External validation of six existing multivariable clinical prediction models for short-term mortality in patients undergoing lung resection.

OBJECTIVES: National guidelines advocate the use of clinical prediction models to estimate perioperative mortality for patients undergoing lung resection. Several models have been developed that may potentially be useful but contemporary external validation studies are lacking. The aim of this study was to validate existing models in a multicentre patient cohort. METHODS: The Thoracoscore, Modified Thoracoscore, Eurolung, Modified Eurolung, European Society Objective Score and Brunelli models were validated using a database of 6600 patients who underwent lung resection between 2012 and 2018. Models were validated for in-hospital or 30-day mortality (depending on intended outcome of each model) and also for 90-day mortality. Model calibration (calibration intercept, calibration slope, observed to expected ratio and calibration plots) and discrimination (area under receiver operating characteristic curve) were assessed as measures of model performance. RESULTS: Mean age was 66.8 years (±10.9 years) and 49.7% (n = 3281) of patients were male. In-hospital, 30-day, perioperative (in-hospital or 30-day) and 90-day mortality were 1.5% (n = 99), 1.4% (n = 93), 1.8% (n = 121) and 3.1% (n = 204), respectively. Model area under the receiver operating characteristic curves ranged from 0.67 to 0.73. Calibration was inadequate in five models and mortality was significantly overestimated in five models. No model was able to adequately predict 90-day mortality. CONCLUSIONS: Five of the validated models were poorly calibrated and had inadequate discriminatory ability. The modified Eurolung model demonstrated adequate statistical performance but lacked clinical validity. Development of accurate models that can be used to estimate the contemporary risk of lung resection is required.

Impella LD microaxial pump supporting combined mitral and coronary surgery in a patient with dilated cardiomyopathy. A short bridge to recovery?

Cardiac surgeons have to face the problem of impaired left ventricle function in patients undergoing routine valve or coronary procedures. The intra-aortic balloon pump is not always effective in preventing cardiac failure. The idea of using a microaxial rotating pump as a short-term perioperative support seems to be a convenient solution. The case of a patient with dilated cardiomyopathy undergoing combined mitral and coronary surgery with elective use of the Impella LD pump is presented. Various options of applying the Impella device are discussed, especially as a bridge to transplant or bridge to recovery.

Pulmonary hypertension - intra- and early postoperative management in patients undergoing lung transplantation.

BACKGROUND: Single lung transplantation, bilateral lung transplantation and combined heart-lung transplantation are the procedures currently being performed in patients with arterial pulmonary hypertension and pulmonary hypertension as a result of end-stage lung disease. In patients with severe pulmonary hypertension, regardless of its aetiology, general anaesthesia and mechanical ventilation could precipitate the onset of cardiac failure and the necessity of extracorporeal circulation employment. AIM: To assess the clinical and prognostic value of the pulmonary artery pressure (PAP) measured during the intra- and early postoperative period in patients undergoing lung transplantation. METHODS: We analysed 20 patients undergoing lung transplantation in the Silesian Centre for Heart Disease in Zabrze, of whom 13 suffered from pulmonary hypertension before the operation. The PAP was measured using Swan-Ganz catheters. RESULTS: Pulmonary artery pressure markedly decreased after transplantation (systolic, diastolic and mean PAP values were 31/19/23 mmHg, respectively) but in 3 recipients the mean PAP exceeded 25 mmHg (45/23/30 mmHg). In all 3 cases a cardiopulmonary bypass was required and single-lung transplantation was performed. Pulmonary hypertension immediately after the operation was the potential marker of lung dysfunction (pulmonary oedema, ischaemia-reperfusion injury, infection) - all 3 patients with increased PAP developed complications. CONCLUSIONS: Lung transplantation is associated with a significant reduction in pulmonary artery pressures immediately after graft implantation. The persistence of pulmonary hypertension in the early postoperative period suggests temporal allograft dysfunction and affects the post-operative outcome.