Is internal mammary artery graft beneficial in emergent coronary artery bypass surgery? A Society of Thoracic Surgeons national database analysis.

BACKGROUND: Often, only saphenous vein grafts (SVGs) are used in emergent coronary artery bypass graft (CABG) procedures to provide quicker myocardial revascularization despite its lower long-term patency relative to the internal mammary artery (IMA) grafts. We examined differences between IMA and non-IMA graft recipients in emergent CABGs and its impact on in-hospital outcomes. METHODS: Retrospective review of Society of Thoracic Surgeon National Database was done to identify patients age ≥18 years undergoing primary emergent isolated CABG between 2013 and 2016. Emergent salvage, non-LAD disease, subclavian stenosis and revascularization with other arterial grafts were excluded. The study population was divided in two groups: IMA and non-IMA groups. Demographics, preoperative, intraoperative factors and postoperative outcomes were analyzed between the groups. RESULTS: Of 18,280 emergent CABGs during the study period, 16281 had IMA used and 1999 had only vein grafts. The IMA group was younger, more likely to be male, had lower creatinine and higher ejection fraction. The non-IMA and IMA groups were then propensity risk matched with ratio of 1:2 which showed significantly higher in-hospital mortality in the non-IMA group (15% vs. 7%, P<0.0001). The non-IMA groups also had higher rates bleeding (5% vs. 3%, P<0.01), renal failure (10% vs.6%, P<0.0001) and prolonged vent (44% vs. 30%, P<0.0001). CONCLUSIONS: IMA grafts in primary isolated emergent CABGs are associated with significantly lower rates of in-hospital mortality. Even for emergent CABG there may be a clinical benefit in using IMA grafts rather than SVGs only.

Objective Donor Scoring System for Lung Transplantation.

BACKGROUND: There is no objective method to estimate post-lung transplant survival solely on the basis of cumulative donor risk factors. METHODS: The United Network Organ Sharing thoracic transplant database was queried to identify patients who underwent lung transplantation between 2005 and 2015. A Cox proportional hazard model was generated using a training set to identify donor risk factors significantly associated with posttransplant survival. Significant donor risk factors were assigned a score on the basis of their hazard ratio. Donor risk score was calculated for each patient by adding the individual donor risk factor scores. Donors in the validation set were then categorized into low-risk (score = 0), intermediate-risk (score = 1), and high-risk (score >1) categories on the basis of the cumulative risk score. The Lung Allocation Score was used as a surrogate for recipient risk. Survival for each risk group was calculated using Kaplan-Meier curves. RESULTS: The donor risk groups' respective survival at 1 year was 85%, 81%, and 77%, and at 5 years it was 53%, 50%, and 42% (p < 0.001). The combination of low-risk recipients and low-risk donors had 1- and 5-year survival of 89% and 59%, respectively. The combination of high-risk recipients and high-risk donors had 1- and 5-year survival of 70% and 30%, respectively. CONCLUSIONS: The proposed lung donor scoring system is a simple, easy to use method that can aid transplant surgeons in the selection of a potential lung transplant donor. Using the lung donor score in conjunction with the Lung Allocation Score can allow for matching of recipients and donors, to optimize posttransplant outcomes.

Valvectomy Versus Replacement for the Surgical Treatment of Tricuspid Endocarditis.

BACKGROUND: Optimal surgical treatment of infective tricuspid endocarditis is debatable, especially in the setting of inherent social and pathologic concerns. This study compared tricuspid valve repair, replacement, and excision for the treatment of infective endocarditis METHODS: A single-center cardiac surgery database was queried to identify patients aged older than 18 years who underwent tricuspid valve operations for infective endocarditis between 2012 and 2016. Patients were divided into three groups by the type of tricuspid valve operation: valvectomy, repair, or replacement. Patients were evaluated to identify differences between preoperative factors and outcomes, including death, length of stay, and complications. RESULTS: During the study period, 63 patients underwent surgical treatment of infective tricuspid valve endocarditis. Demographic and baseline characteristics were comparable across all groups, except that the valve repair group was older compared with valvectomy and replacement (46 vs 29 and 31 years, respectively; p = 0.007), with more hypertension, elevated creatinine, and a lower incidence of diffuse, bilateral pulmonary emboli. Staphylococcus species were the most common organisms. The incidence of death, bleeding requiring reoperation, major stroke, prolonged ventilator time, intensive care unit stay, and overall hospital length of stay were similar in all groups. Of patients undergoing initial valvectomy, 36% were available for follow-up at 1 year, highlighting the challenges associated with the intravenous drug abuse cohort. Patients who underwent tricuspid valvectomy in the group available for follow-up had significantly lower unplanned readmission rates at 1 year. CONCLUSIONS: Tricuspid valve endocarditis patients who undergo tricuspid valve excision, repair, and replacement have similar 30-day operative mortality, as defined by The Society of Thoracic Surgeons. Excision patients have significantly lower unplanned readmission rates at 1 year. Tricuspid valvectomy is an acceptable initial treatment in this high-risk group as part of a surgical strategy to identify patients who are candidates for eventual valve replacement. Further study of long-term outcomes and survival is warranted.

Use of drug intoxicated donors for lung transplant: Impact on survival outcomes.

INTRODUCTION: The number of increasing deaths due to the opioid epidemic has led to a potential greater supply of organ donors. There is hesitancy to use drug intoxicated donors, and we evaluated their impact on post-transplant survival. BACKGROUND: Patients ≥18 years of age undergoing lung transplantation and donors from whom at least one organ was donated between January 2005 and March 2015 were selected from the United Network of Organ Sharing database. Baseline characteristics and post-transplant survival were compared between drug intoxicated and all other donors. RESULTS: The utilization of drug intoxicated donors increased from 1.86% in 2005 to 6.23% in 2014. The 2 study groups had similar characteristics including age, gender, and Lung Allocation Score. As compared to all other donors, drug intoxicated donors were younger (29.1 ± 9.4 vs 34.6 ± 13.4 years, P < .0001), less likely to be male (52% vs 61%, P < .0001), and had a greater smoking history (14% vs 11%, P .04). There was no difference in post-lung transplant survival at 1, 3, and 5 years between drug intoxicated donors (85%, 64%, and 47%) and non-drug intoxicated donors (83%, 65%, and 51%). CONCLUSION: Transplantation utilizing drug intoxicated donor lungs has significantly increased over the past decade without significantly impacting post-transplant survival.

Does Donor Age and Double Versus Single Lung Transplant Affect Survival of Young Recipients?

BACKGROUND: In an effort to expand the donor pool for lung transplants, numerous studies have examined the use of advanced age donors with mixed results, including decreased survival among younger recipients. We evaluated the impact of the use of advanced age donors and single versus double lung transplantation on posttransplant survival. METHODS: The United Network for Organ Sharing database was retrospectively queried between January 2005 and June 2014 to identify lung transplant patients aged at least 18 years. Patients were stratified by recipient age 50 years or less, donor age 60 years or more, and single versus double lung transplantation. Overall survival was assessed using the Kaplan-Meier method. Multivariable survival analysis was performed using a Cox proportional hazards model. RESULTS: In all, 14,222 lung transplants were performed during the study period. With univariate analysis, donor lungs aged 60 years or more were associated with slightly worse 5-year survival (44% versus 52%; p < 0.001). Among recipients aged more than 50 years, this trend was not present in the multivariate model (hazard ratio 1.23, p = 0.055). Among recipients aged 50 years or more, receiving older donor lungs showed worse survival with the use of single lung transplant (5-year survival 15% versus 50%, p = 0.01). No significant difference in survival between young and old donors was seen when double lung transplant was performed (p = 0.491). Cox proportional hazards model showed a trend toward interaction between single lung transplantation and older donors (hazard ratio 2.36, p = 0.057). CONCLUSIONS: Reasonable posttransplant outcomes can be achieved with use of advanced age donors in all recipient groups. Double lung transplantation should be performed when older donors (age more than 60) are used in young recipients (age 50 or less).

Metabolic syndrome as a predictor for postoperative complications after urologic surgery.

OBJECTIVE: To elucidate whether metabolic syndrome (MS) has an effect on outcomes after nephrectomy, prostatectomy, or cystectomy. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program's database, patients undergoing cystectomy, nephrectomy, or prostatectomy between 2005 and 2011 were reviewed to assess for the presence of MS and a variety of perioperative complications. RESULTS: The overall complication rate for cystectomy, nephrectomy, and prostatectomy was 52.4%, 20.2%, and 8.7%, respectively. On multivariate analysis controlling for age, sex, body mass index, cardiac comorbidity, functional status, surgical approach (prostatectomy and nephrectomy), and surgery within 30 days, MS was not associated with perioperative complications in patients undergoing cystectomy (odds ratio [OR], 0.760; 95% confidence interval [CI], 0.476-1.213). On multivariate analysis, the presence of MS was a significant predictor of perioperative complications after radical nephrectomy (adjusted OR, 1.489; 95% CI, 1.146-1.934). With regards to prostatectomy, MS was not a significant predictor of complications (OR, 1.065; 95% CI, 0.739-1.535). CONCLUSION: Patients in this cohort with MS undergoing cystectomy or prostatectomy did not experience a higher rate of complications compared with patients without MS, although patients with MS undergoing nephrectomy had a higher complication rate. It may be warranted to preoperatively counsel patients with MS undergoing nephrectomy that complication rates may be higher.