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Debate continues regarding the superiority of porcine vs pericardial bioprostheses, and data relevant to this comparison are scant. This study compared late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. Adults undergoing mitral valve replacement with 1 first-generation porcine valve model and 1 pericardial valve line were reviewed from a prospectively maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine, 36% ± 2%; pericardial, 38% ± 3%; P =.5) and cumulative incidence of mitral valve structural deterioration (porcine, 18% ± 2%; pericardial, 19% ± 3%; P =.3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35 of 50 [70%] vs 38 of 106 [36%]; P <.001), and it was more likely severe mitral regurgitation in porcine valves (80 of 106 [75%] vs 19 of 50 [38%]; P <.0001). After adjustment, structural deterioration was associated with younger patient age (P <.001) but not valve type. At 10 years, porcine valves demonstrated a higher cumulative incidence of mitral reoperation (19% ± 2% vs 9% ± 2%; P <.001) and reoperation for structural deterioration (15% ± 1% vs 6% ± 2%; P =.007). This study demonstrated similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprostheses in mitral valve replacement. The study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. The failure mode may have a greater influence on surgeon decision making regarding valve choice. [Display omitted] [ABSTRACT FROM AUTHOR]

There is no consensus on the optimal allograft sizing strategy for lung transplantation in restrictive lung disease. Current methods that are based on predicted total lung capacity (pTLC) ratios do not account for the diminutive recipient chest size. The study investigators hypothesized that a new sizing ratio incorporating preoperative recipient computed tomographic lung volumes (CTVol) would be associated with postoperative outcomes. A retrospective single-institution study was conducted of adults undergoing primary bilateral lung transplantation between January 2016 and July 2020 for restrictive lung disease. CTVol was computed for recipients by using advanced segmentation software. Two sizing ratios were calculated: pTLC ratio (pTLC donor /pTLC recipient) and a new volumetric ratio (pTLC donor /CTVol recipient). Patients were divided into reference, oversized, and undersized groups on the basis of ratio quintiles, and multivariable models were used to assess the effect of the ratios on primary graft dysfunction and survival. CTVol was successfully acquired in 218 of 220 (99.1%) patients. In adjusted analysis, undersizing on the basis of the volumetric ratio was independently associated with decreased primary graft dysfunction grade 2 or 3 within 72 hours (odds ratio, 0.42; 95% CI, 0.20-0.87; P =.02). The pTLC ratio was not significantly associated with primary graft dysfunction. Oversizing on the basis of the volumetric ratio was independently associated with an increased risk of death (hazard ratio, 2.27; 95% CI, 1.04-4.99; P =.04], whereas the pTLC ratio did not have a significant survival association. Using computed tomography–acquired lung volumes for donor-recipient size matching in lung transplantation is feasible with advanced segmentation software. This method may be more predictive of outcome compared with current sizing methods, which use gender and height only. [ABSTRACT FROM AUTHOR]

The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time. We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ2, Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019. Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P <.001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P =.46) and Asian/Pacific Islander (25% vs 15%, P =.08) applicants. There was also an increase in the proportions of women (28% vs 24%, P =.024) and White (61% vs 58%, P =.007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P =.08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low. I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment. [Display omitted] [ABSTRACT FROM AUTHOR]

Conventional ultrafiltration (CUF) during cardiopulmonary bypass (CPB) serves to hemoconcentrate blood volume to avoid allogeneic blood transfusions. Previous studies have determined CUF volumes as a continuous variable are associated with postoperative acute kidney injury (AKI) after cardiac surgery, but optimal weight-indexed volumes that predict AKI have not been described. Retrospective cohort. Single-center university hospital. A total of 1,641 consecutive patients who underwent elective cardiac surgery between June 2013 and December 2015. The CUF volume was removed during CPB in all participants as part of routine practice. The authors investigated the association of dichotomized weight-indexed CUF volume removal with postoperative AKI development to provide pragmatic guidance for clinical practice at the authors' institution. Primary outcomes of postoperative AKI were defined by the Kidney Disease: Improving Global Outcomes staging criteria and dichotomized, weight-indexed CUF volumes (mL/kg) were defined by (1) extreme quartiles (Q3) and (2) Youden's criterion that best predicted AKI development. Multivariate logistic regression models were developed to test the association of these dichotomized indices with AKI status. Postoperative AKI occurred in 827 patients (50.4%). Higher CUF volumes were associated with AKI development by quartiles (CUF >Q 3 = 32.6 v CUF < Q 1 = 10.4 mL/kg; odds ratio [OR] = 1.68, 95% CI: 1.19-2.3) and Youden's criterion (CUF ≥ 32.9 v CUF <32.9 mL/kg; OR = 1.60, 95% CI: 1.21-2.13). Despite similar intraoperative nadir hematocrits among groups (p = 0.8), higher CUF volumes were associated with more allogeneic blood transfusions (p = 0.002) and longer lengths of stay (p < 0.001). Removal of weight-indexed CUF volumes > 32 mL/kg increased the risk for postoperative AKI development. Importantly, CUF volume removal of any amount did not mitigate allogeneic blood transfusion during elective cardiac surgery. Prospective studies are needed to validate these findings. [Display omitted] [ABSTRACT FROM AUTHOR]

• High FFP:RBC transfusion has reduced total product usage in many surgical cohorts • Large-volume transfusion, platelets and FFP are linked to PGD in lung transplantation • High FFP:RBC transfusion was associated with more severe PGD at 72hours • Lung transplantation transfusion algorithms merit continued investigation Lung transplantation is associated with a significant risk of needed transfusion. Although algorithm-based transfusion strategies that promote a high fresh frozen plasma:red blood cells (FFP:RBC) ratio have reduced overall blood product requirements in other populations, large-volume transfusions have been linked to primary graft dysfunction (PGD) in lung transplantation, particularly use of platelets and plasma. The authors hypothesized that in lung transplant recipients requiring large-volume transfusions, a higher FFP:RBC ratio would be associated with increased PGD severity at 72 hours. Observational retrospective review. Single tertiary academic center. Adult patients undergoing bilateral or single orthotopic lung transplantation and receiving >4 U PRBC in the first 72 hours from February 2014 to March 2019. None. Patient demographics, operative characteristics, blood transfusions, and outcomes including PGD scores and length of stay were collected. Eighty-nine patients received >4U PRBC, had available 72-hour PGD data, and were included in the study. These patients were grouped into a high-ratio (>1:2 units of FFP:RBC, N = 38) or low-ratio group (<1:2 units of FFP:RBC, N = 51). Patients in the high-ratio group received more transfusions and factor concentrates and had significantly longer case length. The high-ratio group had a higher rate of severe PGD at 72 hours (60.5% v 23.5%, p = 0.0013) and longer hospital length of stay (40 v 32 days, p = 0.0273). In bleeding lung transplantation patients at high risk for PGD, a high FFP:RBC transfusion ratio was associated with worsened 72-hour PGD scores when compared with the low-ratio cohort. [ABSTRACT FROM AUTHOR]

Patterns of use of older donor lungs within this previously underused donor population are poorly characterized. This study examined factors associated with the use of older donor lung allografts and factors associated with survival in recipients of these lungs. Adult donors in the United Network for Organ Sharing registry who donated 1 or more organs for transplantation between 2006 and 2018 were analyzed and stratified into older (age >55 years) and younger (age ≤55 years) cohorts. Multivariable logistic and Cox regression were used to identify factors associated with transplantation of older donor lungs and factors associated with survival, respectively. Overall, 202,477 donors were included and stratified by age (older, 40,406 [20%]; younger, 162,071 [80%]). Compared with younger donors, older donors had an increased rate of consent for donation not requested by organ procurement organizations (7.5% vs 1.7%). Donor factors significantly associated with decreased lung use included male sex, increasing donor age, black race, Hispanic ethnicity, cigarette use, cocaine use, donation after circulatory death status, and PaO 2 /FiO 2 (P/F ratio) lower than 350. In recipients of older donor lungs, increasing donor age (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01, 1.05), recipient age 47 years or older (HR 1.03; 95% CI, 1.02, 1.04), and male sex (HR, 1.19; 95% CI, 1.02, 1.39) portended worse survival. Barriers in consenting practices, concerns about organ function, and recipient survival prevent the widespread use of aged allografts for lung transplantation. Better understanding of factors associated with worse outcomes of older donors and modification of organ procurement organization consenting practices may increase the use of these higher-risk donor organs. [ABSTRACT FROM AUTHOR]

Sensitized candidates with unacceptable antigens are a group that demands special attention in organ transplantation. Calculated panel reactive antigen (cPRA) is not used to modify allocation priorities in lung transplantation. The impact of cPRA on waiting list time and mortality is unknown. We performed a retrospective review of candidates for lung transplantation listed from May 2005 to 2018. Data from the Organ Procurement and Transplantation Network/United Network for Organ Sharing STAR (Standard Analysis and Research) dataset was paired with additional unacceptable human leukocyte antigen (UA-HLA) data, which were used to calculate the listing cPRA. Candidates were stratified based on the lack of UA-HLAs or cPRA level for candidates with unacceptable antigens reported. Unadjusted competing risks and adjusted subdistribution hazard models were fit. A total of 29,085 candidates met inclusion criteria for analysis. Of these, 23,562 (81%) with no UA-HLAs, 3472 (11.9%) with a cPRA less than 50, and 2051 with a cPRA greater than or equal to 50 (7.1%). On adjusted analysis, a cPRA greater than or equal to 50 was independently associated with increased waitlist mortality at 1 year (hazard ratio, 1.71; 95% confidence interval, 1.55-1.88; P <.001) and decreased rate of transplantation (71.9% vs 69.5% vs 44.4%; P <.001). Furthermore, patients with a cPRA greater than or equal to 50 had a longer waitlist time compared with a cPRA less than 50 and no UA-HLA candidates (mean 293.69 days vs 162.38 days and 143.26 days, respectively; P <.001). However, once transplanted, posttransplant survival among the cohorts was similar. Further evaluation of organ allocation with consideration of a candidate's cPRA may be warranted in order to optimize equity in access to transplants. [ABSTRACT FROM AUTHOR]

Massive hemoptysis represents a life-threatening disorder that has numerous different causes. The development of recombinant factor concentrates has allowed for novel treatments in this emergency setting. This report describes a patient with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy. The postoperative course was complicated by massive hemoptysis resulting in severe hypoxemia that required extracorporeal membrane oxygenation and multiple daily blood transfusions. After failure of conservative and interventional approaches, recombinant factor VII was administered by bronchial isolation. After treatment, the patient's hemoptysis dramatically resolved, with eventual hospital discharge and excellent function at follow-up. This case presents the use of intrapulmonary activated factor VII to control massive hemoptysis. [ABSTRACT FROM AUTHOR]

Background: Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery and is associated with worse outcomes. The cardiac autonomic nervous system is implicated in the pathogenesis of POAF.Objective: The purpose of this study was to determine the efficacy and safety of selective cardiac autonomic modulation in preventing POAF.Methods: In this randomized, double-blind, placebo-controlled trial, adults undergoing cardiac surgery were randomized 1:1 to intraoperative injection of 250 units onabotulinumtoxinA (botulinum toxin type A [BoNTA]) or placebo into epicardial fat pads. The study was powered to detect a 40% reduction in relative risk of POAF. Time to first episode of in-hospital POAF was the primary outcome, evaluated in patients receiving injection. Additionally, incidence of POAF, length of stay (LOS), and adverse events were examined.Results: The trial assigned 145 patients to injection, 15 of whom were dropped before treatment, leaving 130 patients for analysis. Overall, 36.5% (23/63) of BoNTA-treated patients developed POAF compared with 47.8% (32/67) of placebo-treated patients. The time-to-event analysis revealed a hazard ratio of 0.69 (95% confidence interval 0.41-1.19; P = .18) for the BoNTA vs placebo arm. There were no significant differences in postoperative hospital LOS (median [interquartile range] 6.0 [3.4] vs 6.2 [3.7] days; P = .51) or adverse events prolonging LOS (27/63 [42.9%] vs 30/67 [44.8%]; P = .83) in patients receiving BoNTA vs placebo.Conclusion: Epicardial injection of onabotulinumtoxinA was without discernible adverse effects, but we failed to detect a significant difference in risk of POAF. Future large-scale studies of epicardial onabotulinumtoxinA injection as a potential POAF prevention strategy should be designed to study smaller, but clinically meaningful, treatment effects. [ABSTRACT FROM AUTHOR]

Background Outcome of mitral valve replacement in extreme scenarios of small mitral annulus with the use of the Regent mechanical aortic valve is not well documented. Methods Records were examined in 31 consecutive patients who underwent mitral valve replacement with the use of the aortic Regent valve because of a small mitral annulus. Results Mean age was 60 ± 14 years. Mitral stenosis or mitral annulus calcification was present in 30 of 31 patients (97%). Concurrent procedures were performed in 17 of 31 patients (55%). Median valve size was 23 mm. Mean mitral gradient coming out of the operating room was 4.2 ± 1.5 mm Hg and at follow-up echocardiogram performed at a median of 32 months after the procedure was 5.8 ± 2.4 mm Hg. Conclusions A Regent aortic mechanical valve can be a viable option with a larger orifice area than the regular mechanical mitral valve in a problematic situation of a small mitral valve annulus. Moreover, the pressure gradients over the valve are acceptable intraoperatively and over time. [ABSTRACT FROM AUTHOR]

Background The number of adults referred to high-volume centers for extracorporeal membrane oxygenation (ECMO) is increasing. Outcomes of patients requiring transport are not well characterized, and referral guidelines are lacking. This study describes the experience and outcomes of a single high-volume center. Methods A retrospective study was performed that included adults undergoing ECMO between June 2009 and December 2015. Patient characteristics and outcomes were acquired from the medical record. Logistic regression was used to identify predictors of survival to hospital discharge. The Kaplan-Meier method was used to depict rates of survival. Results Of 133 patients, 77 (57.9%) underwent venoarterial (VA) ECMO and 56 (42.1%) underwent venovenous (VV) ECMO. Median transport distance was 88.8 miles (range 0.2–1,434 miles). Median duration of support was 6 days (range, 1–32.5 days). Age older than 60 years, pulmonary hypertension, and body mass index (BMI) greater than 30 were associated with worse survival to discharge for VA ECMO; a history of hypertension and presence of left ventricular (LV) vent were associated with better survival. Age older than 60 years and diabetes were associated with worse survival to hospital discharge for VV ECMO. Survival to decannulation was 66.2% and 76.8%, and to hospital discharge it was 48.1% and 69.6% for VA and VV ECMO, respectively. Of hospital survivors, Kaplan-Meier estimates of 1-year survival were 82.4% and 95.5% for VA and VV, respectively. Conclusions Outcomes are favorable after transport to high-volume ECMO centers. Guidelines and infrastructure for short- and long-distance ECMO transport is imperative for the efficient and successful management of these patients. [ABSTRACT FROM AUTHOR]

Objective Progression of mitral regurgitation (MR) after orthotopic lung transplantation (OLT) may be an underrecognized phenomenon due to the overlapping symptomatology of pulmonary and valvular disease. Literature evaluating the progression of MR after OLT currently is limited to case reports. Therefore, the hypothesis that MR progresses after OLT was tested and the association of preprocedure MR with postoperative mortality was assessed. Design A retrospective cohort. Setting A tertiary-care hospital. Participants Patients who underwent OLT between January 1, 2003 and February 4, 2012. Interventions After receiving institutional review board approval, a preprocedure transesophageal echocardiogram was compared with a postoperative transthoracic echocardiogram (TTE) to determine the progression of MR. Univariate and multivariate association between preprocedure MR grade and 1- and 5-year mortality was assessed. A p value of<0.05 was considered statistically significant. Measurements and Main Results From 715 patients who underwent OLT, 352 had a postoperative TTE and were included in the evaluation of progression of MR. Five patients had progression of MR postoperatively, and the mean change in MR score of –0.04 was found to be nonsignificant ( p = 0.25). Mortality data were available for 634 of the 715 patients. After covariate adjustment, there was no significant association between MR grade and 1-year mortality (p = 0.20) or 5-year mortality (p = 0.46). Conclusions This study rejected the hypothesis that primary and secondary MR progresses after OLT and found that preprocedure MR was not associated with increased postoperative mortality. Despite the findings that MR does not progress in all patients, there is a subset of patients for whom MR progression is clinically significant. [ABSTRACT FROM AUTHOR]

Arterial cannulation for veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is most commonly established via the aorta, axillary, or femoral vessels, yet their inherent complications are not well characterized. The purpose of this study was to compare the outcomes and complication rates of central vs peripheral cannulation. Adult patients undergoing VA ECMO between June 2009 and April 2015 were reviewed in this retrospective single-center study. Patient characteristics, clinical outcomes, and details related to deployment were extracted from the medical record. Complications and survival rates were compared between patients by cannulation strategy. Of 131 VA ECMO patients, there were 36 aortic (27.5%), 16 axillary (12.2%), and 79 femoral (60.3%) cannulations. Other than a lower mean age with femoral cannulations (53.9 ± 13.9 years) vs aortic (60.3 ± 12.2 years) and axillary (59.8 ± 12.4 years) (P = 0.032), the baseline patient characteristics were not statistically different. Central cannulation was more common in patients transferred from outside facilities (74.3% central vs 51.6% peripheral) (P = 0.053). Seven of 36 aortic cannulations were via anterior thoracotomy (19.4%). Forty of 131 patients underwent extracorporeal cardiopulmonary resuscitation (30.5%), 33 of whom were femorally cannulated. Peripheral cannulation carried a 29.5% rate of vascular complications compared with an 11.1% rate of mediastinal bleeding with central cannulation. Incidence of stroke and overall survival between groups were not statistically different. Central cannulation is a viable alternative to peripheral cannulation. Central cannulation avoids high rates of extremity morbidity without causing significant risks of alternative morbidity or death. [ABSTRACT FROM AUTHOR]

In an era of broader lung sharing, different-team transplantation (DT, procuring team from nonrecipient center) may streamline procurement logistics; however, safety and cost implications of DT remain unclear. To understand whether DT represents a safe means to reduce lung transplant (LTx) costs, we compared posttransplant outcomes and lung procurement and index hospitalization costs among matched DT and same-team transplantation (ST, procuring team from recipient center) cohorts at a single, high-volume institution. We hypothesized that DT reduces costs without compromising outcomes after LTx. Patients who underwent DT between January 2016 to May 2020 were included. A cohort of patients who underwent ST was matched 1:3 (nearest neighbor) based on recipient age, disease group, lung allocation score, history of previous LTx, and bilateral versus single LTx. Posttransplant outcomes and costs were compared between groups. In total, 23 DT and 69 matched ST recipients were included. Perioperative outcomes and posttransplant survival were similar between groups. Compared with ST, DT was associated with similar lung procurement and index hospitalization costs (DT vs ST, procurement: median $65,991 vs $58,847, P =.16; index hospitalization: median $294,346 vs $322,189, P =.7). On average, procurement costs increased $3263 less per 100 nautical miles for DT versus ST; DT offered cost-savings when travel distances exceeded approximately 363 nautical miles. At our institution, DT and ST were associated with similar post-LTx outcomes; DT offered cost-savings with increasing procurement travel distance. These findings suggest that DT may mitigate logistical and financial burdens of lung procurement; however, further investigation in a multi-institutional cohort is warranted. [Display omitted] [ABSTRACT FROM AUTHOR]

Objectives: We sought to determine the prognostic significance of extralobar nodal metastases versus intralobar nodal metastases in patients with lung cancer and pathologic stage N1 disease. Methods: A retrospective review of a prospectively maintained lung resection database identified 230 patients with pathologic stage II, N1 non–small cell lung cancer from 1997 to 2011. The surgical pathology reports were reviewed to identify the involved N1 stations. The outcome variables included recurrence and death. Univariate and multivariate analyses were performed using the R statistical software package. Results: A total of 122 patients had extralobar nodal metastases (level 10 or 11); 108 patients were identified with intralobar nodal disease (levels 12-14). The median follow-up was 111 months. The baseline characteristics were similar in both groups. No significant differences were noted in the surgical approach, anatomic resections performed, or adjuvant therapy rates between the 2 groups. Overall, 80 patients developed recurrence during follow-up: 33 (30%) of 108 in the intralobar and 47 (38%) of 122 in the extralobar cohort. The median overall survival was 46.9 months for the intralobar cohort and 24.4 months for the extralobar cohort (P < .001). In a multivariate Cox proportional hazard model that included the presence of extralobar nodal disease, age, tumor size, tumor histologic type, and number of positive lymph nodes, extralobar nodal disease independently predicted both recurrence-free and overall survival (hazard ratio, 1.96; 95% confidence interval, 1.36-2.81; P = .001). Conclusions: In patients who underwent surgical resection for stage II non–small cell lung cancer, the presence of extralobar nodal metastases at level 10 or 11 predicted significantly poorer outcomes than did nodal metastases at stations 12 to 14. This finding has prognostic importance and implications for adjuvant therapy and surveillance strategies for patients within the heterogeneous stage II (N1) category. [Copyright &y& Elsevier]

Background: This study was undertaken to review a large series of resections of colorectal pulmonary metastases in the era of modern chemotherapy. Methods: A retrospective chart review of prospectively maintained thoracic surgery databases identified 378 patients who underwent pulmonary resection for colorectal cancer metastases with curative intent from 1998 to 2007. Results: The primary site of disease was rectum (52%), left colon (26%), right colon (16%), and unknown (6%). Before thoracic recurrence, 166 patients (44%) had previously undergone resection of extrathoracic metastases. Median disease-free interval (DFI) was 24 months from the time of the primary operation. The number of metastatic deposits resected was one in 60%, two in 20%, three in 10%, and four or more in 10%. Chemotherapy was administered to 87 patients (23%) before resection and to 169 patients (45%) after resection. Three-year recurrence-free survival was 28%, and 3-year overall survival was 78%. Multivariable analysis revealed age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three as independent predictors of recurrence. Of 44 patients with three or more lesions and less than 1 year DFI, none was cured by operation. By contrast, recurrence-free survival was 49% at 3 years for those with one lesion and DFI greater than 1 year. Conclusions: Age younger than 65 years, female sex, DFI less than 1 year, and number of metastases greater than three predict recurrence. Medical management alone should be considered standard for patients who have both three or more pulmonary metastases and less than 1 year DFI. [Copyright &y& Elsevier]

Objectives: The outcomes of patients with metastatic melanoma are poor. Although prognostic models have been developed to predict the occurrence of pulmonary metastasis from cutaneous melanoma, few data exist to define the outcomes of these patients once metastasis has occurred. The objective of this study was to discriminate predictors of survival for patients with pulmonary metastatic melanoma. Methods: We found 1720 patients with pulmonary metastasis listed in a prospective comprehensive cancer center database of 14,057 consecutive patients with melanoma (Jan 1, 1970–June 1, 2004). Demographic and histopathologic data, time and location of recurrences, number of pulmonary nodules, and subsequent therapies were collected. Univariate and multivariate Cox proportional hazards models were used to identify predictors of survival for patients with pulmonary metastatic melanoma. Results: The median survival was 7.3 months after development of pulmonary metastasis. Significant predictors of survival from the multivariate model included nodular histologic type (P = .033), disease-free interval (P < .001), number of pulmonary metastases (P = .012), presence of extrathoracic metastasis (P < .001), and performance of pulmonary metastasectomy (P < .001). Interactions were identified between metastasectomy and disease-free interval and presence of extrathoracic metastasis. Surgery was associated with a survival advantage of 12 months for patients with a disease-free interval longer than 5 years (19 vs 7 months, P < .01) and of 10 months for patients without extrathoracic metastasis (18 vs 8 months, P < .01). Conclusions: When all other identified risk factors were controlled for mathematically, metastasectomy maintained a significant survival advantage for patients with pulmonary metastatic melanoma. These data support the role of surgery for a select subset of patients with pulmonary metastasis. [Copyright &y& Elsevier]

Reoperative lung transplantation (LTx) survival has improved over time such that a growing number of patients may present for third-time LTx (L3Tx). To understand the safety of L3Tx, we evaluated perioperative outcomes and 3-year survival after L3Tx at a high-volume US LTx center. This retrospective study included all patients who underwent bilateral L3Tx at our institution. Using an optimal matching technique, a primary LTx (L1Tx) cohort was matched 1:2 and a second-time LTx (L2Tx) cohort 1:1. Recipient, operative, and donor characteristics, perioperative outcomes, and 3-year survival were compared among L1Tx, L2Tx, and L3Tx groups. Eleven L3Tx, 11 L2Tx, and 22 L1Tx recipients were included. Among L3Tx recipients, median age at transplant was 37 years and most (73%) had cystic fibrosis. L3Tx was performed median 6.0 and 10.6 years after L2Tx and L1Tx, respectively. Compared to L1Tx and L2Tx recipients, L3Tx recipients had greater intraoperative transfusion requirements, a higher incidence of postoperative complications, and a higher rate of unplanned reoperation. Rates of grade 3 primary graft dysfunction at 72 hours, extracorporeal membrane oxygenation at 72 hours, reintubation, and in-hospital mortality were similar among groups. There were no differences in 3-year patient (log-rank p = 0.61) or rejection-free survival (log-rank p = 0.34) after L1Tx, L2Tx, and L3Tx. At our institution, L3Tx was associated with similar perioperative outcomes and 3-year patient survival compared to L1Tx and L2Tx. L3Tx represents the only safe treatment option for patients with allograft failure after L2Tx; however, further investigation is needed to understand the long-term survival and durability of L3Tx. [ABSTRACT FROM AUTHOR]

Atrioesophageal fistula (AEF) is a rare complication after radiofrequency ablation for atrial fibrillation but is associated with high mortality, usually due to sepsis or neurologic injury. We report the case of a patient who presented with an AEF and dense neurologic deficits who had complete neurologic recovery after management with emergent surgical repair without the use of cardiopulmonary bypass and with implementation of postoperative hyperbaric oxygen therapy. [ABSTRACT FROM AUTHOR]

Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004). At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy. [ABSTRACT FROM AUTHOR]

We present our institution's protocol for evaluating and transplanting thoracic organs from COVID-19 positive donors and report the outcomes to date. Hearts from donors testing positive for COVID-19 on any test were eligible for transplantation at our institution provided the donor exhibited no evidence of hypercoagulability or COVID-19 induced hyperinflammatory state during terminal hospitalization. Lungs were eligible if the donor first tested PCR positive on nasopharyngeal swab (NPS) for COVID-19 > 20 days prior to procurement and had a negative lower respiratory tract specimen. We performed 14 thoracic transplants in 13 recipients using organs from COVID-19 positive donors. None of the recipients or healthcare members acquired COVID-19. No recipients suffered unexpected acute rejection. Patient survival is 92% to date, with graft survival 93%. The use of hearts from COVID-19 positive donors may be safe and effective. Transplantation of lungs is unresolved but may be cautiously pursued under the restricted circumstances. [ABSTRACT FROM AUTHOR]

Six hours was historically regarded as the limit of acceptable ischemic time for lung allografts. However, broader sharing of donor lungs often necessitates use of allografts with ischemic time >6 hours. We characterized the association between ischemic time ≥8 hours and outcomes after lung transplantation using a contemporary cohort from a high-volume institution. Patients who underwent primary isolated bilateral lung transplantation between 1/2016 and 5/2020 were included. Patients bridged to transplant with extracorporeal membrane oxygenation or mechanical ventilation, and ex-vivo perfusion cases were excluded. Recipients were stratified by total allograft ischemic time <8 hours (standard) vs ≥8 hours (long). Perioperative outcomes and post-transplant survival were compared between groups. Of 358 patients, 95 (26.5%) received long ischemic time (≥8 hours) lungs. Long ischemic time recipients were more likely to be male and have donation after circulatory death donors than standard ischemic time recipients. On unadjusted analysis, long and standard ischemic time recipients had similar survival, and similar rates of grade 3 primary graft dysfunction at 72 hours, extracorporeal membrane oxygenation post-transplant, acute rejection within 30 days, reintubation, and post-transplant length of stay. After adjustment, long and standard ischemic time recipients had comparable risks of mortality or graft failure. In a modern cohort, use of lung allografts with "long" ischemic time ≥8 hours were associated with acceptable perioperative outcomes and post-transplant survival. Further investigation is required to better understand how broader use impacts post-lung transplant outcomes and the implications for smarter sharing under an evolving national allocation policy. [ABSTRACT FROM AUTHOR]

The optimal transplant strategy for patients with end-stage lung disease complicated by secondary pulmonary hypertension (PH) is controversial. The aim of this study is to define the role of single lung transplantation in this population. We performed a retrospective study of lung transplant recipients using the Organ Procurement and Transplantation Network/United Network for Organ Sharing Standard Transplant Analysis and Research registry. Adult recipients that underwent isolated lung transplantation between May 2005 and June 2015 for end-stage lung disease because of obstructive or restrictive etiologies were identified. Patients were stratified by mean pulmonary artery pressure ([mPAP] ≥ or < 40 mm Hg) and by treatment—single (SOLT) or bilateral (BOLT) orthotopic lung transplantation. The primary outcome measure was overall survival (OS), which was estimated using the Kaplan-Meier method and compared by the log-rank test. To adjust for donor and recipient confounders, Cox proportional hazards models were developed to estimate the adjusted hazard ratio of mortality associated with elevated mPAP in SOLT and BOLT recipients. A total of 12,392 recipients met inclusion criteria. Of recipients undergoing SOLT, those with mPAP ≥40 were shown to have lower survival, with 5-year OS of 43.9% (95% confidence interval 36.6–52.7; p = 0.007). Of recipients undergoing BOLT, OS was superior to SOLT, and no difference in 5-year OS between mPAP ≥ and <40 was observed (p = 0.15). In the adjusted analysis, mPAP ≥40 mm Hg was found to be an independent predictor for mortality in SOLT, but not BOLT recipients. This finding remained true on multivariable analysis. In patients undergoing SOLT, mPAP ≥40 was associated with an adjusted hazard ratio for mortality of 1.31 (1.08–1.59, p = 0.07). In BOLT, mPAP was not associated with increased hazard (adjusted hazard ratio 1.04, p = 0.48). There is a reduced survival when a patient with severe secondary PH undergoes SOLT. This increased mortality hazard is not seen in BOLT. It appears that a BOLT may negate the adverse effect that severe PH has on OS, and may be superior to SOLT in patients with mPAP over 40 mm Hg. [ABSTRACT FROM AUTHOR]

BACKGROUND Donors with characteristics that may increase the likelihood of disease transmission with transplantation are noted as increased risk via Public Health Service criteria. This study aimed to establish the implications of declining an increased-risk donor (IRD) organ offer in lung transplantation. METHODS Adult candidates waitlisted for isolated lung transplantation in the United States using the Organ Procurement and Transplantation Network /United Network of Organ Sharing registry from 2007 to 2017 were identified. Individual match run files identified candidate recipients who matched to an IRD offer. Competing-risks analysis ascertained the likelihood of survival to transplantation. A stratified Cox model and restricted mean survival times estimated the survival benefit associated with the acceptance of an IRD organ. RESULTS A total of 6,963 candidates met inclusion criteria, and 1,473 (21.2%) accepted an IRD offer. Candidates who accepted an IRD offer were older, more likely to be male, and had a higher lung allocation score at the time of listing (all p < 0.05). At 1 year after an IRD offer decline, 70.5% of candidates underwent a lung transplant, 13.8% died or decompensated, and 14.9% were still awaiting transplant. Compared with those who declined, candidates who accepted the IRD offer had significantly improved cumulative mortality at 1 year (14.1% vs 23.9%, p < 0.001) and 5 years (48.4% vs 53.8%, p < 0.001). CONCLUSIONS IRD organ declination is associated with a decreased rate of lung transplantation and worse survival. Overall post-transplant survival rates for those who survive to transplantation are equivalent. [ABSTRACT FROM AUTHOR]

BACKGROUND Blood type O lung allografts may be allocated to blood type identical (type O) or compatible (non-O) candidates. We tested the hypothesis that the current organ allocation schema in the United States—based on the Lung Allocation Score—prejudices against the allocation of allografts to type O candidates, given that the pool of potential donors is smaller. METHODS We performed a retrospective cohort review of the Organ Procurement and Transplantation Network/United Network of Organ Sharing registry from May 2005 to March 2017 for adult candidates on the waiting list for first-time isolated lung transplantation. Demographic data were compiled and described, and 1:1 nearest-neighbor propensity score matching was used to adjust for age and Lung Allocation Score at listing. RESULTS A total of 26,396 candidates met inclusion criteria: 14,329 type non-O and candidates and 12,068 type O candidates. After matching, 11,951 candidates were included in each group. Of these, 77.0% of type non-O underwent lung transplantation vs 73.1% type O (p < 0.001). At 1 year, the waiting list mortality was higher for type O candidates (12.5%) than for non-O candidates (10.1%, p < 0.001). Of those undergoing transplantation, 5-year survival rates were similar. CONCLUSIONS Type O candidates experience lower rates of transplantation and higher rates of waiting list mortality compared with matched type non-O candidates. Further evaluation of regional sharing of allografts to increase transplantation rates for type O candidates may be warranted to optimize equity in access to transplants. [ABSTRACT FROM AUTHOR]