Necroptosis in the Pathophysiology of Disease

Over the past 15 years, elegant studies have demonstrated that in certain conditions, programed cell death resembles necrosis and depends on a unique molecular pathway with no overlap with apoptosis. This form of regulated necrosis is represented by necroptosis, in which the receptor-interacting protein kinase-3 and its substrate mixed-lineage kinase domain-like protein play a crucial role. With the development of knockout mouse models and molecular inhibitors unique to necroptotic proteins, this cell death has been found to occur in virtually all tissues and diseases evaluated. There are different immunologic consequences depending on whether cells die through apoptosis or necroptosis. Therefore, distinguishing between these two forms of cell death may be crucial during pathologic evaluations. In this review, we provide an understanding of necroptotic cell-death and highlight diseases in which necroptosis has been found to play a role. We also discuss the inhibitors of necroptosis and the ways these inhibitors have been used in preclinical models of diseases. These two discussions offer an understanding of the role of necroptosis in diseases and will foster efforts to pharmacologically target this unique yet pervasive form of programed cell death in the clinic.

Acquisition of chemiluminescent signals from immunoblots with a digital single-lens reflex camera

We found that certain mid-range consumer-level digital single-lens reflex (SLR) cameras using full-frame complementary metal oxide semiconductor (CMOS) sensors outperform X-ray film in acquiring signals from immunoblots that use enhanced chemiluminescence for detection. These cameras exhibit a sensitivity comparable to X-ray film, yet they provide a 3-fold increase in linear dynamic range and substantial cost savings over time, are more convenient to use, and eliminate the chemical waste associated with processing film.

Macrophage Biology in Cardiovascular Diseases

Macrophages have a key functional role in the pathogenesis of various cardiovascular diseases, such as atherosclerosis and aortic aneurysms. Their accumulation within the vessel wall leads to sustained local inflammatory responses characterized by secretion of chemokines, cytokines, and matrix protein degrading enzymes. Here, we summarize some recent findings on macrophage contribution to cardiovascular disease. We focus on the origin, survival/death, and phenotypic switching of macrophages within vessel walls.

Initiation/promotion assay for chemical carcinogens in rat liver

A short-term initiation/promotion bioassay has been developed in rat liver using putative preneoplastic foci as the endpoint for the detection of chemical carcinogens. The two protocols of the bioassay used in this study were varied according to the time 2/3 partial hepatectomy was performed in relation to when the initiator or test substance was given. After 7 weeks of promotion with phenobarbital in the drinking water, the rats were killed and the liver was sectioned, stained and scored for gamma-glutamyl transpeptidase (GGTase)-positive foci. The appearance of GGTase-positive foci was taken as an indication of initiation of carcinogenesis by the chemical. Acetylaminofluorene (AAF), aflatoxin B1 (AFB1), benzo(a)pyrene (BaP), diethylnitrosamine (DENA), 7,12-dimethylbenzo(a)anthracene, (DMBA), dimethylhydrazine (DMH), dimethylnitrosamine (DMN) and urethane were positive in the assay, while benzene and N-methyl-N-nitro-N-nitrosoguanidine (MNNG) were negative. Phenobarbital promoted the response of AAF, AFB1, BaP, DENA, DMBA, DMH and DMN. Partial hepatectomy 24 h prior to initiation increased the response of AAF, BaP, DENA, DMBA and DMH. The initiation/promotion assay in rat liver which includes (1) partial hepatectomy at 24 h prior to administering the test chemical; (2) phenobarbital promotion, and (3) GGTase-positive foci as an indication of carcinogenic activity: appears to be sensitive to a wide variety of chemical carcinogens.

Isoaspartate accumulation in mouse brain is associated with altered patterns of protein phosphorylation and acetylation, some of which are highly sex-dependent

Isoaspartate (isoAsp) formation is a major source of protein damage that is kept in check by the repair function of protein L-isoaspartyl methyltransferase (PIMT). Mice deficient in PIMT accumulate isoAsp-containing proteins, resulting in cognitive deficits, abnormal neuronal physiology and cytoarchitecture, and fatal epileptic seizures 30–60 days after birth. Synapsins I and II, dynamin-1, collapsin response mediator protein 2 (CRMP2), and α/β-tubulin are major targets of PIMT in brain. To investigate links between isoAsp accumulation and the neurological phenotype of the KO mice, we used Western blotting to compare patterns of in vivo phosphorylation or acetylation of the major PIMT targets listed above. Phosphorylations of synapsins I and II at Ser-9 were increased in female KO vs. WT mice, and acetylation of tubulin at Lys-40 was decreased in male KO vs. WT mice. Average levels of dynamin-1 phosphorylation at Ser-778 and Ser-795 were higher in male KO vs. WT mice, but the statistical significance (P>0.1) was low. No changes in phosphorylation were found in synapsins I and II at Ser-603, in CRMP2 at Ser-522 or Thr-514, in DARPP-32 at Thr-34, or in PDK1 at Ser-241. General levels of phosphorylation assessed with Pro-Q Diamond stain, or an anti-phosphotyrosine antibody, appeared similar in the WT and KO mice. We conclude that isoAsp accumulation is associated with altered functional status of several neuronal proteins that are highly susceptible to this type of damage. We also uncovered unexpected differences in how male and female mice respond to isoAsp accumulation in the brain.

Necroptosis is associated with Rab27-independent expulsion of extracellular vesicles containing RIPK3 and MLKL

Extracellular vesicle (EV) secretion is an important mechanism used by cells to release biomolecules. A common necroptosis effector-mixed lineage kinase domain like (MLKL)-was recently found to participate in the biogenesis of small and large EVs independent of its function in necroptosis. The objective of the current study is to gain mechanistic insights into EV biogenesis during necroptosis. Assessing EV number by nanoparticle tracking analysis revealed an increased number of EVs released during necroptosis. To evaluate the nature of such vesicles, we performed a newly adapted, highly sensitive mass spectrometry-based proteomics on EVs released by healthy or necroptotic cells. Compared to EVs released by healthy cells, EVs released during necroptosis contained a markedly higher number of unique proteins. Receptor interacting protein kinase-3 (RIPK3) and MLKL were among the proteins enriched in EVs released during necroptosis. Further, mouse embryonic fibroblasts (MEFs) derived from mice deficient of Rab27a and Rab27b showed diminished basal EV release but responded to necroptosis with enhanced EV biogenesis as the wildtype MEFs. In contrast, necroptosis-associated EVs were sensitive to Ca2+ depletion or lysosomal disruption. Neither treatment affected the RIPK3-mediated MLKL phosphorylation. An unbiased screen using RIPK3 immunoprecipitation-mass spectrometry on necroptotic EVs led to the identification of Rab11b in RIPK3 immune-complexes. Our data suggests that necroptosis switches EV biogenesis from a Rab27a/b dependent mechanism to a lysosomal mediated mechanism.

Fenestrated-branched endovascular aortic repair in patients with chronic kidney disease

OBJECTIVE

Renal function impairment is a common complication after open repair of complex abdominal aortic aneurysms and thoracoabdominal aortic aneurysms (TAAAs). The purpose of this study was to assess renal perioperative outcomes and renal function deterioration after fenestrated-branched endovascular aneurysm repair (F/BEVAR) in patients with chronic kidney disease (CKD).

METHODS

The study included 186 patients who underwent F/BEVAR between 2013 and 2018 for suprarenal, juxtarenal, and type I to type IV TAAAs. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) study equation. Postoperative acute kidney injury (AKI) and CKD were defined using RIFLE criteria (Risk, Injury, Failure, Loss, and End-stage renal disease) and CKD staging system (stage ≥3, GFR <60 mL/min/1.73 m²), respectively. For those without baseline CKD, renal decline was defined as a drop in GFR <60 mL/min/1.73 m² (ie, progression to CKD stage 3 or higher). For patients with baseline renal dysfunction, GFR decline ≥20% or progression in CKD stage (ie, from stage 3 to stage 4) was considered renal decline.

RESULTS

CKD was present in 83 patients (44.6%). Postoperative AKI was diagnosed in 27 patients (14.5%); 13 (48.1%) had history of CKD and 14 (51.9%) had adequate renal function preoperatively (P = .8). None of these patients required permanent renal replacement therapy. Intraoperative technical success was 100%. Overall 30-day mortality was 1.1%. There was no difference in 30-day mortality in patients with (1.2%) and without (1.0%) CKD (P = .5). During a median follow-up time of 12 months (interquartile range, 6-23 months), renal decline was observed in 21 patients (25.3%) with previous CKD and in 11 patients (10.6%) without CKD (P = .01). Among patients with previous CKD, 18 patients (9%) progressed from stage 3 CKD to stage 4. In patients with progression in CKD stage, two (5%) had renal stent stenosis requiring restenting. Among patients with renal decline, 13 had juxtarenal aneurysms (21.3%), 27 had suprarenal aneurysms (44.3%), and 21 had TAAAs (34.3%; P = .4). Subset analysis of patients who developed AKI in the immediate postoperative period found that patients with a history of CKD were less likely to experience freedom from renal decline.

CONCLUSIONS

F/BEVAR is an effective and safe procedure for patients with complex abdominal aortic aneurysms and TAAAs, even among patients with CKD. The frequency of AKI was not affected by pre-existing CKD. Midterm outcomes demonstrated that progression of CKD was more frequent among patients with pre-existing CKD, but permanent renal replacement therapy was not required. Anatomic extent of aneurysms did not affect CKD progression. CKD patients are susceptible to renal decline over time if they experience AKI in the postoperative period. Therefore, preventing AKI in the postoperative period should be regarded as a priority. Long-term effects of CKD after F/BEVAR remain to be elucidated.

Long-term survival after descending thoracic and thoracoabdominal aortic aneurysm repair

OBJECTIVE

Patients with descending thoracic aortic aneurysms (dTAA) or thoracoabdominal aortic aneurysms (TAAA) often have a variety of medical comorbidities. Those that are deemed acceptable for intervention undergo complicated repairs with good early outcomes. The purpose of this study was to identify variables that were associated with mortality over time.

METHODS

This was a retrospective review of a prospectively maintained database at our institution from 1983 to 2015. Patients were included if they underwent open or endovascular repair for dTAA or TAAA. Patients were excluded if they were intervened on for traumatic transections. The primary outcome for the study was long-term survival. Secondary outcomes included aortic-related mortality. We had mortality and survival data on all patients.

RESULTS

A total of 946 patients met our study criteria with a median follow-up of 102.8 months (interquartile range [IQR], 58.9-148.2 months). The median age of the cohort was 71 years (IQR, 63-77 years) with the majority of patients being male (58.1%). The extent of TAAA pathology was as follows: type I (14.2%), type II (21.2%), type III (17.1%), type IV (26.2%), and dTAA (21.2%). A total of 147 patients (15.5%) had a prior dissection. The median diameter of aneurysm was 6.4 cm (IQR, 6.0-7.0 cm). A total of 158 patients (16.7%) underwent endovascular repair over the study period. Variables associated with mortality over time were age, surgical era, acute pathology, dissection, preoperative creatinine, and type IV TAAAs. In addition, experiencing the following complications in the postoperative period was associated with mortality over time: neurological, cardiac, and pulmonary. Aortic-related mortality was 2.1% (n = 20) over the study period. Patients who underwent endovascular repair for acute conditions had better long-term survival when compared with open repair. However, there were no differences in long-term survival between open and endovascular repair for nonacute cases. In addition, repair in the more modern era was associated with improved survival.

CONCLUSIONS

TAAAs can be repaired with reasonable perioperative mortality rates. Once patients undergo repair of their aneurysm, aortic-related mortality remains low. The addition of endovascular options has dramatically changed management of patients with dTAA and TAAA. Further, endovascular repair was associated with decreased perioperative mortality and significantly increased long-term survival in acute patients. Patients undergoing TAAA repair are generally considered high risk and therefore require extensive long-term follow-up for management of their comorbidities and complications, because these are the main contributors to mortality over time.

Acute Kidney Injury in Patients Undergoing Cardiopulmonary Bypass for Lung Transplantation

BACKGROUND

Cardiopulmonary bypass (CPB) is often used to support patients undergoing lung transplantation who are intolerant of anatomic manipulation or single lung ventilation during the procedure. However, CPB may be associated with adverse outcomes. We evaluated the hypothesis that CPB is associated with increased acute kidney injury (AKI) and postoperative mortality after lung transplantation.

MATERIALS AND METHODS

This was a retrospective review of our institutional lung transplant database at the University of Texas Southwestern Medical Center from 2012 to 2018. Patients were grouped based on their need for CPB. The primary outcome was AKI within 48 h of transplantation, which was defined as Kidney Disease Improving Global Outcomes stage 1 or greater. Secondary outcomes included all-cause mortality.

RESULTS

A total of 426 patients underwent lung transplantation with 39.0% (n = 166) requiring CPB. There were no differences in demographics and comorbidities, including baseline renal function, between CPB and no CPB. CPB use was higher in recipients with interstitial lung diseases and primary pulmonary hypertension. Median lung allocation score was higher in those needing CPB (47 [interquartile range, 40-59] versus 39 [interquartile range, 35-47]). Patients requiring CPB were significantly more likely to experience AKI (61.44% versus 36.5.3%, P < 0.01) and postoperative hemodialysis (6.6% versus 0.4%, P < 0.01). On multivariable analysis, CPB was significantly associated with postoperative AKI (odds ratio, 1.66; 95% CI, 1.01-2.75; P = 0.04). Thirty-day mortality was higher in patients undergoing CPB (4.2% versus 0.8%, P = 0.03).

CONCLUSIONS

CPB for lung transplantation is associated with a higher incidence of AKI, renal failure requiring hemodialysis, and 30-d mortality. CPB should be used selectively for lung transplantation.

Antifungal Therapy in Fungal Necrotizing Soft Tissue Infections

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are life-threatening surgical emergencies associated with high morbidity and mortality. Fungal NSTIs are considered rare and have been largely understudied. The purpose of this study was to study the impact of fungal NSTIs and antifungal therapy on mortality after NSTIs.

METHODS

A retrospective chart review was performed on patients with NSTIs from 2012 to 2018. Patient baseline characteristics, microbiologic data, antimicrobial therapy, and clinical outcomes were collected. Patients were excluded if they had comfort care before excision. The primary outcome measured was in-hospital mortality.

RESULTS

A total of 215 patients met study criteria with a fungal species identified in 29 patients (13.5%). The most prevalent fungal organism was Candida tropicalis (n = 11). Fungal NSTIs were more prevalent in patients taking immunosuppressive medications (17.2% versus 3.2%, P = 0.01). A fungal NSTI was significantly associated with in-hospital mortality (odds ratio, 3.13; 95% confidence interval, 1.16-8.40; P = 0.02). Furthermore, fungal NSTI patients had longer lengths of stay (32 d [interquartile range, 16-53] versus 19 d [interquartile range, 11-31], P < 0.01), more likely to require initiation of renal replacement therapy (24.1% versus 8.6%, P = 0.02), and more likely to require mechanical ventilation (64.5% versus 42.0%, P = 0.02). Initiation of antifungals was associated with a significantly lower rate of in-hospital mortality (6.7% versus 57.1%, P = 0.01).

CONCLUSIONS

Fungal NSTIs are more common in patients taking immunosuppressive medications and are significantly associated with in-hospital mortality. Antifungal therapy is associated with decreased in-hospital mortality in those with fungal NSTIs. Consideration should be given to adding antifungals in empiric treatment regimens, especially in those taking immunosuppressive medications.

Endovascular Aortic Repair in Patients of Advanced Age

PURPOSE

Treatment decisions for the elderly with abdominal aortic aneurysms (AAAs) are challenging. With advancing age, the risk of endovascular aneurysm repair (EVAR) increases while life expectancy decreases, which may nullify the benefit of EVAR. The purpose of this study was to quantify the impact of EVAR on 1-year mortality in patients of advanced age.

MATERIALS AND METHODS

The 2003-2020 Vascular Quality Initiative Database was utilized to identify patients who underwent EVAR for AAAs. Patients were included if they were 80 years of age or older. Exclusions included non-elective surgery or missing aortic diameter data. Predicted 1-year mortality of untreated AAAs was calculated based on a validated comorbidity score that predicts 1-year mortality (Gagne Index, excluding the component associated with AAAs) plus the 1-year aneurysm-related mortality without repair. The primary outcome for the study was 1-year mortality.

RESULTS

A total of 11 829 patients met study criteria. The median age was 84 years [81, 86] with 9014 (76.2%) being male. Maximal AAA diameters were apportioned as follows: 39.6% were <5.5 cm, 28.6% were 5.5-5.9 cm, 21.3% were 6.0-6.9 cm, and 10.6% were ≥7.0 cm. The predicted 1-year mortality rate without EVAR was 11.9%, which was significantly higher than the actual 1-year mortality rate with EVAR (8.2%; p<0.001). The overall rate of perioperative MACE was 4.4% (n = 516). Patients with an aneurysm diameter <5.5cm had worse actual 1-year mortality rates with EVAR compared to predicted 1-year mortality rates without EVAR. In contrast, those with larger aneurysms (≥5.5cm) had better actual 1-year mortality rates with EVAR. The benefit from EVAR for those with Gagne Indices 2-5 was largely restricted to those with AAAs ≥ 7.0cm; whereas those with Gagne Indices 0-1 experience a survival benefit for AAAs larger than 5.5 cm.

CONCLUSION

The current data suggest that EVAR decreases 1-year mortality rates for patients of advanced age compared to non-operative management in the elderly. However, the survival benefit is largely limited to those with Gagne Indices 0-1 with AAAs ≥ 5.5 cm and Gagne Indices 2-5 with AAAs ≥ 7.0 cm. Those of advanced age may benefit from EVAR, but realizing this benefit requires careful patient selection.

Transfer Is Associated with a Higher Mortality Rate in Necrotizing Soft Tissue Infections

Background: Necrotizing soft tissue infections (NSTI) are a surgical emergency with significant morbidity and mortality rates. It has been thought that NSTIs are best treated in large tertiary centers. However, the effect of transfer has been under-studied. We examined whether transfer status is associated with a higher mortality rate in NSTIs. Methods: We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with NSTI seen from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (T-NSTI) were compared with those who were treated initially at a tertiary center (P-NSTI). The primary endpoint was in-hospital death. Results: A total of 138 patients with NSTI met our study criteria, 39 transfer patients (28.0%) and 99 (72.0%) who were treated primarily at our institutions. The mortality rate was significantly higher for T-NSTI patients than P-NSTI patients (35.9% versus 14.1%; p < 0.01) with an adjusted odds ratio of 5.33 (95% confidence interval 1.02-28.30; p = 0.04). The need for hemodialysis was an independent predictor of in-hospital death. Treatment at a Level 1 trauma center and current smoking status were independent protectors???? of in-hospital death. For the transfer patients, the timing of transfer and debridement status were not different in survivors and non-survivors. However, there was a trend toward a lower in-hospital mortality rate if patients were transferred early without prior debridement than in all other transfers (21.4% versus 40.0%; p = 0.21). The in-hospital mortality rate was significantly lower at the Level 1 trauma center than at the non-trauma tertiary center (15.5% versus 34.3%; p = 0.02). Conclusion: Transfer status is an independent predictor of in-hospital death in patients with NSTI. Larger, multi-institutional studies are needed to elucidate further what factors contribute to the higher mortality rate in these patients.

Outcomes after Open Lower Extremity Revascularization in Patients with Critical Limb Ischemia

BACKGROUND

For decades, open intervention was the treatment of choice in patients requiring lower extremity revascularization. In the endovascular era, however, open and endovascular revascularization are options. The implications of prior revascularization on the outcomes for subsequent revascularization are not known. In the present study, we evaluated 30-day outcomes after open lower extremity revascularization for critical limb ischemia (CLI) in those who had previous interventions.

METHODS

The 2012-2017 open lower extremity bypass Participant User Data Files from the National Surgical Quality Improvement Program were used to identify a cohort of patients with CLI. Patients whose operation was considered emergent were excluded from the analysis. Patients were stratified on whether they had a previous open or endovascular intervention or undergoing a primary revascularization. The primary outcome measure was 30-day major adverse limb events (MALEs). Secondary outcomes included major adverse cardiac events (MACEs) and wound complications.

RESULTS

A total of 12,668 patients met study criteria with 59.6% (n = 7,549) undergoing a primary open revascularization, 22.4% (n = 2,839) having a prior endovascular intervention, and 18.0% (n = 2,280) having a prior open revascularization. There were notable differences in the baseline characteristics between the 3 groups. In addition, there were differences in the reason for intervention (rest pain versus tissue loss), type of revascularization, and type of conduit used between the 3 groups. After adjustment, a prior open revascularization was significantly associated with 30-day MALE when compared with a primary revascularization (adjusted odds ratio, 1.69; 95% confidence interval, 1.47-1.94; P < 0.001) and prior endovascular intervention (adjusted odds ratio, 1.76; 95% confidence interval, 1.46-2.12; P < 0.001). There were no differences in outcomes between primary revascularization and prior endovascular patients. There were no differences between MACEs or wound complications between the 3 groups.

CONCLUSIONS

A prior endovascular intervention does not seem to accrue any additional short-term risk when compared with primary revascularization, suggesting an endovascular-first approach may be a safe strategy in patients with CLI. However, a prior open intervention is significantly associated with 30-day MALE in patients undergoing redo open revascularization, which may be related to the rapid decline in patients once they have exhausted their best open revascularization option.

Trainee Reliance on Public Service Loan Forgiveness

OBJECTIVE

The Public Service Loan Forgiveness (PSLF) program is an option to trainees to help alleviate federal education debt. The prevalence of PSLF utilization and how this may impact career decisions of trainees is unknown. The purpose of this study was to understand the prevalence, impact, and understanding of PSLF participation on trainees.

DESIGN

IRB-approved anonymous survey asking study subjects to report demographics, financial status, and reliance on PSLF. In addition, study subjects were asked to report their participation in PSLF, the possible impact of PSLF participation on career decisions, and to identify the qualifications needed to complete PSLF.

SETTING

Online anonymous survey.

PARTICIPANTS

The survey was offered to all physician trainees in all specialties at the University of Texas, Southwestern, University of Wisconsin, Madison, and University of Michigan, Ann Arbor.

RESULTS

There were 934 respondents, yielding a 37.6% response rate. A total of 416/934 (44.5%) respondents were actively or planning on participating in the PSLF program with 175/934 (18.7%) belonging to a surgical specialty. Those belonging to a surgical specialty were more likely to be PSLF participants compared to medical specialties (53.1% versus 42.6%, p = 0.01). For those participating in PSLF, 82/416 (19.7%) stated this participation impacted career decisions. A total of 275/934 (29.4%) respondents obtained and 437/934 (46.8%) wanted to receive formal training/lectures in regards to the PSLF program. Of those actively or planning on participating in the PSLF program, only 58/416 (13.9%) were able to correctly identify all of the qualifications/criteria to complete the program.

CONCLUSIONS

A large proportion of trainees rely on the PSLF program for education loan forgiveness with approximately 20% reporting participation impacted career decisions. Additionally, the majority may not fully understand PSLF criteria. Programs should strongly consider providing a formal education regarding PSLF to their trainees.

Cardiac transplantation in adults with congenital heart disease: A single center case series

BACKGROUND

Adult congenital heart disease (CHD) transplant recipients historically experienced worse survival early after transplantation. We aim to review updated trends in adult CHD transplantation.

METHODS

We performed a single center case series of adult cardiac transplants from January 2013 through July 2020. Outcomes of patients with CHD were compared to non-CHD. The primary outcome was overall survival. Secondary outcomes included a variety of post-operative complications.

RESULTS

18/262 (7%) transplants were CHD recipients. CHD patients were younger with median age 41 (32-47) versus 58 (48-65) (P < .001). Fontan circulation for single ventricle physiology was present in 4/18 (22%) of CHD recipients, while 16/18 (89%) had systemic right ventricles. CHD recipients had higher rates of previous cardiovascular operations (94% vs. 51%, P < .001). 9/18 (50%) of CHD patients required reconstructive procedures at the time of transplant. Operative and cardiopulmonary bypass times were longer for the CHD cohort (7.5 h [6.6-8.5] vs. 5.6 h [4.6-7] P < .001) and (197 min [158-240] vs. 130 [105-167] P < .001), respectively. There were no differences in operative complications or survival between CHD and non-CHD recipients.

CONCLUSIONS

These data highlight the added technical challenges of performing adult CHD transplants. However, similar outcomes can be achieved as for non-CHD recipients.

SUMMARY

Modern advances in palliation of congenital heart defects (CHD) has led to increased survival into adulthood. Many of these patients require heart transplantation as adults. There are limited data on adult CHD transplantation. Historically, these patients have had worse perioperative outcomes with improved long-term survival. We retrospectively analyzed 262 heart transplants at a single center, 18 of which were for adult CHD. Here, we report our series of 18 CHD recipients. We detail the palliative history of all CHD patients and highlight the added technical challenges for each of the 18 patients at transplant. In our analysis, CHD patients had more prior cardiovascular surgeries as well as longer transplant operative and bypass times. Despite this, there were no differences in perioperative and long-term outcomes. We have added patient and institution specific data for transplanting patients with adult CHD. We hope that our experience will add to the growing body of literature on adult CHD transplantation.

Selection criterion for endovascular aortic repair in those with chronic kidney disease

OBJECTIVE

Endovascular aortic repair (EVAR) is the preferred method of repair for abdominal aortic aneurysms (AAAs). However, patients with advanced chronic kidney disease (CKD) are a high-risk group, and it is unknown which patients with CKD benefit from EVAR vs continued surveillance. The purpose of this study was to identify which patients with advanced CKD may benefit from EVAR.

METHODS

The Vascular Quality Initiative Database was utilized to identify elective EVARs for AAAs. Patients were excluded if they underwent urgent or emergent repairs. CKD stages were categorized based on preoperative estimated glomular filtration rate (eGFR) and dialysis status. Predicted 1-year mortality of untreated AAAs was calculated by modifying a validated comorbidity score that predicts 1-year mortality (Gagne Index) without repair. The primary outcome was actual 1-year mortality, which was compared with the predicted 1-year mortality without repair.

RESULTS

A total of 34,926 patient met study criteria. There were differences in Gagne Indices among the varying classes of CKD. Patients with CKD 4 and CKD 5 had the highest 1-year mortality rates, followed by CKD 3b, which was significantly higher than those with CKD 1 and CKD 2. Patients with CKD 4 had no differences between actual 1-year mortality with EVAR and predicted 1-year survival without EVAR across all AAA sizes. Those with CKD 5 had worse actual 1-year survival with EVAR than predicted 1-year survival without EVAR for AAAs <5.5 cm. Patients with CKD 5 only experienced an actual mortality benefit with EVAR compared with predicted 1-year mortality without EVAR for AAAs ≥7.0 cm.

CONCLUSION

The current data suggest that patients with CKD 3b, 4, and 5 represent a high-risk group who may not benefit from elective EVAR utilizing traditional size criteria. Patients with CKD 4 and 5 with AAAs <5.5 cm do not benefit from elective EVAR. In patients with CKD 5, elective EVAR may need to be reserved for AAAs ≥7.0 cm unless there are other concerning anatomic characteristics.

Risk Factors for Nonhome Discharge After Esophagectomy for Neoplastic Disease

BACKGROUND

Esophagectomies are known to be technically challenging operations that create significant physiologic changes. These patients often require assisted care postoperatively that necessitates a nonhome discharge. The purpose of this study was to assess factors associated with nonhome discharge after esophagectomy for neoplastic disease.

METHODS

The 2016 to 2017 American College of Surgeons National Surgical Quality Improvement Program Esophagectomy database was queried to identify patients who underwent esophagectomy for a neoplasm. Patients were excluded if they died within 30 days of their operation, the index operation was considered emergent, or had missing data for the variables of interest. Multivariable analysis was performed to identify which factors were predictive of nonhome discharge.

RESULTS

One thousand seven patients were included. Of those, 121 (12.0%) had a nonhome discharge. Multivariable analysis showed that the following factors were associated with nonhome discharge: Modified Charlson comorbidity index (adjusted odds ratio [aOR], 2.04; 95% confidence interval [CI], 1.49-2.86), partially dependent preoperative functional status (aOR, 13.18; 95% CI, 1.07-315.67), urinary tract infection (aOR, 5.25; 95% CI, 1.32-20.41), and length of stay (aOR, 1.12; 95% CI, 1.08-1.16).

CONCLUSIONS

We identified various factors associated with nonhome discharge. Early identification of patients who are at risk for nonhome discharge is important for early discharge planning, which may decrease nonmedical delays and healthcare costs.

Survival after multiple episodes of cardiac arrest

BACKGROUND

Cardiopulmonary resuscitation (CPR) is widely used in response to cardiac arrest. However, little is known regarding outcomes for those who undergo multiple episodes of cardiac arrest while in the hospital.

OBJECTIVES

The purpose of this study was to evaluate the association of multiple cardiac events with in-hospital mortality for patients admitted to our tertiary care hospital who underwent multiple code events.

METHODS

We performed a retrospective cohort study on all patients who underwent cardiac arrest from 2012 to 2016. Primary outcome was survival to discharge. Secondary outcomes included post-cardiac-arrest neurologic events (PCANE), non-home discharge, and one-year mortality.

RESULTS

There were 622 patients with an overall mortality rate of 78.0%. Patients undergoing CPR for cardiac arrest once during their admission had lower in-hospital mortality rates compared to those that had multiple (68.9% versus 91.3%, p<.01). Subset analysis of those who had multiple episodes of CPR revealed that more than one event within a 24-hour period led to significantly higher in-hospital mortality rates (94.7% versus 74.4%, p<.01). Other variables associated with in-hospital mortality included body mass index, female sex, malignancy, and increased down time per code. Patients that had a non-home discharge were more likely to have sustained a PCANE than those that were discharged home (31.4% versus 3.9%, p<.01). A non-home discharge was associated with higher one-year mortality rates compared to a home discharge (78.4% versus 54.3%, p=.01).

CONCLUSION

Multiple codes within a 24-hour period and the average time per code were associated with in-hospital mortality in cardiac arrest patients.

Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG

Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.

Renal Artery Aneurysms in the Inpatient Setting

BACKGROUND

The risk of rupture of renal artery aneurysms (RAAs) remains undefined. A recent paper from the Vascular Low-Frequency Disease Consortium (VLFDC) identified only 3 ruptures in 760 patients. However, over 80% of patients in the VLFDC study were treated at large academic centers, which may not reflect the pattern of care of RAAs nationwide. Thus, the purpose of this study was to evaluate the pattern of nonelective versus elective surgery requiring inpatient admission for RAAs, including nephrectomies, and their outcomes using a national database.

METHODS

The National Inpatient Sample (NIS) database from 2012 to 2018 was utilized. Patients with a primary diagnosis of RAAs were identified using ICD-9 and ICD-10 codes. Ruptured RAAs (rRAAs) were identified utilizing surrogate ICD codes. The primary outcome variables for this study were proportion of RAAs requiring non-elective surgery and in-hospital mortality.

RESULTS

A total of 590 inpatient admissions for RAA were identified with 554 procedures at 467 hospitals across the country. Of the 590 inpatient admissions, 380 (64.4%) admissions were deemed nonelective. There was an increasing proportion of nonelective admissions over the study period. The overall rate of nephrectomies was 7.1% (n = 42). In-hospital mortality rate for the cohort was 1.4% (n = 8) with no differences in in-hospital mortality in the elective versus nonelective setting (1.0% vs. 1.6%; P = 0.718). In the nonelective setting, patients requiring a nephrectomy (n = 23) had significantly higher rates of in-hospital mortality compared those not requiring a nephrectomy (8.7% vs. 1.1%, P = 0.045). rRAA (n = 50) patients had significantly higher in-hospital mortality compared to the remainder of the cohort (6.0% vs. 0.9%, P = 0.024). rRAA patients were also more likely to undergo a nephrectomy compared to the remainder of the cohort (16.0% vs. 6.3%, P = 0.019).

CONCLUSIONS

These data demonstrate that treatment of RAAs are primarily done in the nonelective setting with a high proportion of ruptures, which could continue to rise as the threshold for repair has decreased.