 1.70, 95% CI: 1.06-2.74, p = 0.03). Although NCSPs in patients supported with ECMO does not increase mortality, it results in increased morbidity and longer hospital stay.

Postoperative outcomes with cholecystectomy in lung transplant recipients.

INTRODUCTION: There is a paucity of data on outcomes for lung transplant (LT) recipients requiring general surgery procedures. This study examined outcomes after cholecystectomy in LT recipients using a large database. METHODS: The National Inpatient Sample Database (2005-2010) was queried for all LT patients requiring laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). RESULTS: There were a total of 377 cholecystectomies performed in LT patients. The majority were done for acute cholecystitis (n = 218; 57%) and were done urgently/emergently (n = 258; 68%). There were a total of 304 (81%) laparoscopic cholecystectomies and 73 (19%) OC. There was no difference in age when comparing the laparoscopic and open groups (53.6 vs 55.5 years; P = .39). In addition, the Charlson Comorbidity Index was similar in the 2 groups (P = .07). Patients undergoing OC were more likely to have perioperative myocardial infarction, pulmonary embolus, or any complication compared with the laparoscopic group. Total hospital charges ($59,137.00 vs $106,329.80; P = .03) and median duration of stay (4.0 vs 8.0 days; P = .02) were both greater with open compared with LC. CONCLUSION: Cholecystectomy can be performed safely in the LT population with minimal morbidity and mortality.

Use of Heavy Drinking Donors in Heart Transplantation is Not Associated With Worse Mortality.

BACKGROUND: Although orthotopic heart transplantation (OHT) remains the preferred treatment for end-stage heart failure, there continues to be a critical shortage of organ donors. The goal of this study is to examine outcomes after orthotopic OHT using heavy drinking donors (HDDs) in a large, national database. METHODS: The United Network for Organ Sharing database was examined for all primary, adult OHT carried out from 2005 to 2012. RESULTS: There were 14,928 total OHT performed during the study period with 2,274 (15.2%) using HDD. Recipients of HDD were older (53.4 vs. 51.9 years, P < 0.001), more likely men (80.7 vs 74.4%, P < 0.001), less likely sex mismatched (21.5 vs 27.5%, P < 0.001), more likely race mismatched (57.4 vs 52.4%, P < 0.001), and had less total HLA mismatches (4.55 vs 4.65, P < 0.001). The HDD were older (37.0 vs 30.5 years, P < 0.001), more likely men (82.2 vs 69.9%, P < 0.001), and more likely to have heavy cigarette use (38.1 vs 13.2%, P < 0.001). Length of stay was not different (20.3 vs 19.7 days, P = 0.02). On multivariate analysis, use of HDD was not associated with mortality at 30 days (hazards ratio [HR], 1.12; 95% confidence interval [95% CI], 0.90-1.39; P = 0.30), 1 year (HR, 0.96; 95% CI, 0.83-1.11; P = 0.56), and at 5 years (HR, 1.02; 95% CI, 0.91-1.13; P = 0.79). Variables associated with mortality at 5 years included increasing donor age, prolonged ischemic time, worsening recipient creatinine, recipient black race, sex mismatch, and extracorporeal membrane oxygenation or mechanical ventilation as a bridge to transplantation. CONCLUSION: Heart transplantation can be performed using carefully selected HDDs with good outcomes.

Noncardiac surgery in patients on mechanical circulatory support.

This study examined outcomes in patients with left ventricular assist device (LVAD) and extracorporeal membrane oxygenation (ECMO) requiring noncardiac surgical procedures and identified factors that influence outcomes. All patients with mechanical circulatory support (MCS) devices at our institution from 2002 to 2013 undergoing noncardiac surgical procedures were reviewed. There were 148 patients requiring MCS during the study period, with 40 (27.0%) requiring 62 noncardiac surgical procedures. Of these, 29 (72.5%) had implantable LVAD and 11 (27.5%) were supported with ECMO. The two groups were evenly matched with regard to age (53.6 vs. 54.5 years, p = 0.87), male sex (71.4 vs. 45.5%, p = 0.16), and baseline creatinine (1.55 vs. 1.43 mg/dl, p = 0.76). Patients on ECMO had greater demand for postoperative blood products (0.8 vs. 2.8 units of packed red blood cells, p = 0.002) and greater postoperative increase in creatinine (0.07 vs. 0.44 mg/dl, p = 0.047). Median survival was markedly worse in ECMO patients. Factors associated with mortality included ECMO support, history of biventricular assist device, and postoperative blood transfusion. Preoperative aspirin was associated with survival. These findings demonstrate the importance of careful surgical hemostasis and minimizing perioperative blood transfusions in patients on MCS undergoing noncardiac surgical procedures. In addition, low-dose antiplatelet therapy should be continued perioperatively.

Examining ABO compatible donors in double lung transplants during the era of lung allocation score.

BACKGROUND: The short-term and long-term effect of using ABO compatible donors in the era of lung allocation score is unknown. This study determined if carefully selected ABO compatible donors could be used in double lung transplantation (DLT) with good outcomes. METHODS: The United Network for Organ Sharing database was retrospectively reviewed for adult DLT from May 2005 to December 2011. RESULTS: Of 6,655 double lung transplants, 493 (7.4%) were with ABO compatible donors and 6,162 (92.6%) were with ABO identical donors. In multivariate analysis, use of ABO compatible donors was not associated with mortality at 30 days (HR, 1.16; 95% CI, 0.76 to 1.79, p = 0.49), 1 year (HR, 1.10; 95% CI, 0.86 to 1.42, p = 0.46), and 5 years (HR, 1.06; 95% CI, 0.83 to 1.34, p = 0.65). Variables associated with mortality at 5 years were donor female sex, donor age 60 years or greater, prolonged ischemic time, increasing recipient creatinine, recipient age, race mismatch, and mechanical ventilation or extracorporeal membrane oxygenation as a bridge to transplantation. Length of stay was longer in the ABO compatible group (30.9 vs 25.9 days, p = 0.001). Acute rejection episodes on index hospitalization (8.8 vs. 8.9%, p = 1.00), peak posttransplant forced expiratory volume in 1 second (FEV1) (82.7 vs 79.7%, p = 0.053), and decrement in FEV1 over time were not different (p = 0.13). Freedom from bronchiolitis obliterans syndrome was similar (1,475 vs 1,454 days, p = 0.17). CONCLUSIONS: The use of ABO compatible donors in the era of lung allocation score was not associated with short-term or long-term mortality and resulted in equivalent posttransplant lung function. A DLT with carefully selected ABO compatible donors can result in excellent outcomes.

"Permissive hypoventilation" in a swine model of hemorrhagic shock.

BACKGROUND: Many penetrating trauma patients in severe hemorrhagic shock receive positive pressure ventilation (PPV) upon transport to definitive care, either by intubation (INT) or bag-valve mask (BVM). Using a swine hemorrhagic shock model that simulates penetrating trauma, we proposed that severely injured patients may have better outcomes with "permissive hypoventilation," where manual breaths are not given and oxygen is administrated passively via face mask (FM). We hypothesized that PPV has harmful physiologic effects in severe low-flow states and that permissive hypoventilation would result in better outcomes. METHODS: The carotid arteries of Yorkshire pigs were cannulated with a 14-gauge catheter. One group of animals (n = 6) was intubated and manually ventilated, a second received PPV via BVM (n = 7), and a third group received 100% oxygen via FM (n = 6). After placement of a Swan-Ganz catheter, the carotid catheters were opened, and the animals were exsanguinated. The primary end point was time until death. Secondary end points included central venous pressure, cardiac output, lactate levels, serum creatinine, CO2 levels, and pH measured in 10-minute intervals. RESULTS: Average survival time in the FM group (50.0 minutes) was not different from the INT (51.1 minutes) and BVM groups (48.5 minutes) (p = 0.84). Central venous pressure was higher in the FM group as compared with the INT 10 minutes into the shock phase (8.3 mm Hg vs. 5.2 mm Hg, p = 0.04). Drop in cardiac output (p < 0.001) and increase in lactate (p < 0.05) was worse in both PPV groups throughout the shock phase. Creatinine levels were higher in both PPV groups (p = 0.04). The FM group was more hypercarbic and acidotic than the two PPV groups during the shock phase (p < 0.001). CONCLUSION: Although permissive hypoventilation leads to respiratory acidosis, it results in less hemodynamic suppression and better perfusion of vital organs. In severely injured penetrating trauma patients, consideration should be given to immediate transportation without PPV.

Single-lung transplantation with ABO-compatible donors results in excellent outcomes.

BACKGROUND: The goal of this study was to determine if carefully selected ABO-compatible donors in single-lung transplantation results in acceptable outcomes. METHODS: The United Network for Organ Sharing database was reviewed for adult single-lung transplant recipients from May 2005 to December 2011. Recipients of lungs from ABO-compatible donors were compared with those of ABO-identical donors. Mortality was examined with risk-adjusted multivariable Cox proportional hazards regression using significant univariate predictors. RESULTS: Of 3,572 single-lung transplants, 342 (9.6%) were from ABO-compatible donors. The two groups were evenly matched in recipient age (60.8 vs 60.2 years, p = 0.28), male gender (61.8% vs 58.2%, p = 0.10), lung allocation score (43.4 vs 42.6, p = 0.32), forced expiratory volume in 1 second (FEV1; 41.2% vs 40.8%, p = 0.32), and ischemic time (4.2 vs 4.0 hours, p = 0.09), and donor age (34.4 vs 32.9, p = 0.07) and male gender (61.5 vs 65.5, p = 0.14). ABO-compatible donors were less likely to be race mismatched (58.3% vs 50.9%, p = 0.01). Median survival was not different (1,284.0 vs 1,540 days, p = 0.39). On multivariate analysis, lungs from ABO-compatible donors were not associated with mortality (hazard ratio, 1.02; 95% confidence interval, 0.85-1.22; p = 0.86). Prolonged ischemic time, increasing recipient creatinine, increasing recipient age, race mismatch, class I plasma reactive antigen panel > 10%, and the use of mechanical ventilation or extracorporeal membrane oxygenation were associated with mortality. Peak post-transplant FEV1 (64.5% vs 64.0%, p = 0.69) and decrement in FEV1 over time were similar (p = 0.82). CONCLUSIONS: This large multi-institutional analysis of ABO-compatible donors in single-lung transplantation demonstrates that careful selection of ABO-compatible donors results in excellent outcomes.

Continuous flow left ventricular assist device technology has influenced wait times and affected donor allocation in cardiac transplantation.

OBJECTIVE: Bridge to transplantation patients with continuous flow left ventricular assist devices (cfLVADs) are assigned United Network for Organ Sharing status 1A or 1B priority while awaiting orthotopic heart transplantation. We investigated the influence of cfLVAD on the waitlist times and organ allocation. METHODS: The United Network for Organ Sharing database was examined from 2005 to 2012 for patients with cfLVAD and pulsatile flow LVAD (pLVAD). These 2 cohorts were compared with patients who did not receive LVAD. RESULTS: Of 16,476 total orthotopic heart transplantations, 3270 (19.8%) were performed on patients with an LVAD as a bridge to transplantation. The cfLVAD group had the longest total waitlist time (259.6 days) compared with the pLVAD (134.6 days) and non-LVAD (121.7 days) groups (P < .001). The cfLVAD group spent more time in status 1A (44.7 days) than did the pLVAD (32.1 days) and non-LVAD (16.4 days) cohorts (P < .001). The median waitlist survival was better for the cfLVAD group (1234.0 days) than in the pLVAD (441.0 days) and non-LVAD (471.0 days) groups (P < .001). The cfLVAD recipients were older, had a greater body mass index, and more often had diabetes than did pLVAD and non-LVAD patients. The cfLVAD cohort received hearts from older, more often male donors, with a greater body mass index. Post-transplant survival was not significantly different among the 3 groups on Kaplan-Meier analysis (P = .12). CONCLUSIONS: Despite being older, less favorable recipients, the cfLVAD patients spent more time in status 1A and had greater waitlist survival. This might allow cfLVAD patients to receive preferred donor hearts, which might allow for better post-transplant survival.

Prehospital intubation does not decrease complications in the penetrating trauma patient.

Intubation in the prehospital setting does not result in a survival benefit in penetrating trauma. However, the effect of prehospital intubation (PHI) on the development of in-hospital complications has yet to be determined. The goal of this study was to determine if PHI in patients with penetrating trauma results in reduced mortality and in-hospital complications. Patient records for all Category 1 trauma activations as a result of penetrating injury admitted to our institution from 2006 to 2010 were reviewed. There were 1615 Category 1 trauma activations with 152 (9.8%) intubated in the field. A total of 1311 survived initial resuscitative efforts to permit hospital admission with 55 (4.2%) being intubated in the field. For patients surviving to admission, prehospital intubation was associated with increased mortality (hazard ratio, 8.266; 95% confidence interval [CI, 4.336 to 15.758; P < 0.001). After correcting for Injury Severity Score, PHI was not protective against pulmonary complications (odds ratio [OR], 0.724; 95% CI, 0.229 to 2.289; P = 0.582), deep vein thrombosis/pulmonary embolus (OR, 0.838; 95% CI, 0.281 to 2.494; P = 0.750), sepsis (OR, 0.572; 95% CI, 0.201 to 1.633; P = 0.297), wound infections (OR, 1.739; 95% CI, 0.630 to 4.782; P = 0.286), or complications of any kind (OR, 1.020; 95% CI, 0.480 to 2.166; P = 0.959). For victims of penetrating trauma, immediate transportation by emergency medical personnel may result in improved outcomes.

Impact of extracorporeal membrane oxygenation or mechanical ventilation as bridge to combined heart-lung transplantation on short-term and long-term survival.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV) can be used as a bridge to heart-lung transplantation (HLT). The goal of this study was to determine if pretransplantation ECMO or MV affects survival in HLT. METHODS: The United Network for Organ Sharing database was reviewed for all adult patients receiving HLT from 1995 to 2011. The primary outcome measured was risk-adjusted all cause mortality. RESULTS: There were 542 adult patients received HLT during the study period. Of these, 15 (2.8%) required ECMO and 22 (4.1%) required MV as a bridge to transplantation. The groups were evenly matched with regards to recipient age, recipient gender, ischemic time, donor age, and donor gender. The ECMO cohort had worse survival than the control group at 30 days (20.0% vs. 83.5%) and 5 years (20.0% vs. 47.4%; P<0.001). When compared with control, patients requiring MV had worse survival at 1 month (77.3% vs. 83.5%) and 5 years (26.5% vs. 47.4%; P<0.001). The use of ECMO (hazard ratio [HR]=3.820, 95% confidence interval [CI]=1.600-9.116; P=0.003) or MV (HR=2.011, 95% CI=1.069-3.784; P=0.030) as a bridge to transplantation was independently associated with mortality on multivariate analysis. Recipient female gender was associated with survival (HR=0.754, 95% CI=0.570-0.998; P=0.048). CONCLUSIONS: HLT recipients bridged by MV or ECMO have increased short-term and long-term mortality. Further studies are needed to optimize survival in these high-risk patients.

Surgical management of tricuspid valve endocarditis in systemically infected patients.

BACKGROUND AND AIM OF THE STUDY: Isolated bacterial tricuspid valve (TV) endocarditis is usually managed medically. Whilst the indications and optimal timing for surgical treatment of the condition have not been clearly defined, it is hypothesized that early surgery in patients who are bacteremic and/or have evidence of systemic seeding is superior to medical treatment. METHODS: All cases of isolated TV endocarditis reported between 2006 and 2011 at the authors' institution were reviewed. Patients with bacteremia and/or systemic seeding who were treated surgically after short-term medical therapy were compared to an equivalent group of patients who remained under long-term medical treatment only. RESULTS: A total of 45 patients with isolated TV endocarditis showed evidence of bacteremia and/or systemic seeding. Of these patients, 10 (22.2%) were treated surgically with valve repair or replacement, and 35 (77.8%) received long-term medical therapy only. The 30-day and one-year survival rates in both groups were comparable (100% versus 88.6%, p = 0.27). Patients treated surgically had clear blood cultures sooner (2.0 versus 6.7 days, p = 0.04), defervesced earlier (0 versus 9.0 days, p = 0.02), and demonstrated a complete resolution of TV vegetations (100% versus 30.0%, p = 0.003). Change in creatinine clearance (+22.1 versus +11.6 ml/min, p = 0.40) and durations of vasopressor support (6.8 versus 8.9 h, p = 0.86), mechanical ventilation (8.5 versus 32.2 h, p = 0.44), ICU stay (148.1 versus 53.8 h, p = 0.14) and total hospital stay (32.1 versus 24.6 days, p = 0.22) were not different between groups. Long-term echocardiogram surveillance demonstrated a higher prevalence of moderate-severe tricuspid regurgitation in the medically treated patients (75.0 versus 0.0%, p < 0.001). None of the patients treated surgically was readmitted with prosthetic valve endocarditis. CONCLUSION: Early surgery is warranted in patients with isolated TV endocarditis who are bacteremic and/or systemically infected despite optimal medical therapy.