Impact of cerebrovascular accidents on lung transplant survival.

BACKGROUND: Cerebrovascular accidents (CVA) are a source of postoperative morbidity. Existing data on CVA after lung transplantation (LT) are limited. We aimed to evaluate the impact of CVA on LT survival. METHODS: A retrospective analysis of LT recipients at the University of Texas Southwestern Medical Center was performed. Data was obtained from the institutional thoracic transplant database between January 2012 and December 2018, which consisted of 476 patients. Patients were stratified by the presence of a postoperative CVA. Univariate comparisons of baseline characteristics, operative variables, and postoperative outcomes between the cohorts were performed. Survival was analyzed by Kaplan-Meier method. Aalen's additive regression model was utilized to assess mortality hazard over time. RESULTS: The incidence of CVA was 4.2% (20/476). Lung allocation score was higher in the CVA cohort (46.2 [41.7, 57.3] vs. 41.5 [35.8, 52.2], p = 0.04). There were no significant differences in operative variables. CVA patients had longer initial intensive care unit (ICU) stays (316 h [251, 557] vs. 124 [85, 218], p < 0.001) and longer length of stay (22 days [17, 53] vs. 15 [11, 26], p = 0.007). CVA patients required more ICU readmissions (35% vs. 15%, p = 0.02) and had a lower rates of home discharge (35% vs. 71%, p < 0.001). Thirty-day mortality was higher in the CVA cohort (20% vs. 1.3%, p < 0.001). Overall survival was lower in the CVA cohort (log rank p = 0.044). CONCLUSIONS: Postoperative CVA following LT was associated with longer ICU stays, more ICU readmissions, longer length of stay, and fewer home discharges. Thirty day and long-term mortality were significantly higher in the CVA group.

Acute Kidney Injury in Patients Undergoing Cardiopulmonary Bypass for Lung Transplantation.

BACKGROUND: Cardiopulmonary bypass (CPB) is often used to support patients undergoing lung transplantation who are intolerant of anatomic manipulation or single lung ventilation during the procedure. However, CPB may be associated with adverse outcomes. We evaluated the hypothesis that CPB is associated with increased acute kidney injury (AKI) and postoperative mortality after lung transplantation. MATERIALS AND METHODS: This was a retrospective review of our institutional lung transplant database at the University of Texas Southwestern Medical Center from 2012 to 2018. Patients were grouped based on their need for CPB. The primary outcome was AKI within 48 h of transplantation, which was defined as Kidney Disease Improving Global Outcomes stage 1 or greater. Secondary outcomes included all-cause mortality. RESULTS: A total of 426 patients underwent lung transplantation with 39.0% (n = 166) requiring CPB. There were no differences in demographics and comorbidities, including baseline renal function, between CPB and no CPB. CPB use was higher in recipients with interstitial lung diseases and primary pulmonary hypertension. Median lung allocation score was higher in those needing CPB (47 [interquartile range, 40-59] versus 39 [interquartile range, 35-47]). Patients requiring CPB were significantly more likely to experience AKI (61.44% versus 36.5.3%, P < 0.01) and postoperative hemodialysis (6.6% versus 0.4%, P < 0.01). On multivariable analysis, CPB was significantly associated with postoperative AKI (odds ratio, 1.66; 95% CI, 1.01-2.75; P = 0.04). Thirty-day mortality was higher in patients undergoing CPB (4.2% versus 0.8%, P = 0.03). CONCLUSIONS: CPB for lung transplantation is associated with a higher incidence of AKI, renal failure requiring hemodialysis, and 30-d mortality. CPB should be used selectively for lung transplantation.

Saved by the VAC: Minimally Invasive Removal of a Surely Fatal Right Heart Thrombus in a Patient with Advanced Heart Failure.

Intracardiac thrombi are associated with an increased morbidity and mortality due to their unpredictability and embolic potential. Right heart thrombus is infrequently encountered in clinical practice outside the scenario of acute pulmonary embolism with hemodynamic compromise, and even more uncommon is the presence of a massive right heart thrombus. Embolic potential is high, and historically, management has revolved around open surgical removal or systemic thrombolysis. We hereby present a case of a massive right heart thrombus in a high surgical risk patient, which was successfully removed using a percutaneous aspiration device.

Percutaneous Aspiration for Septic Thrombi in Burn Patients.

Therapeutic interventions are limited for high-risk burn patients with caval and intracardiac septic thrombi. Percutaneous thrombectomy represents a less invasive alternative to median sternotomy. However, there is limited literature on application of this approach and outcomes in these patients. We report two cases of patients with large total body surface area burns with similar caval and right intracardiac septic thrombi. Both patients were successfully treated using a percutaneous aspiration device.

Packed red blood cell transfusion associates with acute kidney injury after transcatheter aortic valve replacement.

BACKGROUND: Acute kidney injury after cardiac surgery significantly associates with morbidity and mortality. Despite not requiring cardiopulmonary bypass, transcatheter aortic valve replacement patients have an incidence of post-procedural acute kidney injury similar to patients who undergo open surgical aortic valve replacement. Packed red blood cell transfusion has been associated with morbidity and mortality after cardiac surgery. We hypothesized that packed red blood cell transfusion independently associates with acute kidney injury after transcatheter aortic valve replacement, after accounting for other risk factors. METHODS: This is a single-center retrospective cohort study of 116 patients undergoing transcatheter aortic valve replacement. Post-transcatheter aortic valve replacement acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Univariate comparisons between patients with and without post-transcatheter aortic valve replacement acute kidney injury were made for clinical characteristics. Multivariable logistic regression was used to assess independent association of packed red blood cell transfusion with post-transcatheter aortic valve replacement acute kidney injury (adjusting for pre-procedural renal function and other important clinical parameters). RESULTS: Acute kidney injury occurred in 20 (17.2%) subjects. Total number of packed red blood cells transfused independently associated with post-procedure acute kidney injury (OR = 1.67 per unit, 95% CI 1.13-2.47, P = 0.01) after adjusting for pre-procedure estimated glomerular filtration rate (OR = 0.97 per ml/min/1.73m2, 95% CI 0.94-1.00, P = 0.05), nadir hemoglobin (OR = 0.88 per g/dL increase, CI 0.61-1.27, P = 0.50), and post-procedure maximum number of concurrent inotropes and vasopressors (OR = 2.09 per inotrope or vasopressor, 95% CI 1.19-3.67, P = 0.01). CONCLUSION: Packed red blood cell transfusion, along with post-procedure use of inotropes and vasopressors, independently associate with acute kidney injury after transcatheter aortic valve replacement. Further studies are needed to elucidate the pathobiology underlying these associations.

Ultraportable Oxygen Concentrator Use in U.S. Army Special Operations Forward Area Surgery: A Proof of Concept in Multiple Environments.

INTRODUCTION: A limitation to surgical care in an austere environment is the supply of oxygen to support mechanical ventilation and general anesthesia. Portable oxygen concentrators (OCs) offer an alternative to traditional compressed oxygen tanks. OBJECTIVES: We set out to demonstrate that a low-pressure OC system could supply the mechanical ventilation needs in an austere operating environment. METHODS: An ultraportable OC (SAROS Model 3000, SeQual Technologies, Ball Ground, Georgia) was paired with an Impact 754 ventilator (Impact Instrumentation, West Caldwell, New Jersey) to evaluate the delivered fraction of inspired oxygen (FiO2) to a test lung across a range of minute ventilations and at altitudes of 1,200 and 6,500 feet above sea level. RESULTS: The compressor-driven Impact ventilator was able to deliver FiO2 at close to 0.9 for minute ventilations equal to oxygen flow. Pairing two OCs expanded the range of minute ventilations supported. OCs were less effective at concentrating oxygen at higher altitudes. CONCLUSIONS: These results demonstrate that low-pressure, ultraportable OCs are capable of delivering high FiO2 during mechanical ventilation in austere locations at both low and high altitudes. Ultraportable OCs could therefore be sufficient to support forward area surgical procedures and positively impact logistics.

"Prophylactic" tricuspid repair for functional tricuspid regurgitation.

BACKGROUND: The optimal management of functional tricuspid regurgitation (FTR) in the setting of mitral valve operations remains controversial. The objective of this study is to compare the outcomes of congestive heart failure patients who underwent a prophylactic tricuspid operation for FTR as a component of their initial mitral valve procedure with those who underwent a redo tricuspid operation at a later date for residual FTR. METHODS: Patients with FTR repaired as a redo operation between 2004 and 2012 were identified. These patients were propensity-matched 1:2 with contemporaneous patients with FTR or tricuspid dilatation who underwent tricuspid repair at the same time as mitral valve repair. Demographic information, postoperative complications, and short-term and long-term mortality rates were compared between groups. RESULTS: There were 21 patients treated with redo tricuspid valve repair matched with 42 patients treated prophylactically. There were 3 deaths at 30 days in the redo group (14%), compared with zero in the prophylactic group (p=0.03). Overall long-term mortality in the redo group was 29% (6 of 21), with a mean 31 months of follow-up, but was only 14% (6 of 42) in the prophylactic group, with a mean 25 months of follow-up. Kaplan-Meier long-term survival analysis did not reveal a difference between groups (log-rank p=0.37) once the perioperative period was survived. CONCLUSIONS: Redo tricuspid valve repair for residual FTR can be performed with acceptable short-term and long-term mortality. However, treatment of FTR at the time of the initial intervention should be considered, because it is safe and effective. A randomized, controlled trial of prophylactic tricuspid operation for FTR at the time of the mitral operation may be warranted.

Identical tricuspid ring sizing in simultaneous functional tricuspid and mitral valve repair: A simple and effective strategy.

OBJECTIVE: Mitral valve repair for functional mitral regurgitation is common. Concomitant tricuspid valve repair for associated functional tricuspid regurgitation has gained favor. Controversy exists regarding annuloplasty sizing for tricuspid valve repair. METHODS: Patients with heart failure having functional mitral regurgitation at the University of Michigan and undergoing mitral valve repair and tricuspid valve repair using identical sized annuloplasty rings between April 2007 and January 2012 were identified. Demographic and clinical records were retrospectively reviewed. Institutional review board approval was obtained for this study. RESULTS: Fifty-three patients met inclusion criteria. Mean age was 65 ± 1.7 years. Preoperative New York Heart Association class was III or IV in 81% (43) and mean left ventricular ejection fraction was 33% ± 2.2%. All patients had moderate or greater mitral regurgitation preoperatively and moderate or severe tricuspid regurgitation or a preoperative tricuspid annulus diameter greater than 40 mm. There was no 30-day mortality. Mean immediate postoperative tricuspid valve gradient was 1.75 ± 0.12 mm Hg and was 2.3 ± 0.19 mm Hg at 4 weeks. Four weeks postoperatively 88% (42/48) of patients had tricuspid regurgitation considered to be mild or less. There was no significant decline in right ventricular function by echocardiography over this time period. CONCLUSIONS: Functional tricuspid regurgitation can be repaired using an undersized rigid annuloplasty ring. Our data suggest that an identical sizing strategy can be used for tricuspid valve repair, as was used for mitral valve repair, without development of tricuspid stenosis or negative effect on right ventricular function. This method seems to prevent recurrence of significant tricuspid regurgitation. The technique we describe provides effective and reproducible results.

Can lung cancer screening by computed tomography be effective in areas with endemic histoplasmosis?

OBJECTIVE: Low-dose chest computed tomography (CT) is being evaluated in several national trials as a screening modality for the early detection of lung cancer. The goal of the present study was to determine whether lung cancer screening could be done while minimizing the number of benign biopsy specimens taken in an area endemic for histoplasmosis. METHODS: The subjects were recruited by letters mailed to area physicians and local advertisement. The inclusion criteria were age older than 50 years and at least a 20 pack-year smoking history. The exclusion criteria were symptoms suggestive of lung cancer or a history of malignancy in the previous 5 years. The participants completed a questionnaire and underwent a chest CT scan at baseline and annually for 5 years. The management of positive screening results was determined using a defined algorithm: annual follow-up CT scan for nodules less than 5 mm; 6-month follow-up CT scan for nodules 5 to 7 mm; review by our multidisciplinary tumor board for nodules 8 to 12 mm; and biopsy for nodules greater than 12 mm. RESULTS: A total of 132 patients were recruited. Of the 132 patients, 61% had positive baseline CT findings and 22% had positive findings on the annual CT scans. Six cancers were detected. Of these 6 patients, 5 had stage I disease and underwent lobectomy, and 1 had stage IIIA disease and underwent induction chemotherapy and radiotherapy followed by lobectomy. All patients were alive and disease free at a mean follow-up of 41.7 ± 18.6 months. No biopsies were performed for benign lesions. Also, no cancers were missed when the protocol was followed. CONCLUSIONS: Screening with CT can be done effectively in an area endemic for histoplasmosis while minimizing benign biopsies.

Traumatic diaphragmatic injury: experience from a level I trauma center.

OBJECTIVE: Traumatic diaphragmatic injuries (TDI) are uncommon but associated with substantial morbidity and mortality. We sought to analyze patients with TDI at a large trauma center and associated county coroner to identify characteristics predictive of increased mortality. METHODS: We queried a level I university trauma center and associated county coroner databases containing >20,000 patients to identify patients with ICD-9 diagnoses pertaining to TDI from January 1992 through May 2005. Once identified, hospital records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the Student t-test, chi-square analysis, analysis of variance, and multiple logistic regression. RESULTS: TDI were identified in 254 individuals. Two hundred (79%) survived to undergo operation. Of the 81 (32%) deaths, 33 (41%) occurred before arrival at the trauma center. Survivors were younger, had lesser injury severity scores (ISS), were more likely to be female, and had more bilateral injuries (P < or = .002 all) than nonsurvivors. By multiple logistic regression analyses, increased age (odds ratio [OR], 1.044; 95% confidence interval [CI], 1.015-1.074; P = .0029) and greater ISS (OR, 1.145; 95% CI, 1.103-1.188; P < .0001) were predictors of the probability of death in all patients. CONCLUSION: Although TDI may indicate substantive trauma burden in any patient, those with greater ISS and advanced age are at the greatest risk of death.

Spontaneous left main coronary artery dissection complicated by pseudoaneurysm formation in pregnancy: role of CT coronary angiography.

We report a case of a 26-year-old female, who presented at 34 weeks of an uncomplicated pregnancy with an acute ST elevation anterior wall myocardial infarction. Cardiac catheterization suggested a left main coronary artery dissection with pseudoaneurysm formation. The patient's course was complicated by congestive heart failure. She was initially managed conservatively by a multidisciplinary team including heart failure specialists, obstetricians, and cardiovascular surgeons. 4 days after admission, her LMC was imaged by dual-source 64 slice Cardiac computed tomography, coronary dissection was identified extending to the lumen, and the presence of pseudoaneurysm was confirmed. She underwent subsequently a staged procedure, which included placement of an intra-aortic balloon pump, cesarean section, and coronary artery bypass grafting. This case illustrates the utility of coronary artery CT imaging to assess the complexity and stability of coronary artery dissections, thereby helping to determine the need for, and timing of revascularization procedures.

Coronary effluent from a preconditioned heart activates the JAK-STAT pathway and induces cardioprotection in a donor heart.

Preconditioning (PC) protects against ischemia-reperfusion (I/R) injury via the activation of the JAK-STAT pathway. We hypothesized that the mediators responsible for PC can be transferred to naive myocardium through the coronary effluent. Langendorff-perfused hearts from male Sprague-Dawley rats were randomized to paired donor/acceptor protocols with or without PC in the presence or absence of the JAK-2 inhibitor AG-490 (n = 6 for each group). Warmed, oxygenated coronary effluent collected during the reperfusion phases of PC (3 cycles of 5 min ischemia and 5 min reperfusion) was administered to acceptor hearts. The hearts were then subjected to 30 min ischemia and 40 min reperfusion. The left ventricles were analyzed for phosphorylated (p)STAT-1, pSTAT-3, Bax, Bcl, Bcl-X(L)/Bcl-2-associated protein (BAD), and caspase-3 expression by Western blot. A separate group of hearts (n = 6) was analyzed for STAT activation immediately after the transfer of the PC effluent (no I-R). Baseline cardiodynamics were not different among the groups. End-reperfusion maximal change in pressure over time (+dP/dt(max)) was significantly (P < 0.05) improved in acceptor PC (3,637 +/- 199 mmHg/s) and donor PC (4,304 +/- 347 mmHg/s) hearts over non-PC donor (2,020 +/- 363 mmHg/s) and acceptor (2,624 +/- 345 mmHg/s) hearts. Similar differences were seen for minimal change in pressure over time (-dP/dt(min)). STAT-3 activation was significantly increased in donor and acceptor PC hearts compared with non-PC hearts. Conversely, pSTAT-1 and Bax expression was decreased in donor and acceptor PC hearts compared with non-PC hearts. No differences in Bcl, BAD, or caspase-3 expression were observed. Treatment with AG-490 attenuated the recovery of +/-dP/dt in acceptor PC hearts and significantly reduced pSTAT-3 expression. The PC coronary effluent activates JAK-STAT signaling, limits apoptosis, and protects myocardial performance from I/R injury.

STAT-3 activation is necessary for ischemic preconditioning in hypertrophied myocardium.

The JAK-STAT pathway is activated in the early and late phases of ischemic preconditioning (IPC) in normal myocardium. The role of this pathway and the efficacy of IPC in hypertrophied hearts remain largely unknown. We hypothesized that phosphorylated STAT-3 (pSTAT-3) is necessary for effective IPC in pressure-overload hypertrophy. Male Sprague-Dawley rats 8 wk after thoracic aortic constriction (TAC) or sham operation underwent echocardiography and Langendorff perfusion. Randomized hearts were subjected to 30 min of global ischemia and 120 min of reperfusion with or without IPC in the presence or absence of the JAK-2 inhibitor AG-490 (AG). Functional recovery and STAT activation were assessed. TAC rats had a 31% increase in left ventricular mass (1,347 +/- 58 vs. 1,028 +/- 43 mg, TAC vs. sham, P < 0.001), increased anterior and posterior wall thickness but no difference in ejection fraction compared with sham-operated rats. In TAC, IPC improved end-reperfusion maximum first derivative of developed pressure (+dP/dt(max); 4,648 +/- 309 vs. 2,737 +/- 343 mmHg/s, IPC vs. non-IPC, P < 0.05) and minimum -dP/dt (-dP/dt(min); -2,239 +/- 205 vs. -1,215 +/- 149 mmHg/s, IPC vs. non-IPC, P < 0.05). IPC increased nuclear pSTAT-1 and pSTAT-3 in sham-operated rats but only pSTAT-3 in TAC. AG in TAC significantly attenuated +dP/dt(max) (4,648 +/- 309 vs. 3,241 +/- 420 mmHg/s, IPC vs. IPC + AG, P < 0.05) and -dP/dt(min) (-2,239 +/- 205 vs. -1,323 +/- 85 mmHg/s, IPC vs. IPC + AG, P < 0.05) and decreased only nuclear pSTAT-3. In myocardial hypertrophy, JAK-STAT signaling is important in IPC and exhibits a pattern of STAT activation distinct from nonhypertrophied myocardium. Limiting STAT-3 activation attenuates the efficacy of IPC in hypertrophy.

Video-assisted thoracoscopic splanchnicectomy for pain control in chronic pancreatitis.

BACKGROUND: : Management of pain in patients with chronic pancreatitis can be frustrating. The authors retrospectively evaluated their experience with video-assisted thoracoscopic surgery (VATS) for pain secondary to chronic pancreatitis. METHODS: : From September 1999 to August 2004, 16 patients underwent VATS for pain associated with chronic pancreatitis. Data were collected retrospectively. RESULTS: : Eight patients were female and 8 were male. Their ages ranged from 17 to 81 years, with a mean age of 40 years. There were 22 VATS splanchnicectomies performed: 7 right, 10 left, and 5 bilateral. The average operative time was 75 minutes for right VATS splanchnicectomy, 86 minutes for left VATS splanchnicectomy, and 88 minutes for bilateral VATS splanchnicectomies. The average length of stay (LOS) was 2.6 days after right VATS splanchnicectomy, 2.2 days after left VATS splanchnicectomy, and 1 day after bilateral VATS splanchnicectomies. Two cases were nonelective and not included in the determination of LOS. No postoperative complications occurred in any of the patients admitted for elective operations. Postoperative mortality was zero. Complete resolution of pain occurred in 4 patients (25%): 1 right splanchnicectomy, 1 left splanchnicectomy, and 2 bilateral splanchnicectomies. Total pancreatectomy with islet cell transplant was subsequently performed in 5 patients (31%), who improved but then had recurrent pain. Continued chronic pain managed with nonsteroidal antiinflammatory drugs and narcotic analgesics was the result in 7 patients (44%) CONCLUSIONS: : Video-assisted thoracoscopic splanchnicectomy surgery may alleviate pain in patients with chronic pancreatitis. It can be performed with minimal morbidity and mortality, and has been safe and useful in the workup, evaluation, and management of pain associated with chronic pancreatitis.