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Recovering lungs with pulmonary edema due to abnormal kidney function is considered one of the expanded selection criteria for lung transplant. The aim of this study is to assess lung transplant recipients' survival from donors with abnormal kidney function and to determine differences in lung recovery rates from donors with and donors without abnormal kidney function. We reviewed the United Network for Organ Sharing registry for first-time adult lung transplant donors and recipients from June 2005 to March 2017. Donor kidney function was categorized into three groups based on estimated glomerular filtration rate: group I, greater than 60 mL/min; group II, 15 to 59 mL/min; and group III, less than 15 mL/min. Recipient survival was stratified based on estimated glomerular filtration rate using Kaplan-Meier. A multivariate Cox Regression model with known risk factors that affect survival was used to compare survival among groups. Comparison of lung recovery among the three groups was also performed. Lung recovery rates were 29.7% (15,670 of 52,747), 19.4% (3879 of 20,040), and 18.1% (704 of 3898) for groups I, II, and III, respectively. The 1-, 3-, and 5-year recipient survival rates were 86.2%, 69.2%, and 55.7% for group I; 84.9%, 66.9%, and 53.8% for group II; and 85.5%, 65.3%, and 50.3% for group III, respectively (adjusted P =.25; multivariate Cox regression method). When group I was used as reference, the adjusted hazard ratio for group II was 1.04 (95% CI, 0.98-1.10) and for group III, it was 1.08 (95% CI, 0.96-1.23), after adjusting with the multivariate Cox regression model. There was no significant difference in lung recipient survival. The lung recovery rate from donors with abnormal kidney function was lower compared with that of donors with normal kidney function. [ABSTRACT FROM AUTHOR]

Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support can be associated with significant deconditioning due to the requirement for strict bedrest as a result of femoral arterial cannulation. To address this issue, we evaluated our experience with ambulation in patients with peripheral femoral cannulation for VA-ECMO. Methods All patients that were peripherally cannulated for VA-ECMO over a 2-year period were retrospectively reviewed. Patients that ambulated at least once while supported with VA-ECMO were included in the analysis. The primary outcomes were safety and feasibility of ambulation, defined as the absence of major bleeding, vascular, or decannulation events. Results Of 104 patients placed on VA-ECMO, 15 ambulated with a femoral arterial cannula. Forty-six percent of patients were placed on VA-ECMO for decompensated heart failure, and 54% for massive pulmonary embolism. Twenty-seven percent of patients were cannulated during active cardiopulmonary resuscitation. The median length of time from cannulation to out of bed was 3 (range, 0 to 26) days. The median length of time from cannulation to initial ambulation was 4 (range, 1 to 42) days. The median distance of the first postcannulation walk was 300 feet. Neither flow nor speed decreased during or after ambulation. There were no major bleeding events, vascular complications, or decannulation events associated with ambulation. The median intensive care unit length of stay and hospital length of stay were 12 and 21 days, respectively. One-year survival was 100% for ambulating patients. Conclusions Ambulating patients supported with VA-ECMO, despite femoral arterial cannulation, appears feasible and safe in carefully selected patients. [ABSTRACT FROM AUTHOR]

Background Cardiac surgery for structural heart disease has poor outcomes in the presence of cardiogenic shock or advanced heart failure. We applied venoarterial extracorporeal membrane oxygenation (ECMO) to restore end-organ function and resuscitate patients before high-risk cardiac operation. Methods Twelve patients with cardiogenic shock and end-organ failure were evaluated for cardiac surgery. The average Society of Thoracic Surgeons mortality risk was 24% ± 13%. Patients were peripherally cannulated on ECMO for 7 ± 4 days, before undergoing operation for prosthetic mitral stenosis (n = 4), ruptured papillary muscle (n = 4), ischemic ventricular septal defect (n = 3), or severe aortic stenosis (n = 1). Results Mean age was 61 ± 8 years. Comorbidities included acute renal failure (n = 11), inotrope requirement (n = 10), intraaortic balloon pump (n = 8), severe acidosis (n = 6), high-dose vasopressor requirement (n = 8), and cardiac arrest (n = 1). With ECMO support, vasopressor requirement, central venous pressure, creatinine, lactate, pH, pulmonary hypertension, and The Society of Thoracic Surgeons mortality risk and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II all improved significantly. Care was withdrawn in 1 patient on ECMO with initially unknown anoxic brain injury. No patients required dialysis at discharge. Complications included 1 permanent stroke. All operative patients survived to hospital discharge. Average length of follow-up was 420 days, with 2 patient deaths at 76 and 230 days and 6 patients surviving over 1 year. Conclusions ECMO can be used as a bridge to heart valve or septal defect surgery in severely decompensated patients. Through recovery of end-organ function, ECMO may allow surgical correction of structural heart disease in patients considered inoperable or convert a salvage situation to an elective operation. Visual Abstract [ABSTRACT FROM AUTHOR]

Donation after circulatory death is defined as donation after cardiac arrest and circulatory cessation. The number of circulatory death donors is growing and significantly increases the organ donor pool. Shortening the warm ischemia time is pivotal in the outcomes and survival after transplant. We describe simplified and safe technique for lung flush during lung recovery from donors after circulatory death. [ABSTRACT FROM AUTHOR]

Background We previously investigated preoperative variables associated with qualitative inflow cannula malposition in the HeartMate II (Thoratec-Abbott, Abbott Park, IL) continuous-flow left ventricular assist device. In this report, we assess inflow cannula malposition quantitatively in recipients of both the HeartMate II and the HeartWare (Medtronic-HeartWare, Minneapolis, MN) and examine its association with device thrombosis. Methods Malposition was quantified based on angular deviation from a hypothetic ideal inflow cannula position in two orthogonal computed tomography imaging planes. Ideal position lies on a line from the apex to the center of the mitral valve. Positive anterior plane angulation indicates deviation toward the superior free wall; negative, toward the inferior wall. Positive lateral plane angulation indicates deviation toward the septum; negative, toward the lateral wall. Device thrombosis was assessed based on clinical criteria. Results Fifty-four HeartMate II patients and 68 HeartWare patients were analyzed. Inflow cannula deviation was significantly higher for HeartMate II than for HeartWare (anterior plane angle 36.7 ± 16.8 versus −18.7 ± 11.6 degrees, p < 0.001; lateral plane angle 23.7 ± 20.1 versus 0.2 ± 15.0 degrees, p < 0.001. Pump thrombosis occurred in 31% of HeartMate II patients and 2.9% of HeartWare patients ( p < 0.001). In a multivariate model, HeartMate II and increasing inflow cannula deviation toward the septum were associated with higher thrombosis risk (odds ratio 1.35 per 10-degree increase). Conclusions We found distinct device-dependent differences in inflow cannula positioning and thrombosis, with HeartWare showing both less malposition and less thrombosis. Malposition toward the ventricular septum may contribute to pump thrombosis through a vicious cycle of suction events, low flow, and speed reduction. [ABSTRACT FROM AUTHOR]

Background The management of massive pulmonary embolism remains challenging, with a considerable mortality rate. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for massive pulmonary embolism has been reported, its use as salvage therapy has been associated with poor outcomes. We reviewed our experience utilizing an aggressive, protocolized approach of VA-ECMO to triage, optimize, and treat these patients. Methods All patients with a massive pulmonary embolism who were placed on VA-ECMO, as an initial intervention determined by protocol, were retrospectively reviewed. ECMO support was continued until organ optimization was achieved or neurologic status was determined. At that time, if the thrombus burden resolved, decannulation was performed. If substantial clot burden was still present with evidence of right ventricular (RV) strain, operative therapy was undertaken. Results Twenty patients were identified. Before cannulation, all patients had an RV-to-left ventricular ratio greater than 1.0 and severe RV dysfunction. The median duration of ECMO support was 5.1 days, with significant improvement in end-organ function. Ultimately, 40% received anticoagulation alone, 5% underwent catheter-directed therapy, and 55% underwent surgical pulmonary embolectomy. Care was withdrawn in 1 patient with a prolonged pre-cannulation cardiac arrest after confirmation of neurologic death. In-hospital and 90-day survival was 95%. At discharge, 18 of 19 patients had normal RV function, and 1 patient, who received catheter-directed therapy, had mild dysfunction. Conclusions VA-ECMO appears to be an effective tool to optimize end-organ function as a bridge to recovery or intervention, with excellent outcomes. This approach may allow clinicians to better triage patients with massive pulmonary embolism to the appropriate therapy on the basis of recovery of RV function, residual thrombus burden, operative risk, and neurologic status. [ABSTRACT FROM AUTHOR]

Background In addition to severe hypoxia and hypercapnia, acute respiratory distress syndrome (ARDS) can present with substantial hemodynamic compromise, requiring inotropic or vasopressor support or both. Either venovenous (VV) or venoarterial (VA) extracorporeal membrane oxygenation (ECMO) can be offered in this situation. However, a contemporary comparison of these two cannulation strategies has yet to be well described. Methods The Extracorporeal Life Support Organization Registry was reviewed for all cases of adult ARDS in patients that required inotropic agents or vasopressors or both before ECMO initiation (2009 to 2013). Pre-ECMO clinical data, ECMO variables, and outcomes were compared, based on initial cannulation strategy (VV or VA ECMO). Results Of 717 ECMO runs, there were 591 VV ECMO and 126 VA ECMO cases. Over the study period, the proportion of VA ECMO cases decreased from 20% (n = 37 of 184, 2009 to 2010) to 19% (n = 59 of 312, 2011 to 2012) to 14% (n = 30 of 221, 2013). Conversion from VV ECMO to VA ECMO was 4%. VV ECMO was associated with less gastrointestinal bleeding and hemolysis, but overall rates of bleeding, stroke, and renal failure were similar. Survival to discharge was 58% for VV ECMO in contrast to 43% for VA ECMO ( p = 0.002). Multivariable regression analysis revealed VV ECMO to be an independent predictor of survival to discharge relative to VA ECMO. Conclusions In this review of ARDS patients requiring pre-ECMO hemodynamic support, VV ECMO was not associated with worse survival or complication rates compared with VA ECMO. These data suggest that, in appropriately selected patients, it may be reasonable to initially institute VV ECMO support, reserving VA ECMO for conversion for refractory hypotension. [ABSTRACT FROM AUTHOR]

Background Given substantial advances in venovenous extracorporeal membrane oxygenation (ECMO) technology, long-term support is increasingly feasible. Although the benefits of short-term ECMO as a bridge to recovery in acute respiratory distress syndrome (ARDS) are well described, the utility and outcomes of long-term support remain unclear. Methods Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed and analyzed separately for those requiring ECMO support for less than 3 weeks or for 3 weeks or longer. Demographic factors, ECMO variables, and outcomes were assessed. Results Fifty-five patients with ARDS received ECMO during the study period, with 11 patients requiring long-term ECMO support and a median duration of 36 (interquartile range: 24 to 68) days. Recovery was the initial goal in all patients. Pre-ECMO mechanical ventilatory support, indices of disease severity, and the ECMO cannulation strategy were similar between the two groups. Eight (73%) patients receiving long-term support were bridged to recovery, and 1 patient was bridged to transplantation after a refractory course. Eight (73%) patients receiving long-term support and 25 (57%) patients receiving short-term support survived to 30 days and hospital discharge. Conclusions Previously, long-term ECMO support was thought to be associated with unfavorable outcomes. This study, however, may provide support for the efficacy of ECMO support even for 3 weeks or more as a bridge to recovery or transplantation. [ABSTRACT FROM AUTHOR]

Background The incidence and consequences of deep venous thrombosis (DVT) and pulmonary embolism (PE) have not been described recently in lung transplant recipients. We sought to characterize DVT and PE in a contemporary series of lung transplant recipients and describe their association with clinical outcomes. Methods The records of all lung transplant recipients from July 1, 2008, to June 30, 2013, were reviewed and analyzed. DVT was diagnosed by venous duplex ultrasonography. PE was diagnosed by computed tomography angiography, nuclear ventilation/perfusion scanning, or pulmonary angiography. Results The study comprised 117 patients who underwent 123 transplants. The median age was 63 years (range, 17 to 77 years). Forty-five patients (39%) had evidence of lower extremity DVT, 53 (45%) had no evidence of lower extremity DVT, and 19 (16%) were not tested. Fifty-three (45%) had evidence of upper extremity DVT, 30 (26%) had no evidence of upper extremity DVT, and 34 (29%) were not tested. Eighteen (15%) had evidence of PE, 82 (70%) had no evidence of PE, and 17 (15%) were not tested. A multivariable, stepwise Cox proportional hazards model revealed that the presence of lower extremity DVT (hazard ratio, 2.43; 95% confidence interval, 1.29 to 4.64), use of cardiopulmonary bypass (hazard ratio, 2.21; 95% confidence interval, 1.04 to 4.68), and unilateral lung transplantation (hazard ratio, 2.13; 95% confidence interval, 1.07 to 4.25) were associated with diminished survival. Conclusions The incidence of DVT and PE in lung transplant recipients is high. Posttransplant surveillance and treatment based on findings are warranted. [ABSTRACT FROM AUTHOR]

Background The use of venovenous extracorporeal membrane oxygenation (ECMO) has increased as a bridge to recovery for acute respiratory distress syndrome (ARDS) refractory to conventional support. Morbid obesity can pose a significant challenge to obtaining indexed flows, and outcomes in this population are not well described. Methods Patients requiring ECMO for ARDS between January 2009 and November 2012 were retrospectively reviewed. Demographics, ECMO variables, and outcomes were assessed. Morbid obesity and super obesity were defined as a body mass index (BMI) greater than 40 kg/m 2 and greater than 50 kg/m 2 , respectively. Results Fifty-five patients with ARDS were placed on ECMO during the study period. Twelve were morbidly obese with a BMI of 49.0 kg/m 2 (interquartile range [IQR]: 45.4–57.3 kg/m 2 ). Pre-ECMO mechanical ventilatory support and indices of disease severity were similar between the 2 groups, as were cannulation strategy and duration of ECMO support. Nine (75%) morbidly obese patients and 27 (63%) non–morbidly obese patients were successfully weaned from ECMO support, and patient survival to time of discharge was 67% and 58%, respectively. In the subset of super obese patients (n = 6; BMI, 57.3 kg/m 2 [IQR: 51.3–66.5 kg/m 2 ]), recovery and midterm survival was 100%. Conclusions In this review, class III obesity was not associated with poorer outcomes, and based on these data, ECMO support should not be withheld from this patient population. [ABSTRACT FROM AUTHOR]

Background. Sirolimus (SIR) has been shown to stabilize the lung function in lung transplant recipients with bronchiolitis obliterans syndrome (BOS). However, there is no long-term data on the prophylactic us of SIR in lung transplant recipients. This retrospective study examines the effects of SIR in the prevention of BOS. Methods. From 1999 to 2009, 24 lung transplant recipients whose maintenance immunosuppression regimen consisted of tacrolimus (Tac), mycophenolate mofetil (MMF) or azathioprine (AZA), and prednisone (Pred), were switched to Tac, SIR, and Pred at I year after transplantation. From these 24 patients, 5 developed side effects that necessitated the cessation of SIR within 1 year, while 19 patients tolerated long-term use of SIR. The clinical outcomes of these 19 patients (SIR group) were compared with 22 lung transplant recipients whose immunosupression regimen consisted of Tac, MMF or AZA, and Pred from the time of transplant (MMF group). Survival rates and freedom from BOS were calculated by the Kaplan-Meier method. Results. The SIR group had a lower incidence of BOS and viral infection (p = 0.05), and higher survival rates (p = 0.004). The SIR group had lower levels of Tac and received less Pred. The incidences of acute rejection, carcinoma, hypertension, and diabetes were similar between both groups. Conclusions. Results from this study suggest that conversion to SIR 1 year after lung transplantation improves survival and decreases the development of BOS. Randomized studies with higher number of patients are needed to determine the prophylactic efficacy of sirolimus in preventing the development of BOS. [ABSTRACT FROM AUTHOR]

Infection of an endoventricular patch used for left ventricular aneurysm repair with formation of cardiocutaneous fistula is a rare but potentially serious complication. We report an adult patient who developed a cardiocutaneous fistula 1 year after repair of a third left ventricular aneurysm. The patient was successfully treated with a redo operation using a bovine pericardial patch with omental flap coverage. He is alive and well 10 years later. [ABSTRACT FROM AUTHOR]

: BackgroundWe investigated whether intrathymic inoculation of donor bone marrow at the time of transplantation induced long-term acceptance of lung allografts.: MethodsFour- to-six-week-old August Copenhagen Irish (ACI) and Wistar Furth (WF) rats were used as donors and recipients, respectively. After being inoculated intrathymically with either donor-specific (ACI) or third-party (F344) bone marrow (2.0 × 107 cells/lobe), the recipient (WF) animal received a left lung transplant from an ACI donor. A short course of tacrolimus (1 mg/kg per day for 5 days) was administered. Animals were sacrificed at timed intervals after transplantation, and rejection was graded on a scale of 0 (none) to 4 (severe).: ResultsAt 28 days, animals receiving donor-specific bone marrow have lower (p < 0.01) median rejection grade (MRG = 0.25; n = 6) than those receiving third-party bone marrow (MRG = 3; n = 6) and controls (no bone marrow; MRG = 2.5; n = 6). Animals receiving intrathymic donor bone marrow accepted lung allografts up to 380 days with minimal rejection (MRG = 2; n = 6). Long-term lung recipients also accepted a challenging donor-specific heart graft (n = 4) for more than 150 days. In mixed lymphocyte reaction assays, T lymphocytes of WF recipients that had received intrathymic bone marrow (from ACI donor) exhibited low response (similar to self antigens) to donor (ACI) cells, but reacted strongly (five times higher) to third-party (F344) cells.: ConclusionsIntrathymic inoculation of donor bone marrow at the time of transplantation along with a short course of tacrolimus induces long-term acceptance of lung allografts in rats. This simple approach of tolerance induction may have clinical application. [Copyright &y& Elsevier]

Venovenous (V-V) extracorporeal membrane oxygenation (ECMO) is used for respiratory failure that is suspected to be reversible (bridge to recovery), or as a bridge to lung transplantation. Patients with proximal airway obstruction due to endobronchial malignancy can develop acute respiratory failure, and may benefit from V-V ECMO as a bridge to airway intervention, further treatment, and eventual recovery. We describe a case of a superior sulcus tumor with tracheobronchial and superior vena cava invasion causing both respiratory failure and superior vena cava syndrome. This was treated successfully with V-V ECMO, bronchial stenting, and radiotherapy. [ABSTRACT FROM AUTHOR]