The impact of the COVID-19 pandemic on cardiac surgery and transplant services in Ireland's National Centre.

BACKGROUND: Irish health services have been repurposed in response to the COVID-19 pandemic. Critical care services have been re-focused on the management of COVID-19 patients. This presents a major challenge for specialities such as cardiothoracic surgery that are reliant on intensive care unit (ICU) resources. AIM: The aim of this study was to evaluate the impact of the COVID-19 pandemic on activity at the cardiothoracic surgical care at the National Cardiothoracic Surgery and Transplant Centre. METHODS: A comparison was performed of cardiac surgery and transplant caseload for the first 4 months of 2019 and 2020 using data collected prospectively on a customised digital database. RESULTS: Cardiac surgery activity fell over the study period but was most impacted in March and April 2020. Operative activity fell to 49% of the previous years' activity for March and April 2020. Surgical acuity changed with 61% of all cases performed as inpatient transfers after cardiology admission in contrast with a 40% rate in 2019. Valve surgery continued at 89% of the expected rate; coronary artery bypass surgery was performed at 61% of the expected rate and major aortic surgery at 22%. Adult congenital heart cases were not performed in March or April 2020. One heart and one lung transplant were performed in this period. CONCLUSIONS: In March and April of 2020, the spread of COVID-19 and the resultant focus on its management resulted in a reduction in cardiothoracic surgery service delivery.

Evaluation of Risk Factors for Heart-Lung Transplant Recipient Outcome: An Analysis of the United Network for Organ Sharing Database.

BACKGROUND: Heart-lung transplantation (HLTx) is an effective treatment for patients with advanced cardiopulmonary failure. However, no large multicenter study has focused on the relationship between donor and recipient risk factors and post-HLTx outcomes. Thus, we investigated this issue using data from the United Network for Organ Sharing database. METHODS: All adult patients (age ≥18 years) registered in the United Network for Organ Sharing database who underwent HLTx between 1987 and 2017 were included (n=997). We stratified the cohort by patients who were alive without retransplant at 1 year (n=664) and patients who died or underwent retransplant within 1 year of HLTx (n=333). The primary outcome was the influence of donor and recipient characteristics on 1-year post-HLTx recipient death or retransplant. Kaplan-Meier curves were created to assess overall freedom from death or retransplant. To obtain a better effect estimation on hazard and survival time, the parametric Accelerated Failure Time model was chosen to perform time-to-event modeling analyses. RESULTS: Overall graft survival at 1-year post-HLTx was 66.6%. Of donors, 53% were male, and the mean age was 28.2 years. Univariable analysis showed advanced donor age, recipient male sex, recipient creatinine, recipient history of prior cardiac or lung surgery, recipient extracorporeal membrane oxygenation support, transplant year, and transplant center volume were associated with 1-year post-HLTx death or retransplant. On multivariable analysis, advanced donor age (hazard ratio [HR], 1.017; P=0.0007), recipient male sex (HR, 1.701; P=0.0002), recipient extracorporeal membrane oxygenation support (HR, 4.854; P<0.0001), transplant year (HR, 0.962; P<0.0001), and transplantation at low-volume (HR, 1.694) and medium-volume centers (HR, 1.455) in comparison with high-volume centers (P=0.0007) remained as significant predictors of death or retransplant. These predictors were incorporated into an equation capable of estimating the preliminary probability of graft survival at 1-year post-HLTx on the basis of preoperative factors alone. CONCLUSIONS: HLTx outcomes may be improved by considering the strong influence of donor age, recipient sex, recipient hemodynamic status, and transplant center volume. Marginal donors and recipients without significant factors contributing to poor post-HLTx outcomes may still be considered for transplantation, potentially with less impact on the risk of early postoperative death or retransplant.

State of the Art of Combined Heart-Lung Transplantation for Advanced Cardiac and Pulmonary Dysfunction.

Over the last several decades, significant advances and improvements in care of transplant patients have resulted in markedly improved outcomes. A number of options are available for patients with advanced cardiopulmonary dysfunction requiring transplantation. There is a debate about when isolated heart or isolated lung transplantation is no longer possible or advisable and combined heart-lung transplantation is justified. Organ availability and allocation severely limit the latter option to very few well-selected patients. We review practice patterns, trends, and outcomes after triple-organ heart-lung transplant (HLTx) worldwide, as well as our own experience with heart-lung transplant in the modern era.

Combined heart-lung transplantation: a perspective on the past and the future.

During the last 20 years, there has been a shift away from combined heart-lung transplantation (HLT) in favor of bilateral lung transplantation. This paradigm shift allowed for the donor heart to be transplanted to another patient. However, HLT remains to be the definitive surgical treatment for certain congenital heart disorders and Eisenmenger's syndrome. With a growing population of adult patients with congenital heart disease, there remains a need for HLT. This article provides a perspective on the past and the future of HLT.

My approach to cardiothoracic transplantation and the role of the histocompatibility and immunogenetics laboratory in a rapidly developing field.

Cardiothoracic transplantation presents specific challenges. The lack of long-term replacement therapy (such as dialysis for kidney patients) creates a more urgent situation than for other forms of transplantation, necessitating a different approach. This review looks at ways in which the challenges are being met and the integral role of the histocompatibility and immunogenetics laboratory.

Trend in lung transplantation in the U.S.: an analysis of the UNOS registry.

The number of lung transplants continues to increase in the U.S. The most significant change over the last decade occurred after the 2005 implementation of LAS. When the percentage of patients being transplanted increased even further, while time-to-transplant and the number of patients dying on the waiting list significantly declined. As a result of implementation of LAS in 2005, IPF recipients became the largest group to receive a lung transplant. And the number of transplants for patients age 60 and over has increased significantly. The number of DL transplants performed yearly increased while the number of SL transplants has remained relatively consistent throughout the last decade. Though the gender distribution of recipients has fluctuated each year, the proportion of females receiving lung transplant has decreased. Of the deceased-donor DL and SL transplant recipients, 69% had a cold ischemia time between 3-6 hrs. And 79% of primary DL and SL transplant recipients had a 0% PRA. 6. A higher number of HLA mismatches impacts unfavorably on graft survival rates; yet, surprisingly, zero HLA A-B-DR MM also have an unfavorable impact; Recipients with less than two hours of cold ischemia-time (n = 815, 4.3%) have the worst five-year graft survival; PRA levels greater than 25% have an unfavorable impact on graft survival.

Heart and lung transplantation in the United States, 1996-2005.

This article examines the Organ Procurement and Transplantation Network/Scientific Registry of Transplant Recipients data on heart and lung transplantation in the United States from 1996 to 2005. The number of heart transplants performed and the size of the heart waiting list continued to drop, reaching 2126 and 1334, respectively, in 2005. Over the decade, post-transplant graft and patient survival improved, as did the chances for survival while on the heart waiting list. The number of deceased donor lung transplants increased by 78% since 1996, reaching 1407 in 2005 (up 22% from 2004). There were 3170 registrants awaiting lung transplantation at the end of 2005, down 18% from 2004. Death rates for both candidates and recipients have been dropping, as has the time spent waiting for a lung transplant. Other lung topics covered are living donation, recent surgical advances and changes in immunosuppression regimens. Heart-lung transplantation has declined to a small (33 procedures in 2005) but important need in the United States.

Current status of lung transplantation in Poland: experience of the Silesian Center for Heart Diseases.

Until the year 2001, lung transplantation was not available in Poland, as the only one among other kinds of solid organs transplantation. In 2001, in the Silesian Center for Heart Diseases the first successful combined heart-lung-one-block transplantation was performed. In 2003 and 2004, a successful single lung transplantation in Poland was performed in our center. Here the authors presented their experience with lung transplantation including the indications for specific types of transplantation, the immunosuppressive regimen, the management of early and late stages after lung transplantation, the infection complications, and the current problems with lung transplantation progress.

Current concepts and controversies in lung transplantation.

This article reviews the history of organ transplantation, specifically focusing on the advances leading to the first successful human lung transplant. It also provides an overview of the com-mon indications and general selection criteria for lung transplant recipients, highlights areas of current controversy in pulmonary transplantation, reviews current approaches to posttransplantation immunosuppression, and discusses common complications seen intransplant recipients.

Thoracic organ transplantation.

This article presents an overview of factors associated with thoracic transplantation outcomes over the past decade and provides valuable information regarding the heart, lung, and heart-lung waiting lists and thoracic organ transplant recipients. Waiting list and post-transplant information is used to assess the importance of patient demographics, risk factors, and primary cardiopulmonary disease on outcomes. The time that the typical listed patient has been waiting for a heart, lung, or heart-lung transplant has markedly increased over the past decade, while the number of transplants performed has declined slightly and survival after transplant has plateaued. Waiting list mortality, however, appears to be declining for each organ and for most diseases and high-severity subgroups, perhaps in response to recent changes in organ allocation algorithms. Based on perceived inequity in organ access and in response to a mandate from Health Resources and Services Administration, the lung transplant community is developing a lung allocation system designed to minimize deaths on the waiting list while maximizing the benefit of transplant by incorporating post-transplant survival and quality of life into the algorithm. Areas where improved data collection could inform evolving organ allocation and candidate selection policies are emphasized.

Current status of paediatric heart, lung, and heart-lung transplantation.

Since the first successful heart transplantation by Christian Barnard in 1967, there have been over 60 000 heart transplants performed worldwide. Around 350 paediatric heart transplants are now performed annually and approximately 10% of these are in the UK.