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Shapiro AB, Fritz AV, Kiley S, Sharma S, Patel P, Heckman A, Martin AK, Goswami R. Comparison of Intraoperative Blood Product Use During Heart Transplantation in Patients Bridged with Impella 5.5 versus Durable Left Ventricular Assist Devices. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00303-3. [PMID: 39003127 DOI: 10.1053/j.jvca.2024.04.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 07/15/2024]
Abstract
OBJECTIVE To determine if the intraoperative transfusion requirements differ based on the mechanical circulatory device used as a bridge to heart transplantation. DESIGN A single-center retrospective analysis of intraoperative transfusion requirements in all patients undergoing heart or heart/kidney transplantation between November 2018 and July 2021 who were bridged with a temporary (Impella 5.5) or durable left ventricular assist device (LVAD). SETTING A tertiary care hospital. PARTICIPANTS Forty-three adult patients bridged to heart or heart/kidney transplantation with a temporary or durable LVAD between 2018 and 2021 INTERVENTIONS: Recording of baseline characteristics and intraoperative transfusion requirements, including packed red blood cells, fresh frozen plasma, cryoprecipitate, autologous blood salvage, and platelets. The difference in cardiopulmonary bypass times, intensive care unit length of stay, and the vasoactive inotrope score following transplantation were also recorded. MEASUREMENTS AND MAIN RESULTS The primary outcome was the volume of blood products transfused intraoperatively. Patients who underwent bridge to transplantation using the Impella 5.5 had statistically significant lower median transfusions of cryoprecipitate (155 mL versus 200 mL, p = 0.015), autologous blood salvage (675 mL versus 1,125 mL, p ≤ 0.01), and platelets (412 mL versus 675 mL, p ≤ 0.01). Additionally, there was a trend toward lower transfusion of intraoperative packed red blood cells (4.5 units versus 6.5 units, p = 0.29) and fresh frozen plasma (675 mL versus 800 mL, p = 0.11), but these were not statistically significant. CONCLUSIONS The results suggest a reduction in certain intraoperative transfusion requirements in patients undergoing heart transplantation bridged with the Impella 5.5 versus durable left ventricular assist device.
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Affiliation(s)
- Anna Bovill Shapiro
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
| | - Ashley Virginia Fritz
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Sean Kiley
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Shriya Sharma
- Division of Transplantation and Advanced Heart Failure, Mayo Clinic, Jacksonville, FL
| | - Parag Patel
- Division of Transplantation and Advanced Heart Failure, Mayo Clinic, Jacksonville, FL
| | - Alexander Heckman
- Department of Cardiology, Oregon Health and Science University, Portland, OR
| | - Archer Kilbourne Martin
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Rohan Goswami
- Division of Transplantation and Advanced Heart Failure, Mayo Clinic, Jacksonville, FL
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2
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Akbar AF, Zhou AL, Wang A, Feng ASN, Rizaldi AA, Ruck JM, Kilic A. Special Considerations for Advanced Heart Failure Surgeries: Durable Left Ventricular Devices and Heart Transplantation. J Cardiovasc Dev Dis 2024; 11:119. [PMID: 38667737 PMCID: PMC11050210 DOI: 10.3390/jcdd11040119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Heart transplantation and durable left ventricular assist devices (LVADs) represent two definitive therapies for end-stage heart failure in the modern era. Despite technological advances, both treatment modalities continue to experience unique risks that impact surgical and perioperative decision-making. Here, we review special populations and factors that impact risk in LVAD and heart transplant surgery and examine critical decisions in the management of these patients. As both heart transplantation and the use of durable LVADs as destination therapy continue to increase, these considerations will be of increasing relevance in managing advanced heart failure and improving outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, 1800 Orleans Street, Zayed 7107, Baltimore, MD 21287, USA; (A.F.A.); (A.L.Z.); (A.W.); (A.S.N.F.); (A.A.R.); (J.M.R.)
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3
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Michael S, Sofia MG, Wei W, Patrick G, John A, Dana A. Efficacy of the Hepcon system in reducing hemorrhagic and thrombotic complications in antiphospholipid syndrome patients undergoing cardiac surgery. Perfusion 2023:2676591231197990. [PMID: 37608561 DOI: 10.1177/02676591231197990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
INTRODUCTION Patients with Antiphospholipid Syndrome (APS) undergoing cardiopulmonary bypass (CPB) surgery are at increased risk for thrombotic and hemorrhagic complications. Anticoagulation during CPB is typically monitored with activated clotting time (ACT) which may be falsely prolonged in patients with APS. The Hepcon Hemostasis Management System quantitatively determines the whole blood heparin concentration through heparin/protamine titration. METHODS This was a retrospective study of APS patients who underwent cardiac surgery requiring CPB at the Cleveland Clinic between April 2013, and July 2020. The primary endpoint was the composite rate of hemorrhagic or thromboembolic complications per surgical case in patients monitored by Hepcon versus patients monitored by ACT. Secondary endpoints were median volume of chest tube output and packed red blood cell (PRBC) transfusion within the first three post-operative days. RESULTS 43 patients were included. 20 (47%) patients were monitored using Hepcon while 23 (53%) were monitored using ACT. For the primary endpoint of rate of thromboembolic or hemorrhagic complications per surgical case, there was no statistically significant difference between the Hepcon and ACT groups (HMS, 6/20 [30%]; ACT, 7/23 [30%]; p = >0.99). For the secondary endpoints, there was no statistically significant difference in median post-operative chest tube output (780 mL vs. 850 mL; p = 0.88) and median post-operative PRBC transfusion (1 unit vs. 0 unit; p = 0.28) between the Hepcon and ACT groups, respectively. CONCLUSION There was no difference in the composite outcome of thrombotic or hemorrhagic complications in patients monitored by Hepcon versus those monitored by ACT.
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Affiliation(s)
- Sheu Michael
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Molina Garcia Sofia
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Wei Wei
- Department of Biostatistics, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Grady Patrick
- Department of Perfusion, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Apostolakis John
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Angelini Dana
- Department of Hematology and Medical Oncology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Hess NR, Hickey GW, Keebler ME, Huston JH, McNamara DM, Mathier MA, Wang Y, Kaczorowski DJ. Left ventricular assist device bridging to heart transplantation: Comparison of temporary versus durable support. J Heart Lung Transplant 2023; 42:76-86. [PMID: 36182653 DOI: 10.1016/j.healun.2022.08.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/25/2022] [Accepted: 08/28/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Since the revision of the United States heart allocation system, increasing use of mechanical circulatory support has been observed as a means to support acutely ill patients. We sought to compare outcomes between patients bridged to orthotopic heart transplantation (OHT) with either temporary (t-LVAD) or durable left ventricular assist devises (d-LVAD) under the revised system. METHODS The United States Organ Network database was queried to identify all adult OHT recipients who were bridged to transplant with either an isolated t-LVAD or d-LVAD from 10/18/2018 to 9/30/2020. The primary outcome was 1-year post-transplant survival. Predictors of mortality were also modeled, and national trends of LVAD bridging were examined across the study period. RESULTS About 1,734 OHT recipients were analyzed, 1,580 (91.1%) bridged with d-LVAD and 154 (8.9%) bridged with t-LVAD. At transplant, the t-LVAD cohort had higher total bilirubin levels and greater prevalence of pre-transplant intravenous inotrope usage and mechanical ventilation. Median waitlist time was also shorter for t-LVAD. At 1 year, there was a non-significant trend of increased survival in the t-LVAD cohort (94.8% vs 90.1%; p = 0.06). After risk adjustment, d-LVAD was associated with a 4-fold hazards for 1-year mortality (hazard ratio 3.96, 95% confidence interval 1.42-11.03; p = 0.009). From 2018 to 2021, t-LVAD bridging increased, though d-LVAD remained a more common bridging strategy. CONCLUSIONS Since the 2018 allocation change, there has been a steady increase in t-LVAD usage as a bridge to OHT. Overall, patients bridged with these devices appear to have least equivalent 1-year survival compared to those bridged with d-LVAD.
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Affiliation(s)
- Nicholas R Hess
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin W Hickey
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Mary E Keebler
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Jessica H Huston
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Dennis M McNamara
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Michael A Mathier
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Yisi Wang
- University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pennsylvania.
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5
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Mariani C, Loforte A, Gliozzi G, Cavalli GG, Botta L, Martìn Suarez S, Potena L, Pacini D. Impact of prior sternotomy on survival and allograft function after heart transplantation: A single center matched analysis. J Card Surg 2022; 37:868-879. [PMID: 35032070 DOI: 10.1111/jocs.16224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 10/25/2021] [Accepted: 11/16/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Orthotopic heart transplantation (OHT) remains the gold standard for the treatment of end-stage heart failure. The number of patients who have had at least one prior sternotomy while awaiting transplantation has increased over the years reaching 50% in the last ISHLT registry report. We analysed our institutional transplant activity focusing on prior-sternotomy setting to identify the real burden of this preoperative variable and its potential consequences. METHODS Between 2000 and 2020, a total of 512 consecutive adult patients underwent OHT. We divided them into two groups according to the previous sternotomy variable: a prior sternotomy group (PS-group, n = 131, 25.6%) and a heart transplant as first sternotomy group (FS-group, n = 381, 74.4%). After propensity score matching, a total of 106 matched-pairs were identified for the final analysis. RESULTS The overall 30-day mortality was similar in the two groups (7.5% vs. 5.7%, p = .58). The prior sternotomy was not an independent risk factor for 90-day mortality (odds ratio: 0.89, p = .81). In the matched sample, prior cardiac surgery was not predictive for any major postoperative complication: primary graft failure, AKI, bleeding, acute respiratory insufficiency, need for extra-corporeal life support (p > .05). The log-rank test revealed no significant difference between the two groups in the unmatched and matched pools (p = .93 and 0.69 respectively. At univariable analysis prior sternotomy was not associated with an increased risk of posttransplant mortality (hazard ratio: 0.87, p = .599). CONCLUSIONS Despite it increases surgical complexity, the reoperation alone does not represent a proper risk factor and among different co-variates that may affect post-OHT outcomes.
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Affiliation(s)
- Carlo Mariani
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Antonio Loforte
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giulio G Cavalli
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Luca Botta
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sofia Martìn Suarez
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Luciano Potena
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery IRCCS Azienda Ospedaliero-Universitaria di Bologna, St. Orsola Policlinic-Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Aili SR, Lo P, Villanueva JE, Joshi Y, Emmanuel S, Macdonald PS. Prevention and Reversal of Frailty in Heart Failure - A Systematic Review. Circ J 2021; 86:14-22. [PMID: 34707071 DOI: 10.1253/circj.cj-21-0819] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Frailty is prevalent in patients with heart failure (HF) and associated with increased morbidity and mortality. Hence, there has been increased interest in the reversibility of frailty following treatment with medication or surgery. This systematic review aimed to assess the reversibility of frailty in patients with HF before and after surgical interventions aimed at treating the underlying cause of HF. It also aimed to assess the efficacy of cardiac rehabilitation and prehabilitation in reversing or preventing frailty in patients with HF.Methods and Results:Searches of PubMed, MEDLINE and Academic Search Ultimate identified studies with HF patients undergoing interventions to reverse frailty. Titles, abstracts and full texts were screened for eligibility based on the PRISMA guidelines and using predefined inclusion/exclusion criteria in relation to participants, intervention, control, outcome and study design. In total, 14 studies were included: 3 assessed the effect of surgery, 7 assessed the effect of rehabilitation programs, 2 assessed the effect of a prehabilitation program and 2 assessed the effect of program interruptions on HF patients. CONCLUSIONS Overall, it was found that frailty is at least partially reversible and potentially preventable in patients with HF. Interruption of rehabilitation programs resulted in deterioration of the frailty status. Future research should focus on the role of prehabilitation in mitigating frailty prior to surgical intervention.
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Affiliation(s)
| | - Phillip Lo
- Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
| | | | - Yashutosh Joshi
- Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
| | - Sam Emmanuel
- Faculty of Medicine, University of Notre Dame.,Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
| | - Peter S Macdonald
- Heart Transplant Unit, St Vincent's Hospital.,Victor Chang Cardiac Research Institute.,Faculty of Medicine, University of New South Wales
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7
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Redo orthotopic heart transplantation in the current era. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01506-3. [DOI: 10.1016/j.jtcvs.2021.09.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 09/10/2021] [Accepted: 09/14/2021] [Indexed: 11/24/2022]
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8
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Kainuma A, Ning Y, Kurlansky PA, Wang AS, Axom K, Farr M, Sayer G, Uriel N, Naka Y, Takeda K. Changes in waitlist and posttransplant outcomes in patients with adult congenital heart disease after the new heart transplant allocation system. Clin Transplant 2021; 35:e14458. [PMID: 34398487 DOI: 10.1111/ctr.14458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/14/2021] [Accepted: 08/11/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE In 2018, the United Network for Organ Sharing (UNOS) introduced new criteria for heart allocation. This study sought to assess the impact of this change on waitlist and posttransplant outcomes in adult congenital heart disease (ACHD) recipients. METHODS Between January 2010 and March 2020, we extracted first heart transplant ACHD patients listed from the UNOS database. We compared waitlist and post-transplant outcomes before and after the policy change. RESULTS A total of 1206 patients were listed, 951 under the old policy and 255 under the new policy. Prior to transplant, recipients under the new policy era were more likely to be treated with extracorporeal membrane oxygenation (P = .018), and have intra-aortic balloon pumps (P < .001), and less likely to have left ventricular assist devices (P = .027).Compared to patients waitlisted in the pre-policy change era, those waitlisted in the post policy change era were more likely to receive transplants (P = .001) with no significant difference in waiting list mortality (P = .267) or delisting (P = .915). There was no difference in 1-year survival post-transplant between the groups (P = .791). CONCLUSION The new policy altered the heart transplant cohort in the ACHD group, allowing them to receive transplants earlier with no changes in early outcomes after heart transplantation.
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Affiliation(s)
- Atsushi Kainuma
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Columbia University, New York, New York, USA
| | - Paul A Kurlansky
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Amy S Wang
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Kelly Axom
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Maryjane Farr
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Gabriel Sayer
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Nir Uriel
- Department of Medicine/Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Yoshifumi Naka
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, New York, USA
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9
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Nordan T, Critsinelis AC, Mahrokhian SH, Kapur NK, Thayer KL, Chen FY, Couper GS, Kawabori M. Bridging With Extracorporeal Membrane Oxygenation Under the New Heart Allocation System: A United Network for Organ Sharing Database Analysis. Circ Heart Fail 2021; 14:e007966. [PMID: 33951934 DOI: 10.1161/circheartfailure.120.007966] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of the new donor heart allocation system on survival following bridging to transplantation with venous-arterial extracorporeal membrane oxygenation remains unknown. The new allocation system places extracorporeal membrane oxygenation-supported candidates at the highest status. METHODS The United Network for Organ Sharing database was queried for adults bridged to single-organ heart transplantation with extracorporeal membrane oxygenation from October 2006 to February 2020. Association between implementation of the new system and recipient survival was analyzed using Kaplan-Meier estimates, Cox proportional hazards models, and propensity score matching. RESULTS Of 364 recipients included, 173 and 191 were transplanted under new and old systems, respectively. Compared with the old system, waitlist time was halved under the new system (5 versus 10 days, P<0.01); recipients also demonstrated lower rates of prior cardiac surgery (32.9% versus 44.5%, P=0.03) and preoperative ventilation (30.6% versus 42.4%, P=0.02). Unadjusted 180-day survival was 90.2% (95% CI, 84.7%-94.2%) and 69.6% (95% CI, 62.6%-76.1%) under the new and old systems, respectively. Cox proportional hazards analysis demonstrated listing and transplantation under the new system to be an independent predictor of post-transplant survival (adjusted hazard ratio, 0.34 [95% CI 0.20-0.59]). Propensity score matching demonstrated a similar trend (hazard ratio, 0.36 [95% CI, 0.19-0.66]). Candidates listed under the new system were significantly less likely to experience waitlist mortality or deterioration (subhazard ratio, 0.38 [95% CI, 0.25-0.58]) and more likely to survive to transplant (subhazard ratio, 4.29 [95% CI, 3.32-5.54]). CONCLUSIONS Recipients transplanted following extracorporeal membrane oxygenation bridging to transplantation under the new system achieve greater 180-day survival compared with the old and demonstrate less preoperative comorbidity. Waitlist outcomes have also improved significantly under the new allocation system.
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Affiliation(s)
- Taylor Nordan
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | | | - Shant H Mahrokhian
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | - Navin K Kapur
- Department of Cardiology (N.K.K., K.L.T.), Tufts Medical Center, Boston, MA
| | - Katherine L Thayer
- Department of Cardiology (N.K.K., K.L.T.), Tufts Medical Center, Boston, MA
| | - Frederick Y Chen
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | - Gregory S Couper
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
| | - Masashi Kawabori
- Department of Cardiac Surgery (T.N., S.H.M., F.Y.C., G.S.C., M.K.), Tufts Medical Center, Boston, MA
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10
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Daubenspeck D, González LS, Gerlach RM, Chaney MA. Unique Complications Associated With the Subclavian Intra-Aortic Balloon Pump. J Cardiothorac Vasc Anesth 2020; 35:2212-2222. [PMID: 33485757 DOI: 10.1053/j.jvca.2020.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/25/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Danisa Daubenspeck
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL
| | - Laura S González
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Rebecca M Gerlach
- Department of Anesthesiology and Critical Care, Preoperative Anesthesia Clinic, University of New Mexico, Albuquerque, NM; Preoperative Anesthesia Clinic, University of New Mexico, Albuquerque, NM
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL.
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11
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Kulkarni S, Szeto WY, Jha S. Preoperative Computed Tomography in the Adult Cardiac Surgery Patient. Curr Probl Diagn Radiol 2020; 51:121-129. [PMID: 33414038 DOI: 10.1067/j.cpradiol.2020.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022]
Abstract
Increasingly, computed tomography is requested for preoperative planning prior to cardiac surgery. Common pathologies, such as aortic and mitral annular calcification, can influence the choice of surgical technique or approach. In this article, we present a case-based review of primary and reoperative sternotomies that focuses on the clinical relevance of the common pathologies and findings in pre-operative computed tomography images, with respect to surgical decision-making and management.
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Affiliation(s)
- Sagar Kulkarni
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Penn Presbyterian Medical Center, Philadelphia, PA
| | - Saurabh Jha
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA
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12
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Ribeiro RVP, Alvarez JS, Fukunaga N, Yu F, Adamson MB, Foroutan F, Cusimano RJ, Yau T, Ross H, Alba AC, Billia F, Badiwala MV, Rao V. Redo sternotomy versus left ventricular assist device explant as risk factors for early mortality following heart transplantation. Interact Cardiovasc Thorac Surg 2020; 31:603-610. [DOI: 10.1093/icvts/ivaa180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/19/2020] [Accepted: 07/26/2020] [Indexed: 01/06/2023] Open
Abstract
Abstract
OBJECTIVES
There is an increasing proportion of patients with a previous sternotomy (PS) or durable left ventricular assist device (LVAD) undergoing heart transplantation (HT). We hypothesized that patients with LVAD support at the time of HT have a lower risk than patients with PS and may have a comparable risk to patients with a virgin chest (VC).
METHODS
This is a single-centre retrospective cohort study of all adults who underwent primary single-organ HT between 2002 and 2017. Multivariable Cox regression analyses were performed to compare 30-day and 1-year mortality between transplanted patients with a VC (VC-HT), a PS (PS-HT) or an LVAD explant (LVAD-HT).
RESULTS
Three hundred seventy-nine patients were analysed (VC-HT: 196, PS-HT: 94, LVAD-HT: 89). A larger proportion of patients in the LVAD-HT group were males (83%), had blood group O (52%), non-ischaemic aetiology (70%) and sensitization (67%). The PS-HT group had a higher frequency of patients with congenital heart disease (30%) and PSs compared to LVAD-HT patients (P < 0.001). PS-HT and LVAD-HT patients required a longer bypass time (P < 0.001) and showed a greater estimated blood loss (P < 0.001). Postoperatively, LVAD-HT required haemodialysis more frequently than the VC-HT group (P = 0.031). Multivariable analyses found that PS-HT patients had increased 30-day mortality compared to VC-HT [hazard ratio (HR) 2.63, 95% confidence interval (CI) 1.15–6.01; P = 0.022] while LVAD-HT did not (HR 2.17, 95% CI 0.96–4.93; P = 0.064). At 1-year, neither PS-HT nor LVAD-HT groups were significantly associated with increased mortality compared to VC-HT.
CONCLUSIONS
Transplants in recipients with PS-HT demonstrated increased early mortality compared to VC-HT patients. Although LVAD explant is often technically challenging, this population demonstrated similar mortality compared to those VC-HT patients. The chronic and perioperative support provided by the LVAD may play a favourable role in early patient outcomes compared to other redo sternotomy patients.
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Affiliation(s)
- Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Juglans Souto Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Naoto Fukunaga
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Frank Yu
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mitchell Brady Adamson
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Farid Foroutan
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Robert James Cusimano
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Terrence Yau
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Heather Ross
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Ana Carolina Alba
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Filio Billia
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mitesh Vallabh Badiwala
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
- Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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13
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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14
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Huckaby LV, Seese LM, Mathier MA, Hickey GW, Kilic A. Intra-Aortic Balloon Pump Bridging to Heart Transplantation: Impact of the 2018 Allocation Change. Circ Heart Fail 2020; 13:e006971. [PMID: 32757643 PMCID: PMC9057452 DOI: 10.1161/circheartfailure.120.006971] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND This study evaluates the impact of the 2018 allocation policy change on outcomes of orthotopic heart transplantation (OHT) in patients bridged with intra-aortic balloon pumps (IABPs). METHODS Adult (≥18 years) patients undergoing OHT between 2013 and 2019 who were bridged with an IABP were stratified based on temporal relation to the policy change. Univariate analysis was used to compare baseline characteristics and postoperative outcomes. Multivariate Cox regression analysis was used to estimate risk-adjusted predictors of post-transplant mortality. RESULTS A total of 1342 (8.6%) OHT patients were bridged with an IABP during the study period. Rates of bridging with IABP to OHT increased significantly after the policy change (7.0% versus 24.9%, P<0.001). The mean recipient age was 54.1±12.1 years with 981 (73.1%) patients being male. Baseline characteristics were similar between the 2 groups whereas post-policy change patients spent fewer days on the waitlist (15 versus 35 days, P<0.001), had longer ischemic times (3.5 versus 3.0 hours, P<0.001), and received organs from a greater distance (301 versus 105 miles, P<0.001). By multivariable analysis, days on the waitlist (for every 30 days; odds ratio, 1.01 [95% CI, 1.00-1.02], P=0.031) and diabetes mellitus (odds ratio, 1.87 [95% CI, 1.16-3.02], P=0.011) emerged as significant predictors of post-transplant mortality. After the policy change, waitlisted patients requiring IABP support were more likely to survive to transplant (76.4 versus 89.8%, P<0.001). CONCLUSIONS IABP utilization has increased over 3-fold since the 2018 policy change with improved waitlist outcomes and comparable post-OHT survival. Thus, bridging patients to OHT with IABPs appears to be an effective strategy in the current era.
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Affiliation(s)
- Lauren V Huckaby
- Division of Cardiac Surgery (L.V.H., L.M.S., A.K.), University of Pittsburgh Medical Center, PA
| | - Laura M Seese
- Division of Cardiac Surgery (L.V.H., L.M.S., A.K.), University of Pittsburgh Medical Center, PA
| | - Michael A Mathier
- Division of Cardiology (M.A.M., G.W.H.), University of Pittsburgh Medical Center, PA
| | - Gavin W Hickey
- Division of Cardiology (M.A.M., G.W.H.), University of Pittsburgh Medical Center, PA
| | - Arman Kilic
- Division of Cardiac Surgery (L.V.H., L.M.S., A.K.), University of Pittsburgh Medical Center, PA
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15
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Zhu Y, Shudo Y, Lingala B, Baiocchi M, Oyer PE, Woo YJ. Outcomes after heart retransplantation: A 50-year single-center experience. J Thorac Cardiovasc Surg 2020; 163:712-720.e6. [DOI: 10.1016/j.jtcvs.2020.06.121] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/10/2020] [Accepted: 06/27/2020] [Indexed: 12/15/2022]
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16
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Early and long-term results of heart transplantation with reoperative sternotomy. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:120-126. [PMID: 32175152 DOI: 10.5606/tgkdc.dergisi.2020.18586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/16/2019] [Indexed: 11/21/2022]
Abstract
Background This study aims to investigate the effects of reoperative sternotomy on early and long-term outcomes after heart transplantation. Methods We retrospectively reviewed data of a total of 92 patients (72 males, 20 females; mean age 36 years; range, 3 to 61 years) who underwent orthotopic heart transplantation between May 1998 and July 2014. The patients were divided into three groups. Group A (n=23) included patients who underwent previous cardiac surgery with sternotomy other than ventricular assist device implantation; Group B (n=12) included patients who were bridged-to-transplant with a ventricular assist device; and Group C (n=57) included patients who for the first time underwent heart transplantation without previous sternotomy. Preoperative and operative data of the three groups were compared. The short- and long-term outcomes of all groups were analyzed. Results There was no significant difference among the groups, except for the age and preoperative international normalized ratio. Total ischemia time in the ventricular assist device group was longer than Group C. The length of intensive care unit stay was also longer in the ventricular assist device group than the other groups. The amount of postoperative chest tube drainage and blood transfusion was higher in Group A. Early mortality rate was significantly higher in Group A. There was no significant difference in survival among the three groups in the long-term. According to the logistic regression analysis, no variable was found to be a significant risk factor for mortality. Conclusion Reoperative sternotomy other than ventricular assist device implantation was found to be a risk factor for early mortality; however, mid and long-term survival rates were similar to patients in whom transplantation was the primary procedure. In patients with reoperative sternotomy, heart transplantation can be performed with similar risks to patients without resternotomy with careful selection and accurate pre- and intraoperative surgical approach.
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17
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Guglin M, Zucker MJ, Borlaug BA, Breen E, Cleveland J, Johnson MR, Panjrath GS, Patel JK, Starling RC, Bozkurt B. Evaluation for Heart Transplantation and LVAD Implantation. J Am Coll Cardiol 2020; 75:1471-1487. [DOI: 10.1016/j.jacc.2020.01.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/02/2020] [Accepted: 01/07/2020] [Indexed: 12/11/2022]
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18
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Miller RJ, Clarke BA, Howlett JG, Khush KK, Teuteberg JJ, Haddad F. Outcomes in patients undergoing cardiac retransplantation: A propensity matched cohort analysis of the UNOS Registry. J Heart Lung Transplant 2019; 38:1067-1074. [DOI: 10.1016/j.healun.2019.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/18/2019] [Accepted: 07/02/2019] [Indexed: 01/06/2023] Open
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19
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Jacob S, Lima B, Gonzalez‐Stawinski GV, El‐Sayed Ahmed MM, Patel PC, Belli EV, Makey IA, Thomas M, Landolfo K, Landolfo C, Leoni Moreno JC, Yip DS, Pham SM. Extracorporeal membrane oxygenation as a salvage therapy for patients with severe primary graft dysfunction after heart transplant. Clin Transplant 2019; 33:e13538. [DOI: 10.1111/ctr.13538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/27/2019] [Accepted: 03/09/2019] [Indexed: 01/13/2023]
Affiliation(s)
- Samuel Jacob
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
| | - Brian Lima
- Department of Cardiothoracic Surgery Baylor University Medical Center Dallas Texas
| | | | - Magdy M. El‐Sayed Ahmed
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
- Department of Surgery, Faculty of Medicine Zagazig University Zagazig Egypt
| | - Parag C. Patel
- Division of Transplant Medicine Mayo Clinic Jacksonville Florida
| | - Erol V. Belli
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
| | - Ian A. Makey
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
| | - Mathew Thomas
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
| | - Kevin Landolfo
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
| | - Carolyn Landolfo
- Department of Cardiovascular Medicine Mayo Clinic Jacksonville Florida
| | | | - Daniel S. Yip
- Division of Transplant Medicine Mayo Clinic Jacksonville Florida
| | - Si M. Pham
- Department of Cardiothoracic Surgery Mayo Clinic Jacksonville Florida
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20
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Axtell AL, Fiedler AG, Lewis G, Melnitchouk S, Tolis G, D’Alessandro DA, Villavicencio MA. Reoperative sternotomy is associated with increased early mortality after cardiac transplantation. Eur J Cardiothorac Surg 2019; 55:1136-1143. [DOI: 10.1093/ejcts/ezy443] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/20/2018] [Accepted: 11/24/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrea L Axtell
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Amy G Fiedler
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - David A D’Alessandro
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Mauricio A Villavicencio
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
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21
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Khayata M, ElAmm CA, Sareyyupoglu B, Zacharias M, Oliveira GH, Medalion B. HeartMate II pump exchange with HeartMate III implantation to the descending aorta. J Card Surg 2019; 34:47-49. [PMID: 30597627 DOI: 10.1111/jocs.13969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Removal of the HeartMate II left ventricular assist device (LVAD) usually requires a sternotomy. We report a case of HeartMate III LVAD implantation to the descending aorta via a left thoracotomy while leaving most of the HeartMate II device in place to avoid redo-sternotomy.
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Affiliation(s)
- Mohamed Khayata
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine, Division of Cardiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Chantal A ElAmm
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine, Division of Cardiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Basar Sareyyupoglu
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Michael Zacharias
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine, Division of Cardiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Guilherme H Oliveira
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Medicine, Division of Cardiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Benjamin Medalion
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio.,Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
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22
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An Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) analysis of hospitalization, functional status, and mortality after mechanical circulatory support in adults with congenital heart disease. J Heart Lung Transplant 2018; 37:619-630. [DOI: 10.1016/j.healun.2017.11.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 10/12/2017] [Accepted: 11/13/2017] [Indexed: 11/19/2022] Open
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23
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Still S, Shaikh AF, Qin H, Felius J, Jamil AK, Saracino G, Chamogeorgakis T, Rafael AE, MacHannaford JC, Joseph SM, Hall SA, Gonzalez-Stawinski GV, Lima B. Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation†. Interact Cardiovasc Thorac Surg 2018; 27:343-349. [DOI: 10.1093/icvts/ivy084] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 02/22/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sasha Still
- Department of General Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Asad F Shaikh
- College of Medicine, Texas A&M Health Science Center, Dallas, TX, USA
| | - Huanying Qin
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Joost Felius
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Aayla K Jamil
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Giovanna Saracino
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
| | - Themistokles Chamogeorgakis
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Aldo E Rafael
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Juan C MacHannaford
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Susan M Joseph
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Shelley A Hall
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Division of Cardiology, Baylor University Medical Center, Dallas, TX, USA
| | - Gonzalo V Gonzalez-Stawinski
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
| | - Brian Lima
- Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA
- Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA
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24
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Hensley NB, Kostibas MP, Yang WW, Crawford TC, Mandal K, Gupta PB, Frank SM, Brown CH. Blood utilization in revision versus first-time cardiac surgery: an update in the era of patient blood management. Transfusion 2018; 58:168-175. [PMID: 28990242 PMCID: PMC6519923 DOI: 10.1111/trf.14361] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/18/2017] [Accepted: 08/18/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Relative to first-time (primary) cardiac surgery, revision cardiac surgery is associated with increased transfusion requirements, but studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. The current study was performed as an update to determine if this finding is still evident in the PBM era. STUDY DESIGN AND METHODS Primary and revision cardiac surgery cases were compared in a retrospective database analysis at a single tertiary care referral center. Two groups of patients were assessed: 1) those having isolated coronary artery bypass (CAB) or valve surgery and 2) all other cardiac surgeries. Intraoperative and whole hospital transfusion requirements were assessed for the four major blood components. RESULTS Compared to the primary cardiac surgery patients, the revision surgery patients required approximately twofold more transfused units intraoperatively (p < 0.0001) and approximately two- to threefold more transfused units for the whole hospital stay (p < 0.0001). Intraoperative massive transfusion (>10 red blood cell [RBC] units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% [p < 0.0001] for isolated CAB or valve and 6.1% vs. 1.9% [p < 0.0001] for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6-10 RBC units) and massive intraoperative transfusion. CONCLUSIONS In the era of PBM, with restrictive transfusion strategies and a variety of methods for blood conservation, revision cardiac surgery patients continue to have substantially greater transfusion requirements relative to primary cardiac surgery patients. This difference in transfusion requirement was greater than what has been previously reported in the pre-PBM era.
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Affiliation(s)
- Nadia B Hensley
- Department of Anesthesiology/Critical Care Medicine, Baltimore, Maryland
| | - Megan P Kostibas
- Department of Anesthesiology/Critical Care Medicine, Baltimore, Maryland
| | - William W Yang
- Department of Anesthesiology/Critical Care Medicine, Baltimore, Maryland
| | | | | | | | - Steven M Frank
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, Baltimore, Maryland
| | - Charles H Brown
- Department of Anesthesiology/Critical Care Medicine, Baltimore, Maryland
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25
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Foroutan F, Alba AC, Guyatt G, Duero Posada J, Ng Fat Hing N, Arseneau E, Meade M, Hanna S, Badiwala M, Ross H. Predictors of 1-year mortality in heart transplant recipients: a systematic review and meta-analysis. Heart 2017; 104:151-160. [DOI: 10.1136/heartjnl-2017-311435] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/17/2017] [Accepted: 06/06/2017] [Indexed: 11/04/2022] Open
Abstract
ObjectiveA systematic summary of the observational studies informing heart transplant guideline recommendations for selection of candidates and donors has thus far been unavailable. We performed a meta-analysis to better understand the impact of such known risk factors.MethodsWe systematically searched and meta-analysed the association between known pretransplant factor and 1-year mortality identified by multivariable regression models. Our review used the Grading of Recommendations, Assessment, Development and Evaluation for assessing the quality of assessment. We pooled risk estimates by using random effects models.ResultsRecipient variables including age (HR 1.16 per 10-year increase, 95% CI 1.10–1.22, high quality), congenital aetiology (HR 2.35, 95% CI 1.62 to 3.41, moderate quality), diabetes (HR 1.37, 95% CI 1.15 to 1.62, high quality), creatinine (HR 1.11 per 1 mg/dL increase, 95% CI 1.06 to 1.16, high quality), mechanical ventilation (HR 2.46, 95% CI 1.48 to 4.09, low quality) and short-term mechanical circulatory support (MCS) (HR 2.47, 95% CI 1.04 to 5.87, low quality) were significantly associated with 1-year mortality. Donor age (HR 1.20 per 10-year increase, 95% CI 1.14 to 1.26, high quality) and female donor to male recipient sex mismatch (HR 1.38, 95% CI 1.06 to 1.80, high quality) were significantly associated with 1-year mortality. None of the operative factors proved significant predictors.ConclusionHigh-quality and moderate-quality evidence demonstrates that recipient age, congenital aetiology, creatinine, pulsatile MCS, donor age and female donor to male recipient sex mismatch are associated with 1-year mortality post heart transplant. The results of this study should inform future guideline and predictive model development.
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26
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Bienia S, Feider A, Griauzde R, Patel KD, Minhaj MM. CASE 13—2016 Minimally Invasive Left Ventricular Assist Device Insertion Without Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2016; 30:1716-1726. [DOI: 10.1053/j.jvca.2015.12.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Indexed: 11/11/2022]
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27
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Tibrewala A, Nassif ME, Andruska A, Shuster JE, Novak E, Vader JM, Ewald GA, LaRue SJ, Silvestry S, Itoh A. Use of adenosine diphosphate receptor inhibitor prior to left ventricular assist device implantation is not associated with increased bleeding. J Artif Organs 2016; 20:42-49. [PMID: 27830349 DOI: 10.1007/s10047-016-0932-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
Abstract
Current guidelines recommend adenosine diphosphate receptor inhibitors (ADPRi) be discontinued 5-7 days prior to cardiac surgery due to increased bleeding events, rates of re-exploration, and transfusions. However, the risks of left ventricular assist device (LVAD) implantation in patients taking an ADPRi have not previously been studied. We retrospectively identified 134 eligible patients with ischemic cardiomyopathy that underwent LVAD implantation between July 2009 and August 2013. The cohorts received an ADPRi ≤5 days of surgery (n = 25) versus >5 days prior or not at all (n = 109). Subgroup analyses adjusted for differences in frequency of redo sternotomy between cohorts, excluded patients that received an ADPRi >1 year prior to surgery, and excluded patients with a redo sternotomy. The ADPRi and control groups did not have significant differences in the primary outcomes, intraoperative PRBC units transfused (3.0 vs. 4.0, p = 0.12) or chest tube output within 24 h of surgery (1.66 L vs. 1.80 L, p = 0.61). After adjusting for differences in frequency of redo sternotomy (ADPRi vs. control, 12 vs. 52%, p ≤ 0.001), no significant difference in PRBC units transfused (3.1 vs. 3.5, p = 0.59) or chest tube output (2.04 L vs. 2.04 L, p = 0.98) was seen. No significant difference in 30-day mortality (8.0 vs. 11.0%, p = 0.63), 90-day mortality (16.4 vs. 23.3%, p = 0.42), or length of stay (29.0 vs. 28.0, p = 0.61) was seen. In this single-center experience, use of an ADPRi ≤5 days prior to LVAD implantation was not associated with increased bleeding, length of stay, or mortality.
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Affiliation(s)
- Anjan Tibrewala
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael E Nassif
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Adam Andruska
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Jerrica E Shuster
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Eric Novak
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin M Vader
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Gregory A Ewald
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Shane J LaRue
- Division of Cardiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Scott Silvestry
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Campus Box 8234, 660 S Euclid Avenue, St. Louis, MO, 63110, USA
| | - Akinobu Itoh
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Campus Box 8234, 660 S Euclid Avenue, St. Louis, MO, 63110, USA.
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28
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Infectious complications after cardiac transplantation in patients bridged with mechanical circulatory support devices versus medical therapy. J Heart Lung Transplant 2016; 35:1116-23. [DOI: 10.1016/j.healun.2016.04.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/19/2016] [Accepted: 04/25/2016] [Indexed: 02/08/2023] Open
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29
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Awad M, Czer L, De Robertis M, Mirocha J, Ruzza A, Rafiei M, Reich H, Trento A, Moriguchi J, Kobashigawa J, Esmailian F, Arabia F, Ramzy D. Adult Heart Transplantation Following Ventricular Assist Device Implantation: Early and Late Outcomes. Transplant Proc 2016; 48:158-66. [DOI: 10.1016/j.transproceed.2015.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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Prior sternotomy increases the mortality and morbidity of adult heart transplantation. Transplant Proc 2015; 47:485-97. [PMID: 25769596 DOI: 10.1016/j.transproceed.2014.10.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/05/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study investigated the effect of prior sternotomy (PS) on the postoperative mortality and morbidity after orthotopic heart transplantation (HTx). METHODS Of 704 adults who underwent HTx from December 1988 to June 2012 at a single institution, 345 had no PS (NPS group) and 359 had ≥ 1 PS (PS group). Survival, intraoperative use of blood products, intensive care unit (ICU) and hospital stays, frequency of reoperation for bleeding, dialysis, and >48-hour ventilation were examined. RESULTS The NPS and PS groups had similar 60-day survival rates (97.1 ± 0.9% vs 95.3 ± 1.1%; P = .20). However, the 1-year survival was higher in the NPS group (94.7 ± 1.2% vs 89.7 ± 1.6%; hazard ratio [HR], 1.98; 95% CI, 1.12-3.49; P = .016). The PS group had longer pump time and more intraoperative blood use (P < .0001 for both). Postoperatively, the PS group had longer ICU and hospital stays, and higher frequencies of reoperation for bleeding and >48-hour ventilation (P < .05 for all comparisons). Patients with 1 PS (1PS group) had a higher 60-day survival rate than those with ≥ 2 PS (2+PS group; 96.7 ± 1.1% vs 91.1 ± 3.0%; HR, 2.70; 95% CI, 1.04-7.01; P = .033). The 2+PS group had longer pump time and higher frequency of postoperative dialysis (P < .05 for both). Patients with prior VAD had lower 60-day (91.1 ± 3.0% vs 97.1 ± 0.9%; P = .010) and 1-year (87.4 ± 3.6% vs 94.7 ± 1.2%; P = .012) survival rates than NPS group patients. Patients with prior CABG had a lower 1-year survival than NPS group patients (89.0 ± 2.3% vs 94.7 ± 1.2%; P = .018). CONCLUSION The PS group had lower 1-year survival and higher intraoperative blood use, postoperative length of ICU and hospital stays, and frequency of reoperation for bleeding than the NPS group. Prior sternotomy increases morbidity and mortality after HTx.
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Gaffey AC, Phillips EC, Howard J, Hung G, Han J, Emery R, Goldberg L, Acker MA, Woo YJ, Atluri P. Prior Sternotomy and Ventricular Assist Device Implantation Do Not Adversely Impact Survival or Allograft Function After Heart Transplantation. Ann Thorac Surg 2015; 100:542-9. [DOI: 10.1016/j.athoracsur.2015.02.093] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 11/29/2022]
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Matsumoto Y, Shibata SC, Maeda A, Yoshioka D, Kamibayashi T, Uchiyama A, Sawa Y, Fujino Y. Early postoperative management of heart transplant recipients with current ventricular assist device support in Japan: experience from a single center. J Anesth 2015; 29:868-73. [PMID: 26162779 DOI: 10.1007/s00540-015-2044-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 06/24/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE This study reviews our experience with the perioperative management of heart transplant (HT) recipients and explores how prior ventricular assist device (VAD) support affects the requirements for postoperative mechanical ventilation and circulatory support. METHODS AND RESULTS A retrospective database review was performed from 2007 to 2014. Early postoperative outcomes were compared between VAD and non-VAD groups. Forty-four patients were studied. The mean age was 38 ± 13 years, 30% were female, and 88% experienced non-ischemic heart failure. Forty patients (91%) required VAD support at the time of HT, with a mean duration of 864 ± 351 days. The median postoperative mechanical ventilation times in the VAD and non-VAD groups were 54 [95% confidence interval (CI) 42.9-297.3] and 15 (95% CI 4.8-30.0; p = 0.0199) hours, respectively. The VAD group experienced increased bleeding during the first 48 h after HT (6.7 ± 3.5 vs. 1.8 ± 0.75 l, p = 0.004). Mechanical circulatory support with intra-aortic balloon pumping or venoarterial extracorporeal membrane oxygenation was required in 30% of VAD group patients. Increased bleeding and primary graft failure were the main causes of prolonged mechanical ventilation. CONCLUSIONS HT recipients with VAD support required longer mechanical ventilation periods and mechanical circulatory support in the postoperative period.
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Affiliation(s)
- Yu Matsumoto
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Sho C Shibata
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Akihiko Maeda
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka, Japan
| | - Takahiko Kamibayashi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Akinori Uchiyama
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
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Donor evaluation in heart transplantation: The end of the beginning. J Heart Lung Transplant 2014; 33:1105-13. [DOI: 10.1016/j.healun.2014.05.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 05/16/2014] [Accepted: 05/28/2014] [Indexed: 12/20/2022] Open
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Robotic-assisted implantation of ventricular assist device after sternectomy and pectoralis muscle flap. ASAIO J 2014; 60:742-3. [PMID: 25072555 DOI: 10.1097/mat.0000000000000124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Left ventricular assist devices are increasingly important in the management of advanced heart failure. Most patients who benefit from these devices have had some prior cardiac surgery, making implantation of higher risk. This is especially true in patients who have had prior pectoralis flap reconstruction after sternectomy for mediastinitis. We outline the course of such a patient, in whom the use of robotic assistance allowed for a less invasive device implantation approach with preservation of the flap for transplantation.
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Aloia TA, Cooper A, Shi W, Vauthey JN, Lee JE. Reoperative surgery: a critical risk factor for complications inadequately captured by operative reporting and coding of lysis of adhesions. J Am Coll Surg 2014; 219:143-50. [PMID: 24862888 DOI: 10.1016/j.jamcollsurg.2014.03.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/02/2014] [Accepted: 03/18/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Reoperative surgery is suspected, but not proven, to increase postoperative complication rates. In the absence of a specific definition for reoperative surgery, the American College of Surgeons NSQIP has proposed using procedural coding for lysis of adhesions (LOA) as a surrogate for reoperative surgery to risk adjust hospitals. We hypothesized that coding of reoperative surgery will be associated with worse 30-day outcomes and, for abdominal procedures, will be more accurate than operative dictation and coding of "lysis of adhesions." STUDY DESIGN Reoperative surgery was categorized at the time of data abstraction from February 2012 to December 2012 for all NSQIP cases collected at a single institution by independent surgical clinical reviewers. Reoperative surgery classification and coding of LOA were compared with each other and with 30-day outcomes. The setting was a tertiary cancer center, multispecialty NSQIP model. During the study period, 1,289 operations were classified as nonreoperative (n = 793), regionally reoperative (n = 39; prior surgery in an adjacent area of current operation), or locally reoperative (n = 457; prior surgery at same site or organ). RESULTS In the multispecialty cohort, the non-risk-adjusted rates of overall 30-day morbidity, serious morbidity, and mortality were 21.5%, 17.7%, and 0.5%. Compared with nonreoperative surgery (overall 30-day morbidity 16.8%, serious morbidity 13.9%, and mortality .38%), both regionally reoperative surgery (overall 30-day morbidity 30.8%, serious morbidity 28.2%, and mortality 2.5%) and locally reoperative surgery (overall 30-day morbidity 28.9%, serious morbidity 23.4%, and mortality .66%) were associated with worse outcomes (p < 0.001). One hundred ninety-nine of the 327 gastrointestinal/laparotomy cases were recorded as reoperative, but only of 20 of these were CPT coded as LOA (sensitivity = 10%). CONCLUSIONS Reoperative surgery is frequent, increases the risk of complications, and can be captured. Operative LOA coding vastly under reports reoperative surgery and, therefore, is not an adequate surrogate for this important risk factor.
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Affiliation(s)
- Thomas A Aloia
- University of Texas, MD Anderson Cancer Center, Houston, TX.
| | - Amanda Cooper
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Weiming Shi
- University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Jeffrey E Lee
- University of Texas, MD Anderson Cancer Center, Houston, TX
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Chest wall, thymus, and heart vascularized composite allograft proof of concept cadaveric model for heart transplantation. Ann Plast Surg 2014; 73:102-4. [PMID: 24918739 DOI: 10.1097/sap.0000000000000181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The use of vascularized composite allografts allows for the reconstruction of complex scenarios that previously have required multistaged operations. Heart transplantation often follows a series of previous operations leading to chest wall deformities and significant mediastinal adhesions that can limit the use of larger hearts, making it difficult to find a suitable donor. Further, research has shown that the use of vascularized bone marrow and vascularized thymus in transplantation potentially prolongs graft survival with decreased immunosuppression requirements. The authors propose using a vascularized composite allograft of the chest wall consisting of sternum and thymus in conjunction with the heart for cardiac transplantation to allow for more flexibility from the donor pool, maintain chest wall integrity and physiology, and potentially immunoregulate the concomitant solid organ transplant.
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Khalpey Z, Sydow N, Slepian MJ, Poston R. How to do it: thoracoscopic left ventricular assist device implantation using robot assistance. J Thorac Cardiovasc Surg 2013; 147:1423-5. [PMID: 24630216 DOI: 10.1016/j.jtcvs.2013.11.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/13/2013] [Accepted: 11/22/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Zain Khalpey
- Departments of Cardiothoracic Surgery and Cardiology, University of Arizona, Tucson, Ariz.
| | - Nicole Sydow
- Departments of Cardiothoracic Surgery and Cardiology, University of Arizona, Tucson, Ariz
| | - Marvin J Slepian
- Departments of Cardiothoracic Surgery and Cardiology, University of Arizona, Tucson, Ariz
| | - Robert Poston
- Departments of Cardiothoracic Surgery and Cardiology, University of Arizona, Tucson, Ariz
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