Cerebral protection strategies for type A aortic dissection repair.

Importance: Techniques to preserve neurological function during type A aortic dissection repairs have been broadly discussed in the literature and heavily debated. Despite the effectiveness of various approaches, a consensus lacks on how to maintain optimal cerebral temperature during surgery. This review examines the three predominant cerebral protection strategies in aortic arch reconstructions: straight deep hypothermic circulatory arrest (sDHCA), retrograde cerebral perfusion (RCP), and antegrade cerebral perfusion (ACP). Observations: The signature characteristics of sDHCA, RCP, and ACP are similar-hypothermia, with or without cerebral perfusion. Employing cerebral perfusion techniques may prolong operative times, while ACP permits operation at higher body temperatures, albeit with restricted operative durations. Conclusion: For type A dissection arch reconstructions, sDHCA, RCP, and ACP can be successfully implemented. Factors such as operative times and individual patient conditions should be considered when choosing a cerebral protection strategy.

Increased Risk Donors Utilized in Lung Transplantation At A Single Center.

Introduction: In 2013, the US Public Health Service (PHS) updated guidelines for high-risk donor organs and renamed the category increased risk. Project Aims: We compared survival of patients who received increased risk or non-increased risk donor lungs to determine if PHS designated increased risk donor lungs were an underutilized resource. Design: This retrospective cohort analysis compared survival and utilization rates of increased-risk and non-increased-risk donor lungs used in lung transplantation at a single institution over a period of 8 years (Feb-2012 through Mar-2020). Survival was assessed using Kaplan-Meier analysis and compared by log-rank test. Cox proportional hazards modeling was used to analyze impact on survival of variables significantly associated with risk status, including recipient ethnicity, lung allocation score (LAS), donor age, year of transplant procedure, and lung transplant type. Results: Of 744 lung transplant recipients from February 2012 through March 2020, there were 192 (26%) recipients of increased risk designated lungs. In 2012 and 2013, 6% and 0% respectively of the lungs transplanted were increased risk labeled. After the PHS guidelines were nationally implemented in February 2014, the proportion of increased risk lung transplants rose to 7% (2014), 21% (2015), 27% (2016), 35% (2017), 28% (2018), 27% (2019), and 40% (January-March 2020). Kaplan-Meier analysis and log-rank test comparison showed no significant difference in survival between patients that received increased risk versus non-increased risk labeled lungs (P = 0.47). Conclusions: Our analysis suggested the 2013 PHS increased risk designation threatened underutilization of viable donor lungs, providing further support for the 2020 PHS changes.

Anastomotic Suturing Techniques and Their Association With Post-Lung Transplantation Complications.

INTRODUCTION: Currently, standard practice is to use the continuous suturing technique on the bronchial anastomosis during lung transplantation. This study used a large cohort to investigate and contrast continuous and interrupted suturing techniques, comparing survival outcomes and occurrence of postoperative bronchial complications to examine if utilization of interrupted suturing has merit. METHODS: Survival outcomes of 740 single-center lung transplant recipients over 8 y (February 2012-March 2020) were compared by suturing techniques: either continuous or interrupted at the bronchial anastomosis. Clinical parameters and demographics were compared between two suturing groups, with P values < 0.05 considered significant. The groups were compared for postoperative morbidity, including need for bronchial interventions. Survival was compared using Kaplan-Meier curves and log-rank tests. Cox regression analysis was run with statistically significant variables to study association with survival. RESULTS: Of the 740 patients, 462 received the continuous suturing technique and 278 received the interrupted suturing technique. Most demographic and clinical data were not statistically significant between the two groups, and those that were significant were not associated with worse survival outcomes, with the exception of the variable diagnosis. Bronchial complications were comparable between the continuous and interrupted groups (12.6% versus 10.4%, P = 0.382). Extracorporeal membrane oxygenation (ECMO) use did not differ significantly between the two groups (P = 0.12). The Kaplan-Meier curve showed comparable survival between groups (P = 0.98), and Cox regression analysis showed that only diagnosis, bronchial complications, and ECMO utilization were associated with different survival outcomes. Chronic obstructive pulmonary disorder was shown to be associated with more favorable survival outcomes as opposed to idiopathic pulmonary fibrosis and the category "other". The need for ECMO and the occurrence of a bronchial complication were also associated with worse survival outcomes. CONCLUSIONS: Both techniques showed reasonable post-transplant outcomes, as our study demonstrated similar survival outcomes and bronchial complication rates.

Lung Transplant Type and Donor Age in Idiopathic Pulmonary Fibrosis: A Single Center Study.

BACKGROUD: Idiopathic pulmonary fibrosis (IPF) accounts for a marked proportion of diagnoses on the US lung transplant (LTx) list. The effects of single (SLT) versus double LTx (DLT) and lung donor age on survival in IPF remain unclear and were investigated in this study. METHODS: We retrospectively assessed survival of LTx recipients with IPF at a single institution from February 2012-March 2020. Survival was analyzed and compared between LTx types (SLT and DLT), donor ages, and the combined groups (LTx type & donor age) using Kaplan-Meier survival analysis and compared by log-rank test. P-values less than 0.05 were considered significant. RESULTS: Of 744 LTx patients at our institution, 307 (41.3%) were diagnosed with IPF, of which 208 (67.8%) were SLT, and 97 (31.6%) were DLT (2 excluded patients underwent heart-lung transplantation). There was no significant difference in survival due to LTx type (P = 0.41) or for patients with donor age <50 or ≥50 y (P = 0.46). Once stratified by both LTx type and donor age, analysis showed no significant difference in survival between the four groups (P = 0.69). CONCLUSIONS: With ethical consideration for organ allocation, as the average age of the US population increases, donor lungs aged ≥50 are an increasingly useful resource in LTx. Our findings suggest donor age and LTx type do not significantly affect survival. Therefore, SLT, and donor lungs aged ≥50 ought to be more readily considered as non-inferior options for LTx in patients with IPF.