Synthesis and crystal structure of a new chiral α-amino-oxime nickel(II) complex.

A dinuclear nickel complex with (S)-limonene based amino-oxime ligand has been isolated and its crystal structure determined. The resolved structure of dichloridobis-{(2S,5R)-2-methyl-5-(prop-1-en-2-yl)-2-[(pyridin-2-yl)methyl-amino]-cyclo-hexan-1-one oxime}dinickel(II), [Ni2Cl2(C16H23ClN3O)2], at 100 K has monoclinic (P21) symmetry. The two NiII ions in the dinuclear complex are each coordinated in a distorted octa-hedral environment by three nitro-gen atoms, a terminal chloride and two µ bridging chlorides. Each oxime ligand is coordinated to nickel(II) by the three nitro-gen atoms, leading to two five-membered chelate rings, each displaying an envelope conformation. In the crystal, numerous inter-molecular and intra-molecular hydrogen bonds lead to the formation of a three-dimensional network structure.

Rare and unusual case of anti-factor XI antibodies in patient with plasma cell leukemia.

BACKGROUND: The acquired inhibitors of coagulation have been observed in very rare cases of monoclonal gammopathies. We report a very rare case of anti-factor XI antibodies in patient with plasma cell leukemia (PCL). CASE PRESENTATION: This is a 59-year-old male patient without pathological history, admitted to the nephrology department for management of renal insufficiency and anemia syndrome. The history and physical examination revealed stigmata of hemorrhagic syndrome including hemothorax and hemoptysis. The hemostasis assessment showed an isolated prolonged activated partial thromboplastin time (APTT) with APTT ratio = 2.0.The index of circulating anticoagulant (37.2%) revealed the presence of circulating anticoagulants. The normalized dilute Russell viper venom time ratio of 0.99 has highlighted the absence of lupus anticoagulants. The coagulation factors assay objectified the decrease of the factor XI activity corrected by the addition of the control plasma confirming the presence of anti-factor XI autoantibodies. In addition, the blood count showed bicytopenia with non-regenerative normocytic normochromic anemia and thrombocytopenia. The blood smear demonstrated a plasma cell count of 49% (2842/mm3) evoking PCL. The bone marrow was invaded up to 90% by dystrophic plasma cells. The biochemical assessment suggested downstream renal and electrolyte disturbances from exuberant light chain production with abnormalities including hyperuricemia, hypercalcemia, elevated lactate dehydrogenase, non nephrotic-range proteinuria and high level of C reactive protein. The serum protein electrophoresis showed the presence of a monoclonal peak. The serum immunofixation test detects the presence of monoclonal free lambda light chains. He was treated with velcade, thalidomide and dexamethasone. The patient died after 2 weeks despite treatment. CONCLUSION: Both PCL and anti-factor XI inhibitors are two very rare entities. To the best of our knowledge, this is the first reported case of a factor XI inhibitor arising in the setting of PCL. Factor inhibitors should be suspected in patients whose monoclonal gammopathies are accompanied by bleeding manifestations.

Comparison of Outcomes of Coronary Artery Bypass Grafting Using Internal Mammary Graft Versus Percutaneous Coronary Intervention for Isolated Proximal Left Anterior Descending Narrowing.

There are limited contemporary studies comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for isolated proximal left anterior descending (LAD) disease. Increasing stent length and decreasing stent diameters are associated with increased risk of restenosis and adverse outcomes after PCI. Whether these parameters influence outcomes when comparing CABG and PCI is unclear. We compared CABG and PCI in 3,473 patients who underwent revascularization for isolated proximal LAD disease from 2004 to 2015 at Harefield Hospital, UK; 3,078 patients (89%) had PCI and 384 patients had CABG (11%). We analyzed all-cause mortality at 3 years. The unadjusted mortality rates were similar (PCI vs CABG: 9.5% vs 7.0%, p = 0.109). PCI was associated with comparable mortality (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.70 to 1.89, p = 0.593), even when stratified to bare-metal stents (HR 1.58, 95% CI 0.89 to 2.80, p = 0.121); first-generation drug-eluting stents (FDES; HR 1.16, 95% CI 0.67 to 2.02, p = 0.597); and second-generation DES (SDES; HR 0.98, 95% CI 0.53 to 1.82, p = 0.946). Stent diameters did not influence outcomes, but PCI was associated with higher mortality when stent length ≥30 mm (HR 2.12, 95% CI 1.12 to 4.03, p = 0.022). There was a linear association between stent length and mortality, and for every 1-mm increase in stent length, the 3-year mortality increased by 0.32%. In conclusion, for patients with isolated proximal LAD disease, PCI and CABG were associated with similar mortality. Increasing stent length was progressively associated with worse outcomes with PCI. For longer segments of disease requiring stent lengths ≥30 mm, CABG may be associated with better outcomes.

Outcomes of minimally invasive lung transplantation in a single centre: the routine approach for the future or do we still need clamshell incision?

OBJECTIVES: Minimally invasive lung transplantation (MILT) via bilateral anterior thoracotomies has emerged as a novel surgical strategy with potential patient benefits when compared with transverse thoracosternotomy (clamshell incision, CS). The aim of this study is to compare MILT with CS by focusing on operative characteristics, postoperative organ function and support and mid-term clinical outcomes at Harefield Hospital. METHODS: It was a retrospective observational study evaluating all bilateral sequential lung transplants between April 2010 and November 2013. RESULTS: CS was performed in 124 patients and MILT in 70 patients. Skin-to-skin surgical time was less in the MILT group [285 (265, 339) min] compared with CS [380 (306, 565) min] and MILT-cardiopulmonary bypass [426 (360, 478) min]. Ischaemic time was significantly longer (502 ± 116 vs 395 ± 145 min) in the MILT group compared with CS (P < 0.01). Early postoperative physiological variables were similar between groups. Patients in the MILT group required less blood [2 (0, 4) vs 3 (1, 5) units, P = 0.16] and platelet transfusion [0 (0, 1) vs 1 (0, 2) units, P < 0.01]. The median duration of mechanical ventilation was shorter (26 vs 44 h, P < 0.01) and intensive therapy unit stay was 2 days shorter (5 vs 7) in the MILT group. While overall survival was similar, fraction of expired volume in 1 s (FEV1) and forced vital capacity (FVC) were consistently higher in the MILT group compared with CS during mid-term follow-up after transplantation. Specifically, FEV1 and FVC were, respectively, 86 ± 21 and 88 ± 18% predicted in the MILT group compared with 74 ± 21 and 74 ± 19% predicted in the CS group (P < 0.01) at the 6-month follow-up. CONCLUSIONS: MILT was successfully introduced at our centre as a novel operative strategy. Despite longer ischaemic times and a more complex operation and management, MILT appears to offer early postoperative and mid-term clinical benefits compared with our traditional approach of clamshell operations. These observations warrant larger definite studies to further evaluate the impact of MILT on physiological, clinical and patient-reported outcomes.

Long-term results after lung transplantation using organs from circulatory death donors: a propensity score-matched analysis†.

OBJECTIVES: Due to organ shortage in lung transplantation (LTx), donation after circulatory death (DCD) has been implemented in several countries, contributing to an increasing number of organs transplanted. We sought to assess long-term outcomes after LTx with organs procured following circulatory death in comparison with those obtained from donors after brain death (DBD). METHODS: Between January 2007 and November 2013, 302 LTxs were performed in our institution, whereby 60 (19.9%) organs were retrieved from DCD donors. We performed propensity score matching (DCD:DBD = 1:2) based on preoperative donor and recipient factors that were significantly different in univariate analysis. RESULTS: After propensity matching, there were no statistically significant differences between the groups in terms of demographics and preoperative donor and recipient characteristics. There were no significant differences regarding intraoperative variables and total ischaemic time. Patients from the DCD group had significantly higher incidence of primary graft dysfunction grade 3 at the end of the procedure (P = 0.014), and significantly lower pO2/FiO2 ratio during the first 24 h after the procedure (P = 0.018). There was a trend towards higher incidence of the need for postoperative extracorporeal life support in the DCD group. Other postoperative characteristics were comparable. While the overall cumulative survival was not significantly different, the DCD group had significantly poorer results in terms of bronchiolitis obliterans syndrome (BOS)-free survival in the long-term follow-up. CONCLUSIONS: Long-term results after LTx with organs procured following DCD are in general comparable with those obtained after DBD LTx. However, patients transplanted using organs from DCD donors have a predisposition for development of BOS in the longer follow-up.

Does postoperative blood pressure influence development of aortic regurgitation following continuous-flow left ventricular assist device implantation?†.

OBJECTIVES: The true impact of postoperative blood pressure (BP) control on development of aortic regurgitation (AR) following continuous-flow left ventricular assist device (CF-LVAD) implantation remains uncertain. This study examines the influence of BP in patients with de novo AR following CF-LVAD implantation. METHODS: All patients with no or

Preoperative predictors and outcomes of right ventricular assist device implantation after continuous-flow left ventricular assist device implantation.

OBJECTIVE: The outcomes of ventricular assist device therapy remain limited by right ventricular failure. We sought to define the predictors and evaluate the outcomes of right ventricular failure requiring right ventricular assist device support after long-term continuous-flow left ventricular assist device implantation. METHODS: Records of all continuous-flow left ventricular assist device recipients for the last 10 years were analyzed, including patients on preoperative intra-aortic balloon pump, extracorporeal membrane oxygenation, and short-term ventricular assist device support. Perioperative clinical, echocardiographic, hemodynamic, and laboratory data of continuous-flow left ventricular assist device recipients requiring right ventricular assist device support (right ventricular assist device group) were compared with the rest of the patient cohort (control group). RESULTS: Between July 2003 and June 2013, 152 patients underwent continuous-flow left ventricular assist device implantation as a bridge to transplantation. The overall postoperative incidence of right ventricular assist device support was 23.02% (n = 35). Right ventricular assist device implantation did not significantly affect eventual transplantation (P = .784) or longer-term survival (P = .870). Preoperative right ventricular diameter (P < .001), tricuspid annular plane systolic excursion (P < .001), previous sternotomy (P = .002), preoperative short-term mechanical support (P = .005), left atrial diameter (P = .014), female gender (P = .020), age (P = .027), and preoperative bilirubin levels (P = .031) were univariate predictors of right ventricular assist device implantation. Multivariate analysis revealed lesser tricuspid annular plane systolic excursion (P = .013; odds ratio, 0.613; 95% confidence interval, 0.417-0.901) and smaller left atrial diameter (P = .007; odds ratio, 0.818; 95% confidence interval, 0.707-0.947) as independent predictors of right ventricular assist device implantation. Receiver operating characteristic curve of tricuspid annular plane systolic excursion yielded an area under the curve of 0.85 (95% confidence interval, 0.781-0.923), with cutoff tricuspid annular plane systolic excursion less than 12.5 mm having 84% sensitivity and 75% specificity. CONCLUSIONS: Lesser tricuspid annular plane systolic excursion and smaller left atrial diameter are independent predictors of the need for right ventricular assist device support after continuous-flow left ventricular assist device implantation. Right ventricular assist device implantation does not adversely affect eventual transplantation or survival after continuous-flow left ventricular assist device implantation.

Propensity Score Adjusted Comparison of MIDCAB Versus Full Sternotomy Left Anterior Descending Artery Revascularization.

OBJECTIVE: Minimally invasive direct coronary artery bypass (MIDCAB) has been proposed as an attractive alternative to full sternotomy (FS) revascularization in isolated left anterior descending (LAD) artery disease not suitable for percutaneous coronary intervention. However, surgeons are still reluctant to perform MIDCAB owing to concerns about early and late outcomes. We aimed to compare short- and long-term outcomes after MIDCAB versus FS revascularization. METHODS: Prospectively collected data from institutional database were reviewed. Data for late mortality were obtained from the General Register Office. MIDCAB was performed in 318 patients, whereas 159 had FS, according to the surgeon's preference, among 477 patients with isolated LAD disease. Inverse propensity score weighting was used to estimate treatment effects on short- and long-term outcomes. RESULTS: In the propensity score-adjusted analysis, FS revascularization versus MIDCAB was associated increased rate of surgical site infection [4 (2.8%) versus 1 (0.7%); P = 0.04]. The 2 groups did not significantly differ with regard to other complications including operative mortality. Mean length of hospital stay was similar for the 2 groups. After a mean follow-up time of 6.2 years (interquartile range, 3.5-9.7 years), compared to MIDCAB, FS was not associated with an improved late survival (ß coef, -1.42; standard error, 1.65; P = 0.39) or risk reduction for repeat revascularization (ß coef, 1.22; standard error, 1.41; P = 0.15). CONCLUSIONS: MIDCAB was associated with a trend toward better short-term outcomes and excellent long-term results comparable to FS revascularization. According to these findings, surgeons should not be reluctant to perform MIDCAB in isolated LAD disease.

Multiple arterial grafting confers survival advantage compared to percutaneous intervention with drug-eluting stents in multivessel coronary artery disease: A propensity score adjusted analysis.

BACKGROUND: The best revascularisation strategy for multivessel coronary artery disease (MVD) is still controversial. Percutaneous coronary intervention (PCI) utilising drug eluting stents (DES) has emerged as an acceptable alternative to conventional coronary artery bypass grafting (CABG) in the last decade. However, multiple arterial grafting (MAG) is superior revascularisation strategy compared with conventional CABG utilising single internal mammary artery and currently there is a paucity of comparison of DES and MAG. We aimed to investigate whether MAG offers advantage over DES-PCI in MVD. METHODS: A total of 6126 patients with MVD (≥ 2 vessel) underwent CABG (n = 4652) or PCI (n = 1474) at a single institution. MAG was performed in 1372 CABG cases and DES were implanted in 1222 PCI cases. Propensity score adjusted analysis was performed to investigate the potential survival advantage of MAG over PCI. Mean follow-up was 4.9 years. RESULTS: Risk for late death was comparable after DES-PCI and conventional CABG (HR 1.11; 95%CI 0.9 to 1.33; P = 0.25). However, DES-PCI was associated with an increased risk for late death compared to MAG (HR 1.53; 95%CI 1.08 to 2.91; P = 0.02). DES-PCI was also associated with a 3.51 fold increased risk for repeat revascularisation over MAG (95%CI 2.60 to 4.75; P < 0.0001) and 2.66 fold increased risk for repeat revascularisation over conventional CABG (95%CI 2.11 to 3.36; P < 0.0001). CONCLUSIONS: MAG improved late survival and offered superior freedom from repeat revascularisation compared to DES-PCI. When feasible, MAG should be strongly recommended in patients with MVD.

Extracorporeal life support in patients with refractory cardiogenic shock: keep them awake.

OBJECTIVES: Traditionally, patients on extracorporeal life support (ECLS) are sedated and mechanically ventilated and therefore prone to complications related to immobility and ventilation. We adopted this 'Awake ECLS' strategy for the patients with refractory cardiogenic shock (RCS) as a bridge to decision. METHODS: Sixty-eight patients with RCS were supported by ECLS (All veno-arterial) in years 2010-2014. Patients that could not survive 24 h after ECLS implantation (9 patients) were excluded from the study. Study population constituted 59 patients-'Awake' group (n = 18; maintained awake without intubation) and 'Control' group (n = 41; intubated and required mechanical ventilation). RESULTS: Nine (50%) patients were awake at implantation, with 5 of them remaining free of sedation and ventilator support through to explantation. Nine patients were ventilated at the time of implantation but subsequently extubated and remained non-intubated and ventilator free. Post-ECLS survival at 1 month was 78 and 42% while the survival to discharge was 78 and 37% in awake and control group, respectively. CONCLUSIONS: ECLS as a bridge to decision in RCS is effective in restoring adequate systemic perfusion and recovering end-organ function. ECLS can be initiated in awake patients with RCS and patients can be awakened on ECLS. The 'awake ECLS' strategy may avoid complications related to mechanical ventilation, sedation and immobilization. RCS patients supported on ECLS without severe metabolic acidosis, multiorgan failure, intra-aortic balloon pump or uncertain neurological status are more likely to be weaned from the ventilator. Patients that are awake at the time of ECLS implantation are more likely to remain awake during ECLS.

Survival probability loss from percutaneous coronary intervention compared with coronary artery bypass grafting across age groups.

BACKGROUND: Whether the survival benefit from coronary artery bypass grafting (CABG), compared with percutaneous coronary intervention (PCI), for multivessel disease extends to the older segment of the population remains unclear. We aimed to investigate whether the effect on survival of PCI compared with CABG is related to the age of the patient. METHODS: Propensity score-matching analysis was conducted on 6723 patients (PCI = 1097, CABG = 5626) with multivessel coronary artery disease. In the PCI group, drug-eluting stents were used in 917 (83.5%) patients; bare metal stents were used in only 180 patients (16.5%). Nonparametric, bootstrap, point-wise confidence limits were obtained for PCI:CABG odds and hazard ratios for early (within 12 months) and late hazard phase (beyond 12 months) for a variety of age groups. RESULTS: After a mean follow-up time of 5.5 ± 3.2 years, a total of 301 deaths were recorded in the matched sample (208 in the PCI group and 93 in the CABG group). Overall survival was 95% ± 0.6% versus 95% ± 0.6% at 1 year, 84% ± 1.0% versus 92.4% ± 0.8% at 5 years, and 75% ± 1.6% versus 90% ± 1.0% at 8 years, for the PCI and CABG groups, respectively (log rank P < .001). PCI did not confer any significant benefit compared with CABG during the early hazard phase (within 12 months), but the survival-probability loss from PCI compared with CABG during the late hazard phase was present across all age groups. The hazard ratio declined from 3.8 to 3.4 and was statistically significant (lower limit >1 across all ages, ranging from 1.5 to 2.4). CONCLUSIONS: Compared with PCI, CABG leads to a significant reduction in late-phase mortality across all age groups.

Right internal mammary artery versus radial artery as second arterial conduit in coronary artery bypass grafting: a case-control study of 1526 patients.

OBJECTIVE: Additional arterial grafts such as the right internal mammary artery (RIMA) or the radial artery (RA) have been proposed to improve long term outcomes in coronary artery bypass grafting (CABG). RA is largely preferred over RIMA as it is less technically demanding and there is a perception that bilateral IMA usage increases the risk of sternal wound complications. However, there is a paucity of direct comparison of the two conduits to guide surgeons to choose the best second arterial conduit for CABG. METHODS: A propensity score adjusted analysis of patients undergoing multiple arterial grafting with RIMA (n = 747) and RA (n = 779) during the study period (2001-2013) was conducted to investigate the impact of the two strategies on early and late outcomes. RESULTS: RIMA did not increase the incidence of postoperative complications including deep sternal wound infection (P = 0.8). Compared to the RIMA, the RA was associated with an increased risk for late mortality (Hazard Ratio [HR] 1.9; 95% confidence interval (CI) 1.2-3.1; P = 0.008) and repeat revascularization (HR 1.5; 95% CI 1.0-2.2; P = 0.044). A trend towards an extra risk for late mortality from RA over RIMA was observed among diabetic (HR 3.3; 95% CI 1.1-9.7) and obese patients (HR 2.1; 95% CI 0.8-5.46). CONCLUSIONS: RIMA as a second conduit did not increase the operative risk including sternal wound complications and improved long term outcomes including overall survival when compared to RA. This advantage was stronger among diabetic and obese patients. These findings strongly support RIMA as the first choice second arterial conduit in CABG. Further randomized studies with angiographic control and long-term follow-up are needed to address this issue.

A UK Single Centre Retrospective Analysis of the Relationship between Haemodynamic Changes and Outcome in Patients Undergoing Prolonged Left Ventricular Assist Device Support.

PURPOSE: Despite their efficacy, LVADs remain associated with serious complications. The relationship between haemodynamic changes during support and outcome remains inadequately characterised. This association was investigated in LVAD recipients undergoing prolonged support. METHODS: Forty patients receiving LVAD therapy for >2 years were reviewed retrospectively (mean support duration was 38.62 ± 15.28). Pre- and on-LVAD haemodynamic data were assessed in three groups: (1) those receiving ongoing support (n = 24); (2) those who underwent cardiac transplantation (n = 4); (3) those who died during support (n = 12). RESULTS: For group 1 and 2, LVAD support achieved a decrease in mean PAP, mean PCWP, TPG, and PVR and an increase in thermodilution blood flow (TBF) with significance at ≤5% level. For group 3, there were non-significant changes in TPG and PVR at the 5% level but for mean PAP, mean PCWP, and TBF the changes were similar to Groups 1 and 2 with significance at ≤5% level. Aggregated data from all three groups showed a 58% increase in TBF on LVAD support. CONCLUSION: Highly significant and favourable haemodynamic changes were found. However, group 3 did not undergo decrease in TPG and PVR possibly because of suboptimal LVAD flow, right heart dysfunction and unavoidable prolongation of support.

Impact of the second internal thoracic artery on short- and long-term outcomes in obese patients: a propensity score matched analysis.

OBJECTIVES: A limited number of patients undergoing coronary artery bypass grafting (CABG) currently receive bilateral internal thoracic arteries (BITA) as a consequence of lack of evidence on survival benefit and concerns about sternal wound complications. This study was undertaken to determine the impact of BITA grafting on short- and long-term outcomes in obese patients. METHODS: Propensity score matching for short- and long-term outcomes was conducted for 1522 obese (body mass index ≥ 30 kg/m(2)) patients undergoing CABG using BITA (n = 229, 15.0%) or a single internal thoracic artery (SITA, n = 1293, 85.0%). RESULTS: Propensity score matching created 229 matching sets. In the matched sample, operative mortality (within 30 days) occurred in 3 (1.3%) and 4 (1.7%) patients in the BITA and SITA groups, respectively (P = 1). Deep sternal wound infection occurred in 6 (2.6%) and 2 (0.9%) patients (P = .2) in the BITA and SITA group, respectively. After a median follow-up of 4.5 ± 3.3 years, the use of BITA was associated with an improved late survival (hazard ratio [HR], 0.35; 95% confidence interval [CI], 0.13-0.97; P = .03) and a reduced need for repeat revascularization (HR, 0.45; 95% CI, 0.23-0.85; P = .01). CONCLUSIONS: BITA grafting can be safely offered to obese patients with significant long-term advantages without substantial additional risk of operative complications including deep sternal wound infection.

Evaluation of the organ care system in heart transplantation with an adverse donor/recipient profile.

BACKGROUND: A severe shortage of available donor organs has created an impetus to use extended criteria organs for heart transplantation. Although such attempts increase donor organ availability, they may result in an adverse donor-recipient risk profile. The TransMedics Organ Care System (OCS) (TransMedics, Inc, Boston) allows preservation of the donor heart by perfusing the organ at 34°C in a beating state, potentially reducing the detrimental effect of cold storage and providing additional assessment options. We describe a single-center experience with the OCS in high-risk heart transplant procedures. METHODS: Thirty hearts were preserved using the OCS between February 2013 and January 2014, 26 of which (86.7%) were transplanted. Procedures were classified as high risk based on (1) donor factors, ie, transport time more than 2.5 hours with estimated ischemic time longer than 4 hours, left ventricular ejection fraction (LVEF) less than 50%, left ventricular hypertrophy (LVH), donor cardiac arrest, alcohol/drug abuse, coronary artery disease or (2) recipient factors, ie, mechanical circulatory support or elevated pulmonary vascular resistance (PVR), or both. RESULTS: Donor and recipient age was 37 ± 12 years and 43 ± 13 years, respectively. Allograft cold ischemia time was 85 ± 17 minutes and OCS perfusion time was 284 ± 90 minutes. The median intensive care unit stay was 6 days. One death (3.8%) was observed over the follow-up: 257 ± 116 (109-445 days). There was preserved allograft function in 92% of patients, with a mean LVEF of 64% ± 5%. CONCLUSIONS: Use of the OCS is associated with markedly improved short-term outcomes and transplant activity by allowing use of organs previously not considered suitable for transplantation or selection of higher risk recipients, or both.

Risk factors predictive of one-year mortality after lung transplantation.

OBJECTIVES: Lung transplantation (LTx) is a life-saving therapy for patients with end-stage lung disease. However, there remains a significant postoperative complication rate and mortality in this extreme patient group. The aim of the present study was to identify donor, recipient and perioperative risk factors for one-year mortality after LTx. METHODS: A total of 252 LTxs were performed in our institution between 2007 and 2013. Donor and recipient demographics and clinical characteristics of 1-year survivors and non-survivors were collected and compared retrospectively. Multivariate logistic regression analysis was performed on univariate predictors for 1-year mortality with an entry criterion of P < 0.05. RESULTS: Multivariate analysis revealed female-to-male transplantation (95% CI: 0.088-0.767; P = 0.015), lower pO2/FiO2-ratio at 72 h postoperatively (95% CI: 0.988-0.999; P = 0.024), need for postoperative extracorporeal membrane oxygenation (ECMO) support (95% CI: 0.035-0.658; P = 0.012) and on-pump technique (95% CI: 0.007-0.944; P = 0.045) as the only independent predictors for 1-year mortality. Mainly unplanned intraoperative conversion to cardiopulmonary bypass contributed to poorer survival in patients who underwent LTx using cardiopulmonary bypass (P < 0.001). CONCLUSIONS: Our results show that the unplanned use of CPB (conversion from off- to on-pump) might adversely affect outcome after LTx. Also, the negative impact of female-to-male transplantation should not be underestimated during recipient selection. Furthermore, poor early postoperative oxygenation, particularly with the need for extracorporeal oxygenation, might be a very strong negative prognostic factor after LTx.

Guidance for the use of bilateral internal thoracic arteries according to survival benefit across age groups.

OBJECTIVE: Increasing evidence from observational cohort studies supports a survival advantage from bilateral internal thoracic artery (BITA) relative to single internal thoracic artery (SITA) grafts in patients undergoing coronary artery bypass grafting. Whether the survival benefit from BITA is related to patient age and any potential age cutoff for the loss of survival benefit from BITA remain to be determined. METHODS: Flexible parametric spline survival model was used to investigate the survival benefit from BITA across patient age groups. The study population consisted of 4190 patients undergoing coronary artery bypass grafting with SITA (n = 3442; 81%) or BITA (n = 748; 19%). RESULTS: A total of 376 deaths (BITA, n = 29; SITA, n = 347) were recorded after a mean follow-up of 4.9 ± 3.2 years (maximum, 12.2 years). Nonparametric survival probabilities at 1-, 5-, and 10-year follow-ups were 94.9% ± 0.3% versus 98.0% ± 0.5%, 90.7% ± 0.5% versus 95.5% ± 0.9%, and 84.2% ± 1.0% versus 93.7% ± 1.4% in the SITA and BITA groups, respectively. Interaction between age and BITA (age*BITA) was found to affect survival significantly (coefficient, 0.056; SE, 0.02; P = .015). BITA was associated with reduced risk of mortality in patients aged 69 years and younger (fully adjusted hazard ratio, 0.49; 95% confidence interval, 0.24-0.98; P = .04). On the other hand, for patients aged older than 69 years, BITA did not add any significant survival advantage (adjusted hazard ratio, 1.27; 95% confidence interval, 0.75-2.14; P = .37). CONCLUSIONS: This study provides robust scientific evidence for the loss of survival benefit from BITA for patients older than 69 years.

Outcomes after implantation of 139 full-support continuous-flow left ventricular assist devices as a bridge to transplantation.

OBJECTIVES: Left ventricular assist devices (LVADs) are a routine treatment for patients with advanced heart failure as a bridge to transplantation. The aim of this study was to present our institutional experience and mid-term outcomes after implantation of 139 continuous-flow (cf) LVADs as a bridge to transplantation. METHODS: One hundred and thirty-nine consecutive LVAD implantations were performed in our institution between July 2007 and August 2013. The mean age of the population was 44.0 ± 13.7 years and 24 (17%) of the patients were female. A substantial number of the patients were on preoperative mechanical support: 35 (25%) with an intra-aortic balloon pump, 9 (6.5%) with an extracorporeal membrane oxygenator and 25 (18%) with previous LVAD, for LVAD exchange. RESULTS: The mean support duration was 514 ± 481 days, whereas the longest support duration was 2493 days (>6 years). The overall cumulative survival rate following cfLVAD implantation was 89% at 30 days, 76% at 1 year and 66% at 2 years (Fig. 1). There was a statistically significant difference in survival in favour of first LVAD implantation compared with VAD exchange: 91 vs 80% at 30 days, 79 vs 57% at 1 year and 70 vs 43% at 2 years (log-rank P = 0.010). Postoperatively, patients had a significant improvement in end-organ function 1 month after LVAD implantation. In addition, comparison of two different devices [HeartMate II (HM II) and HeartWare] using propensity score matching showed no significant differences in survival and most postoperative adverse events. However, patients supported with HM II required significantly more units of fresh frozen plasma (P = 0.020) with a trend towards a higher use of red blood cells (P = 0.094), and were also more likely to develop percutaneous site infections (P = 0.022). CONCLUSIONS: HM II and HeartWare cfLVADs have excellent early postoperative outcomes and good mid-term survival, despite a considerable number of patients needing VAD exchange.

The influence of bilateral internal mammary arteries on short- and long-term outcomes: a propensity score matching in accordance with current recommendations.

OBJECTIVES: We undertook a single-center, 12 years outcomes analysis of the influence of bilateral internal mammary arteries (BIMA) over single internal mammary artery (SIMA) on short-term outcomes and long-term outcomes by means of propensity score matching technique in accordance to current recommendations. METHODS: A propensity score was generated for each patient from a multivariable logistic regression model based on 20 pretreatment covariates. The study population consisted of 4195 patients undergoing coronary artery bypass graft procedure using SIMA (n = 3445; 78.3%) or BIMA (n = 750; 21.7%). A total of 750 matching sets were derived. RESULTS: The BIMA group was associated with an increased rate of superficial sternal wound infection (5.6% vs 1.7%; P = .0001) but the incidence of deep sternal wound infection was comparable between the 2 groups, at 2.1% and 1.5% in BIMA and SIMA groups, respectively (P = .43). With regard to other postoperative complications the 2 groups were comparable. Operative mortality rate did not significantly differ between the 2 groups, at 0.7% and 1.2% in the BIMA and SIMA groups, respectively (P = .28). After a mean follow-up time of 4.8 ± 3.2 years, BIMA use was associated with a significantly lower risk for late mortality (hazard ratio, 0.61; 95% confidence interval 0.38-0.97; P = .03) and need for repeat revascularization (hazard ratio, 0.75; 95% confidence interval, 0.53-0.96; P = .03). CONCLUSIONS: When compared with SIMA grafting, BIMA use did not increase operative morbidity and mortality and was associated with a better long-term survival.

The impact of arterial cannulation strategy on operative outcomes in aortic surgery: evidence from a comprehensive meta-analysis of comparative studies on 4476 patients.

OBJECTIVES: There is a growing perception that peripheral cannulation through the femoral artery, by reversing the flow in the thoracoabdominal aorta, may increase the risk of retrograde brain embolization in aortic surgery. Central cannulation sites, including the right axillary artery, have been reported to improve operative outcomes by allowing antegrade blood flow. However, peripheral cannulation still remains largely used because a consensus for the routine use of central cannulation approaches has not been reached. METHODS: A meta-analysis of comparative studies reporting operative outcomes using central cannulation versus peripheral cannulation was performed. Pooled weighted incidence rates for end points of interest were obtained using an inverse variance model. RESULTS: A total of 4476 patients were included in the final analysis. Central cannulation was used in 2797 patients, and peripheral cannulation was used in 1679 patients. Central cannulation showed a protective effect on in-hospital mortality (risk ratio, 0.59; 95% confidence interval, 0.48-0.7; P < .001) and permanent neurologic deficit (risk ratio, 0.71; 95% confidence interval, 0.55-0.90; P = .005) when compared with peripheral cannulation. A trend toward an increased benefit in terms of reduced in-hospital mortality was observed when only the right axillary artery was used as the central cannulation approach (risk ratio, 0.35; 95% confidence interval, 0.22-0.55; P < .001; I(2) = 0%). CONCLUSIONS: Central cannulation was superior to peripheral cannulation in reducing in-hospital mortality and the incidence of permanent neurologic deficit. This superiority was particularly evident when the axillary artery was used for central cannulation.