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Objectives: More than 200 patients have benefited from lung transplantation who failed to recover from COVID-19-induced acute respiratory distress (ARDS) with conventional ventilatory support and/ or extracorporeal membrane oxygenation support (ECMO) in USA. We aim to share our experience and lessons learned at our institute through this case series. Method(s): After IRB approval, we performed a retrospective chart review and identified 37 patients who received ECMO for COVID-19 induced ARDS between May 2020 through January 2022. Out of these, 12 received a formal consultation from the transplant team. We studied patient characteristics, interventions during ECMO support, and evaluation outcomes. Result(s): Most of our patients had single organ failure i.e., lung, except for two who required dialysis after ECMO initiation. Six out of the 12 patients received bilateral lung transplant. One patient received the transplant before ECMO initiation. However, the patient required two runs of ECMO after the transplant due to postop complications from suspected COVID19 reinfection and deceased on postoperative day 101. All the patients after transplant had an expedited recovery except one who required prolonged hospitalization before starting physical therapy. The median length of hospital stay for the transplant group was 148 (89- 194) days and for the non-transplant group was 114 (58-178) days. The 30-day survival rate was 100% for the transplant group. At a median follow-up of 207 (0- 456) days after discharge, 5(83.3%) patients in the transplant group and 3(50%) patients in the nontransplant group were alive. In the non-transplant group, 4 patients received ECMO support for more than 75 days and at last follow-up 2 were alive and functioning well without needing new lungs. This asks for an objective prospective study to define the timeline of irreversibility of the lung injury. Conclusion(s): Lung transplantation is a viable salvage option in patients with COVI-19 induced irreversible lung injury. However, the irreversibility of the lung injury and the timing of lung transplant remains to be determined case-by-case. (Figure Presented).
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Objectives: Extracorporeal membrane oxygenation (ECMO) is well established in cardiorespiratory failure. Here we report the use of ECMO in an airway emergency to provide respiratory support. Method(s): Informed consent was obtained from patient at the time of admission. Result(s): A 48-year-old with COVID-19 requiring venovenous ECMO (VVECMO) for 32 days and tracheostomy for 47 days had developed tracheal stenosis three months after tracheostomy removal, and undergone tracheal resection and reconstruction. He presented two weeks later with acute dyspnea, bloody drainage and a bulge in his neck with coughing. A computerized tomography (CT) of the cervical spine and chest showed dehiscence of the tracheal wound and a gap in the trachea. He was managed with High Flow Nasal Canula and supported on VVECMO support using 25 Fr. right femoral drainage cannula and 23 Fr. left IJ return cannula. A covered stent was placed, neck wound was irrigated and debrided. Patient was decannulated after 10 days on ECMO. Future therapeutic considerations include mediastinal tracheostomy, aortic homograft interposition of the disrupted segment of trachea with stent placement and permanent self-expandable stent with internal silicone stent. Conclusion(s): ECMO is increasingly used in complex thoracic surgery as well as in the perioperative period as salvage support. One of the areas where it has shown promising results is traumatic main bronchial rupture, airway tumor leading to severe airway stenosis, and other complex airway problems. The ease of cannulation, the technological advances and growing confidence in the management of ECMO patients are the main reasons for the expansion of ECMO use beyond conventional indications. The case described above is an example of the use of ECMO in the perioperative management of impending respiratory failure due to airway obstruction or disconnection. (Figure Presented).
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Ex vivo lung perfusion (EVLP) could impact waitlist morbidity and mortality by increasing the number of transplantable allografts. Remote EVLP with a centralized lung evaluation system (CLES) at a dedicated facility has been shown to be feasible. There are no reports comparing the outcomes of remote vs local EVLP. Our institution has access to both modes of EVLP. Hereby, we describe the outcomes for remote EVLP (r-EVLP) and local EVLP (l-EVLP) at Mayo Clinic Florida. We did a retrospective analysis of the demographics, clinical characteristics, and outcomes of recipients of lungs that underwent EVLP as part of a r-EVLP clinical trial (NCT02234128) or at Lung Bioengineering Jacksonville (l-EVLP) with data obtained from the patient's electronic medical record. The r-EVLP cohort (n=10) tended to be younger than the l-RVLP cohort (n=12) (57.3 vs 61.6 years), and had a lower percentage of female recipients (20% vs 41.67% respectively). 80% of recipients were white in both cohorts. Most recipients were in the diagnosis group D (restrictive lung disease) in both cohorts. Three recipients in the l-EVLP group received a lung transplant due to complications from COVID-19. There were 5 single lung transplants (SLTx) in the r-EVLP (50%) and one in l-EVLP (8.33%). Lungs from donors after circulatory death (DCD) accounted for 40% of the allografts in the r-EVLP cohort and for 16.67% in the l-EVLP group. The median cold ischemia time (CIT) 1 was 5h:27min for the r-EVLP and 4h:35min for l-EVLP. The median CIT-2 time was 4h:16min for the r-EVLP and 3h:12min for the l-EVLP. EVLP time was similar for both groups. The median total preservation time was 13h:44min for the r-EVLP and 11h:38min for the l-EVLP cohorts. One (10%) in the r-EVLP and five (42%) in the l-EVLP groups were on ECMO at 72 hours post-transplant. Most of the remaining patients in both groups had a PGD-1 at 72 hours. All patients were alive at 30 days, and there was one death on each group at 1-year. At our center, survival at 1-year appeared similar in recipients of lungs assessed on r-EVLP or l-EVLP. Postoperative ECMO was used more frequently in the l-EVLP group. Median CIT-1 and CIT-2 were longer in the r-EVLP compared to the l-EVLP group by 52 and 64 minutes, respectively. Limitations of this study include single center retrospective experience, small sample size and lack of long-term outcomes. Future research comparing r-EVLP vs l-EVLP is warranted. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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SESSION TITLE: Rare Cases in Cardiothoracic Surgery SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Membranous dehiscence after tracheal resection is an uncommon but deadly complication. It may present acutely with loss of airway, insidiously with progressive stridor, infection or subcutaneous emphysema, or asymptomatically. Treatment may be conservative if the separation is minimal but may require re-exploration if the defect is more severe. The extent of dehiscence amenable to conservative treatment is not well described in the literature. This case report describes the conservative treatment of a posterior membrane dehiscence. CASE PRESENTATION: A 50-year-old woman suffered from stridor due to tracheal stenosis after prolonged intubation from COVID-19. Endobronchial treatments were unsuccessful because of a malacic segment of airway. Via a cervical approach, approximately 2cm of malacic trachea was resected. Reconstruction was performed with a running suture of the posterior membrane and interrupted, figure-of-eight sutures of the anterior trachea. On postoperative day 5, the patient developed subcutaneous emphysema. A CT scan was obtained (Figure 1A), demonstrating disruption of the membranous portion of the anastomosis. As the patient's breathing was not affected, conservative treatment was preferred. She was encouraged to maintain her neck in a flexed position while continuously monitored with a pulse oximeter and treated with intravenous and aerosolized antibiotics. A repeat CT scan was obtained one week after (Figure 1B), showing no residual tracheal wall defect. Postoperative bronchoscopy showed that the posterior membrane had healed entirely. She remains asymptomatic on follow-up visits. DISCUSSION: Wound dehiscence after tracheal resection and reconstruction occurs in about 1-4% of the cases (1, 2), and it is associated with a significant morbidity and a 0.6% chance of mortality (1). We believe the membranous anastomosis failed because the posterior membrane was inflamed and adhered to the esophagus during the index operation. We did not want to perform a bronchoscopy in this situation, as positioning and coughing could exacerbate the dehiscence. As her breathing was unaffected at this point, we debated between a conservative or invasive approach. Conservative management is preferred for small defects and mild symptoms (3), but there is sparse further elaboration in the literature. Because the cartilaginous anastomosis appeared intact and she was breathing spontaneously, we decided to treat conservatively with expectant management. This included aggressive treatment with antibiotics to avoid infection and further anastomotic breakdown. More examples are needed to establish the likelihood of success with conservative treatment versus revisional surgery for partial dehiscence. CONCLUSIONS: Dehiscence after tracheal resection increases morbidity and mortality significantly. This is an example of a posterior membrane dehiscence that resolved spontaneously with conservative measures. Reference #1: Stock C, Gukasyan N, Muniappan A, Wright C, Mathisen D. Hyperbaric oxygen therapy for the treatment of anastomotic complications after tracheal resection and reconstruction. J Thorac Cardiovasc Surg. 2014;147(3):1030-5. Reference #2: Young A, Bigcas JLM. Tracheal Resection. [Updated 2022 Feb 16]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563234/. Reference #3: Auchincloss HG, Wright CD. Complications after tracheal resection and reconstruction: prevention and treatment. J Thorac Dis. 2016;8(Suppl 2):S160-7. DISCLOSURES: No relevant relationships by Rocio Castillo-Larios No relevant relationships by Magdy El-Sayed Ahmed No relevant relationships by Sebastian Fernandez-Bussy No relevant relationships by daniel hernandez No relevant relationships by Samuel Jacob No relevant relationships by Ian Makey No relevant relationships by Sai Priyanka Pulipaka No relevant relationships b Mathew Thomas No relevant relationships by Alejandra Yu Lee-Mateus