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1.
Ann Card Anaesth ; 27(3): 246-248, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38963360

RESUMO

ABSTRACT: We present a case of cardiogenic shock secondary to refractory polymorphic ventricular tachycardia associated with coronary ischemia resulting in cardiac arrest. Following the return of spontaneous circulation, the patient was cannulated for peripheral venoarterial extracorporeal membrane oxygenation (V-A ECMO) in anticipation of high-risk "protected" percutaneous coronary intervention (PCI). Under full V-A ECMO support, inotropes and vasopressors were weaned off, and the patient underwent uneventful PCI of left circumflex and obtuse marginal lesions. After 48 hours, the patient was decannulated and could be discharged home alive 16 days after his initial cardiac arrest.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca , Intervenção Coronária Percutânea , Taquicardia Ventricular , Humanos , Oxigenação por Membrana Extracorpórea/métodos , Taquicardia Ventricular/terapia , Masculino , Intervenção Coronária Percutânea/métodos , Parada Cardíaca/terapia , Parada Cardíaca/etiologia , Choque Cardiogênico/terapia , Choque Cardiogênico/etiologia , Choque Cardiogênico/cirurgia , Pessoa de Meia-Idade
3.
Ann Vasc Surg ; 99: 58-64, 2024 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-37972728

RESUMO

BACKGROUND: Venous thromboembolism (VTE) incidence after thoracic and fenestrated endovascular aortic repair (TEVAR/FEVAR) is high (up to 6-7%) relative to other vascular procedures; however, the etiology for this discrepancy remains unknown. Notably, patients undergoing TEVAR/FEVAR commonly receive cerebrospinal fluid drains (CSFDs) for neuroprotection, requiring interruption of perioperative anticoagulation and prolonged immobility. We hypothesized that CSFDs are a risk factor for VTE after TEVAR/FEVAR. METHODS: Consecutive TEVAR/FEVAR patients at a single center were reviewed (2011-2020). Cerebrospinal fluid drains (CSFDs) were placed based on surgeon preference preoperatively or for spinal cord ischemia (SCI) rescue therapy postoperatively. The primary end-point was VTE occurrence, defined as any new deep venous thrombosis (DVT) or pulmonary embolism (PE) confirmed on imaging within 30 days postoperatively. Routine postoperative VTE screening was not performed. Patients with and without VTE, and subjects with and without CSFDs were compared. Logistic regression was used to explore associations between VTE incidence and CSFD exposure. RESULTS: Eight hundred ninety-seven patients underwent TEVAR/FEVAR and 43% (n = 387) received a CSFD at some point during their care (preoperative: 94% [n = 365/387]; postoperative SCI rescue therapy: 6% [n = 22/387]). CSFD patients were more likely to have previous aortic surgery (44% vs. 37%; P = 0.028) and received more postoperative blood products (780 vs. 405 mL; P = 0.005). The overall VTE incidence was 2.2% (n = 20). 70% (14) patients with VTE had DVT, 50% (10) had PE, and 20% (4) had DVT and PE. Among TEVAR/FEVAR patients with VTE, 65% (n = 13) were symptomatic. Most VTEs (90%, n = 18) were identified inhospital and the median time to diagnosis was 12.5 (interquartile range 7.5-18) days postoperatively. Patients with VTE were more likely to have nonelective surgery (95% vs. 41%; P < 0.001), had higher American Society of Anesthesiologists classification (4.1 vs. 3.7; P < 0.001), required longer intensive care unit admission (24 vs. 12 days; P < 0.001), and received more blood products (1,386 vs. 559 mL; P < 0.001). Venous thromboembolism (VTE) incidence was 1.8% in CSFD patients compared to 3.5% in non-CSFD patients (odds ratio 0.70 [95% confidence interval 0.28-1.78, P = 0.300). However, patients receiving CSFDs postoperatively for SCI rescue therapy had significantly greater VTE incidence (9.1% vs. 1.1%; P = 0.044). CONCLUSIONS: CSFD placement was not associated with an increased risk of VTE in patients undergoing TEVAR/FEVAR. Venous thromboembolism (VTE) risk was greater in patients undergoing nonelective surgery and those with complicated perioperative courses. Venous thromboembolism (VTE) risk was greater in patients receiving therapeutic CSFDs compared to prophylactic CSFDs, highlighting the importance of careful patient selection for prophylactic CSFD placement.


Assuntos
Procedimentos Endovasculares , Embolia Pulmonar , Isquemia do Cordão Espinal , Tromboembolia Venosa , Humanos , Correção Endovascular de Aneurisma , Tromboembolia Venosa/diagnóstico por imagem , Tromboembolia Venosa/epidemiologia , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/métodos , Resultado do Tratamento , Fatores de Risco , Isquemia do Cordão Espinal/diagnóstico , Isquemia do Cordão Espinal/epidemiologia , Isquemia do Cordão Espinal/etiologia , Embolia Pulmonar/etiologia , Estudos Retrospectivos
5.
J Cardiothorac Surg ; 18(1): 352, 2023 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-38044429

RESUMO

BACKGROUND: The role of ACTA2 mutations in Familial Aortic Disease has been increasingly recognized. We describe a highly penetrant variant (R118Q) in a family with aortic disease. CASE REPORT: A patient presented to us for elective repair of an ascending aortic aneurysm with a family history of his mother expiring after aortic dissection. Genetic testing revealed he was a heterozygous carrier of the ACTA2 missense mutation R118Q. Subsequently, all living family members were tested for this variant and a full medical history was obtained to compile a family tree for the variant and penetrance of an aortic event (defined as lifetime occurrence of aortic surgery / dissection). In total 9 family members were identified and underwent genetic testing with 7/9 showing presence of the ACTA2 R118Q mutation or an aortic event. All patients over the age of 50 (n = 4) had an aortic event. Those events occurred at ages 54, 55, 60, and 62 (mean event at 57.8 ± 3.9 years). Three family members with the variant under the age of 40 have not had an aortic event and most are undergoing regular aortic surveillance via CT scan. CONCLUSIONS: Existing studies of known ACTA2 mutations describe a 76% aortic event rate by 85 years old. The R118Q missense mutation is a less common ACTA2 variant, estimated to be found in about 5% of patients with known mutations. Prior studies have predicted the R118Q mutation to have a slightly decreased risk of aortic events compared to other ACTA2 mutations. In this family, however, we demonstrate 100% penetrance of aortic disease above age 50. In today's era of excellent outcomes in elective aortic surgery, our team aggressively offers elective repair. We advocate for strict aortic surveillance for patients with this variant and would consider elective aortic replacement at 4.5 cm, or at an even smaller diameter in patients with a strong family history of dissection who are identified with this mutation.


Assuntos
Aneurisma da Aorta Torácica , Doenças da Aorta , Dissecção Aórtica , Idoso de 80 Anos ou mais , Humanos , Masculino , Pessoa de Meia-Idade , Actinas/genética , Aorta , Aneurisma da Aorta Torácica/genética , Aneurisma da Aorta Torácica/cirurgia , Dissecção Aórtica/genética , Dissecção Aórtica/cirurgia , Mutação , Adulto
6.
Ann Vasc Surg ; 97: 248-256, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37714262

RESUMO

BACKGROUND: Endovascular repair of thoracoabdominal aortic aneurysms (TAAA) and juxtarenal aortic aneurysms (JAA) with fenestrated and/or branched endografts (B/FEVAR) has become common. Physician modified endografts for patients presenting with symptomatic or contained ruptures has made B/FEVAR a feasible option in nonelective settings. The purpose of this study was to describe our 10-year institutional experience with endovascular interventions for TAAA in elective and nonelective cases to evaluate differences in outcomes and the clinical risk factors associated with nonelective presentation. METHODS: A prospectively maintained database was retrospectively queried for patients undergoing B/FEVAR for TAAA and JAA at a single tertiary care academic institution between 1/2011 and 12/2020. Data collected included demographics, comorbidities, presenting symptoms, aneurysm characteristics, and clinical outcomes. Nonelective repair was defined as any patient that presented through the Emergency Department, as a hospital transfer, or as a direct admission from clinic and had aortic repair performed during the same admission. Univariate analyses were used to compare patients. The primary outcomes were 30-day and 1-year mortality. Secondary outcomes included perioperative complications and nonhome discharge. RESULTS: Between 1/201 and 12/2020, a total of 208 patients underwent B/FEVAR for TAAA (173) and JAA (35). Nonelective repair was performed in 44 (21%) patients with 39 for TAAA (23%) and 5 for JAA (14%). Nonelective patients were younger (71 ± 11 vs. 74 ± 7 years, P = 0.03), more likely to be self-pay or have Medicaid (11% vs. 2%, P = 0.02) and had a different race distribution compared to the elective cohort (P < 0.01). Thirty-day mortality was 4% (n = 6) in elective repairs and 7% (n = 3) in nonelective repairs. One-year mortality was 13% (n = 22) in elective repairs and 18% (n = 8) in nonelective repairs. There were no differences between patients receiving elective versus nonelective repair in 30-day (P = 0.40) or 1-year mortality (P = 0.47). Nonelective patients had longer median duration of stay (11 interquartile range (IQR) 6-15 vs. 5 IQR 4-8, P < 0.01), postoperative length of stay (7 IQR 5-12 vs. 4 IQR 3-7, P < 0.01), and more intensive care unit days (6 IQR 3-8 vs. 3 IQR 2-5, P < 0.01). There were no differences in other secondary outcomes between elective and nonelective patients including inpatient and access-related complications, re-interventions, and nonhome discharge (P > 0.05 for all comparisons). A composite "any complication" occurred more frequently in patients with nonelective repair (50% vs. 35%, P = 0.03). CONCLUSIONS: Endovascular repair for TAAA or JAA is a good option in patients undergoing nonelective surgical intervention, with comparable 30-day mortality, 1-year mortality, and perioperative morbidity to that of patients undergoing elective B/FEVAR.


Assuntos
Aneurisma da Aorta Abdominal , Aneurisma da Aorta Toracoabdominal , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Endovasculares/efeitos adversos , Aneurisma da Aorta Abdominal/diagnóstico por imagem , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Abdominal/complicações , Fatores de Risco , Complicações Pós-Operatórias
7.
Surgery ; 174(6): 1476-1482, 2023 12.
Artigo em Inglês | MEDLINE | ID: mdl-37718170

RESUMO

BACKGROUND: Traditionally, acute uncomplicated type B aortic dissections are managed medically, and acute complicated dissections are managed surgically. Self-pay patients with medically managed acute uncomplicated type B aortic dissections may fare worse than their insured counterparts. METHODS: In this single-center, retrospective cohort study, demographics, follow-up, and outcomes of patients with acute type B aortic dissections from 2011 to 2020 were analyzed. RESULTS: In total, 159 patients presented with acute type B aortic dissections; 102 were complicated and managed with thoracic endovascular aortic repair, and 57 were uncomplicated and managed medically. A total of 32% (n = 51) were self-pay. Self-pay patients were from areas with worse area deprivation indices (71% vs 63%, P = .024). They more often reported alcohol abuse (28% vs 7%, P < .001), cocaine/methamphetamine use (16% vs 5%, P = .028), and nonadherence to home antihypertensives (35% vs 11%, P < .001). Self-pay patients less often had a primary care physician (65% vs 7%, P < .001) or took antihypertensives before admission (31% vs 58%, P = .003). Self-pay patients frequently required financial assistance at discharge (63%), most often using charity funds (46%). Few patients (7%) qualified for our hospital's financial assistance program, and most (78%) remained uninsured at the first follow-up. Self-pay acute uncomplicated type B aortic dissections patients had the lowest rate of follow-up (31% vs 66%, P < .001) and were more likely to represent emergently (75% vs 0%, P = .033) compared to insured acute uncomplicated type B aortic dissections patients. Self-pay patients were more likely to follow up after thoracic endovascular aortic repair for acute complicated type B aortic dissections (82% vs 31%, P < .001). CONCLUSION: Self-pay patients have multiple, interconnected, complex socioeconomic factors that likely influence preadmission risk for dissection and post-discharge adherence to optimal medical management. Further research is needed to clarify treatment strategies in this high-risk group.


Assuntos
Dissecção Aórtica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Anti-Hipertensivos , Estudos Retrospectivos , Assistência ao Convalescente , Fatores de Risco , Procedimentos Endovasculares/efeitos adversos , Resultado do Tratamento , Implante de Prótese Vascular/efeitos adversos , Alta do Paciente , Dissecção Aórtica/terapia , Cobertura do Seguro
9.
Artigo em Inglês | MEDLINE | ID: mdl-36509568

RESUMO

OBJECTIVE: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) can cause permanent neurologic deficits and poor long-term survival. Targeted treatment of new SCI symptoms after TEVAR (rescue therapy [RT]) might improve/resolve neurologic symptoms but few data characterize the association of specific interventions with SCI outcomes. We evaluated the effectiveness of post-TEVAR RT at our tertiary aortic center. METHODS: Our institutional TEVAR database was reviewed for SCI incidence and details of RT. This included cerebrospinal fluid drainage (CSFD), medical therapy, and optimization of spinal cord oxygen delivery. SCI outcomes were categorized at discharge as paralysis/paraparesis and temporary/permanent. RESULTS: Nine hundred forty-three TEVAR procedures were performed in 869 patients from 2011 to 2020. Post-TEVAR SCI occurred in 7.8% (n = 74) with permanent paraplegia in 1.5%. Older patient age, chronic obstructive pulmonary disease, and previous abdominal aortic surgery were predictive of SCI. Half (n = 37) of SCI episodes resulted in only temporary paralysis/paraparesis. Rescue postoperative cerebrospinal fluid drains were implanted in 3.7% (n = 35) of procedures and was predicted by higher American Society of Anesthesiologists class, lower serum hemoglobin level, elevated international normalized ratio, bilateral iliac artery occlusion, nonelective procedures, and penetrating atherosclerotic ulcer/intramural hematoma indication. The most commonly used RTs were emergent placement of or increased drainage from an existing cerebrospinal fluid drain (87.8%), induced/permissive hypertension (77.0%), corticosteroid bolus (36.5%), and naloxone infusion (33.8%). Neurologic improvement occurred in 68.9% (n = 51/74). New/increased drainage was associated with improved SCI outcome. CONCLUSIONS: Permanent paraplegia from post-TEVAR SCI is rare (1.5%). Older patients with comorbidities carry greater post-TEVAR SCI risk. SCI symptoms improved/resolved with CSFD and multimodal RT in 68.9% of patients, but no intervention was independently associated with improvement. TEVAR centers should have robust protocols for timely and safe CSFD placement to augment RT strategies for SCI.

10.
JTCVS Tech ; 14: 9-28, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35967198

RESUMO

Objective: Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) is associated with permanent neurologic deficit and decreased survival. Prophylactic cerebrospinal fluid (CSF) drainage (CSFD) in TEVAR is controversial. We evaluated the usage of CSFD in TEVAR at our tertiary aortic center. Methods: Our institutional TEVAR database was reviewed to determine the frequency of CSFD usage/complications. Complications were categorized as mild (headache/CSF leak not requiring intervention, urinary retention), moderate (headache/CSF leak requiring intervention, drain malfunction requiring replacement), or severe (intrathecal hemorrhage, CSFD-attributable neurologic deficit). The relationships between CSFD complications and patient/procedural characteristics, CSFD placement timing, and survival were analyzed. Results: Nine hundred thirty-six TEVAR procedures were performed in 869 patients from 2011 to 2020. Three hundred ninety CSFD drains were placed in 373 (41.7%) TEVAR patients. Most CSFD drains (89.5%) were pre-TEVAR. Most post-TEVAR drains were placed for new SCI symptoms (n = 21). Twenty-five patients (6.4%) suffered 32 CSFD complications. Most (n = 17) were mild in severity. Severe CSFD complications occurred in 5/432 (1.1% CSF drains) patients. No patient/procedural characteristics were predictive of CSFD complications. Post implant CSFD placement for new SCI symptoms conferred an increased risk of CSFD complication (odds ratio, 6.9; 95% CI, 2.42-19.6; P < .01). The long-term survival of the CSFD complication cohort did not differ from the overall population. Conclusions: Post-TEVAR CSFD placement for new SCI symptoms was associated with substantially greater risk of CSFD complications. Avoidance of post-implant therapeutic drain placement might be the key to prevention of CSFD complications, favoring a strategy of selective pre-implant drain placement in patients at higher risk for SCI.

11.
Acta Crystallogr B Struct Sci Cryst Eng Mater ; 78(Pt 1): 20-32, 2022 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-35129117

RESUMO

Synthetic and naturally occurring forms of tricopper orthotellurate, CuII3TeVIO6 (the mineral mcalpineite) have been investigated by 3D electron diffraction (3D ED), X-ray powder diffraction (XRPD), Raman and infrared (IR) spectroscopic measurements. As a result of the diffraction analyses, CuII3TeVIO6 is shown to occur in two polytypes. The higher-symmetric CuII3TeVIO6-1C polytype is cubic, space group Ia3, with a = 9.537 (1) Šand V = 867.4 (3) Å3 as reported in previous studies. The 1C polytype is a well characterized structure consisting of alternating layers of CuIIO6 octahedra and both CuIIO6 and TeVIO6 octahedra in a patchwork arrangement. The structure of the lower-symmetric orthorhombic CuII3TeVIO6-2O polytype was determined for the first time in this study by 3D ED and verified by Rietveld refinement. The 2O polytype crystallizes in space group Pcca, with a = 9.745 (3) Å, b = 9.749 (2) Å, c = 9.771 (2) Šand V = 928.3 (4) Å3. High-precision XRPD data were also collected on CuII3TeVIO6-2O to verify the lower-symmetric structure by performing a Rietveld refinement. The resultant structure is identical to that determined by 3D ED, with unit-cell parameters a = 9.56157 (19) Å, b = 9.55853 (11) Å, c = 9.62891 (15) Šand V = 880.03 (2) Å3. The lower symmetry of the 2O polytype is a consequence of a different cation ordering arrangement, which involves the movement of every second CuIIO6 and TeVIO6 octahedral layer by (1/4, 1/4, 0), leading to an offset of TeVIO6 and CuIIO6 octahedra in every second layer giving an ABAB* stacking arrangement. Syntheses of CuII3TeVIO6 showed that low-temperature (473 K) hydrothermal conditions generally produce the 2O polytype. XRPD measurements in combination with Raman spectroscopic analysis showed that most natural mcalpineite is the orthorhombic 2O polytype. Both XRPD and Raman spectroscopy measurements may be used to differentiate between the two polytypes of CuII3TeVIO6. In Raman spectroscopy, CuII3TeVIO6-1C has a single strong band around 730 cm-1, whereas CuII3TeVIO6-2O shows a broad double maximum with bands centred around 692 and 742 cm-1.


Assuntos
Elétrons , Análise Espectral Raman , Difração de Pó , Espectrofotometria Infravermelho , Difração de Raios X
12.
J Card Surg ; 36(9): 3296-3305, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34173279

RESUMO

BACKGROUND: The COVID-19 pandemic has disrupted all aspects of healthcare, including cardiothoracic surgery (CTS). We sought to determine the pandemic's impact on CTS trainees' educational experiences. METHODS: A survey was developed and distributed to members of the Thoracic Surgery Residents Association and other international CTS trainees. Trainees were asked to evaluate their cumulative experiences and share their overall perceptions of how CTS training had been impacted during the earliest months of the COVID-19 pandemic (i.e., since March 01, 2020). Surveys were distributed and responses were recorded June 25-August 05, 2020. In total, 748 surveys were distributed and 166 responses were received (overall response rate 22.2%). Of these, 126 of 166 responses (75.9%) met inclusion criteria for final analysis. RESULTS: Final responses analyzed included 45 of 126 (35.7%) United States (US) and 81 of 126 (64.3%) international trainees, including 101 of 126 (80.2%) senior and 25 of 126 (19.8%) junior trainees. Most respondents (76/126, 43.2%) lost over 1 week in the hospital due to the pandemic. Juniors (12/25, 48.0%) were more likely than seniors (20/101, 19.8%) to be reassigned to COVID-19-specific units (p < .01). Half of trainees (63/126) reported their case volumes were reduced by over 50%. US trainees (42/45, 93.3%) were more likely than international trainees (58/81, 71.6%) to report reduced operative case volumes (p < .01). Most trainees (104/126, 83%) believed their overall clinical acumen was not adversely impacted by the pandemic. CONCLUSIONS: CTS trainees in the United States and abroad have been significantly impacted by the COVID-19 pandemic, with time lost in the hospital, decreased operative experiences, less time on CTS services, and frequent reassignment to COVID-19-specific care settings.


Assuntos
COVID-19 , Internato e Residência , Especialidades Cirúrgicas , Humanos , Pandemias , SARS-CoV-2 , Inquéritos e Questionários , Estados Unidos , Recursos Humanos
13.
Cardiol Ther ; 10(1): 89-109, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33515370

RESUMO

Coronary revascularization for multivessel disease remains a common and costly source of hospitalizations in the United States. Surgical techniques influence outcomes for coronary bypass and also affect the need for percutaneous coronary intervention in the future. As more radial access has been used for coronary angiography, consideration for use of the radial artery as a surgical conduit remains unclear. Saphenous vein grafts are commonly used for coronary bypass, however long-term patency remains suboptimal, and is also associated with a higher risk of adverse events with percutaneous coronary intervention. Thus, understanding the interplay between coronary bypass techniques and percutaneous coronary intervention has become increasingly important.

14.
J Card Surg ; 35(3): 710-712, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31971286

RESUMO

As patient survival after cardiac transplantation has improved over the course of the last several decades, clinicians are now faced with late complications. This includes aortic stenosis which, traditionally, has been treated with reoperative sternotomy and aortic valve replacement. Transcather aortic valve replacement (TAVR) offers a minimally invasive alternative in this high-risk population. A small but growing number of cases of TAVR after heart transplantation in high-risk patients have been reported in the last 10 years; we now present a case of aortic valve replacement via a transcatheter approach 24 years after cardiac transplantation.


Assuntos
Valva Aórtica/cirurgia , Transplante de Coração , Complicações Pós-Operatórias/cirurgia , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/cirurgia , Humanos , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Reoperação , Esternotomia , Fatores de Tempo , Resultado do Tratamento
15.
Clin Transplant ; 34(3): e13801, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31999865

RESUMO

Many lung donor offers are refused despite increasing demand. Portable normothermic ex vivo lung perfusion (EVLP) could increase donor yield by monitoring and reconditioning extended criteria donor (ECD) lungs. We report its use in human lungs declined for clinical transplantation. Ten sets of such lungs were procured from brain-dead donors and underwent 24 hours of normothermic EVLP using a perfusate based on donor whole blood. Hemodynamic and ventilatory data and P:F ratios were measured. Advanced donor age and borderline oxygenation (donor mean P:F 228 ± 73) were the most commonly cited reasons for refusal for transplantation. There was no significant worsening of pulmonary hemodynamics or compliance or significant P:F decline during preservation in the overall cohort. Mean P:F ratio in the overall cohort was 315 ± 88 mm Hg after 24 hours EVLP. At EVLP termination 5/10 lung blocks met standard EVLP thresholds for acceptability for transplant. Eventual EVLP performance was poorly predicted by donor P:F ratio but well predicted by data gathered early in EVLP. Portable normothermic EVLP is useful for transportation, monitoring, and reconditioning of ECD lungs. Early EVLP measurements are more effective than preprocurement donor P:F in predicting eventual allograft performance. We advocate an aggressive strategy of evaluation of ECD lungs using blood-based EVLP.


Assuntos
Transplante de Pulmão , Preservação de Órgãos , Humanos , Pulmão , Perfusão , Doadores de Tecidos , Isquemia Quente
16.
J Thorac Dis ; 11(4): 1130-1144, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31179055

RESUMO

BACKGROUND: Alpha-1-antitrypsin (A1AT) deficiency (A1ATD) is characterized by accelerated degradation of lung function. We examined our experience with lung transplantation for chronic obstructive pulmonary disease (COPD) with and without A1ATD to compare survival and rates of postoperative surgical complications. METHODS: Patients with A1ATD and non-A1ATD COPD undergoing lung transplantation from 1988-2015 at our institution were analyzed. Complications were categorized into non-gastroenteritis gastrointestinal (GI), wound, airway, and reoperation for bleeding. Overall and complication-free survival were evaluated using Kaplan-Meier curves and Cox proportional hazards models. RESULTS: Three hundred and eighty-five patients underwent lung transplant for COPD (98 A1ATD). For A1ATD, 56.1% underwent single lung transplantation (80.6% for COPD). Early overall and complication-free survival was worse for A1ATD, but this trend reversed at longer follow up. Unadjusted estimated survival showed advantage for COPD at 90 days and 1 year, which attenuated by 5 years and reversed at 10 years (P<0.001). On adjusted analysis, A1ATD was associated with a trend toward lower complication-free survival at 90 days and 1 year, due partly to increased rates of post-transplant GI pathology, particularly in the era of the lung allocation score (LAS). CONCLUSIONS: A1ATD lung recipients had worse short-term complication-free survival but improved long-term survival compared to COPD patients. A1ATD was associated with greater risk of new GI pathology after transplant. Close monitoring of A1ATD patients with timely evaluation of GI complaints after transplant is warranted.

17.
ASAIO J ; 65(3): 252-256, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29750684

RESUMO

Early readmission (within 30 days) after left ventricular assist device (LVAD) implantation might be a marker for increased mortality. We retrospectively reviewed the records of 277 adults who underwent continuous-flow LVAD implantation from 2005 through 2015 at our institution. The baseline characteristics of patients who were (versus were not) readmitted within 30 days after LVAD implantation were compared. To assess the impact of 30 day readmission on long-term survival, we used multivariate Cox regression. We also compared the cardiac transplant rate between the two groups. Of the 277 patients, 217 (78.3%) underwent LVAD implantation as a bridge-to-transplant; 76 (27.4%) of the 277 were readmitted within 30 days. The most common reason for readmission was volume overload (23.6%), followed by gastrointestinal bleeding (15.8%). Male gender, previous smoking, a higher baseline creatinine level, higher Model for End Stage Liver Disease Excluding INR (MELD-XI) score, and postoperative gastrointestinal bleeding or stroke were each associated with 30 day readmission. In our final multivariate model, increased mortality was also associated with 30 day readmission (hazard ratio, 1.60; 95% confidence interval, 1.1-2.5). Among the 217 bridge-to-transplant patients, the cardiac transplant rate was similar between the two groups: 18.7 transplants per patient-year among those who were readmitted within 30 days versus 19.7 transplants per patient-year among those who were not (p = 0.26). Among our study patients, 30 day readmission after LVAD implantation was frequent and was associated with increased mortality. It is currently unclear whether the general health of those patients was a factor and whether efforts to reduce 30 day readmission would favorably affect longer-term patient outcomes.


Assuntos
Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Coração Auxiliar , Readmissão do Paciente , Adulto , Idoso , Feminino , Transplante de Coração/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
18.
J Surg Res ; 234: 84-95, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30527505

RESUMO

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined. METHODS: Records of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant. RESULTS: Lung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH. CONCLUSIONS: The use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.


Assuntos
Fibrose Pulmonar Idiopática/cirurgia , Transplante de Pulmão/mortalidade , Idoso , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/cirurgia , Fibrose Pulmonar Idiopática/complicações , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Estudos Retrospectivos , Obtenção de Tecidos e Órgãos
19.
J Surg Educ ; 76(3): 844-855, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30366687

RESUMO

OBJECTIVE: We sought to examine the feasibility of a home practice curriculum of vascular anastomosis in cardiovascular surgery using a low-fidelity simulation platform and to examine its effectiveness in skill acquisition in senior surgical trainees. DESIGN: We organized a multicenter prospective randomized study of senior residents and fellows, who were oriented to a low-fidelity cardiac simulator and an 8-week curriculum of independent practice of aortic and coronary anastomosis. "Treatment" trainees received a simulator and the curriculum. Control trainees received only their usual operative experience. The groups then crossed over; all were studied for 16 weeks in total. Video skill assessments were captured at 0, 8, and 16 weeks and were scored by one blinded investigator using the Joint Council on Thoracic Surgery Education Assessment tool. A post-hoc survey was distributed to invited participants following study completion. SETTING: University of Minnesota Department of Surgery, Mayo Clinic Department of Cardiovascular Surgery, and the University of Texas Health Science Center at Houston. Participants used the simulator in offices, call rooms, and their homes. PARTICIPANTS: Program participation in the study was solicited through the Thoracic Education Cooperative Group. Four institutions expressed interest and a total of 29 trainees were invited to the study and randomized. Of these, 12 (38%) completed the curriculum and submitted the requisite 3 sets of videos (6 treatment, 6 control). All were senior residents and fellows in general and cardiothoracic surgery. RESULTS: No significant differences were detected in assessment scores before and after the curriculum nor before or after the control period in the overall or postgraduate year-stratified populations. Participant case numbers during the study did not have a significant effect on assessment scores. Randomized participants reported strong interest in deliberate practice of technical skills but identified competing clinical and personal obligations and significant barriers to simulation. CONCLUSIONS: Considerable variability in performance existed among participants who completed the study, but overall, the curriculum alone was insufficient to improve simulator Joint Council on Thoracic Surgery Education scores compared to those not undergoing the curriculum. Among senior residents and fellows, provision of a practice curriculum and simulator for repeated practice is feasible but clinical and personal responsibilities were barriers to repetitive practice.


Assuntos
Anastomose Cirúrgica/educação , Competência Clínica , Currículo , Educação de Pós-Graduação em Medicina/métodos , Treinamento por Simulação/métodos , Procedimentos Cirúrgicos Vasculares/educação , Aorta/cirurgia , Vasos Coronários/cirurgia , Estudos Cross-Over , Avaliação Educacional , Estudos de Viabilidade , Feminino , Humanos , Internato e Residência , Masculino , Estudos Prospectivos , Estados Unidos , Gravação em Vídeo
20.
Transpl Int ; 31(12): 1405-1417, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29981183

RESUMO

Portable normothermic EVLP has been evaluated in clinical trials using standard and extended-criteria donor lungs. We describe a swine model of lung transplant following donation after circulatory death using prolonged normothermic EVLP to assess the relationship between EVLP data and acute lung allograft function. Adult swine were anesthetized and heparinized. In the control group (n = 4), lungs were procured, flushed, and transplanted. Treatment swine underwent either standard procurement (n = 3) or agonal hypoxia followed by 1 (n = 4) or 2 hours (H) (n = 4) of ventilated warm ischemia. Lungs were preserved for 24H using normothermic blood-based EVLP then transplanted. Recipients were monitored for 4 H. After 24H of preservation, mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and dynamic compliance (Cdyn ) were improved in all EVLP groups. After transplant, EVLP groups showed similar allograft oxygenation. EVLP PVR, mPAP, and lung block weights had significant negative correlations with post-transplant allograft oxygenation. EVLP P:F ratio did not correlate with acute post-transplant allograft function until 24H of preservation. Data measured in the first 8H of EVLP were sufficient for predicting acute post-transplant allograft function. This study provides a benchmark and platform for evaluation of therapies for donor-related allograft injury in injured lungs treated with prolonged normothermic EVLP.


Assuntos
Pneumopatias/cirurgia , Transplante de Pulmão/métodos , Pulmão/patologia , Perfusão , Aloenxertos , Animais , Modelos Animais de Doenças , Hemodinâmica , Hipóxia , Inflamação , Masculino , Preservação de Órgãos , Oxigênio/química , Edema Pulmonar , Traumatismo por Reperfusão , Suínos , Fatores de Tempo , Transplante Homólogo , Isquemia Quente
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