Papillary muscle rupture following routine aortic valve replacement.

A 56-year-old man who underwent routine aortic valve replacement (AVR) for aortic insufficiency suffered a presumed embolic event to a small vessel supplying the posteromedial papillary muscle. This led to papillary muscle rupture, and severe, acute mitral regurgitation requiring emergent mitral valve replacement 6 days postoperatively. Small-vessel coronary embolization outside the setting of infection/endocarditis leading to infarction and papillary muscle rupture following elective AVR has not been previously described in the literature.

The Mitral Monobloc: A Simplification for Intervalvular Fibrous Body Reconstruction in Endocarditis.

The only viable option in prosthetic valve endocarditis with extensive abscess of the aorto-mitral curtain is radical debridement and reconstruction of the intravalvular fibrous body. This report details a simplified intravalvular fibrous body reconstruction technique.

Outcomes of surgical aortic valve replacement for mixed aortic valve disease.

BACKGROUND: Mixed aortic valve disease (MAVD) is associated with a poorer natural history compared with isolated lesions. However, clinical and echocardiographic outcomes for aortic valve replacement (AVR) in mixed disease are less well understood. METHODS: Retrospective review of AVRs (n=1,011) from 2000-2016. Isolated AVR, AVR + coronary bypass, and AVR + limited ascending aortic replacement were included. Predominant aortic stenosis (AS) group was stratified into group 1 (n=660) with concomitant mild or less aortic insufficiency (AI), and group 2 (n=197) with accompanying moderate or greater AI. Predominant AI group was stratified using the same schema for concomitant AS into groups 3 (n=143) and 4 (n=53). Median follow-up was 3.1 and 4.4 years respectively for AS and AI groups. RESULTS: For the predominant AS group (n=857) preoperatively, group 2 had a larger preoperative left ventricular end diastolic diameter (LVESD) (51.0±8.4 vs. 48.6±7.2, P=0.02) and lower preoperative left ventricular ejection fraction (LVEF) (57.6% vs. 60.2%, P=0.043). No differences in left ventricular (LV) dimensions, LV or right ventricular (RV) function was evident at follow up (P>0.05). After propensity matching for age, operation, and comorbidities, there was no difference in survival (P=0.19). After propensity matching for the predominant AI group (n=196), survival was lower for group 4 compared to 3 (P=0.02). There were no differences in LV dimensions, LV or RV function preoperatively or on follow-up (P>0.05). CONCLUSIONS: Predominant AS associated with higher AI grades had larger LV dimensions and worse LV function preoperatively. These differences resolve after AVR with equivalent survival. However, predominant AI with more severe AS had reduced survival despite AVR.

Natural history of the proximal aorta in patients with descending thoracic aortic disease.

OBJECTIVE: This study investigated the growth and behavior of the ascending aorta in patients with descending thoracic aortic disease. METHODS: We examined 200 patients with descending thoracic aortic disease including acute type B dissection (n = 95), chronic type B dissection (n = 38), intramural hematoma (n = 23), and thoracoabdominal aortic aneurysms (n = 44). Images from computed tomography and magnetic resonance imaging were evaluated after three-dimensional reconstruction to examine the growth rate in those with >1 year of imaging follow-up (n = 108). Survival data were derived from all 200 patients in this study. RESULTS: Average proximal aortic dimensions at the index image were relatively small, measuring 3.65 ± 0.51 cm in the root, 3.67 ± 0.48 cm in the ascending aorta, and 3.50 ± 0.44 cm in the proximal arch. Average growth rate was low for the aortic root, ascending aorta, and proximal arch at 0.36 ± 0.64 mm/y, 0.26 ± 0.44 mm/y, and 0.25 ± 0.44 mm/y, respectively. There was no difference in baseline proximal aortic dimensions and growth rate between the four subgroups. An index aortic diameter ≥4.1 cm grew faster than those <4.1 cm at the ascending aorta (P = .028) and proximal arch (P = .019). There was no difference in aortic growth rates at the aortic root (P = .887). After the index scan, five patients underwent six ascending aortic replacement procedures, leading to a 3% ascending aortic intervention rate. Overall median life expectancy was 86.15 years. CONCLUSIONS: Native ascending aortic growth in patients with descending thoracic aortic disease is slow. We suggest regular follow-up for index ascending aorta ≥4.1 cm because of its larger initial size and more rapid growth.

Cluster analysis of acute ascending aortic dissection provides novel insight into mechanisms of distal progression.

BACKGROUND: Whether primary tear size impacts extent of type A dissection is unclear. Using statistical groupings based on dissection morphology, we examined its relationship to primary tear area. METHODS: We retrospectively reviewed 108 patients who underwent acute ascending dissection repair from 2000-2016. Dissection morphology was characterized using 3-dimensional (3D) reconstructions of computed tomography (CT) scan images. Two-step cluster analysis was performed to group the dissections by examining the true lumen area as a fraction of the total aortic area at various levels. RESULTS: Cluster analysis defined two distinct categories. This first grouping corresponds to DeBakey type I (n=71, 65.7%) with a dissection extending from the ascending aorta to the aortic bifurcation. The second grouping conforms more closely to DeBakey type II dissection (n=37, 34.3%). It differs however from the classic type II definition as the dissection may extend up to the distal arch from the ascending aorta. Compared to type I, this "extended" DeBakey type II had no malperfusion (P<0.05), a larger primary tear area (6.6 vs. 3.7 cm2, P=0.009), and a greater burden of atherosclerotic coronary artery disease (P<0.05). A smaller aortic valve annulus (P=0.025) and a smaller root false lumen area (P=0.017) may explain less aortic valve insufficiency (P<0.05) in extended type II dissections. No differences in complications or survival were seen. CONCLUSIONS: In this series, limited distal extension of DeBakey type II dissections appears to be related to a larger primary tear area and greater atherosclerotic disease burden. It is also associated with less malperfusion and aortic valve insufficiency.

Coronary bypass in left ventricular dysfunction and differential cardiac recovery.

Background We aimed to examine the efficacy of surgical revascularization with respect to improvement in ventricular function and survival in patients with ischemic cardiomyopathy and poor left ventricular function. Methods We retrospectively analyzed the data of 429 patients (median age 64.6 years, 81.1% male) with ejection fractions <40% undergoing isolated primary coronary artery bypass grafting from 2000 to 2016. Techniques included on-pump cardioplegic arrest ( n = 312), off-pump ( n = 75), and on-pump beating heart ( n = 42). Propensity matching was performed to compare the cardioplegic arrest group ( n = 114) with the combined off-pump and beating heart groups ( n = 114). Results Postoperatively, ejection fraction increased by 10.1% ± 13.1% (from 31.4% ± 7.1% to 41.6% ± 13.6%; p < 0.001) and mitral regurgitation grade improved ( p < 0.001) but right ventricular function on echocardiographic assessment worsened over time ( p = 0.04). No difference in ejection fraction improvement was seen in the time periods <1 (9.8% ± 11.2%), 1-5 (11.6% ± 14.5%), and >5 (8.8% ± 14.2%) years ( p = 0.442). Following propensity matching, there was no significant difference between the combined off-pump/beating heart and cardioplegic arrest groups with respect to survival or postoperative complications. Conclusions Patients with moderate to severe left ventricular dysfunction experience long-term improvement in left ventricular ejection fraction after coronary artery bypass. However, right ventricular function often continues to decline, contributing to persistent or worsening heart failure symptoms and late mortality. No difference in survival was seen between the 2 techniques.

Acute retrograde type A aortic dissection: morphologic analysis and clinical implications.

BACKGROUND: This study compares the morphology and outcomes of acute retrograde type A dissections (RTADs) with acute antegrade type A dissections (ATADs), and acute type B dissections. MATERIALS AND METHODS: From 2000 to 2016, there were 12 acute RTADs, 96 ATADs, and 92 type B dissections with available imaging. Dissections were characterized using computerized tomography angiography images. We examined clinical features, tear characteristics, and various morphologic measurements. RESULTS: Compared with acute type B dissections, RTAD primary tears were more common in the distal arch (75% versus 43%, P = 0.04), and the false-to-true lumen contrast intensity ratio at the mid-descending thoracic aorta was lower (0.46 versus 0.71, P = 0.020). RTAD had less false lumen decompression because there were fewer aortic branch vessels distal to the subclavian that were perfused through the false lumen (0.40 versus 2.19, P < 0.001). Compared with ATAD, RTAD had less root involvement where root true-to-total lumen area ratio was higher (0.88 versus 0.76, P = 0.081). Furthermore, RTAD had a lower false-to-true lumen contrast intensity ratio at the root (0.25 versus 0.57, P < 0.05), ascending aorta (0.25 versus 0.72, P < 0.001), and proximal arch (0.39 versus 0.67, P < 0.05). RTAD were more likely to undergo aortic valve resuspension (100% versus 74%, P = 0.044). CONCLUSIONS: RTAD tends to occur when primary tears occur in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared with ATAD, RTAD has less root involvement, and successful aortic valve resuspension is more likely.

Coronary Events in Patients Presenting for Repair of Acute Type A Aortic Dissection.

BACKGROUND: Preoperative coronary angiography is often not performed in acute Type A dissection. We examined differences in the incidence of pre-existing coronary disease and subsequent coronary events between patients undergoing acute Type A dissection repair and patients undergoing elective proximal aortic aneurysm repair. METHODS: From 2000 to 2015, there were 154 acute Type A dissection repairs and 457 elective proximal aortic aneurysm repairs. We performed a retrospective review to evaluate preoperative coronary disease and postoperative coronary interventions such as percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG). RESULTS: A total of 31 (20%) dissection patients and 123 (27%) elective surgery patients had preoperative evidence of coronary artery disease (p = 0.094). All elective surgery patients but only six (4%) dissection patients had preoperative coronary catheterization. More CABGs were performed in the elective surgery group (19%) than in the dissection group (3%, p < 0.001). There were no differences in the incidence of prior PCI, CABG, or myocardial infarction between groups. Following dissection repair, four patients required coronary interventions. Of these, two (1.3%) experienced chest pain and underwent PCI at 4.7 and 4.3 months postoperatively, respectively, and another two experienced symptoms and required PCI at 5 and 7 years, respectively. The 30-day and 14-year mortality rates after dissection repair were 13% and 24%, respectively. Although the dissection group had poorer survival than the elective surgery group (p < 0.001), there was no difference in conditional survival after aortic-related deaths over the first year were censored (p = 0.104). CONCLUSIONS: Given the low incidence of missed significant coronary disease (1.3%), it is reasonable to perform Type A dissection repair without coronary angiography.

Lung transplantation for high-risk patients with idiopathic pulmonary fibrosis.

BACKGROUND: Survival for patients with idiopathic pulmonary fibrosis (IPF) and high lung allocation score (LAS) values may be significantly reduced in comparison to those with lower LAS values. OBJECTIVES: To evaluate outcomes for high-risk IPF patients as defined by LAS values ≥46 (N=42) versus recipients with LAS values <46 (N=89). METHODS: We retrospectively reviewed records of 131 consecutive patients with IPF who received lung transplants at our institution between 1999 and 2013. RESULTS: The mean LAS was significantly higher (59.5, interquartile range 43.9-75.9 vs. 39.3, interquartile range 37.7-44.3; p<0.01) for the high-risk cohort. The higher LAS cohort had significantly lower percent predicted forced vital capacity (FVC) versus recipients with LAS <46 (41.3±14.1% vs. 53.2±16.2%; p<0.01) and required more supplemental oxygen (7±5 vs. 4±2 L/min, p<0.01) prior to transplant versus recipients with LAS <46. Although the incidence of early post-LTX pulmonary complications was increased for the higher LAS group versus recipients with LAS <46, 30-day mortality and actuarial survival did not differ between the two cohorts. CONCLUSIONS: Although lung transplantation in patients with IPF and high LAS values is associated with increased risk of early post-transplant complications, long-term post-transplant survival for our high-LAS cohort was equivalent to that for the lower LAS recipients.

The presence or severity of pulmonary hypertension does not affect outcomes for single-lung transplantation.

Advanced lung disease (ALD) that requires lung transplantation (LTX) is frequently associated with pulmonary hypertension (PH). Whether the presence of PH significantly affects the outcomes following single-lung transplantation (SLT) remains controversial. Therefore, we retrospectively examined the outcomes of 279 consecutive SLT recipients transplanted at our centre, and the patients were split into four groups based on their mean pulmonary artery pressure values. Outcomes, including long-term survival and primary graft dysfunction, did not differ significantly for patients with versus without PH, even when PH was severe. We suggest that SLT can be performed safely in patients with ALD-associated PH.

Lung transplantation from donation after cardiocirculatory death: a systematic review and meta-analysis.

BACKGROUND: Lung transplantation (LTx) can extend life expectancy and enhance the quality of life for select patients with end-stage lung disease. In the setting of donor lung shortage and waiting list mortality, the interest in donation after cardiocirculatory death (DCD) is increasing. We performed a systematic review and meta-analysis to compare outcomes between DCD and conventional donation after brain death (DBD). METHODS: PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and ClinicalTrials.gov were searched. We identified original research studies with 1-year post-transplant survival data involving >5 DCD transplants. We performed meta-analyses examining 1-year survival, primary graft dysfunction, and acute rejection after LTx. RESULTS: We identified 519 citations; 11 observational cohort studies met our inclusion criteria for systematic review, and 6 met our inclusion criteria for meta-analysis. There were no differences found in 1-year mortality after LTx between DCD and DBD cohorts in individual studies or in the meta-analysis (DCD [n = 271] vs DBD [n = 2,369], relative risk [RR] 0.88, 95% confidence interval [CI] 0.59-1.31, p = 0.52, I(2) = 0%). There was also no difference between DCD and DBD in a pooled analysis of 5 studies reporting on primary graft dysfunction (RR 1.09, 95% CI 0.68-1.73, p = 0.7, I(2) = 0%) and 4 studies reporting on acute rejection (RR 0.72, 95% CI 0.49-1.05, p = 0.09, I(2) = 0%). CONCLUSIONS: Survival after LTx from DCD is comparable to survival after LTx from DBD in observational cohort studies. DCD appears to be a safe and effective method to expand the donor pool.

Acute fibrinous and organising pneumonia following lung transplantation is associated with severe allograft dysfunction and poor outcome: a case series.

Acute fibrinous and organising pneumonia (AFOP) is a histopathologic variant of acute lung injury that has been associated with infection and inflammatory disorders and has been reported as a complication of lung transplantation. A retrospective chart review was performed for all patients transplanted at the University of Wisconsin Hospital and Clinics from January 1995 to December 2013 (n = 561). We identified 6 recipients whose clinical course was complicated by AFOP. All recipients were found to have AFOP on lung biopsy or at post-mortem examination, and 5 of the 6 patients suffered progressive allograft dysfunction that led to fatal outcome. Only 1 of the 6 patients stabilised with augmented immunosuppression and had subsequent improvement and stabilisation of allograft function. We could not clearly identify any specific cause of AFOP, such as drug toxicity or infection. Lung transplantation can be complicated by lung injury with an AFOP pattern on histopathologic examination of lung biopsy specimens. The presence of an AFOP pattern was associated with irreversible decline in lung function that was refractory to therapeutic interventions in 5 of our 6 cases and was associated with severe allograft dysfunction and death in these 5 individuals. AFOP should be considered as a potential diagnosis when lung transplant recipients develop progressive decline in lung function that is consistent with a clinical diagnosis of chronic lung allograft dysfunction.

Acuity adaptable patient care unit system shortens length of stay and improves outcomes in adult cardiac surgery: University of Wisconsin experience.

OBJECTIVES: The Acuity Adaptable Patient Care (AAC) unit system allows all beds within a nursing unit to negate the need for transfer with changes in patient status. The unit is specialty specific to all levels of patient care. This system was implemented in March 2006 for cardiothoracic surgery at our institution. The purpose of this study was to evaluate the impact of the AAC system on the outcomes after adult cardiac surgery. METHODS: We retrospectively reviewed 2930 consecutive patients who underwent major adult cardiac procedures between January 2003 and December 2010. The cohorts were divided into the pre-AAC group (January 2003 to February 2006, n = 1029) and the AAC group (March 2006 to December 2010, n = 1901). Patient demographics and postoperative outcomes were assessed. RESULTS: The proportion of coronary artery bypass grafting was significantly lower (pre-AAC vs AAC: 43 vs 35%, P < 0.01), while those of aortic procedure (4 vs 11%, P < 0.01) and mechanical assist device insertion (3 vs 5%, P = 0.02) were higher in the AAC group. After the implementation of the AAC system, the incidence of all complications defined by the Society of Thoracic Surgeons (STS) database (49 vs 34%, P < 0.01), the median length of intensive care unit (ICU) stay (49 [interquartile range (IQR), 27-99] vs 26 [19-45] h, P < 0.01), that of hospital stay (6 [4-10] vs 5 [4-7] days, P < 0.01) and the readmission rate of ICU (5 vs 2% P < 0.01) were significantly decreased. Significant reductions in hospital mortality and the rate of hospital readmission <30 days were not observed. CONCLUSIONS: The implementation of the AAC system has improved the outcomes after major cardiac procedures. The incidence of postoperative complications and length of stay have all decreased significantly without increasing readmission rate. AAC creates a system of fluid care with specialty-trained nursing and other ancillary support that expedites discharge and improves overall patient outcomes.

Lung transplant for interstitial lung disease: outcomes before and after implementation of the united network for organ sharing lung allocation scoring system.

OBJECTIVES: This study was undertaken to evaluate whether the adoption of the united network for organ sharing lung allocation score (LAS) was associated with significant changes in lung transplantation (LTX) outcomes for patients with interstitial lung disease (ILD) who underwent LTX at the University of Wisconsin Hospital and Clinics. METHODS: Outcomes for 107 consecutive patients with various forms of ILD who underwent LTX between January 1993 and March 2009 were examined. Patients transplanted following the implementation of the LAS system (LAS, n = 56) were compared with those transplanted prior to LAS implementation (pre-LAS, n = 51) for whom LAS scores were calculated. RESULTS: Patients with idiopathic pulmonary fibrosis (IPF) comprised the majority of patients with ILD. Recipients transplanted after the implementation of the LAS were significantly older (pre-LAS: 50.4 vs. LAS: 56.7 years, P < 0.01), required more supplemental oxygen (3 vs. 5 l/min, P < 0.01) and displayed lower cardiac index values (3.1 vs. 2.6 l/m(2), P < 0.01). The estimated LAS was significantly increased from 38.3 (pre-LAS) to 43.3 (LAS), P < 0.01. However, waiting time decreased from 266 to 78 days (P < 0.01). The rate of bilateral vs. single LTX was lower (35 vs. 16%, P = 0.02) for the post-LAS group. Cold ischaemic time was shorter in the post-LAS group (434 vs. 299 min, P < 0.01), and the length of hospital stay decreased from 24 to 11 days (P < 0.01). Hospital mortality (11 vs. 7%, P = 0.51) and post-transplant survival did not differ between the groups. CONCLUSIONS: Post-transplant outcomes for patients with ILD or the subset of recipients with IPF were not adversely affected by the implementation of the LAS.

Lung transplant for interstitial lung disease: outcomes for single versus bilateral lung transplantation.

This study was undertaken to evaluate outcomes for single (SLT) vs. bilateral lung transplantation (BLT) in patients with interstitial lung disease (ILD). One hundred and eleven patients with ILD who underwent lung transplantation between January 1993 and March 2009 were evaluated. Recipients with BLT were younger (43 ± 12 vs. 57 ± 7 years), and significantly more patients with non-idiopathic pulmonary fibrosis (IPF) received BLT (50%) vs. patients with IPF (18%). BLT recipients had a significantly longer mean waitlist time (240 vs. 125 days), significantly higher systolic (51 ± 18 vs. 40 ± 11 mmHg) pulmonary artery pressures, were placed on cardiopulmonary bypass more frequently (67 vs. 31%), had a higher incidence of primary graft dysfunction (63 vs. 17%), more frequently were given prolonged peri-operative inhaled nitric oxide and more frequently required prolonged post-operative mechanical ventilatory support (6.0 vs. 1.7 days). Additionally, BLT recipients had a significantly longer intensive care unit (8 vs. 4 days) and hospital (24 vs. 15 days) length of stay. We did not detect a difference in survival (Kaplan-Meier) for SLT vs. BLT. Our findings suggest that outcomes for SLT for patients with ILD are comparable or somewhat superior to those for BLT, and short- and long-term survival are not significantly different for the two procedures.

Colon cancer in lung transplant recipients with CF: increased risk and results of screening.

OBJECTIVE: To determine the incidence of colon cancer in lung transplant recipients with cystic fibrosis (CF) and review screening colonoscopic findings in other recipients with CF. METHODS: A retrospective chart review was performed for all patients with CF transplanted at the University of Wisconsin Hospital and Clinics (January 1994 through December 2010). RESULTS: Four of 70 transplant recipients with CF developed fatal colon carcinoma following transplantation, and the cancer was advanced in all 4 recipients (age 31, 44, 44, 64) at the time of diagnosis. In contrast, only one of 287 recipients transplanted for non-CF indications developed colon cancer. Of all recipients with CF who did not develop colon cancer, 20 recipients underwent screening colonoscopy at 1 to 12 years following transplantation. Seven (35%) of the screened transplant recipients (ages 36, 38, 40, 41, 43, 49, 51) had colonic polyps in locations ranging from cecum to sigmoid colon and up to 3 cm in diameter. CONCLUSIONS: In contrast to non-CF recipients, patients with CF displayed a significant incidence of colon cancer (4 of 70 recipients; 5.7%) with onset ranging from 246 days to 9.3 years post-transplant, which may be due to a combination of their underlying genetic disorder plus intense, sustained immunosuppression following lung transplantation. Colonoscopic screening may identify patients with pre-malignant colonic lesions and prevent progression to colonic malignancy.

Lung transplantation with donation after cardiac death donors: long-term follow-up in a single center.

OBJECTIVE: We sought to examine long-term outcomes at the University of Wisconsin for all lung transplant recipients who received lungs from donation after cardiac death donors since the initiation of this program in 1993. METHODS: Eighteen (4.2%) of the 424 lung transplantations performed in 406 patients between January 1993 and April 2009 used lungs from donation after cardiac death donors. Outcomes for this recipient cohort were compared with those for recipients who received organs from brain-dead donors. RESULTS: Warm ischemic time (from withdrawal of support to reperfusion of organs) was 30 +/- 17 minutes (11-93 minutes). The patient survival rates in the donation after cardiac death group (DCD group) at 1, 3, and 5 years were 88.1% +/- 7.9%, 81.9% +/- 9.5%, and 81.9% +/- 9.5%, respectively. These survival rates were not different from those of the brain-dead donor group (BDD group, P = .66). The incidence of primary graft dysfunction in the DCD group was similar to that of the BDD group (P = .59). However, the incidence of airway complications was somewhat higher in the DCD group. Freedom from bronchiolitis obliterans syndrome at 1, 3, and 5 years in the DCD group was 80.4% +/- 10.2%, 80.4% +/- 10.2%, and 72.3% +/- 11.9%, respectively, and did not differ from the incidence of bronchiolitis obliterans syndrome in the BDD group (P = .59). CONCLUSIONS: Our data show that the long-term patient and graft survival rates after donation after cardiac death lung transplantation were equivalent to those after brain-dead donor lung transplantation. Our findings suggest that the use of donation after cardiac death donors can safely and substantially expand the donor pool for lung transplantation.

The impact of the lung allocation scoring system at the single national Veterans Affairs Hospital lung transplantation program.

OBJECTIVE: The lung allocation score (LAS) has changed the distribution of donor lungs for transplantation. This study was undertaken to evaluate the impact of the LAS on a unique patient population undergoing lung transplantation (LTX) at the single national Veterans Affairs (VA) LT center. METHODS: One hundred and ten consecutive VA patients underwent LTX between 1994 and 2007. Patients transplanted using the LAS (LAS, n=26) were compared to patients transplanted prior to introduction of the LAS (pre-LAS, n=84). RESULTS: Waiting time decreased from 353.8+/-254.7 (pre-LAS) to 238.0+/-306.6 (LAS) days (p<0.01). Recipient diagnoses have changed with an increase in idiopathic pulmonary fibrosis [11% (9/84) pre-LAS vs 46% (12/26) LAS, p<0.01] and a decrease in emphysema [57% (48/84) pre-LAS vs 35% (9/26) LAS, p<0.01]. Mean LAS calculation was 33.1+/-2.9 for pre-LAS versus 41.9+/-9.8 for the LAS (p<0.01). Postoperative complications did not differ between the groups. Length of hospital stay decreased from 44.3+/-42.9 (pre-LAS) to 18.1+/-12.3 (LAS) days (p<0.01). Hospital mortality and 1-year survival did not differ between the pre-LAS and LAS groups (7% vs 8%; p=0.72 and 92% [95% confidence interval (CI) 86-98] vs 92% [CI 82-100]; p=0.23, respectively). CONCLUSIONS: The LAS appears to be achieving its objectives by reducing waitlist time and altering the distribution of lung disease being transplanted on the basis of medical necessity in the U.S. VA population. In addition, the LAS does not appear to have adversely affected short-term post-transplant outcomes in our recipient cohort.

Redo lung transplantation for acute and chronic lung allograft failure: long-term follow-up in a single center.

OBJECTIVE: This study was undertaken to evaluate outcomes of redo lung transplantation (LT) for acute and chronic graft failure. METHODS: Between 1988 and 2007, 388 LT procedures were performed on 369 patients. From those, 17 (4.6%) patients had redo LT once and 2 patients had redo LT twice. Patient survival and recurrence of bronchiolitis obliterans syndrome (BOS) after redo LT were reviewed. RESULTS: The overall survival rates of the 17 redo LT recipients at 1, 2 and 5 years were 59+/-23%, 59+/-23% and 42+/-25%, respectively. For the chronic graft failure group (n=12), survival rates at 1, 2 and 5 years were 67+/-26%, 67+/-26% and 44+/-30%, respectively. These survival rates were significantly lower than the survival rates observed in our experience after primary LT (n=352, 1-, 2- and 5-year survival rates of 88+/-4%, 80+/-4% and 65+/-5%, respectively. For the acute graft failure group (n=5), the 1-year survival rate was 40%; two patients remain free from BOS. Two patients had a second redo LT, one died from multi-organ failure on postoperative day 86 and the other died from pulmonary aspergillosis on postoperative day 214. CONCLUSIONS: Redo LT is a valid therapeutic option for selected patients with BOS and might be an option for highly selected patients with acute lung graft failure. Outcomes from a second redo LT are poor, and a second lung retransplantation must be used very cautiously, if at all.

The impact of the lung allocation score on short-term transplantation outcomes: a multicenter study.

OBJECTIVE: The lung allocation score restructured the distribution of scarce donor lungs for transplantation. The algorithm ranks waiting list patients according to medical urgency and expected benefit after transplantation. The purpose of this study was to evaluate the impact of the lung allocation score on short-term outcomes after lung transplantation. METHODS: A multicenter retrospective cohort study was performed with data from 5 academic medical centers. Results of patients undergoing transplantation on the basis of the lung allocation score (May 4, 2005 to May 3, 2006) were compared with those of patients receiving transplants the preceding year before the lung allocation score was implemented (May 4, 2004, to May 3, 2005). RESULTS: The study reports on 341 patients (170 before the lung allocation score and 171 after). Waiting time decreased from 680.9 +/- 528.3 days to 445.6 +/- 516.9 days (P < .001). Recipient diagnoses changed with an increase in idiopathic pulmonary fibrosis and a decrease in emphysema and cystic fibrosis (P = .002). Postoperatively, primary graft dysfunction increased from 14.1% (24/170) to 22.9% (39/171) (P = .04) and intensive care unit length of stay increased from 5.7 +/- 6.7 days to 7.8 +/- 9.6 days (P = .04). Hospital mortality and 1-year survival were the same between groups (5.3% vs 5.3% and 90% vs 89%, respectively; P > .6) CONCLUSIONS: This multicenter retrospective review of short-term outcomes supports the fact that the lung allocation score is achieving its objectives. The lung allocation score reduced waiting time and altered the distribution of lung diseases for which transplantation was done on the basis of medical necessity. After transplantation, recipients have significantly higher rates of primary graft dysfunction and intensive care unit lengths of stay. However, hospital mortality and 1-year survival have not been adversely affected.