Socioeconomic deprivation is not associated with reduced survival of lung transplant recipients.

BACKGROUND: Important risk factors for long-term survival of lung transplant (LT) recipients are infection, acute graft rejection (AR) and chronic lung allograft dysfunction (CLAD). Socioeconomic deprivation (SED) is associated with increased graft failure rate after heart and kidney transplantation, but has not been investigated in LT recipients. The aim of this study was to evaluate an association between LT recipients' SED status and development of AR, CLAD, and long-term survival. METHODS: This was a retrospective cohort study. Over a 23 y period, 233 patients were identified from the Auckland City Hospital Lung Transplant Registry, Auckland, New Zealand. All patients were divided into two groups according to the 2013 New Zealand Deprivation Index Score. RESULTS: The incidence of AR in the higher SED group was 34.0/100 person-y (95% confidence interval [CI]: 24.7-46.7/100 person-y) and in the lower SED group 40.2/100 person-y (95% CI: 33.5-48.3/100 person-y) (P = 0.373). The incidence of CLAD in the higher SED group was 10.7/100 person-y (95% CI: 6.2-18.4/100 person-y) and 9.3 (6.9-12.5/100 person-y) in the lower SED group (P = 0.645). Mortality in the higher SED group was 12.9/100 person-y (95% CI: 9.2-17.9/100 person-y) and 12.4/100 person-y (95% CI: 10.0-15.3/100 person-y) in the lower SED group (P = 0.834). CONCLUSIONS: SED status of LT recipients in New Zealand has no negative effect on development of AR, CLAD, and patients' survival.

Isolated mediastinal adenopathy: the case for mediastinoscopy.

BACKGROUND: We report our experience with mediastinoscopy at Auckland city hospital, a tertiary referral centre. We wished to examine correlations between clinical diagnosis and that made by histological sampling of enlarged mediastinal nodes particularly in patients with isolated mediastinal adenopathy. METHODS: We retrospectively reviewed clinical records of all patients who underwent mediastinoscopy in a five year period, mediastinoscopy was performed in the presence of enlarged lymph nodes (short axis > 1cm) found at CT. Mediastinoscopy was indicated for diagnostic staging of mediastinal adenopathy related to a parenchymal lung mass, diagnosis of isolated mediastinal adenopathy and diagnosis of mediastinal adenopathy with other CT findings. Data relating to indication, pre-test diagnosis, node stations sampled, histology, and operative complications were collected. RESULTS: Mediastinoscopy was performed in 137 consecutive patients. Seventy five patients had a lung mass, 47 had isolated mediastinal adenopathy and 15 had other CT findings. One operative complication occurred. In those patients with isolated adenopathy the following diagnoses were reached; sarcoidosis 23, TB 15, lymphoma 4, carcinoma 4, no diagnosis 1. Final diagnosis was significantly associated with patient's ethnicity. There was high sensitivity and specificity on comparison of clinical and histological diagnosis for both TB and sarcoidosis cases. CONCLUSIONS: Mediastinoscopy proved to be safe and effective in nodal assessment of the mediastinum. In carefully selected cases procedural morbidity and mortality may be avoided by application of features related to patient's ethnicity and radiological findings.

Repair of injuries to the thoracic aorta and great vessels: Auckland, New Zealand 1995-2004.

BACKGROUND: Traumatic injury to the aorta and great vessels is a surgical emergency with survivors who reach hospital typically having suffered multiple injuries. There are several diagnostic and treatment options available, with new modalities emerging to challenge the gold standards. A review of recent trends in management of these injuries in Auckland, New Zealand was carried out and patient outcomes assessed. METHODS: The charts of patients admitted to Auckland and Green Lane Hospital's cardiothoracic intensive care unit, with a diagnosis of injury to the thoracic aorta or great vessels since 1995 were retrospectively reviewed. Imaging techniques, injury types and treatment methods were analysed along with survival and neurological morbidity. RESULTS: In the study period our unit operated on 29 cases of traumatic rupture of the thoracic aorta or great vessels. Digital subtraction angiography and more recently, multidetector computed tomography scanning have been used to diagnose the injury. Twenty-seven injuries were to the aorta and two to the innominate artery. The 30-day survival rate of those reaching the operating theatre was 90%. There was one case of postoperative hemiparesis and five cases of recurrent laryngeal nerve injury, but none of spinal cord ischaemic injury. Endoluminal stent grafting was carried out for one patient, without complication. CONCLUSIONS: Good survival rates exist for those who reach surgery for traumatic rupture of the aorta or great vessels. Multidetector computed tomography scanning is an alternative to digital subtraction angiography, potentially reducing treatment delay. In addition endoluminal grafting as opposed to open repair has been reported as a safe technique. The injury remains a surgical emergency requiring urgent diagnosis and transfer to an equipped cardiothoracic unit for definitive treatment.

Changing donor and recipient demographics in a heart transplantation program: influence on early outcome.

BACKGROUND: The purpose of this study was to investigate whether broadening acceptance criteria for donor hearts and changing recipient demographics resulted in an increased perioperative morbidity and mortality in a heart transplant program. METHODS: Donor and recipient data of 137 consecutive heart transplants performed from 1987 to 2001 were retrospectively analyzed and divided into three equal eras, each of 5 years: 1987 to 1991, 1992 to 1996, and 1997 to 2001. Multivariate analyses of recipient and donor demographics and operative factors were performed to identify the predictors of low cardiac output, intraaortic balloon pump utilization, 30-day mortality, and duration of intensive care and hospital stay. RESULTS: Significant increases in number of female recipients (p = 0.025), cardiopulmonary bypass (p < 0.001), recipient cross-clamp (p < 0.001), donor age (p = 0.009), donor ischemic times (p < 0.001), use of cardioplegia (p < 0.001) and the bicaval technique (p < 0.001), brain death to retrieval time (p = 0.006), and need for postoperative dialysis were observed for the three study periods, whereas length of intensive care and hospital stay decreased. Female donor (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.0 to 5.7) was identified as a risk factor for low cardiac output. Female donor (OR, 3.7; 95% CI, 1.3 to 10.7), donor cardiac arrest (OR, 6.4; 95% CI, 1.6 to 25.9), and cardiopulmonary bypass time more than 2 hours (OR, 7.6; 95% CI, 2.1 to 28.1) were associated with increased intraaortic balloon pump utilization. Intensive care stay was prolonged by the biatrial technique (OR, 3.9; 95% CI, 1.3 to 11.9) and reduced by the use of cardioplegia (OR, 0.3; 95% CI, 0.1 to 0.9), longer cardiopulmonary bypass (OR, 0.2; 95% CI, 0.1 to 0.6) and aortic cross-clamp times (OR, 0.1; 95% CI, 0.03 to 0.6). CONCLUSIONS: Although a number of significant changes were observed during the study period, no donor, recipient, or operative factors influenced 30-day mortality. This study justifies our current donor and recipient selection policies.

Pediatric experience with the VentrAssist LVAD.

PURPOSE: The purpose of this study is to describe the first experience of implanting a new left ventricular assist device in pediatric patients with end-stage heart failure. DESCRIPTION: In two recent prospective, international, multicenter clinical trials, three children (aged

Mediastinal and pulmonary metastases of malignant ossifying fibromyxoid tumor.

Ossifying fibromyxoid tumor is usually a benign tumor. However some of these tumors with histologic and clinical evidence of malignancy have also been reported and little information is available regarding surgery for metastatic ossifying fibromyxoid tumor. We present a case involving extensive excision of a huge metastatic ossifying fibromyxoid tumor occupying the upper mediastinum and upper half of the right hemithorax.

Biatrial or bicaval technique for orthotopic heart transplantation: which is better?

BACKGROUND: Orthotopic heart transplantation was done by the biatrial technique initially and the bicaval technique has become popular recently. AIMS: This study aims to determine if bicaval technique is advantageous. METHODS: Consecutive transplants performed between 1996 and 2001 were divided into two groups-37 patients done by bicaval and 38 by biatrial technique. Data accumulation was by retrospective study of patient charts. RESULTS: Both groups had similar preoperative variables. There were no differences in low cardiac output (18.9% versus 26.3%, p = 0.62), intraaortic balloon pump insertion (16.2% versus 15.7%, p = 1.0), re-exploration (13.5% versus 18.4%, p = 0.79) and perioperative mortality (5.4% versus 7.9%, p = 1.0) in the bicaval versus biatrial groups. Temporary (13.5% versus 39.4%, p = 0.15) and permanent pacing (0 versus 3 patients) tended to be less frequent and central venous pressure measured at 1-week was lower in the bicaval group (mean 13.8 +/- 6cm versus 14.9 +/- 5.4cm, p = 0.42), but not attaining statistical significance. Severe tricuspid regurgitation was seen in one bicaval versus five biatrial patients at follow-up. CONCLUSIONS: Though bicaval group tended to require less pacing, had less tricuspid regurgitation and had lower central venous pressures, these did not attain statistical significance. There were otherwise no obvious differences in outcome. SHORT ABSTRACT: Seventy five consecutive orthotopic heart transplantations done during the period 1996-2001 by bicaval or biatrial surgical technique were compared. There was no difference in low cardiac output, intraaortic balloon pump insertion and mortality but the bicaval patients tended to have less pacing and diuretic requirements and lower central venous pressures, though not attaining statistical significance.