Predictors of Venous Thromboembolism After Lung Cancer Resection.

BACKGROUND: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in patients undergoing oncologic operations. We sought to identify risk factors for postoperative VTE to define high-risk groups that may benefit from enhanced prophylactic measures. METHODS: A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted on patients who underwent lung cancer resection between 2009 and 2021. Baseline characteristics and postoperative outcomes were compared between patients who did and did not develop a postoperative pulmonary embolism (PE) or deep venous thrombosis. Multivariable regression models identified risk factors associated with VTE. RESULTS: Of 57,531 patients who underwent lung cancer resection, a postoperative PE developed in 758 (1.3%). Patients with PE were more likely to be Black (12% vs 7%, P < .001), have interstitial fibrosis (3% vs 2%, P = .016), and prior VTE (12% vs 6%, P < .001). Postoperative PE was most likely to develop in patients with locally advanced disease who underwent bilobectomy (6% vs 4%, P < .001) or pneumonectomy (8% vs 5%, P < .001). Patients with postoperative PE had increased 30-day mortality (14% vs 3%, P < .001), reintubation (25% vs 8%, P < .001), and readmission (49% vs 15%, P < .001). On multivariable analysis, Black race (odds ratio, 1.74; 95% CI, 1.39-2.16; P < .001), interstitial fibrosis (odds ratio, 1.77; 95% CI, 1.15-2.72; P = .009), extent of resection, and increased operative duration were independently predictive of postoperative PE. A minimally invasive approach compared with thoracotomy was protective. CONCLUSIONS: Because nonmodifiable risk factors (Black race, interstitial fibrosis, and advanced-stage disease) predominate in postoperative PE and VTE-associated mortality is increased, enhanced perioperative prophylactic measures should be considered in high-risk cohorts.

Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis.

OBJECTIVES: Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES: Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION: Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. DATA EXTRACTION: Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS: Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS: ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.

Association between implanted cardioverter-defibrillators and mortality for patients with left ventricular ejection fraction between 30% and 35.

BACKGROUND: Consensus guidelines support the use of implanted cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death in patients with either non-ischaemic or ischaemic cardiomyopathy with left ventricular ejection fraction (LVEF) ≤35%. However, evidence from trials for efficacy specifically for patients with LVEF near 35% is weak. Past trials are underpowered for this population and future trials are unlikely to be performed. METHODS: Patients with lowest LVEF between 30% and 35% without an ICD prior to the lowest-LVEF echo (defined as 'time zero') were identified by querying echocardiography data from 28 November 2001 to 9 July 2020 at the Massachusetts General Hospital linked to ICD treatment status. To assess the association between ICD and mortality, propensity score matching followed by Cox proportional hazards models considering treatment status as a time-dependent covariate was used. A secondary analysis was performed for LVEF 36%-40%. RESULTS: Initially, 526 440 echocardiograms representing 266 601 unique patients were identified. After inclusion and exclusion criteria were applied, 6109 patients remained for the analytical cohort. In bivariate unadjusted comparisons, patients who received ICDs were substantially more often male (79.8% vs 65.4%, p<0.0001), more often white (87.5% vs 83.7%, p<0.046) and more often had a history of ventricular tachycardia (74.5% vs 19.1%, p<0.0001) and myocardial infarction (56.1% vs 38.2%, p<0.0001). In the propensity matched sample, after accounting for time-dependence, there was no association between ICD and mortality (HR 0.93, 95% CI 0.75 to 1.15, p=0.482). CONCLUSIONS: ICD therapy was not associated with reduced mortality near the conventional LVEF threshold of 35%. Although this treatment design cannot definitively demonstrate lack of efficacy, our results are concordant with available prior trial data. A definitive, well-powered trial is needed to answer the important clinical question of primary prevention ICD efficacy between LVEF 30% and 35%.

Association Between Interstitial Lung Disease and Outcomes After Lung Cancer Resection.

BACKGROUND: Prior studies have noted that patients with interstitial lung disease (ILD) possess an increased incidence of lung cancer and risk of postoperative respiratory failure and death. We sought to understand the impact of ILD on national-scale outcomes of lung resection. METHODS: A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted of patients who underwent a pulmonary resection for non-small cell lung cancer between 2009 and 2019. Baseline characteristics and postoperative outcomes were compared between patients with and without ILD (defined as interstitial fibrosis based on clinical, radiographic, or pathologic evidence). Multivariable logistic regression models identified risk factors associated with postoperative mortality, acute respiratory distress syndrome, and composite morbidity and mortality. RESULTS: ILD was documented in 1.5% (1873 of 128,723) of patients who underwent a pulmonary resection for non-small cell lung cancer. Patients with ILD were more likely to smoke (90% vs 85%, P < .001), have pulmonary hypertension (6% vs 1.7%, P < .001), impaired diffusing capacity of lung for carbon monoxide (diffusing capacity of lung for carbon monoxide 40%-75%: 64% vs 51%; diffusing capacity of lung for carbon monoxide <40%: 11% vs 4%, P < .001), and undergo more sublobar resections (34% vs 23%, P < .001) compared with patients without ILD. Patients with ILD had increased postoperative mortality (5.1% vs 1.2%, P < .001), acute respiratory distress syndrome (1.9% vs 0.5%, P < .001), and composite morbidity and mortality (13.2% vs 7.4%, P < .001). ILD remained a strong predictor of mortality (odds ratio, 3.94; 95% CI, 3.09-5.01; P < .001), even when adjusted for patient comorbidities, pulmonary function, extent of resection, and center volume effects. CONCLUSIONS: ILD is a risk factor for operative mortality and morbidity after lung cancer resection, even in patients with normal pulmonary function.

Pre-COVID-19 National Mortality Trends in Open and Video-Assisted Lobectomy for Non-Small Cell Lung Cancer.

INTRODUCTION: In the current era of episode-based hospital reimbursements, it is important to determine the impact of hospital size on contemporary national trends in surgical technique and outcomes of lobectomy. METHODS: Patients aged >18 y undergoing open and video-assisted thoracoscopic surgery (VATS) lobectomy from 2008 to 2014 were identified using insurance claims data from the National Inpatient Sample. The impact of hospital size on surgical approach and outcomes for both open and VATS lobectomy were analyzed. RESULTS: Over the 7-y period, 202,668 lobectomies were performed nationally, including 71,638 VATS and 131,030 open. Although the overall number of lobectomies decreased (30,058 in 2008 versus 27,340 in 2014, P < 0.01), the proportion of VATS lobectomies increased (24.0% versus 46.9%), and open lobectomies decreased (76.0% versus 53.0%, all P < 0.01). When stratified by hospital size, small hospitals had a significant increase in the proportion of open lobectomies (6.4%-12.2%; P = 0.01) and trend toward increased number of VATS lobectomies (2.7%-12.2%). Annual mortality rates for VATS (range: 1.0%-1.9%) and open (range: 1.9%-2.4%) lobectomy did not significantly differ over time (all P > 0.05) but did decrease among small hospitals (4.1%-1.3% and 5.1%-1.1% for VATS and open, respectively; both P < 0.05). After adjusting for confounders, hospital bed size was not a predictor of in-hospital mortality. CONCLUSIONS: Utilization of VATS lobectomies has increased over time, more so among small hospitals. Mortality rates for open lobectomy remain consistently higher than VATS lobectomy (range 0.4%-1.4%) but did not significantly differ over time. This data can help benchmark hospital performance in the future.

Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Bi-institutional Study.

OBJECTIVE: It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery. DESIGN: A retrospective, observational study. SETTING: Two university-affiliated tertiary care centers. PARTICIPANTS: A total of 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariate logistic regression analysis, early extubation (within the first 6 postoperative hours) was not associated with a risk of reintubation after CABG (odds ratio [OR] 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10-year increase, 1.63; 95% CI 1.28-2.08) and AVR (OR per 10-year increase, 1.50; 95% CI 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk. CONCLUSION: Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.

Lung transplantation for chronic obstructive pulmonary disease: A call to modify the lung allocation score to decrease waitlist mortality.

OBJECTIVE: Approximately 40% of lung transplants for chronic obstructive pulmonary disease (COPD) in the lung allocation score era are single lung transplantations (SLTs). We hypothesized that double lung transplantation (DLT) results in superior survival, but that mortality on the waitlist may compel clinicians to perform SLT. We investigated both waitlist mortality in COPD patients with restricted versus unrestricted listing preferences and posttransplant survival in SLT versus DLT to identify key predictors of mortality. METHODS: A retrospective analysis of waitlist mortality and posttransplant survival in patients with COPD was conducted using post-lung allocation score data from the United Network for Organ Sharing database between 2005 and 2018. RESULTS: Of 6740 patients with COPD on the waitlist, 328 (4.87%) died and 320 (4.75%) were removed due to clinical deterioration. Median survival on the waitlist was significantly worse in patients listed as restricted for DLT (4.39 vs 6.09 years; P = .002) compared with patients listed as unrestricted (hazard ratio, 1.34; 95% CI, 1.13-1.57). Factors that increase waitlist mortality include female sex, increased pulmonary artery pressure, and increased wait time. Median posttransplant survival was 5.3 years in SLT versus 6.5 years in DLT (P < .001). DLT recipients are younger, male patients with a higher lung allocation score. The survival advantage of DLT persisted in adjusted analysis (hazard ratio, 0.819; 95% CI, 0.741-0.905). CONCLUSIONS: Restricted listing preference is associated with increased waitlist mortality, but DLT recipients have superior posttransplant survival. Because the lung allocation score does not prioritize COPD, concern for increased waitlist mortality with restricted listing preference may drive continued use of SLT despite better posttransplant survival in DLT.

Contributing factors to lymph node recovery with esophagectomy by thoracic surgeons: an analysis of the Society of Thoracic Surgeons General Thoracic Surgery Database.

Given the association between lymphadenectomy and survival after esophagectomy, and the ongoing development of effective adjuvant protocols for identified residual disease, we determined factors contributing to lymph node yield and effects on postoperative morbidity following esophagectomy by thoracic surgeons. Using the Society of Thoracic Surgeons General Thoracic Surgery Database, all patients who underwent esophagectomy for primary esophageal cancer with gastric conduit reconstruction from 2012 to 2016 were identified. Patient demographics, technical factors, and tumor characteristics associated with lymph node yield were determined using a multivariable multilevel mixed-effects regression model. Associations between lymph node yield and perioperative morbidity and mortality were similarly assessed. A total of 8480 patients were included. The median number of nodes harvested was 16 [Interquartile Range 11-22]. Factors associated with fewer nodes included female gender (b=-0.53, P=0.032), body mass index <18.5 (b=-1.46, P=0.012), prior cardiothoracic surgery (b=-0.73, P=0.015), intraoperative blood transfusion (b=-1.43, P<0.001), squamous cell histology (b=-0.86, P=0.006), and neoadjuvant treatment (b=-1.41, P<0.001). Operative approach significantly affected lymph node yield, with minimally invasive approaches demonstrating higher lymph node counts, and open transhiatal esophagectomy recovering the fewest nodes. Findings were independent of clinical center. There was no association of higher lymph node yield with 30-day mortality, with only slightly increased risk for chyle leak (odds ratio [OR] 1.02, P=0.012). In conclusion, several patient and tumor factors affect lymph node recovery with esophagectomy, independent of hospital center. Technical aspects, specifically minimally invasive approach, play a significant role in quantified lymph node yield. Higher operative lymph node yield was associated with minimal increased morbidity.

Late onset atrial fibrillation in patients undergoing surgical aortic valve replacement.

OBJECTIVE: Aortic valve disease is a risk factor for atrial fibrillation (AF), and AF is associated with increased late mortality and morbidity after cardiac surgery. The evolution of alternative approaches to AF prophylaxis, including less invasive technologies and medical therapies, has altered the balance between risk and potential benefit for prophylactic intervention at the time of surgical aortic valve replacement (SAVR). Such interventions impose incremental risk, however, making an understanding of predictors of new onset AF that persists beyond the perioperative episode relevant. METHODS: We conducted a retrospective single-institution cohort analysis of patients undergoing SAVR with no history of preoperative AF (n = 1014). These patients were cross-referenced against an institutional electrocardiogram (ECG) database to identify those with ECGs 3-12 months after surgery. Logistic regression was used to identify predictors of late AF. RESULTS: Among the 401 patients (40%), who had ECGs in our institution 3-12 months after surgery, 16 (4%) had late AF. Patients with late AF were older than patients without late AF (73 vs. 65, p = .025), and underwent procedures that were more urgent/emergent (38% vs. 15%, p = .015), with higher predicted risk of mortality (2.2% vs. 1.3%, p = .012). Predictors associated with the development of late AF were advanced age, higher preoperative creatinine level and urgent/emergent surgery. CONCLUSIONS: The incidence of late AF 3-12 months after SAVR, is low. Prophylactic AF interventions at the time of SAVR may not be warranted.

Management and outcomes of esophageal perforation.

BACKGROUND: Esophageal perforation is a morbid condition and remains a therapeutic challenge. We report the outcomes of a large institutional experience with esophageal perforation and identify risk factors for morbidity and mortality. METHODS: A retrospective analysis was conducted on 142 patients who presented with a thoracic or gastroesophageal junction esophageal perforation from 1995 to 2020. Baseline characteristics, operative or interventional strategies, and outcomes were analyzed by etiology of the perforation and management approach. Multivariable cox and logistic regression models were constructed to identify predictors of mortality and morbidity. RESULTS: Overall, 109 (77%) patients underwent operative intervention, including 80 primary reinforced repairs and 21 esophagectomies and 33 (23%) underwent esophageal stenting. Stenting was more common in iatrogenic (27%) and malignant (64%) perforations. Patients who presented with a postemetic or iatrogenic perforation had similar 90-day mortality (16% and 16%) and composite morbidity (51% and 45%), whereas patients who presented with a malignant perforation had a 45% 90-day mortality and 45% composite morbidity. Risk factors for mortality included age >65 years (hazard ratio [HR] 1.89 [1.02-3.26], P = 0.044) and a malignant perforation (HR 4.80 [1.31-17.48], P = 0.017). Risk factors for composite morbidity included pleural contamination (odds ratio [OR] 2.06 [1.39-4.43], P = 0.046) and sepsis (OR 3.26 [1.44-7.36], P = 0.005). Of the 33 patients who underwent stent placement, 67% were successfully managed with stenting alone and 30% required stent repositioning. CONCLUSIONS: Risk factors for morbidity and mortality after esophageal perforation include advanced age, pleural contamination, septic physiology, and malignant perforation. Primary reinforced repair remains a reasonable strategy for patients with an esophageal perforation from a benign etiology.

Impact of Obesity on Treatment Approach for Resectable Esophageal Cancer.

BACKGROUND: With the prevalence of obesity and its known association with esophageal cancer, there is increasing need to understand how obesity affects treatment. METHODS: Using The Society of Thoracic Surgeons General Thoracic Surgery Database, we retrospectively evaluated all patients who underwent esophagectomy with gastric conduit reconstruction between 2012 and 2016. Patients were categorized into five body mass index groups. Associations between body mass index and surgical technique, resection, lymphadenectomy, staging, and neoadjuvant treatment were evaluated using multivariable logistic regression models. RESULTS: In all, 8547 patients were included in the analysis. Obese and morbidly obese patients were more likely to undergo open procedures compared with normal-weight patients (odds ratio [OR] 1.18, P = .016; and OR 1.45, P = .007), with longer operative times. Morbidly obese patients had a higher rate of intraoperative conversion from minimally invasive to open approaches (OR 3.75, P = .001). There were no differences in R0 resection or lymphadenectomy, and staging workup was similar. Obese patients were less likely to receive neoadjuvant therapy (OR 0.75, P = .048), and overweight and obese patients were less likely to receive preoperative radiation (OR 0.75, P = .017; and OR 0.71, P = .010). Analyzing by stage, overweight and obese patients with cT2N0 disease were less likely to receive neoadjuvant treatment (OR 0.54, P = .016; and OR 0.37, P < .001). There were no differences in neoadjuvant therapy for cT3 or node-positive disease. CONCLUSIONS: Higher body mass index is associated with increased use of open versus minimally invasive esophagectomy and intraoperative conversion. Whereas staging workup and oncologic outcomes of surgery are similar, overweight and obese patients with cT2N0 disease are less likely to undergo neoadjuvant treatments.

Preoperative dental screening prior to cardiac valve surgery and 90-day postoperative mortality.

BACKGROUND: Preoperative dental screening before cardiac valve surgery is widely accepted but its required scope remains unclear. This study evaluates two preoperative dental screening (PDS) approaches, a focused approach (FocA) and a comprehensive approach (CompA), to compare postsurgical 90-day mortality. METHODS: Retrospective cohort analysis was performed on all patients who underwent valve surgery at Brigham and Women's Hospital with FocA and Massachusetts General Hospital with CompA of PDS approach from January 2009 to December 2016. Patients with intravenous drug abuse and systemic infections were excluded. Univariate, multivariable, and subgroup analysis was performed. RESULTS: A total of 1835 patients were included in the study. With FocA 96% of patients (1097/1143) received dental clearance in a single encounter with 3.3% receiving radiographs and undergoing dental extractions. With CompA 35.5% of patients (245/692) received dental clearance in a single encounter, 94.2% received radiographs, and 21.8% underwent dental extractions. There was no significant difference in 90-day mortality when comparing both PDS approach (10% vs 8.4%, P = .257). This remained unchanged in a multivariable model after adjusting for risk factors (odds ratio:1.32 [95%CI:0.91-1.93] [P = .14]). Reoperation due to infection was less in FocA (0.5%) vs CompA (2.6) (P < .001) and postoperative septicemia was increased in the FocA (1.7%) cohort when compared to the CompA (0.7%) (P < .001) patients. CONCLUSIONS: There was no difference in post valve surgery 90-day mortality between patients who underwent a FocA vs CompA of PDS.

Intra-aortic balloon pump placement in coronary artery bypass grafting patients by day of admission.

INTRODUCTION: Intra-Aortic Balloon Pumps (IABPs) can be utilized to provide hemodynamic support in high risk patients awaiting coronary artery bypass grafting (CABG). There are many indications for IABP and institutional practice patterns regarding the placement of IABPs is variable. As a result, the preoperative placement of an IABP in a patient awaiting CABG is not standardized and may vary according to non-clinical factors. We hypothesize that the rate of IABP placement varies by day of the week. METHODS: A retrospective cohort analysis of the Office of Statewide Health Planning and Development database from 2006 to 2010 was performed. All patients admitted for CABG were included. Patients who died within 24 h of admission and those who had absolute contraindications to IABP placement were excluded. The primary outcome was preoperative IABP placement versus non-placement. A multivariable logistic regression analysis to identify predictors of IABP placement was performed, adjusting for patient demographics, clinical factors, and system variables. RESULTS: A total of 46,347 patients underwent CABG, of which 7695 (16.60%) had an IABP placed preoperatively. On unadjusted analysis, IABP rates were significantly higher on weekends versus weekdays (20.83% vs. 15.70%, p < 0.001). On adjusted analysis, patients awaiting CABG were 1.30 times more likely to have an IABP placed on weekends than on weekdays (OR: 1.30, 95% CI 1.20-1.40, p < 0.001). CONCLUSION: The odds of preoperative IABP placement prior to CABG is significantly increased on weekends compared to weekdays, even when controlling for clinical factors. Further exploration of this phenomenon and its associations are warranted.

Type A aortic dissection in the East and West: A comparative study between two hospitals from China and the US.

BACKGROUND: In this study, we compare the clinical characteristics, intraoperative management, and postoperative outcomes of patients with acute type A aortic dissection (ATAAD) between two academic medical hospitals in the United States and China. METHODS: From January 2011 to December 2017, 641 and 150 patients from Nanjing Drum Tower Hospital (NDTH) and Massachusetts General Hospital (MGH) were enrolled. Patient demographics, clinical features, surgical techniques, and postoperative outcomes were compared. RESULTS: The annual number of patients presenting with ATAAD at MGH remained relatively stable, while the number at NDTH increased significantly over the study period. The average age was 51 years at NDTH and 61 years at MGH (P < .001). The percentage of patients with known hypertension at the two centers was similar. The time interval from onset of symptoms to diagnosis was significantly longer at NDTH than MGH (11 vs 3.5 hours; P < .001). Associated complications at presentation were more common at NDTH than MGH. More than 90% of patients (91% NDTH and 92% MGH) underwent surgery. The postoperative stroke rate was higher at MGH (12% vs 4%; P < .001); however, the 30-day mortality rate was lower (7% vs 16%; P = .006). CONCLUSIONS: There was a significant increase in the number of ATAAD at NDTH during the study period while the number at MGH remained stable. Hypertension was a common major risk factor; however, the onset of ATAAD at NDTH was nearly one decade earlier than MGH. Chinese patients tended to have more complicated preoperative pathophysiology at presentation and underwent more extensive surgical repair.

Fibrotic Response to Neoadjuvant Therapy Predicts Survival in Pancreatic Cancer and Is Measurable with Collagen-Targeted Molecular MRI.

PURPOSE: To evaluate the prognostic value of posttreatment fibrosis in human PDAC patients, and to compare a type I collagen targeted MRI probe, CM-101, to the standard contrast agent, Gd-DOTA, for their abilities to identify FOLFIRINOX-induced fibrosis in a murine model of PDAC. EXPERIMENTAL DESIGN: Ninety-three chemoradiation-treated human PDAC samples were stained for fibrosis and outcomes evaluated. For imaging, C57BL/6 and FVB mice were orthotopically implanted with PDAC cells and FOLFIRINOX was administered. Mice were imaged with Gd-DOTA and CM-101. RESULTS: In humans, post-chemoradiation PDAC tumor fibrosis was associated with longer overall survival (OS) and disease-free survival (DFS) on multivariable analysis (OS P = 0.028, DFS P = 0.047). CPA increased the prognostic accuracy of a multivariable logistic regression model comprised of previously established PDAC risk factors [AUC CPA (-) = 0.76, AUC CPA (+) = 0.82]. In multiple murine orthotopic PDAC models, FOLFIRINOX therapy reduced tumor weight (P < 0.05) and increased tumor fibrosis by collagen staining (P < 0.05). CM-101 MR signal was significantly increased in fibrotic tumor regions. CM-101 signal retention was also increased in the more fibrotic FOLFIRINOX-treated tumors compared with untreated controls (P = 0.027), consistent with selective probe binding to collagen. No treatment-related differences were observed with Gd-DOTA imaging. CONCLUSIONS: In humans, post-chemoradiation tumor fibrosis is associated with OS and DFS. In mice, our MR findings indicate that translation of collagen molecular MRI with CM-101 to humans might provide a novel imaging technique to monitor fibrotic response to therapy to assist with prognostication and disease management.

Survival After Heart Transplantation in Patients Bridged With Mechanical Circulatory Support.

BACKGROUND: The United Network of Organ Sharing (UNOS) heart allocation policy designates patients on ECMO or with nondischargeable, surgically implanted, nonendovascular support devices (TCS-VAD) to higher listing statuses. OBJECTIVES: This study aimed to explore whether temporary circulatory support-ventricular assist devices (TCS-VAD) have a survival advantage over extracorporeal membrane oxygenation (ECMO) as a bridge to transplant. METHODS: The UNOS database was used to conduct a retrospective analysis of adult heart transplants performed in the United States between 2005 and 2017. Survival analysis was performed to compare patients bridged to transplant with different modalities. RESULTS: Of the 24,905 adult transplants performed, 7,904 (32%) were bridged with durable left ventricular assist devices (LVADs), 177 (0.7%) with ECMO, 203 (0.8%) with TCS-VAD, 44 (0.2%) with percutaneous endovascular devices, and 8 (0.03%) with TandemHeart (LivaNova, London, United Kingdom). Unadjusted survival at 1 and 5 years post-transplant was 90 ± 0.4% and 77 ± 0.7% for durable LVAD, 84 ± 3% and 71 ± 4% for all TCS-VAD types, 79 ± 9% and 73 ± 14% for biventricular TCS-VAD, and 68 ± 3% and 61 ± 8% for ECMO. After propensity-matched pairwise comparisons were made, survival after all TCS-VAD types continued to be superior to ECMO (p = 0.019) and similar to LVAD (p = 0.380). ECMO was a predictor of post-transplant mortality in the Cox analysis compared with TCS-VAD (hazard ratio 2.40; 95% confidence interval: 1.44 to 4.01; p = 0.001). CONCLUSIONS: Post-transplant survival with TCS-VAD is superior to ECMO and similar to LVAD in a national database.

Platelet and neutrophil to lymphocyte ratios predict survival in patients with resectable colorectal liver metastases.

BACKGROUND: The prognostic significance of the platelet (PLR) and neutrophil (NLR) to lymphocyte ratios for patients with resectable colorectal cancer liver metastases (CLM) was evaluated. METHODS: Clinicopathologic data from patients who underwent hepatectomy for CLM at two tertiary care hospitals between 1995 and 2017 were collected. Blood counts were evaluated for prognostic significance. RESULTS: 151 patients met inclusion criteria. The median age was 58 years, 44% were female, and 58% had synchronous metastases. Median number of liver metastases was 2, and 59% of patients underwent lobectomy or extended lobectomy. On multivariable analysis, NLR ≥5 (HR 2.46 [1.08-5.60 CI], p = 0.032), PLR ≥ 220 (HR 2.10 [1.04-4.23 CI], p = 0.037), and greater than 2 liver metastases (HR 2.41 [1.06-5.45 CI], p = 0.035) were associated with reduced overall survival. CONCLUSIONS: PLR ≥ 220 and NLR ≥ 5 may have utility as preoperative prognostic markers for overall survival in patients with resectable CLM.

Total Arch Replacement and Frozen Elephant Trunk for Acute Complicated Type B Dissection.

The current management of acute complicated type B aortic dissection is a combination of medical therapy and endovascular repair. Endovascular repair is not feasible when the dissection extends into the aortic arch. We describe 3 patients with acute type B aortic dissection complicated by retrograde arch extension and visceral malperfusion who were successfully treated with a total arch replacement and frozen elephant trunk.