Strategic application of modular risk components to safely increase lung transplantation volume.

OBJECTIVES: Considerable growth of individual lung transplant programs remains challenging. We hypothesized that the systematic implementation of modular risk components to a lung transplantation program would allow for expeditious growth without increasing mortality. METHODS: All consecutive patients placed on the lung transplantation waitlist were reviewed. Patients were stratified by an 18-month period surrounding the systematic implementation of the modular risk components Era 1 (1/2014-6/2015) and Era 2 (7/2015-12/2016). Modular risk components were separately evaluated for donors, recipients, and perioperative features. RESULTS: One hundred and thirty-two waitlist patients (Era 1: 48 and Era 2: 84) and 100 transplants (Era 1: 32 and Era 2: 68) were identified. There was a trend toward decreased waitlist mortality (P = .07). In Era 2, the use of ex vivo lung perfusion (P = .05) and donor-recipient over-sizing (P = .005) significantly increased. Moreover, transplantation with a lung allocation score greater than 70 (P = .05), extracorporeal support (P = .06), and desensitization (P = .008) were more common. Transplant rate significantly improved from Era 1 to Era 2 (325 vs 535 transplants per 100 patient years, P = .02). While primary graft dysfunction (PGD) grade 3 at 72 hours (P = .05) was significantly higher in Era 2, 1-year freedom from rejection was similar (86% vs 90%, P = .69) and survival (81% vs 95%, P = .02) was significantly greater in Era 2. CONCLUSIONS: The systematic implementation of a modular risk components to a lung transplantation program can result in a significant increase in center volume. However, measures to mitigate an expected increase in the incidence of PGD must be undertaken to maintain excellent short and midterm outcomes.

Early tracheostomy after initiation of venovenous extracorporeal membrane oxygenation is associated with decreased duration of extracorporeal membrane oxygenation support.

Timing of tracheostomy placement for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation support is variable and continues to depend on surgeon preference. We retrospectively reviewed all consecutive adult patients supported with peripheral venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome at a single institution with the hypothesis that early tracheostomy (within 7 days of extracorporeal membrane oxygenation initiation) decreases the duration of extracorporeal membrane oxygenation support. The primary endpoint was duration of extracorporeal membrane oxygenation support. Secondary endpoints included mortality, overall and intensive care unit length of stay, duration of mechanical ventilation, and time from extracorporeal membrane oxygenation initiation to liberation from ventilator, intensive care unit discharge, and hospital discharge. Overall and extracorporeal membrane oxygenation-associated hospital costs were compared. A total of 50 patients were identified for inclusion (early n = 21; late n = 29). Baseline characteristics including indices of disease severity were similar between groups. Duration of extracorporeal membrane oxygenation support was significantly shorter in the early tracheostomy group (12 vs. 21 days; p = 0.005). Median extracorporeal membrane oxygenation-related costs were significantly decreased in the early tracheostomy group ($3,624 vs. $5,603, p = 0.03). Early tracheostomy placement is associated with decreased time on extracorporeal membrane oxygenation support and reduced extracorporeal membrane oxygenation-related costs in this cohort. Validation in a prospective cohort or a clinical trial is indicated.

Early Decompressive Laparotomy for Intra-Abdominal Hypertension Following Initiation of Venovenous Extracorporeal Membrane Oxygenation.

Patients supported with venovenous extracorporeal membrane oxygenation are at risk for intra-abdominal hypertension and abdominal compartment syndrome. Flow through the return cannula may be compromised in these patients, resulting in inadequate support and end-organ malperfusion. Early decompressive laparotomy can mitigate these complications and potentially improve outcomes. Here we review a series of nine patients undergoing early decompressive laparotomy for abdominal compartment syndrome at a single institution and propose an algorithmic approach to the management of these patients.

Decontamination and Lung Transplantation of a Patient With Cystic Fibrosis With Resistant Infections.

We describe the use of a decontamination protocol that allowed for successful lung transplantation in a patient with cystic fibrosis with necrotizing pneumonia from highly antibiotic-resistant pathogens (Burkholderia and Psuedomonas species). This strategy may allow for successful lung transplantation in patients with cystic fibrosis with multidrug-resistant infections previously considered nontransplantable.

Occult Chronic Thromboembolic Disease in Patients Presenting for Surgical Pulmonary Embolectomy.

BACKGROUND: Pulmonary embolism is a significant cause of morbidity and mortality. An important subpopulation of patients presenting with acute pulmonary embolism have concurrent undiagnosed chronic thromboembolic disease. We sought to further characterize this subpopulation, specifically in a cohort of patients referred for surgical pulmonary embolectomy. METHODS: A retrospective review of all patients requiring surgical pulmonary embolectomy at a single center (2013-2017) was performed. Chart review and blinded examination of presenting computed tomographic pulmonary angiograms were done to identify clinical and radiographic features associated with acute on chronic disease. A predictive tool utilizing readily accessible variables was then constructed for risk stratification. RESULTS: A total of 90 patients were identified for analysis; 34 were treated by specifically trained pulmonary thromboendarterectomy surgeons. Twelve patients in the subgroup treated by pulmonary thromboendarterectomy surgeons were found to have acute on chronic disease confirmed by intraoperative endarterectomized specimen. On univariate analysis, degree of pulmonary artery and inferior vena cava dilation and duration of respiratory symptoms were statistically significant variables. Severe right ventricular hypertrophy, elevation in N-terminal pro-B-type natriuretic peptide, and unprovoked etiology were also associated with acute on chronic disease. A predictive tool weighing the presence of these features was created allowing for stratification into low-, moderate-, and high-risk patients. The positive predictive value of a high-risk score was 100%. CONCLUSIONS: In this cohort, the prevalence of acute on chronic thromboembolic disease was greater than 1 in 3. Readily available clinical and radiographic features were used to create a predictive tool for risk stratification.

Ambulation With Femoral Arterial Cannulation Can Be Safely Performed on Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support can be associated with significant deconditioning due to the requirement for strict bedrest as a result of femoral arterial cannulation. To address this issue, we evaluated our experience with ambulation in patients with peripheral femoral cannulation for VA-ECMO. METHODS: All patients that were peripherally cannulated for VA-ECMO over a 2-year period were retrospectively reviewed. Patients that ambulated at least once while supported with VA-ECMO were included in the analysis. The primary outcomes were safety and feasibility of ambulation, defined as the absence of major bleeding, vascular, or decannulation events. RESULTS: Of 104 patients placed on VA-ECMO, 15 ambulated with a femoral arterial cannula. Forty-six percent of patients were placed on VA-ECMO for decompensated heart failure, and 54% for massive pulmonary embolism. Twenty-seven percent of patients were cannulated during active cardiopulmonary resuscitation. The median length of time from cannulation to out of bed was 3 (range, 0 to 26) days. The median length of time from cannulation to initial ambulation was 4 (range, 1 to 42) days. The median distance of the first postcannulation walk was 300 feet. Neither flow nor speed decreased during or after ambulation. There were no major bleeding events, vascular complications, or decannulation events associated with ambulation. The median intensive care unit length of stay and hospital length of stay were 12 and 21 days, respectively. One-year survival was 100% for ambulating patients. CONCLUSIONS: Ambulating patients supported with VA-ECMO, despite femoral arterial cannulation, appears feasible and safe in carefully selected patients.

Utilization of Veno-Arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism.

BACKGROUND: The management of massive pulmonary embolism remains challenging, with a considerable mortality rate. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for massive pulmonary embolism has been reported, its use as salvage therapy has been associated with poor outcomes. We reviewed our experience utilizing an aggressive, protocolized approach of VA-ECMO to triage, optimize, and treat these patients. METHODS: All patients with a massive pulmonary embolism who were placed on VA-ECMO, as an initial intervention determined by protocol, were retrospectively reviewed. ECMO support was continued until organ optimization was achieved or neurologic status was determined. At that time, if the thrombus burden resolved, decannulation was performed. If substantial clot burden was still present with evidence of right ventricular (RV) strain, operative therapy was undertaken. RESULTS: Twenty patients were identified. Before cannulation, all patients had an RV-to-left ventricular ratio greater than 1.0 and severe RV dysfunction. The median duration of ECMO support was 5.1 days, with significant improvement in end-organ function. Ultimately, 40% received anticoagulation alone, 5% underwent catheter-directed therapy, and 55% underwent surgical pulmonary embolectomy. Care was withdrawn in 1 patient with a prolonged pre-cannulation cardiac arrest after confirmation of neurologic death. In-hospital and 90-day survival was 95%. At discharge, 18 of 19 patients had normal RV function, and 1 patient, who received catheter-directed therapy, had mild dysfunction. CONCLUSIONS: VA-ECMO appears to be an effective tool to optimize end-organ function as a bridge to recovery or intervention, with excellent outcomes. This approach may allow clinicians to better triage patients with massive pulmonary embolism to the appropriate therapy on the basis of recovery of RV function, residual thrombus burden, operative risk, and neurologic status.

Minimally Invasive Left Ventricular Assist Device Implantation: Implementation Early in a Surgical Career.

OBJECTIVE: Several centers have presented minimally invasive surgical approaches to centrifugal left ventricular assist device implantation. Although minimally invasive implantation has been successfully performed by experienced surgeons, at large implanting centers, it is unknown whether these techniques are widely adoptable. We evaluated the experience of a surgeon early in his career with conventional and minimally invasive approaches to device implantation. METHODS: All consecutive left ventricular assist device implantations by a single surgeon in the first year of practice (2015-2016) were retrospectively reviewed. Patients were stratified by standard approach, conventional full sternotomy versus a minimally invasive approach, left anterior thoracotomy and upper hemisternotomy. Demographics, perioperative variables, and short-term outcomes were compared using Wilcoxon rank-sum test. RESULTS: Thirteen patients were identified: six performed via the standard approach and seven performed via the minimally invasive approach. Preoperative demographics were comparable in both groups. However, there was significantly more preoperative right ventricle dysfunction in the minimally invasive group (P = 0.01). Although operative time was significantly longer in the minimally invasive cohort, there was a trend toward decreased cardiopulmonary bypass time. Six-month survival in both groups was 100%. CONCLUSIONS: Compared with conventional sternotomy, minimally invasive ventricular assist device implantation, performed by a surgeon in his first year of practice, had similar perioperative outcomes and excellent survival. Based on these data, minimally invasive implantation may be a feasible strategy for device implantation even early in a surgeon's career.

Triage and optimization: A new paradigm in the treatment of massive pulmonary embolism.

BACKGROUND: Massive pulmonary embolism (PE) remains a highly fatal condition. Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) and surgical pulmonary embolectomy in the management of massive PE have been reported previously, the outcomes remain less than ideal. We hypothesized that the institution of a protocolized approach of triage and optimization using VA-ECMO would result in improved outcomes compared with historical surgical management. METHODS: All patients with a massive PE referred to the cardiac surgery service between 2010 and 2017 were retrospectively reviewed. Patients were stratified by treatment strategy: historical control versus the protocolized approach. In the historical control group, the primary intervention was surgical pulmonary embolectomy. In the protocol approach group, patients were treated based on an algorithmic approach using VA-ECMO. The primary outcome was 1-year survival. RESULTS: A total of 56 patients (control, n = 27; protocol, n = 29) were identified. All 27 patients in the historical control group underwent surgical pulmonary embolectomy, whereas 2 of 29 patients in the protocol approach group were deemed appropriate for direct surgical pulmonary embolectomy. The remaining 27 patients were placed on VA-ECMO. In the protocol approach group, 15 of 29 patients were treated with anticoagulation alone and 14 patients ultimately required surgical pulmonary embolectomy. One-year survival was significantly lower in the historical control group compared with the protocol approach group (73% vs 96%; P = .02), with no deaths occurring after surgical pulmonary embolectomy in the protocol approach group. CONCLUSIONS: A protocolized strategy involving the aggressive institution of VA-ECMO appears to be an effective method to triage and optimize patients with massive PE to recovery or intervention. Implementation of this strategy rather than an aggressive surgical approach may reduce the mortality associated with massive PE.

Minimally Invasive Surgical Pulmonary Embolectomy: A Potential Alternative to Conventional Sternotomy.

OBJECTIVE: Surgical pulmonary embolectomy has gained increasing popularity over the past decade with multiple series reporting excellent outcomes in the treatment of submassive pulmonary embolism. However, a significant barrier to the broader adoption of surgical pulmonary embolectomy remains the large incision and long recovery after a full sternotomy. We report the safety and efficacy of using a minimally invasive approach to surgical pulmonary embolectomy. METHODS: All consecutive patients undergoing surgical pulmonary embolectomy for a submassive pulmonary embolism (2015-2017) were reviewed. Patients were stratified as conventional or minimally invasive. The minimally invasive approach included a 5- to 7-cm skin incision with upper hemisternotomy to the third intercostal space. The primary outcomes were in-hospital and 90-day survival. RESULTS: Thirty patients (conventional = 20, minimally invasive = 10) were identified. Operative time was similar between the two groups, but cardiopulmonary bypass time was significantly longer in the minimally invasive group (58 vs 94 minutes, P = 0.04). While ventilator time and intensive care unit length of stay were similar between groups, hospital length of stay was 4.5 days shorter in the minimally invasive group, and there was a trend toward less blood product use. In-hospital and 90-day survival was 100%. Within the minimally invasive cohort, median right ventricular dysfunction at discharge was none-mild and no patient experienced postoperative renal failure, deep sternal wound infection, sepsis, or stroke. CONCLUSIONS: Minimally invasive surgical pulmonary embolectomy appears to be a feasible approach in the treatment of patients with a submassive pulmonary embolism. A larger, prospective analysis comparing this modality with conventional surgical pulmonary embolectomy may be warranted.