Extracorporeal membrane oxygenation as a salvage therapy for patients with severe primary graft dysfunction after heart transplant.

BACKGROUND: Severe primary graft dysfunction (PGD) is the leading cause of early death after heart transplant. AIM: To examine the outcomes of heart transplant recipients who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for severe PGD. METHODS: We reviewed electronic health records of adult patients who underwent heart transplant from November 2005 through June 2015. We defined severe PGD according to International Society for Heart and Lung Transplantation consensus statements. RESULTS: Of 1030 heart transplant patients, 31 (3%) had severe PGD and required VA-ECMO. The mean (range) age was 59 (43-69) years. Fifteen patients (48%) underwent prior sternotomy and 10 (32%) received a left ventricular assist device as a bridge to transplant. Severe PGD manifested as failure to wean from cardiopulmonary bypass in 20 patients (65%) and as severe hemodynamic instability in the immediate postoperative period in 10 (32%), including cardiac arrest in 3 (10%). Twenty-five patients (81%) were successfully weaned from VA-ECMO, and 19 (61%) were discharged; the other 12 (39%) died. CONCLUSIONS: Although VA-ECMO is a common method for providing mechanical circulatory support to patients with PGD, multicenter studies are needed to assess factors associated with successful outcomes and improved survival of these patients.

The importance of surgical therapy with expansion of TAVR to low-risk patients.

Despite the landmark release of recent transcatheter aortic valve replacement data, the gold standard of surgical therapy is here to stay. Surgery remains vital in patient populations with low coronary height raising risk of coronary occlusion, aneurysmal ascending aorta, isolated aortic regurgitation, noncalcific disease, bicuspid valves, and multivessel coronary disease, or other structural abnormality requiring cardiac surgery. Consideration of these issues highlights the ongoing importance of multidisciplinary consideration of individual patient cases, careful review of imaging, and preservation of a robust surgical program to complement transcatheter development. As the landscape of valvular heart disease management continues to evolve, the surgeon's role is changing, but by no means diminished and their engagement in heart team decision making remains paramount.

Use of Organ Care System Lung for Single-Lung Transplantation.

The Organ Care System-Lung allows for normothermic lung preservation in double-lung transplantation. Deterioration of the lung bloc may due to a single nonfunctional side, and surgeons need to be aware of this scenario in hopes of preserving the functional side for transplantation.

Hiatal mesh is associated with major resection at revisional operation.

BACKGROUND: Mesh-assisted hiatal closure during foregut surgery is increasing. Our aim was to evaluate the complications that follow revisional foregut surgery. Specifically, we compared surgical indications and perioperative outcomes between patients with and without prior hiatal mesh (PHM). METHODS: We conducted an institutional review board (IRB)-approved retrospective cohort study from a single tertiary-care referral center. Over 37 months, 91 patients underwent revisional foregut surgery. We excluded 13 cases including operations performed primarily for obesity or achalasia. Of the remaining 78 patients, 10 had PHM and 68 were nonmesh patients (NM). RESULTS: The groups were similar in terms of age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and rates and types of anatomic failure. Compared with NM patients, PHM patients had increased estimated blood loss (410 vs. 127 ml, p < 0.01) and operative time (4.07 vs. 2.89 h, p < 0.01). The groups had no difference in perioperative blood transfusion or length of stay. Complete fundoplication was more commonly created in NM patients (2/10 vs. 42/68, p = 0.03). Three of the 10 PHM patients and 3 of the 68 NM patients required major resection. Therefore, PHM patients had 6.8-fold increased risk of major resection compared with NM patients [95% confidence interval (CI) = 1.585, 29.17; p = 0.05]. The NM patients with multiple prior hiatal operations had 4.6-fold increased risk of major resection compared with those with one prior operation (95% CI = 2.919, 7.384; p = 0.03). In PHM patients, however, the number of prior hiatal operations was not associated with major resection. CONCLUSIONS: PHM is associated with increased risk of major resection at revision. The pattern of failure was not different in patients with hiatal mesh, suggesting that hiatal mesh does not eliminate the potential for revision. When performing hiatal herniorrhaphy, the increased risk of recurrence without mesh must be weighed against the potential risk for subsequent major resection when using mesh.

Electric Shock-Induced Coronary Artery Thrombosis and Dissection.

Electric shock-induced myocardial infarction is rare. Shock-induced coronary artery thrombosis and dissection in multiple distributions have not been reported. After shock, coronary thrombosis may cause anginal symptoms, and any coronary artery may be damaged. A 32-year-old man presented with angina and ischemia-related symptoms after 6,000-V electric shock. He reported occasional exertional angina; the stress echocardiography result was positive for ischemia. Cardiac catheterization showed severe multivessel disease, an occluded left anterior descending coronary artery, and an occluded circumflex artery with collateralization to the distal left anterior descending coronary artery. Surgical intervention detected global coronary dissection and thrombosis. Bypass grafting achieved complete revascularization. The patient was successfully discharged home.

Transplantation of a three-lobed donor left lung: A case report.

A true left middle lobe (lingular lobe) is very rare, but accessory fissures can be unexpectedly found at transplant. Pre-transplant knowledge of accessory lobes and accessory fissures aids in preparation, transplantation, postoperative assessment, and long-term care planning; however, fissures and accessory lobes can be overlooked by radiologists during routine evaluation of images. Here, we describe the first left lung with three anatomical lobes that was successfully transplanted into a 63-year-old patient with idiopathic pulmonary fibrosis. This anatomical variation did not change our surgical plan or technique, but surgeons should be aware of this possibility, especially when planning postoperative care.

Triple bridge of mechanical circulatory support to heart transplantation listing: A case report.

A 60-year-old male patient presented to an outside hospital with severe cardiogenic shock. A triple bridge of mechanical circulatory support was utilized to transition him to heart transplantation listing. Initially, coronary artery disease was percutaneously treated and Impella 2.5 was used as mechanical circulatory support for 5 days followed by the second Impella 2.5 for 4 days. Veno-arterial extracorporeal membrane oxygenation support was deployed for 16 days. This was exchanged for HeartWare ventricular assist device support as the third stage of mechanical circulatory support to heart transplantation listing. The patient experienced acute renal failure which was managed by continuous renal replacement therapy then intermittent hemodialysis with eventual complete recovery of the renal function. He was discharged home 56 days after HeartWare ventricular assist device implantation with stable hemodynamic, intact neurologic status and fully recovered renal function. Currently, the patient is listed for heart transplantation.

Two Decades of Lung Retransplantation: A Single-Center Experience.

BACKGROUND: Lung retransplantation (ReTx) comprises an increasing share of lung transplants and recently has shown improved outcomes. The aim of this study was to identify risk factors affecting overall survival after pulmonary ReTx. METHODS: The United Network for Organ Sharing database was used to identify patients undergoing lung transplantation at our institution from 1995 to 2014. Of the total 542 lung transplants performed, 87 (16.1%) were ReTxs. The primary outcome was overall survival. Multivariate Cox regression models were used to assess the effect of recipient and donor characteristics on survival. RESULTS: Of the patients who underwent ReTx, median survival was 2 years. Predictors of worse survival include recipient age between 50 and 60 years (relative risk, 4.3; p = 0.02) or older than 60 years (relative risk, 10.2; p < 0.001), and time to ReTx of less than 2 years (relative risk, 3.8; p = 0.01). ReTx for bronchiolitis obliterans syndrome had longer median survival than for restrictive chronic lung allograft dysfunction (2.7 years vs 0.9 years; p = 0.055). Overall survival of ReTx patients after initiation of the lung allocation score was not significantly different (p = 0.21). CONCLUSIONS: Lung ReTx outcomes are significantly worse than for primary transplantation but may be appropriate in well-selected patients with certain diagnoses. Lung ReTx in patients older than 50 years or within 2 years of primary lung transplantation was associated with decreased survival. Further work is warranted to identify patients who benefit most from ReTx.

Survival After Lung Retransplantation in the United States in the Current Era (2004 to 2013): Better or Worse?

BACKGROUND: To understand the current patient survival after lung retransplantation (LRTx) in the United States, which has historically been worse compared with primary lung transplantation (LPTx). METHODS: The United Network for Organ Sharing (UNOS) registry was retrospectively analyzed to determine survival after adult LRTx performed in 604 (2.48%) of 14,850 patients from 2004 to 2013. After exclusions, 582 LRTx and 13,673 LPTx recipients were selected for analysis. Cox proportional hazards regression models were used to determine the prognosticators of survival after LRTx. Survival after LRTx and LPTx were compared using Kaplan-Meier analysis. RESULTS: The median survival after LRTx was 2.6 years compared with 5.6 years after LPTx. One-year, 3-year, and 5-year survival rates were, respectively, 71.1%, 46.3%, and 34.5% for LRTx, and 84.3%, 66.5%, and 53.3% for LPTx (p < 0.001). On multivariate analysis, patients who had LRTx after a greater than 1-year interval survived longer (relative risk [RR] 0.53; 95% confidence interval [CI] 0.34% to 0.88%; p = 0.008). Lower survival was associated with single-lung transplantations (RR 1.49; 95% CI, 1.06% to 2.07%; p = 0.021), transplantations done between 2009 and 2013 (RR 1.40; CI, 1.01% to 1.94%; p = 0.041), multiple (>1) retransplantations (RR 2.55; 95% CI, 1.14% to 5.72%; p = 0.023), and recipients requiring pre-transplantation ventilator support. The only significant donor variable for poor survival was death due to cerebrovascular accidents (RR 1.98; 95% CI, 1.23% to 3.18%; p = 0.004). CONCLUSIONS: Patient survival after LRTx in the United States has improved compared with historical data but remains lower than LPTx. Careful recipient selection and preoperative optimization based on the factors identified in our study may help utilize resources better and improve survival after LRTx. Bilateral LRTx should be preferentially performed as much as possible. Poor candidates for LRTx include those requiring retransplantations more than once or within 1 year. Prospective multi-institutional studies are necessary to help better understand the actual role of these factors in LRTx.

Laparoscopic cholecystectomy in patients with HeartMate II left ventricular assist devices.

INTRODUCTION: With an expanding population of patients requiring ventricular assist devices, it is inevitable that these patients will require noncardiac surgery. Ventricular assist devices provide mechanical support for a failing heart either as a bridge to transplant or now as a long-term support if transplant is not available, so-called destination therapy. These devices can add significant technical challenges to abdominal surgery, in that the power supply and drivelines crossing the abdomen can potentially be damaged. The use of preoperative or intraoperative imaging may aid in locating these devices and increase patient safety. MATERIALS AND METHODS: We describe a laparoscopic cholecystectomy in two patients supported with HeartMate(®) II (Thoratec Corp., Pleasanton, CA) left ventricular assist devices. Our use of fluoroscopic guidance in port placement is also described. A literature review was performed to assess the frequency of laparoscopic procedures performed on patients with similar ventricular assist devices and of complications associated with the device and other comorbidities. RESULTS: Laparoscopic cholecystectomy was performed without significant intraoperative hemodynamic changes. The use of imaging, such as fluoroscopy, can identify the location of the ventricular assist device and its associated drive wires to assure they are not damaged intraoperatively. CONCLUSIONS: Laparoscopic cholecystectomy can be performed safely on patients with ventricular assist devices. Complications due to damage to the device can be avoided with the assistance of fluoroscopy to identify the implanted abdominal portions of the ventricular assist device. Each laparoscopic procedure performed on these patients presents the surgeon with unique obstacles in which careful operative planning and intraoperative monitoring are essential.

Partial anomalous pulmonary venous return in a lung transplant recipient.

Partial anomalous pulmonary venous return (PAPVR) is a rare condition in which some of the pulmonary veins empty into the systemic venous system. The presence of PAPVR in a lung transplant recipient may cause technical challenges during transplantation. We present a technique for left atrial reconstruction when faced with a recipient with PAPVR. The patient had a left superior pulmonary vein that emptied into the brachiocephalic vein without a left atrial connection. Because of the discrepancy in size of the 2 donor and the single recipient pulmonary veins, left atrial reconstruction was performed before venous anastomosis.

Persistent ischiorectal fistula with supralevator origin secondary to a chronic tubo-ovarian abscess: report of a case and review of the literature.

BACKGROUND: Chronic tubo-ovarian abscess is an uncommon finding in postmenopausal women. This abscess may rupture or fistulize to adjacent organs into the ischiorectal space. CASE: A gravida three, para three, postmenopausal woman with extensive sigmoid diverticulosis presented with perianal fistula of 2 years' duration. Magnetic resonance imaging showed the tract to have a supralevator origin adjacent to the sigmoid colon. She had no recent instrumentation other than preoperative colonoscopy. Intraoperatively, the fistula tract origin was noted to be from a right tubo-ovarian abscess. She was treated with right salpingo-oophorectomy and tract excision/sealing. At 4-month follow-up, the fistula tract was healed with no further drainage. CONCLUSIONS: Tubo-ovarian abscess should be considered in the differential diagnosis of supralevator fistula in postmenopausal women when no other source can be localized.

Treatment of a mycotic descending thoracic aortic aneurysm using endovascular stent-graft placement and rifampin infusion with postoperative aspiration of the aneurysm sac.

PURPOSE: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. CASE REPORT: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. CONCLUSION: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.