Factors Affecting Colorectal Polyp and Cancer Detection Rates in Patients Referred Urgently for Suspected Bowel Cancer.

BACKGROUND/AIM: To investigate factors that affect colorectal polyp or colorectal cancer (CRC) detection amongst patients referred urgently to colorectal services for suspected bowel cancer. PATIENTS AND METHODS: This was a prospective observational study at a UK colorectal centre (2017-2018). Logistic regression determined odds ratios for colorectal polyp or CRC according to age, gender, previous polyp or cancer, and the 6 NICE referral (NG12) categories. RESULTS: A total of 605 patients were included in the study; median age 66 (IQR=54-76); 47.9% male. Nineteen (3.1%) patients had CRC and 64 (10.6%) had polyps. No individual variable increased the likelihood of CRC detection, but male patients had a higher likelihood of having either polyp or CRC (OR=1.72; 95%CI=1.07-2.80; p<0.05). CONCLUSION: At the point of an urgent referral to a colorectal clinic, the likelihood of CRC detection appears to be unaffected by age, gender, or any individual referral criterion. However, overall disease detection may be more likely amongst male patients.

Angiotensin converting enzyme inhibitors and interstage failure in infants with hypoplastic left heart syndrome.

INTRODUCTION: Angiotensin converting enzyme inhibitors are commonly prescribed medications after the Norwood procedure. There are little data that can be used to determine if angiotensin converting enzyme inhibitors improve interstage outcomes in children with single ventricle defects. The objective of this study was to investigate the relationship between angiotensin converting enzyme inhibitors and interstage failure among infants born with hypoplastic left heart syndrome. METHODS: We conducted a retrospective cohort study using data from the National Pediatric Cardiology Quality Improvement Collaborative database (collected between 2008 and 2015). We used logistic regression models to assess the exposure-outcome associations and propensity score matching to account for differences in baseline patient characteristics associated with use of angiotensin converting enzyme inhibitors. RESULTS: A total of 1 487 neonates participated in the study. Thirty-nine percent of patients were prescribed angiotensin converting enzyme inhibitors after the Norwood procedure; 11% experienced interstage failure (death, heart transplantation, and not being a candidate for the second-stage surgery). Before propensity score matching, patients receiving angiotensin converting enzyme inhibitors were significantly more likely to experience interstage failure, compared to patients not on angiotensin converting enzyme inhibitors (OR = 1.44; 95% CI: 1.04, 1.99; P = 0.03). Although there was an increased odds of interstage failure among patients receiving angiotensin converting enzyme inhibitors compared to patients not receiving angiotensin converting enzyme inhibitors in the propensity score-matched cohort, this association was not significantly different (adjusted OR = 1.29; 95% CI: 0.88, 1.95; P = 0.18). CONCLUSION: Angiotensin converting enzyme inhibitor therapy did not demonstrate a beneficial effect on interstage failure among infants with hypoplastic left heart syndrome, even when patient characteristics associated with the use of angiotensin converting enzyme inhibitors were considered.

CC1 Emergent Endovascular Repair of a Ruptured Descending Thoracic Aortic Aneurysm in an Arresting Patient.

OBJECTIVE: Our goal was to present a case of emergent endovascular repair of a ruptured descending aortic aneurysm in an actively arresting patient. PATIENT: The patient was a 75-year-old woman with a known history of a 6.5-cm descending thoracic aortic aneurysm with acute onset of back pain and syncope. A computed tomographic angiogram revealed disruption of the descending thoracic aorta and a mediastinal hematoma. The patient was taken emergently to the operating room. During induction, the patient developed pulseless electrical activity arrest, and cardiopulmonary resuscitation was promptly initiated. The bilateral groins were prepped and draped, and an emergent cutdown was made to gain access to the femoral artery. Wire access of the aortic arch was obtained via a 6F micropuncture sheath, over which a 45- × 45- × 20-mm covered endograft was introduced. Using fluoroscopic guidance alone without angiography, the endograft was rapidly deployed proximally to the level of the distal aortic arch using calcification as a landmark (Fig. CC1-1). Immediately after deployment, the patient regained a pulse, and cardiopulmonary resuscitation was discontinued for a total of 30 minutes of continuous compressions. A right thoracotomy was then performed for evacuation of the hemothorax and ligation of the torn intercostal arteries. The patient was cooled to 35 degrees Celsius for 24 hours post-arrest and a lumbar drain was placed postoperatively. The patient thereafter regained all neurological and end-organ function and at the 6-month follow-up has had no progression of her aneurysm (Fig. CC1-1). CONCLUSIONS: Rapid introduction and deployment of a descending thoracic aortic endograft for a ruptured descending aortic aneurysm is safe and effective in an arresting patient.

Interstage Weight Gain Is Associated With Survival After First-Stage Single-Ventricle Palliation.

BACKGROUND: Low birth and operative weight have been identified as risk factors for death after first-stage single-ventricle palliation. We hypothesize that weight gain after the first-stage operation is associated with transplant-free interstage survival to admission for the second-stage operation. METHODS: We used historical data from the National Pediatric Cardiology Quality Improvement Collaborative database to conduct a longitudinal study to assess the association between weight gain and transplant-free interstage survival. The primary predictor was weight gain. The primary outcome was transplant-free survival. We constructed a repeated-measures logistic regression model using the general estimating equation method to examine the association between weight gain and transplant-free interstage survival. RESULTS: The study population included 1,501 infants who were discharged alive from the first-stage single-ventricle palliation between June 2008 and January 2015. Patients who underwent a hybrid operation (n = 132) or were lost to follow-up (n = 11) were excluded. Transplant-free interstage survival was 90% (1,228 of 1,358). The mean weight gain was 2.5 (SD, 1.0) kg. Adjusted for age at the time of each measurement, the number of measurements, age at discharge from the first-stage operation, sex, diagnosis, postoperative arrhythmia, postoperative complications, and discharge antibiotic therapy, each 100-g increase in weight was associated with an odds ratio of transplant-free interstage survival of 1.03 (95% confidence limit, 1.01, 1.05). CONCLUSIONS: After first-stage single-ventricle palliation, interstage weight gain is significantly associated with transplant-free interstage survival.

Externally visible thrombus partially predicts internal thrombus deposition in extracorporeal membrane oxygenators.

AIM: We sought to quantify the location and volume of thrombus in used hollow-fiber membrane oxygenators and correlate the volume of thrombus with patient demographics, flow characteristics and anticoagulation parameters. METHODS: Hollow-fiber membrane oxygenators (Quadrox D, Maquet, Rastatt, Germany) were collected after clinical use in ECMO circuits and divided into sections. Each section was digitally imaged and analyzed using ImageJ software. The location and total volume (cm3) of thrombus was calculated for different sections. In an effort to predict thrombus formation, we correlated thrombus volume with possible aggravating and mitigating variables. RESULTS: We collected 41 oxygenators from 27 patients. Twenty-seven (66%) were configured in the veno-venous mode and 14 (34%) in the veno-arterial mode. The median duration of use was 131 hours (interquartile range 61-214 hours). Eighteen (44%) were removed when the patient recovered, six (15%) were removed after withdrawal of care and seventeen (41%) were exchanged. The median volume of thrombus was 11.4 cm3 (interquartile range 2.2-44.5 cm3). CONCLUSIONS: A multivariable linear regression model suggested that the combination of median flow, configuration of ECMO and visible thrombus partially predicted internal thrombus volume (adjusted R2=0.39).

Left Ventricular Unloading After Acute Myocardial Infarction Reduces MMP/JNK Associated Apoptosis and Promotes FAK Cell-Survival Signaling.

BACKGROUND: The mechanism underlying left ventricular remodeling and reverse remodeling in the setting of mechanical support following acute myocardial infarction (MI) is unclear. We tested the hypothesis that left ventricular assist device (LVAD) unloading can decrease apoptotic signals after MI. METHODS: An MI model was created in 16 sheep by coronary artery ligation. Eight were unloaded with a LVAD during the first 2 weeks after MI and observed for 10 more weeks. Myocardial tissue was collected from the nonischemic adjacent zone and the remote zone. Proteins in the apoptotic matrix metalloproteinases (MMPs)-2/c-Jun N-terminal kinase (JNK) and prosurvival ß1D-integrin/focal adhesion kinase (FAK) pathway were quantified. RESULTS: Increased TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling) positive nuclei were observed in the MI group and to a lesser extent in the LVAD group (6.18 ± 0.26 versus 0.82 ± 0.18; p < 0.05). Pro-MMP-2, MMP-2, JNK, and phosphorylated (p)-JNK were all elevated in the adjacent zone of the MI-only group but not in the adjacent zone of the LVAD-supported group. There were higher levels of prosurvival p-FAK in the LVAD-supported group than in the MI group. CONCLUSIONS: MMP-2/JNK apoptotic and ß1D-integrin/FAK survival pathways are activated in the nonischemic adjacent zone after MI in adult sheep. LVAD unloading of approximately 50% cardiac output for 2 weeks attenuates remodeling in part by its negative effect on stretch-induced apoptosis and inhibition of MMP-2 activity.

Outcomes of extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in adult cardiac surgery patients.

BACKGROUND: The role of extracorporeal cardiopulmonary resuscitation (ECPR) in adult cardiac surgery patients with refractory cardiac arrest is uncertain. We hypothesized that ECPR would be associated with better than expected outcomes in this group of patients. METHODS: We conducted a single-center retrospective cohort study of adult cardiac surgery patients who underwent ECPR for refractory cardiac arrest during a 6-year period (2010 to 2015). In-hospital mortality, survival at last follow-up, and cerebral performance category (CPC) were examined as outcomes, and potential risk factors for mortality were explored. RESULTS: Twenty-three patients underwent ECPR when spontaneous circulation did not return with conventional resuscitation. Thirty-day mortality was 65.2%, and in-hospital mortality was 69.6%. Six of the 23 patients (26.1%) were discharged with a favorable neurologic outcome, defined as CPC 1 or 2. Most patients who died had multiple organ dysfunction syndrome (43.8%), and a smaller number had severe brain injury (25.0%). Kaplan-Meier survival analysis suggested age as a critical factor affecting survival (P = .04, log-rank test). CONCLUSIONS: ECPR may have a role in younger adult cardiac surgery patients who experience refractory cardiac arrest. Future studies are needed to identify patients who will benefit most from ECPR.

The use of extended criteria donors decreases one-year survival in high-risk lung recipients: A review of the United Network of Organ Sharing Database.

OBJECTIVE: The study objective was to investigate the impact of matching donor quality to recipient severity on survival after lung transplant. METHODS: By using the Organ Procurement and Transplantation Network/United Network for Organ Sharing dataset, we analyzed lung transplant recipients from May 4, 2005, to December 31, 2012. By using adjusted Cox regressions, we identified extended criteria donors as those who had 1 or more of the following: age 65 years or more, smoking history of 20 pack-years or more, diabetes mellitus, or African-American race. All other donors were considered standard donors. Recipients were categorized by lung allocation score: lung allocation score less than 70 and lung allocation score 70 or greater. Our primary outcome was 1-year survival after lung transplantation. RESULTS: Of the 10,995 lung recipients, 3792 (34%) received extended criteria donor organs. Extended criteria donors were associated with an increased hazard of death (hazard ratio [HR], 1.41; 95% confidence interval [CI], 1.26-1.56; P < .001). One-year survival was 87% and 82% (P < .001) for recipients with a lung allocation score less than 70 and 80% and 72% (P = .017) for recipients with a lung allocation score 70 or greater who received standard donor and extended criteria donor organs, respectively. In Cox regression models, the hazard of death was increased for recipients with a lung allocation score less than 70 + extended criteria donor (HR, 1.42; 95% CI, 1.27-1.60; P < .001), recipients with a lung allocation score 70 or greater + standard donor (HR, 1.37; 95% CI, 1.10-1.71; P = .005), and was the highest for recipients with a lung allocation score 70 or greater + extended criteria donor (HR, 1.81; 95% CI, 1.40-2.33; P < .001) compared with recipients with a lung allocation score less than 70 + standard donor. CONCLUSIONS: Extended criteria donors are associated with reduced 1-year survival, and recipients with a lung allocation score 70 or greater who receive extended criteria donor organs have the lowest survival.

Modern Outcomes of Mechanical Circulatory Support as a Bridge to Pediatric Heart Transplantation.

BACKGROUND: Pediatric patients awaiting orthotopic heart transplantation frequently require bridge to transplantation (BTT) with mechanical circulatory support. Posttransplant survival outcomes and predictors of mortality have not been thoroughly described in the modern era using a large-scale analysis. METHODS: The United Network for Organ Sharing database was reviewed to identify pediatric heart transplant recipients from 2005 through 2012. Patients were stratified into three groups: extracorporeal membrane oxygenation (ECMO), ventricular assist device (VAD), and direct transplantation (DTXP). The primary outcome was posttransplant survival. RESULTS: Two thousand seven hundred seventy-seven pediatric patients underwent orthotopic heart transplantation. There were 617 patients who required BTT with mechanical circulatory support (22.2%), of whom there were 428 VAD BTT (69.4%) and 189 ECMO BTT (30.6%). An increase in VAD use was observed during the study period (p < 0.0001). Compared with DTXP, patients in the ECMO BTT group had a lower median age (<1 versus 5 years; p < 0.0001) and were significantly smaller (8 versus 14 kg; p < 0.001), whereas patients in the VAD BTT group were older (8 versus 5 years; p = 0.0002) and larger (24 versus 14 kg; p < 0.001). Actuarial survival was greater in the DTXP group compared with ECMO BTT, but similar to VAD BTT at 30 days and 1, 3, and 5 years. However, this survival difference was lost after censoring the first 4 months after transplant. In multivariable analysis, when restricted to the first 4 months of survival, independent predictors for mortality were ECMO BTT, age, diagnosis, and functional status, whereas VAD BTT was not. CONCLUSIONS: Pediatric patients with DTXP or VAD BTT have equivalent posttransplant survival. However, those requiring ECMO BTT have inferior early posttransplant survival compared with those receiving DTXP.

Venous Thromboembolic Complications of Lung Transplantation: A Contemporary Single-Institution Review.

BACKGROUND: The incidence and consequences of deep venous thrombosis (DVT) and pulmonary embolism (PE) have not been described recently in lung transplant recipients. We sought to characterize DVT and PE in a contemporary series of lung transplant recipients and describe their association with clinical outcomes. METHODS: The records of all lung transplant recipients from July 1, 2008, to June 30, 2013, were reviewed and analyzed. DVT was diagnosed by venous duplex ultrasonography. PE was diagnosed by computed tomography angiography, nuclear ventilation/perfusion scanning, or pulmonary angiography. RESULTS: The study comprised 117 patients who underwent 123 transplants. The median age was 63 years (range, 17 to 77 years). Forty-five patients (39%) had evidence of lower extremity DVT, 53 (45%) had no evidence of lower extremity DVT, and 19 (16%) were not tested. Fifty-three (45%) had evidence of upper extremity DVT, 30 (26%) had no evidence of upper extremity DVT, and 34 (29%) were not tested. Eighteen (15%) had evidence of PE, 82 (70%) had no evidence of PE, and 17 (15%) were not tested. A multivariable, stepwise Cox proportional hazards model revealed that the presence of lower extremity DVT (hazard ratio, 2.43; 95% confidence interval, 1.29 to 4.64), use of cardiopulmonary bypass (hazard ratio, 2.21; 95% confidence interval, 1.04 to 4.68), and unilateral lung transplantation (hazard ratio, 2.13; 95% confidence interval, 1.07 to 4.25) were associated with diminished survival. CONCLUSIONS: The incidence of DVT and PE in lung transplant recipients is high. Posttransplant surveillance and treatment based on findings are warranted.

Long-Term Venovenous Extracorporeal Membrane Oxygenation Support for Acute Respiratory Distress Syndrome.

BACKGROUND: Given substantial advances in venovenous extracorporeal membrane oxygenation (ECMO) technology, long-term support is increasingly feasible. Although the benefits of short-term ECMO as a bridge to recovery in acute respiratory distress syndrome (ARDS) are well described, the utility and outcomes of long-term support remain unclear. METHODS: Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed and analyzed separately for those requiring ECMO support for less than 3 weeks or for 3 weeks or longer. Demographic factors, ECMO variables, and outcomes were assessed. RESULTS: Fifty-five patients with ARDS received ECMO during the study period, with 11 patients requiring long-term ECMO support and a median duration of 36 (interquartile range: 24 to 68) days. Recovery was the initial goal in all patients. Pre-ECMO mechanical ventilatory support, indices of disease severity, and the ECMO cannulation strategy were similar between the two groups. Eight (73%) patients receiving long-term support were bridged to recovery, and 1 patient was bridged to transplantation after a refractory course. Eight (73%) patients receiving long-term support and 25 (57%) patients receiving short-term support survived to 30 days and hospital discharge. CONCLUSIONS: Previously, long-term ECMO support was thought to be associated with unfavorable outcomes. This study, however, may provide support for the efficacy of ECMO support even for 3 weeks or more as a bridge to recovery or transplantation.

Class III Obesity is Not a Contraindication to Venovenous Extracorporeal Membrane Oxygenation Support.

BACKGROUND: The use of venovenous extracorporeal membrane oxygenation (ECMO) has increased as a bridge to recovery for acute respiratory distress syndrome (ARDS) refractory to conventional support. Morbid obesity can pose a significant challenge to obtaining indexed flows, and outcomes in this population are not well described. METHODS: Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed. Demographics, ECMO variables, and outcomes were assessed. Morbid obesity and super obesity were defined as a body mass index (BMI) greater than 40 kg/m(2) and greater than 50 kg/m(2), respectively. RESULTS: Fifty-five patients with ARDS were placed on ECMO during the study period. Twelve were morbidly obese with a BMI of 49.0 kg/m(2) (interquartile range [IQR]: 45.4-57.3 kg/m(2)). Pre-ECMO mechanical ventilatory support and indices of disease severity were similar between the 2 groups, as were cannulation strategy and duration of ECMO support. Nine (75%) morbidly obese patients and 27 (63%) non-morbidly obese patients were successfully weaned from ECMO support, and patient survival to time of discharge was 67% and 58%, respectively. In the subset of super obese patients (n = 6; BMI, 57.3 kg/m(2) [IQR: 51.3-66.5 kg/m(2)]), recovery and midterm survival was 100%. CONCLUSIONS: In this review, class III obesity was not associated with poorer outcomes, and based on these data, ECMO support should not be withheld from this patient population.

Venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation: successful transplantation after 155 days of support.

We present a case of a woman with acute respiratory distress syndrome and irrecoverable lung function that was successfully bridged to lung transplantation after 155 consecutive days of venovenous extracorporeal membrane oxygenation.

Fresh autologous pericardium for leaflet perforation repair in mitral valve infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: There is clear evidence that mitral valve (MV) repair is superior to replacement for MV infective endocarditis (IE). Leaflet perforation is a common pathologic finding in MV IE, and leaflet patch repair with glutaraldehyde-treated autologous or bovine pericardium is the currently accepted method of MV repair. In the present study, fresh autologous pericardium (FAP) was used universally to treat leaflet perforation in MV IE, and the mid-term clinical and echocardiographic outcomes were determined. METHODS: Between 2002 and 2009, a total of 20 patients with leaflet perforations from MV IE underwent patch repair with FAP. Follow up echocardiography was performed in a core laboratory. RESULTS: There was one operative death (5%) secondary to sepsis, and three late deaths (15%). Late echocardiograms were available for review from 16 of the 19 patients (84%) who survived surgery. The mean time to follow up echocardiography was 793 +/- 663 days. The mitral regurgitation (MR) grade was mild or less in 14/16 patients (88%), moderate in one patient (6%), and severe in one patient (6%). The mean gradient was 4.8 +/- 2.7 mmHg, and the ejection fraction was preserved in all patients (63 +/- 4%). No expansion, retraction or calcification of the patches was observed. Freedom from reoperation, reinfection and thromboembolism was 100%. CONCLUSION: Fresh autologous pericardium for MV leaflet patch repair in IE is associated with good mid-term valve function. Given the association between late calcification and the glutaraldehyde treatment of bioprosthetic valves and this favorable experience, it is believed that FAP is an acceptable alternative for leaflet repair in MV IE.

Surgical management of mitral valve infective endocarditis.

Active mitral valve infective endocarditis is a challenging clinical problem with a high rate of mortality. Surgery is currently performed in more than 40% of patients, and selecting those patients who will benefit from surgical intervention and performing a technically sound operation at the proper time are keys to optimizing outcomes. Moderate-to-severe and severe mitral regurgitation, large, mobile vegetations, paravalvular abscess, embolic events, failure of antibiotic therapy, and infection with a fungal organism are indications for prompt operation. The use of computed tomography imaging is important to determine whether there are noncardiac sources of infection, and transesophageal echocardiography is essential to delineate valvular dysfunction, identify paravalvular abscesses, rule out involvement of other valves, and plan operative therapy. In most cases, surgery should not be delayed because of cerebrovascular emboli. Mitral valve repair is favored over replacement whenever possible, is associated with superior short- and long-term outcomes, and should be possible in most cases. Operative mortality is <10% and 5-year survival is >80%.

Pulmonary hypertension adversely affects short- and long-term survival after mitral valve operation for mitral regurgitation: implications for timing of surgery.

OBJECTIVE: We investigated the impact of preoperative pulmonary hypertension (PH) on early and late outcomes after mitral valve operation for mitral regurgitation. METHODS: Systolic pulmonary artery pressure (sPAP) was measured before operation in 873 consecutive patients who underwent mitral valve surgery for mitral regurgitation between January 2002 and January 2010. PH was classified as none (sPAP < 40 mm Hg), mild (40 ≤ sPAP < 50 mm Hg), moderate (50 ≤ sPAP < 60 mm Hg), or severe (sPAP ≥ 60 mm Hg). RESULTS: Increased preoperative sPAP was associated with greater left ventricular dysfunction and dilation, left atrial enlargement, more atrial fibrillation, and tricuspid regurgitation. Operative mortality was correlated with the degree of preoperative PH (2%, 3%, 8%, and 12% for none, mild, moderate, and severe PH, respectively, P < .0001). Long-term survival was related to preoperative sPAP (5-year survival: 88%, 79%, 65%, and 53% for none, mild, moderate, and severe PH, respectively; P < .0001). In multivariable analyses, sPAP was a predictor of both operative mortality (odds ratio, 1.023 per 1 mm Hg increase; 95% confidence interval, 1.003-1.044; P = .0270) and late death (hazard ratio, 1.018 per 1 mm Hg increase; 95% confidence interval, 1.007-1.028; P = .001). Among 284 patients with isolated degenerative mitral regurgitation due to leaflet prolapse, actuarial survival was 97.5%, 91.2%, and 80.5% for none, mild, and moderate to severe PH, respectively (P = .0002). CONCLUSIONS: Preoperative sPAP is a powerful predictor of early and late survival after mitral valve operation for mitral regurgitation. Even modest increases in sPAP adversely affect outcomes. Mitral valve operation should be performed before the development of PH.