Lung transplantation from swimming pool drowning victims: A case series.

The use of donor lungs from victims of drowning remains a rare occurrence, given concerns over lung parenchymal injury and microbial contamination secondary to aspiration. Given this infrequency, there is a relative paucity of literature surrounding the use of organs from drowned donors, with the few that exist on this subject focusing primarily on cases of drowning in naturally occurring bodies of water (i.e., drowning at sea). Little is known regarding the outcomes of utilizing donor lungs from victims of drowning in artificial bodies of water (i.e., swimming pools). Here, we describe three cases of bilateral lung transplantation from donors who drowned in swimming pools, with good short- and long-term outcomes. These cases lend further evidence to the feasibility of using such organs that have traditionally been viewed with much trepidation. With continually growing demand for donor organs, the use of drowned donor lungs may serve as a means to expand the donor pool and lessen the burden of waitlist mortality.

Risk Factors and Outcomes of Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation.

This study aimed to identify outcome determinants for extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) at our institution.This retrospective single-center study reviewed patients on ECMO between 2010 and 2018 and compared clinical characteristics between patients who underwent successful-BTT and those who did not. Additionally, we examined differences between actively versus emergently listed patients and reasons for failure-to-list. Seventy-six patients were placed on ECMO with the intent to bridge to transplant. Of those, 42 were actively on the waitlist (AWL) prior to ECMO initiation, 20 were emergently evaluated and waitlisted (EWL) after ECMO initiation, and 14 failed-to-list. Of the 62 listed patients, 42 (68%) were successfully transplanted. Risk factors of failed-BTT included right ventricular dysfunction prior to ECMO initiation, longer ECMO duration, reduced mobility status, shorter stature, higher prevalence of blood type B, worse kidney and liver function, and increased transfusion requirements. The number of patients transitioned to central VA-ECMO was higher in the failed-BTT group. Thirty-day survival post-transplantation was 98%, with 90% successfully discharged; 1-year survival conditional upon discharge was 97%. AWL and EWL groups had comparable outcomes. Reasons for failure-to-list are not readily modifiable. ECMO-BTT has become a viable option with satisfactory 1-year survival in patients with irreversible lung injury. Our results support rescue transplant for emergently evaluated and waitlisted patients on ECMO. Our data suggests that modification in national organ allocation policies especially as they pertain to high-acuity recipients with rare blood types and short stature could enhance successful outcome.

Limited root repair in acute type A aortic dissection is safe but results in increased risk of reoperation.

OBJECTIVE: Management of the aortic root is a challenge for surgeons treating acute type A aortic dissection. METHODS: We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between 2005 and 2015 and identified patients who underwent either limited root repair or aortic root replacement. Differences in baseline characteristics were balanced with inverse probability weighting to estimate the average treatment effect on the controls. Weighted logistic regression was used to evaluate in-hospital mortality. Weighted Cox proportional hazards regression was used to evaluate differences in the hazard for mid-term death. Reoperation was evaluated with death as a competing risk with the Fine-Gray subdistribution hazard. RESULTS: After we excluded patients managed either nonoperatively or with definitive endovascular repair, there were 293 patients without connective tissue disease who underwent either limited root repair or aortic root replacement. There was no difference in weighted perioperative mortality, odds ratio 0.89 (95% confidence interval [CI], 0.44-1.76, P = .7), and there was no difference in weighted survival, hazard ratio 1.12 (95% CI, 0.54-2.31, P = .8). Risk of reoperation was greater in limited root repair (11.8%, 95% CI, 0.0%-23.8%) than for root replacement (0%), P < .001. CONCLUSIONS: Limited root repair was associated with increased risk of late reoperation after repair of acute type A aortic dissection. Surgeons with adequate experience may consider aortic root replacement in well-selected patients. However, given good outcomes after limited root repair, surgeons should not feel compelled to perform this more-complex operation.

Immediate operation for acute type A aortic dissection complicated by visceral or peripheral malperfusion.

OBJECTIVE: To evaluate the effect of visceral, renal, or peripheral malperfusion on the outcome of acute type A aortic dissection. METHODS: We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between January 2005 and December 2015. Inverse probability weighting was used to account for differences between patients who experienced malperfusion syndromes and those who did not. Weighted logistic regression was used to evaluate in-hospital mortality, and midterm survival was assessed with the restricted mean survival time and weighted Cox regression. Reintervention was assessed with death as a competing risk. RESULTS: There were 305 patients with type A dissection extending beyond the ascending aorta, and 82 (26.9%) presented with a malperfusion syndrome. In-hospital mortality in the malperfusion subgroup was no different compared with patients without malperfusion in weighted logistic regression, odds ratio, 1.50 (95% confidence interval, 0.65-3.47; P = .3). There was no difference in midterm survival using restricted mean survival time, -50.2 days (95% CI, -366.8 to 266.4; P = .8) in patients with malperfusion compared with patients without malperfusion at 8 years. Patients with malperfusion had an increased risk of interventions (12.5%) on aortic branches compared with patients without (5.7%) in weighted analysis at 10-years, hazard ratio, 3.06 (95% CI, 1.24-7.56; P = .02). The median time to reintervention on aortic branches was 2 days for patients with malperfusion compared with 230 days without malperfusion, P = .01. CONCLUSIONS: Immediate operation for acute type A aortic dissection complicated by malperfusion is associated with good results.