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BACKGROUND Postoperative bronchial anastomotic complications are not uncommon in lung transplant recipients. We investigated 2 surgical techniques (continuous and interrupted sutures) during bronchial anastomosis, comparing survival and postoperative bronchial complications. METHODS We retrospectively analyzed 421 patients who were transplanted in our center (February 2012 to March 2018). Patients were divided according to bronchial anastomotic technique (continuous or interrupted). Demographics and clinical parameters were compared for significance (P < .05). Comparison of postoperative morbidity included bronchial complications, venovenous extracorporeal membrane oxygenation support, and intervention requirements. Survival was assessed using Kaplan-Meier curve and log-rank tests (P < .05). RESULTS Of the 421 patients, 290 underwent bronchial anastomoses with continuous suture; 44 of these patients had postoperative bronchial complications (15.2%). Contrarily, 131 patients underwent the interrupted suture technique; 9 patients in this group had postoperative bronchial complications (6.9%). Demographics and clinical parameters included age, sex, ethnicity, etiology, lung allocation score, body mass index, donor age, lung transplant type, cardiopulmonary bypass usage, surgical approaches, and median length of stay. Postoperative complications (continuous vs interrupted) were bronchial complications (P = .017), venovenous extracorporeal membrane oxygenation support (P = .41), venoarterial extracorporeal membrane oxygenation support (P = .38), and complications requiring dilatation with stent placement (P = .09). Kaplan-Meier curve showed better survival in the interrupted group (P = .0002). CONCLUSIONS Our study demonstrated the comparable postoperative results between the continuous and interrupted technique.

Background Coronary artery disease is common in lung transplant patients and has historically been viewed as a contraindication to the procedure. Although this mindset is changing, the effect of prior or perioperative revascularization on lung transplant survival outcomes is not adequately established. Methods We performed a single-center retrospective analysis of all single and double lung transplant patients from 2012 to 2018 (n = 468). Patients were split into 4 groups: (1) patients who received a preoperative percutaneous coronary intervention (n = 34), (2) those who received coronary artery bypass grafting (CABG) before transplantation (n = 25), (3) those that received concomitant CABG during transplantation (n = 29), and (4) those who had lung transplantation with no need for revascularization (n = 380). Groups were compared for demographics, surgical procedure, and survival outcomes. Results The no-revascularization group was statistically younger than the rest (P = .001). The lung allocation score trended toward being higher in the concomitant coronary artery bypass group (P = .03). All groups were predominantly diagnosed with idiopathic pulmonary fibrosis. The proportion of patients with chronic obstructive pulmonary disease was greatest in the group not requiring revascularization (P = .001). Patients with previous CABG were more likely to receive a single lung transplant than a double one (21 versus 4; P = .054). Length of stay, posttransplant survival, and postoperative adverse events were similar among all groups. Conclusions Results suggest that preoperative or intraoperative revascularization does not negatively affect survival in lung transplant patients; lung recipients with coronary artery disease have comparable survival when adequately revascularized.

Background Multidetector computed tomography is vital in preoperative sizing for transcatheter aortic valve replacement. The purpose of this study is to determine whether preoperative transcatheter aortic valve replacement multidetector computed tomography accurately predicts surgical aortic valve prosthesis size. Methods Between July 2012 and July 2017, 102 patients who underwent surgical aortic valve replacement had preoperative aortic valve sizing by multidetector computed tomography. The aortic annulus diameter calculated using multidetector computed tomography was compared with intraoperative valve sizing during surgical aortic valve replacement. Results Forty-one (40.2%) of the 102 patients studied had multidetector computed tomography aortic valve measurements that were accurate. Implanted valves were smaller than multidetector computed tomography calculation in 40 patients (39.2%) and were larger in 21 patients (20.6%). Multidetector computed tomography measurements remained inconsistent with intraoperative sizing regardless of aortic annulus diameter. The variance between multidetector computed tomography annulus measurements and intraoperative sizing was statistically significant. Conclusions Preoperative aortic annulus measurements by our institutional transcatheter aortic valve replacement multidetector computed tomography protocol differed substantially from surgical implant size. There was no trend toward over nor under sizing for the entire cohort. However, patients with large measured annulus diameter were more likely to have a smaller valve implanted than predicted, and patients with small measured annulus diameter were more likely to have a larger valve implanted than predicted. These results may affect preoperative planning for patients undergoing aortic valve replacement.

A 36-year-old woman with cannabinoid hyperemesis syndrome presented with chest pain and was found to have single-vessel coronary artery disease and an aortic mural thrombus. This case describes unique management with coronary artery bypass and surgical thrombectomy because of the patient’s inability to tolerate uninterrupted antiplatelet therapy given her cannabinoid hyperemesis syndrome. (Level of Difficulty: Intermediate.), Central Illustration

Purpose Whereas double lung transplantation (LTx) is a preferred surgical option for the patients with secondary pulmonary arterial hypertension (SPH: defined as a mean pulmonary artery pressure (mPAP) above 25 mmHg), our institutional experiences have demonstrated the unique values of single LTx for SPH. Here, we review our experiences prioritizing single LTx for SPH in an attempt to optimize their opportunities and decrease mortality while waiting. Methods A retrospective review of the LTx database was used to identify patients who underwent single LTx. SPH patients were stratified into mild SPH (mPAP: 25-40 mmHg) and severe SPH (mPAP > 40 mmHg). Recipients without PH transplanted over the same time period were used as controls. Data are reported as severe SPH vs. mild SPH vs. controls. Results Three hundred eighteen patients received single LTx between January 2017 and December 2019. There were 217 patients with mild SPH (mPAP of 32 mmHg), 59 patients with severe SPH (mPAP of 46 mmHg) and 42 patients without PH (controls). There were no significant differences among the groups in their patients’ characteristics except higher pulmonary vascular resistance noted in severe SPH group and morbid obesity noted in mild and severe SPH groups. While severe SPH group required more intraoperative cardiopulmonary support (37.3% vs. 11.1% vs. 5.0%, p Conclusion Our experience supports the option of single LTx for the patients with even severe SPH by utilizing appropriate mechanical circulatory support intraoperatively. In light of the ongoing donor lung shortage, this strategy should be considered for optimizing organ utilization and decreasing waitlist mortality.

Purpose There is a hesitancy to use older donor lungs in lung transplants, and to perform them in older patients. To invalidate the use of donor and recipient age as relative contraindications for lung transplantation, we examined both, and factored in transplant type, then analyzed their effects on survival outcomes using propensity matching. Methods Patients were stratified by recipient age ( Results Using 743 lung transplant patients at our single center over 8 years (Feb-2012 to Mar-2020) in the pre-propensity match, there was a significant difference in survival outcomes for the group: ≥50 donor age ≥70 recipient age group in survival when looking at single vs. double lung transplant (p = 0.038). There were no other statistically significant differences in survival based on donor and recipient age, or transplant type. Post-propensity matching, there was no difference in survival based on the interplay between donor and recipient age, for donor group ≥50 (p = 0.092), for donor group Conclusion While donor and recipient age are undoubtedly important factors to consider during lung transplantation, neither of these independently affects long-term survival. Upon matching, there was no differences in survival for lung transplant patients based on transplant type. Older lungs and older patients can result in reasonable post-transplant outcomes.

Purpose Currently the continuous suturing technique is used on the bronchial anastomosis during lung transplantation. This study investigated that technique vs. the interrupted suturing technique, comparing survival and occurrence of post-operative bronchial complications to examine if a switch in technique is merited. Methods Survival outcomes of 721 single-center lung transplant recipients over 8 years (Feb-2012 to Mar-2020) were compared. Continuous suturing technique was performed with 3/0 polypropylene suture on an SH needle. Interrupted used the same technique for the membranous portion of the anastomosis and multiple interrupted 2/0 polypropylene sutures for the cartilaginous portion. Clinical parameters and demographics were compared. The two groups were compared for post-operative morbidity and survival was compared using Kaplan-Meier curves. Log-rank tests were performed, as was Cox regression analysis, with p Results Of the 721 patients, 429 received the continuous suturing technique while 292 had interrupted suturing technique. Demographics and clinical parameters compared were: age (p=0.008), gender (p=0.643), race (p=0.268), etiology (p Conclusion Although both techniques showed reasonable post-transplant outcomes, our study indicated better survival and relatively fewer complications when using interrupted suturing technique vs continuous. Further long-term study of similar groups with similar long-term follow up in these two groups should be performed to validate this effect.

Background Systemic inflammation after prolonged cardiopulmonary bypass (CPB) can cause serious multiorgan system dysfunction. Mesenchymal stem cells (MSCs) are reported to reduce inflammation and attenuate immune response. We have focused on fetal membrane (FM) as a source to provide a large number of MSCs (FM-MSCs). Allogeneic administration of FM-MSCs has been reported to mitigate autoimmune myocarditis or glomerulonephritis. The aim of this study was to investigate whether allogeneic FM-MSCs attenuate systemic inflammatory responses and lung injury in a rat CPB model. Methods Male Lewis rats (major histocompatibility complex haplotype: RT-1l) were divided randomly into 3 groups (n = 7 each): cannulation alone (sham group), CPB alone (control group), and CPB + MSC (MSC group). An experimental rat CPB model was established, and CPB was maintained for 30 minutes. In the MSC group, MSCs (1 × 10 6 cells) derived from the FM of ACI rats with a different major histocompatibility complex haplotype (RT-1a) were administrated intravenously before CPB initiation. Results Serum concentrations of tumor necrosis factor-α, interleukin-6, and interleukin-1β in the MSC group were significantly lower compared with the control group after CPB. Similarly, mRNA expression of proinflammatory cytokines in the lung was lower in the MSC group. Allogeneic administration of FM-MSCs remarkably decreased the lung injury score, protected alveolar structure, inhibited neutrophil infiltration to the lung interstitium, and stimulated cytoprotective cytokine production in the lung. Conclusions Allogeneic transplantation of FM-MSCs may be a potent strategy to prevent CPB-induced systemic inflammation and acute lung injury by suppressing the expression of inflammatory cytokines and promoting protective factors in the lung.

Purpose Lung transplant (LTx) candidates may have both high and low body-mass index (BMI). We investigated the effects of BMI in lung transplantation outcome and survival. Methods Patients from our center (Feb-2012 to Jul-2019) were divided into 5 BMI groups: Results Out of 609 LTx recipients, etiology was 63.1% IPF, 24.3% COPD, and 12.6% others. Furthermore, 28.2% of patients were either underweight or normal weight, 36.9% were overweight, and 34.7% were obese as measured by BMI. Demographically, the patient population was 66% male, mean age 64±9, race 78% white 15% black, and 7% others, median LOS (17 days) and mean LAS 49±19. Kaplan-Meier graph (figure 1) showed no significant differences in 1,3,5 year survival among all the BMI groups (p=0.57). There were also no significant differences among all the groups with regard to LOS (p=0.91) and LAS (p=0.42). Conclusion Despite larger numbers of overweight patients, there was no evidence of negative effect in survival outcome after LTx. Additionally, LOS and LAS did not have any effect in survival among five groups of BMI. This outcome suggests lung transplantation could be expanded to a wider variety of BMI patients.

Purpose Heart transplantation (HTx) is routine in many eligible patients of different ages including elderly. We investigated the 5 year to 10 year survival outcomes of elderly heart transplantation patients by analyzing the UNOS database. Methods 51,899 patients underwent heart transplantation that were reviewed from the UNOS database (1987-2014). HTx patients were divided into two different age groups based on recipient age, Results Out of 51,899 HTx patients, 51,165 were Conclusion Older heart transplant recipients started to showed gradually increasing statistical separation from the 8th year post-HTx, favoring the younger cohort. However, survival of elderly patients (≥70) to estimated 10 years survival is still a fair probability.

Purpose Coronary artery disease (CAD) has been considered a relative contraindication for concomitant cardiac surgery during lung transplantation. We investigated a cohort of older patients who underwent concomitant coronary artery bypass grafting (CABG) with lung transplantation, to determine whether surgical outcomes were acceptable. Methods Lung transplant procedures with concomitant CABG between March 2012 and July 2019 were retrospectively analyzed. The patients investigated were over 70 years of age.Patients were propensity score-matched by pre-transplantation variables. Outcomes between these two groups were then compared; once using the entire cohort, and once using the propensity score-matched patients. Survival was compared by Kaplan-Meier curve and log-rank tests. Results There were 7 patients aged 70 or older that underwent concomitant CABG with lung transplantation. These 7 patients were 1:3 propensity score-matched with 21 of the 166 patients that did not undergo concomitant CABG. There was no statistically significant difference in survival outcomes between patients over 70 that underwent concomitant CABG and patients over 70 that did not undergo concomitant CABG (p=0.77). When analyzing the two groups after propensity score matching, there was still no statistically significant difference in survival outcomes (p=0.73). Overall survival for patients over 70 that underwent concomitant CABG was 100% at 90 days, 86% at 1 year, and 72% at 3 years. Overall survival for patients over 70 that did not undergo concomitant CABG was 93% at 90 days, 85% at 1 year, and 66% at 3 years. Conclusion Patients over 70 that underwent concomitant CABG with lung transplantation showed no significant difference in survival outcomes when compared to patients over 70 that did not undergo concomitant CABG. Considering this data, patients over 70 with CAD would be reasonable candidates for concomitant CABG with lung transplantation in selected cases.

Purpose It remains unclear whether double lung transplantation (DLT) or single lung transplantation (SLT) is preferred for end-stage chronic obstructive pulmonary disease (COPD) patients. The purpose of this study is to examine the interplay between patient age and pulmonary artery pressure on survival after SLT vs DLT for COPD. Methods We performed a single-center retrospective study of lung transplantations for COPD between February 2012 to March 2020 (n=186). Demographics and clinical parameters were compared between patients based on their pulmonary artery pressure (PAP; PAP 65 years old) and PAP were analyzed using Kaplan-Meier curves and log-rank tests. Cox proportional-hazards regression was also performed. P-value less 0.05 was considered significant. Results Of the 186 COPD patients who received lung transplants, 71 (38.2%) received double-lung transplants and 115 (61.8%) received single-lung transplants. Demographics and clinical parameters between the two PAP groups showed significance in: lung allocation score (p=0.002) and BMI at time of transplant (p 65 years (p=0.723). The Cox model itself, also, did not show a statistically significant improvement in evaluating survival outcomes (p=0.126). Conclusion Lung transplantation outcomes in end-stage COPD patients demonstrated non-inferior results with SLT compared to DLT. When patients were differentiated based on PA pressure, adopting SLT or DLT did not show any survival differences.

Purpose Coronary artery disease (CAD) is not uncommon among lung transplant (LTx) and has been often carefully evaluated before LTx. Those who undergo these pre- and or post-lung transplantation percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG) procedures may be at risk to LTx short-term mortality. The survival outcome of prior or perioperative revascularization has not been adequately established. Methods A single-center retrospective analysis of all single and double LTx patients from Feb-2012 to Mar-2020 (n=748) was performed. Patients were split into 4 groups: (1) patients who received a preoperative PCI (Pre-PCI) (n=55), (2) those who received preoperative CABG (Pre-CABG) (n=38), (3) those who received concomitant CABG during LTx (Con-CABG) (n=47), (4) those who had LTx with no need for revascularization (n=607). Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. P-value Results The no revascularization group was statistically younger than the rest (P Conclusion Our results suggest that preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Selected patients with coronary artery disease may benefit when intervened during lung transplant procedure.

Acute kidney injury (AKI) is a common complication accompanying cardiopulmonary bypass (CPB) and is independently associated with increased morbidity and death. Diabetes mellitus increases the risk for AKI after CPB. Epigallocatechin-3-gallate (EGCG) is a major component of the polyphenolic fraction of green tea, which possesses cardioprotective activities, as previously reported. We hypothesized that EGCG also possesses a renoprotective effect through its diverse biochemical properties and assessed the effect on renal function after CPB for diabetic rats.Goto-Kakizaki rats developing type 2 diabetes mellitus were randomly assigned to one of the following groups: sham (n = 10), CPB (CPB alone, n = 9), or EGCG (CPB + EGCG, n = 10). CPB was conducted for 30 minutes at a flow rate of 100 mL/kg/min in the CPB and EGCG groups. Rats assigned to the EGCG group were administrated EGCG solution orally for 2 weeks before CPB. We evaluated renal biochemical or histologic changes at 24 hours after CPB.Compared with the CPB group, the EGCG group exhibited milder tubular injury histologically (p0.0001) and reduced expression of kidney injury molecule-1, a biomarker for renal tubular injury (p0.0001) and 8-hydroxy-2'-deoxyguanosine (p0.01), indicating attenuated oxidant stress.Preoperative oral administration of EGCG ameliorates AKI in a CPB model of diabetic rats through antioxidative properties. This simple method could be applied in a clinical setting as a prophylactic renal protection against AKI after CPB, especially for high-risk patients with diabetes mellitus.

Antibody-mediated rejection (AMR) of cardiac allografts mediated by anti-HLA Donor Specific Antibodies (DSA) is one of the major barriers to successful transplantation for the treatment of end-stage heart failure. Therapeutic plasma exchange (TPE) is a first-line treatment for pre-transplant desensitization. However, indications for treatment regimens and treatment end-points have not been well established. In this study, we investigated how sera dilutions could guide TPE regimens for effective peri-operative desensitization and early AMR treatment. Our data show that 1:16 dilutions of EDTA-treated sera and 1.5 volume TPE reduce anti-HLA class I and class II antibody levels in the same manner and, therefore, allows to predict which antibodies would respond to peri-operative TPE. We successfully applied this approach to transplanting three highly sensitized cardiac recipients (CPRA 85-93%) with peri-operative desensitization based on a virtual crossmatch performed on 1:16 diluted serum. Furthermore, we have used sera dilutions to guide DSA treatment post-transplant. Although these findings have to be confirmed in a larger prospective study, our data suggest that serum dilutions can serve as a predictive biomarker to guide peri-operative desensitization and post-transplant immunologic management.

Purpose The method of cardiorespiratory support used during lung transplantation (LTx) has been debated. This study serves to compare survival after LTx in patients who received support from either extracorporeal membrane oxygenation (ECMO) or cardiopulmonary bypass (CPB). Methods We studied 565 LTx performed at a single institution between March 2012 and June 2019. Concomitant cardiac procedures were excluded. 118 underwent CPB, 49 underwent ECMO, and 398 were considered “off-pump”, as they received neither support. Comparisons between groups were performed using Chi-squared or ANOVA test. All significant variables from univariate analysis were included in a Cox regression analysis. Survival was assessed by Kaplan-Meier curve and compared by log rank test. P-values Results There was marginal survival difference (p =0.057) between the CPB, ECMO, and “off-pump” groups when analyzed together. When compared to the “off-pump” group in a Cox regression analysis, CPB (RR. 1.52, 95% CI: 0.99-2.31, p=0.054) and ECMO (RR. 1.71, 95% CI: 0.96-3.04, p=0.070) had borderline significant negative impact on survival. When compared amongst the three support groups, analysis of variances and Chi-squared tests showed no differences in recipient sex (p=0.089), race (p=0.42), donor age (p=0.69), donor type (brain death or donation after cardiac death) (p=0.59) and induction (p=0.38). The “off-pump” group was significantly older (p Conclusion This study demonstrates the borderline significance of CPB and ECMO impact on survival and warrants further exploration into the question of proper cardiorespiratory support in LTx.

Purpose Coronary artery disease (CAD) has been considered a relative contraindication for concomitant cardiac surgery during lung transplantation. We investigated a cohort of younger patients who underwent concomitant coronary artery bypass grafting (CABG) with lung transplantation, to determine whether surgical outcomes were acceptable. Methods Lung transplant procedures with concomitant CABG between March 2012 and July 2019 were retrospectively analyzed. The patients investigated were below 70 years of age.Patients were propensity score-matched by pre-transplantation variables. Outcomes between these two groups were then compared; once using the entire cohort, and once using the propensity score-matched patients. Survival was compared by Kaplan-Meier curve and log-rank tests. Results There were 26 patients below 70 years old that underwent concomitant CABG with lung transplantation. 25 of the 26 patients that underwent concomitant CABG were 1:1 propensity score-matched with 25 of the 410 patients that did not undergo concomitant CABG. There was no statistically significant difference in survival outcomes between patients less than 70 that underwent concomitant CABG and patients less than 70 that did not undergo concomitant CABG (p=0.24). When analyzing the two groups after propensity score matching, there was still no statistically significant difference in survival outcomes (p=0.51).Overall survival for patients less than 70 that underwent concomitant CABG was 100% at 1 year, and 72% at 3 years. Survival for patients that did not undergo concomitant CABG was 87% at 1 year, and 72% at 3 years. Conclusion Patients below 70 that underwent concomitant CABG with lung transplantation showed no significant difference in survival outcomes when compared to patients less than 70 that did not undergo concomitant CABG. Considering this data, patients less than 70 with CAD would be reasonable candidates for concomitant CABG with lung transplantation in selected cases.

Purpose The number of elderly patients requiring a lung transplantation (LTx) continues to grow. However, there are concerns that the age distribution of LTx recipients may be unbalanced, at a detriment to elderly patients. In order to assess the relationship between LTx and recipient age, we investigated the survival outcomes of elderly primary single and double LTx patients through analysis of the UNOS database. Methods We analyzed the UNOS database (1987-2014), investigating single and double LTx recipients based on three separate age groups (≤69, 70-74, and ≥75 years old). Using variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO, inhaled NO usage, blood group, and procedure type, the three groups were compared for any significance (p=0.05). Survival outcomes were compared between the groups (STATA Inc.) and data were presented as mean±standard deviation. Results During 1987 to 2014, 27,980 patients received LTx (n= 16,015 double LTx, and n=11,888 single LTx). Out of total LTx patients, 27,076 patients were ≤69, 729 patients were 70-74, and 98 patients were ≥75 years old. Demographic data showed 54% male, 86% white, 7% black, 5% Latino, and 2% other. Recipient mean age was 55±15 years, with BMI- 24±4 kg/m2, median LOS was 15 days, and blood groups: O-45%, A-40%, B-11%, AB-4%. UNOS showed lower data on ECMO-1% and inhaled NO-0.21% usage. Log-rank test for equality of survival demonstrated significance based on age for patients who received single and double LTx (p Conclusion Survival outcome of single LTx patients did not show any significant statistical difference when performed in elderly patients above 70 years of age. When double LTx were performed, younger patients below 69 years of age seemed to do better in survival compared to elderly patients above 70 years of age. The beneficial survival outcome for single LTx patients extends to an older age than double LTx patients.

Purpose There are controversies regarding which side of the lungs, under-perfused versus over-perfused to be replaced when performing single lung transplantation (LTx). Theoretically, under-perfused lung appears to be better replaced rather than over-perfused lung; however, occasionally over-perfused lung is chosen due to limited organ availability, size discrepancy between the sides, or anatomical complexity, and this is recognized as ‘side-mismatching’ in single LTx. This study aims at evaluating the impact of side-mismatching on transplant outcomes. Methods Graft side-mismatching was defined with a prospectively designed formula using baseline quantitative lung perfusion scan data, and the patients who underwent single LTx between January 2016 and June 2018 were stratified as either side-matched or side-mismatched. A retrospective review of the LTx database was used to obtain short- and mid-term outcomes as well as complications for those patients. Results Two hundred eighteen patients received single LTx between January 2016 and June 2018. Out of these, there were a total of 18 patients had a side-mismatched graft while those with a side-matched graft over the same time period were used as controls. There were no significant differences between the groups in their patients’ characteristics except more patients with age above 70 years old and less patients with secondary pulmonary hypertension noted in the side-mismatched group. While the size-mismatched group consisted of more patients who underwent right single than left single LTx and required more intraoperative cardiopulmonary support (25% vs. 8.2%, p Conclusion Our data suggest that there is no evident increased risk or compromised post-transplant outcomes in performing side-mismatched single LTx when appropriate lung graft as well as intraoperative cardiopulmonary support is chosen. This strategy could optimize organ utilization increasing effective organ supply and decreasing waitlist mortality. In addition, this may contribute to avoiding the surgical or anatomical complexity leading to improved transplant outcomes.

In Japan, transcatheter aortic valve implantation (TAVI) with Edwards-SAPIEN XT valve (Edwards Lifesciences Inc., Irvine, CA, USA) started in October 2013. All institutions should undergo a training period to perform TAVI independently. Balloon aortic valvuloplasty (BAV) as a bridge to TAVI during the training period should be performed with caution to avoid severe aortic regurgitation (AR) because bailout TAVI is not possible. We present a case in which BAV was successfully performed as a bridge to TAVI during the training period. The patient was an 85-year-old man with medically uncontrollable congestive heart failure due to severe aortic valve stenosis. The aortic valve area was 0.60cm2 with a left ventricular ejection fraction of 20%. TAVI was considered a safe but high-risk strategy owing to the unstable hemodynamic condition. We chose BAV as a bridge therapy to TAVI. The aortic annulus diameter was 25.3mm on computed tomography scans. We chose a 20-mm balloon catheter to avoid BAV-induced AR. Transfemoral TAVI was performed successfully 16 days after BAV using a 26-mm SAPIEN XT valve. The postoperative course was uneventful. The case demonstrated BAV as a bridge therapy to TAVI can be safely and effectively performed during the training period.

Adult recipients frequently withdraw from living-donor lobar lung transplantation because of the small size of donor grafts. The right lower lobe is 120% larger than the left lower lobe. We developed a novel surgical technique in which an inverted right lower lobe graft can be transplanted into the left thorax. The first patient was a 43-year-old woman with end-stage idiopathic interstitial pneumonia. Her husband was the only eligible donor for living-donor lobar lung transplantation. His right lower lobe was estimated to provide 45% of the recipient's predicted forced vital capacity, which would provide the borderline function required for living-donor lobar lung transplantation. Since lung perfusion scintigraphy of the recipient showed a right-to-left ratio of 64:36, transplanting the right lower lobe graft into the left thorax and sparing the native right lung was considered the only treatment option. We simulated this procedure using three-dimensional models produced by a three-dimensional printer. In living-donor lobar lung transplantation, all anastomoses were performed smoothly as planned preoperatively. Because of the initial success, this procedure was performed successfully in two additional patients. This procedure enables larger grafts to be transplanted, potentially solving critical size matching problems in living-donor lobar lung transplantation.

Purpose The numbers of lung transplantation (LTx) recipients are gradually increasing worldwide. That leads to the subsequent question whether offering a redo-LTx is a viable option in some of those patients, especially the older patients, who were once transplanted. We investigated the survival outcome of single or double redo-LTx in both younger and elderly recipients analyzing the UNOS database. Methods Patients receiving single or double redo-LTx (n=1092; UNOS data from 1987-2014) were divided into three different groups based on recipient age - ≤69, 70-74, and ≥75 years old. Survival outcome was compared among the three groups using Kaplan-Meier Curve. Variables such as age, gender, ethnicity, BMI, length of stay (LOS), ECMO and inhaled NO usage, blood groups and types of procedures were compared for significance (p Results 498 had single and 594 had lung redo-LTx. 1069 patients were ≤69, 20 patients were 70-74, and 3 patients were over ≥75 years old. Demographic data showed 52% male, 87% white, 6% black, 5% Latino, and 2% others. Patients had BMI- 24 ± 5 kg/m2, median LOS 15 days, and blood groups: O-46%, A-40%, B-10%, AB-4%. Although UNOS data showed ECMO-4% and inhaled NO-1.3% usage, many data were missing from UNOS database for ECMO and inhaled NO. Log-rank test for equality of survival between the three groups showed no difference in survival for single redo-LTx (p=0.89), but demonstrated significance between the age cohorts for double redo-LTx (p=0.004). There was no significant difference in individuals receiving single redo-LTx based on age: ≤69 vs. 70-74 years old (p=0.63), ≤69 vs. ≥ 75 years old (p=0.94), 70-74 vs. ≥75 years old (p=0.91). Conclusion Single lung redo-LTx had no survival difference in different age groups compared to double lung redo-LTx. Older patients had more single lung redo-LTx than younger patients. Single lung redo-LTx data whether contralateral side or the same side lung redo-LTx was performed, were missing in UNOS database.

Purpose Since we recently yielded and presented our results for concomitant lung transplantation (LTx) and coronary artery bypass grafting (CABG) (LTx/CABG) that showed a 100% 1-year survival, more patients with severe coronary artery disease (CAD) have been referred to us, which has driven us to establish our institution's decision-making algorithm for those with concurrent severe CAD in LTx. Methods Between September 2017 and September 2018, we prospectively evaluated 31 consecutive patients with concurrent severe CAD referred for LTx at our center. Severe CAD is defined as the one with at least one of the main coronary artery branches being angiographically significant (>70% stenosis) or when clinical or physiologic criteria are met. An experienced interventional cardiologist and two cardiac surgeons jointly reviewed the CAD severity of all these patients prior to listing and decided their treatment options following the algorithm below. Patients with clinically significant CAD and unstable clinical trajectories were listed for LTx/CABG (Figure). Results Following joint review, revascularization was deemed unnecessary in 5 patients (16%) who eventually underwent LTx alone. Two patients were scheduled for LTx/CABG but underwent LTx alone based on intraoperative judgement. Nine patients (30%) underwent concomitant LTx/CABG. Six were single and three were double LTx. One case was with ECMO bridged to LTx/CABG. All patients with severe CAD who proceeded to transplant were discharged and clinically stable at the end of the study period. Conclusion While multimorbidity in the elderly now constitutes the greatest present medical burden even in LTx, a well-designed selection algorithm contributes to their optimal treatment options leading to improved outcomes following LTx for those with severe CAD.

An 80-year-old male underwent a transcatheter aortic valve implantation (TAVI) for severe senile aortic stenosis. Six weeks after the surgery, he was readmitted to our institution because of a high-grade fever. Transesophageal echocardiography revealed thickening of all three leaflets of the aortic prosthesis and mobile mass on the leaflet, and Streptococcus sanguis was identified from his blood culture. Therefore, he was diagnosed with prosthetic valve endocarditis (PVE) and received intensive intravenous antibiotic therapy. Because he did not respond to the pharmacological therapy, surgical aortic valve replacement (AVR) was indicated although it was considered a relatively high-risk procedure. Herein, we report on the successful surgical AVR in this patient using a pericardial valve after removal of the infected prosthetic valve, and discuss some issues related to this rare complication after TAVI.

Primary mediastinal leiomyosarcoma is an extremely rare malignancy, and the only opportunity for a cure lies with an aggressive surgical approach. We report a 66-year-old woman who underwent complete resection of a giant mediastinal leiomyosarcoma located on the bilateral diaphragm. The tumor encased the inferior vena cava and compressed the adjacent structures. Using cardiopulmonary bypass with 20 minutes of hepatic ischemia, the tumor was completely resected with combined resection and reconstruction of the surrounding structures. Because of the tumor size and location in the boundary area between thoracic and abdominal surgeries, the procedure necessitated the cooperation of many expert surgeons.

We present two cases of aortic valve replacement (AVR) in patients with protruding coronary artery stents from the coronary ostia. In the first case, an 87-year-old female was referred for AVR due to severe aortic stenosis (AS). During the operation, we found stents protruding from the left and the right coronary ostia into the aortic root. We performed AVR with a mechanical valve and coronary artery bypass grafting with the saphenous vein to the left anterior descending artery. In the second case, a 77-year-old female was referred for AVR due to severe AS with a history of healed infective endocarditis. During surgery on the second patient, we found a stent protruding 7mm from the left coronary ostium into the aortic root. The edge of the stent was trimmed, and AVR with a mechanical valve was performed. In both patients, we decided to use a mechanical prosthesis instead of a bioprosthesis because of the risk of leaflet injury. Herein, we discuss some issues regarding patients with AS requiring AVR with prior history of coronary stenting in the coronary ostia. Learning objective: To explore the problem of coronary stents protruding into the ostia in cases of percutaneous coronary intervention of left main or right proximal lesions, which can compromise subsequent aortic valve procedures including surgical aortic valve replacement or even transcatheter aortic valve replacement thereafter.>

SummaryBackground and purposeThere have been no large-scale studies on the impact of diabetes mellitus (DM) on outcomes in Japanese patients undergoing coronary artery bypass grafting (CABG).Methods and subjectsA multi-institutional retrospective cohort study was conducted in 14 Japanese centers. All adult patients who underwent isolated CABG from 2007 to 2008 were included (n=1522, mean age: 68.5years). The definitions of DM were all patients admitted with diagnosis of DM and preoperative glycated hemoglobin (Hb) A1c≥6.5%. Univariate and multivariate analyses were performed to identify the risk of morbidity and mortality.ResultsThere were 849 DM and 572 non-DM patients. Preoperative mean HbA1c were 7.1% in the DM group and 5.7% in the non-DM group (p

Liver cirrhosis is a major risk factor for cardiac surgery using cardiopulmonary bypass. However, percutaneous coronary intervention (PCI) or off-pump coronary artery bypass graft surgery (OPCABG) may be a less invasive alternative strategy.Among the 9,877 patients undergoing first PCI or CABG enrolled in the CREDO-Kyoto Registry (a registry of first-time PCI and CABG patients in Japan), 332 patients diagnosed with liver cirrhosis were entered into the study (age 67.1±9.4 years; 246 male). Liver cirrhosis was diagnosed by liver biopsy or signs of portal hypertension with characteristic morphologic liver and spleen changes.A total of 233 patients received PCI, 58 conventional on-pump CABG (CCABG), and 41 OPCABG. Median follow-up was 3.3 years. The PCI group included less complex coronary lesions such as triple vessel and left main disease (p0.01 each). Propensity score adjusted in-hospital mortality after CCABG or OPCABG was higher than that after PCI; however, the differences were not significant (odds ratio [95% confidence interval]: 6.84 [0.52 to 90.8], p=0.14 for CCABG versus PCI; and 1.86 [0.08 to 45.8], p=0.71 for OPCABG versus PCI). Adjusted overall mortality after CCABG or CABG was lower than that after PCI, but the differences were not significant (0.66 [0.31 to 1.40], p=0.28; and 0.64 [0.28 to 1.49], p=0.31, respectively). Approximately two thirds of patients died of noncardiovascular morbidities (malignancies, including hepatocarcinoma, or hepatic decompression).Because overall noncardiovascular mortality is high among patients with liver cirrhosis, complete revascularization may not be associated with better survival outcomes. Further study is warranted to determine the impact of a coronary revascularization strategy for liver cirrhosis patients.

Amiodarone is a potent anti-atrial fibrillation (AF) agent; however, its systemic administration induces serious side effects such as interstitial pneumonia. To avoid such effects, we developed a local sustained-release system for amiodarone.A biodegradable, cross-linkable dextran disc was developed as a sustained-release carrier for amiodarone. Under general anesthesia, Japanese white rabbits underwent median sternotomy and the biodegradable disc with or without amiodarone (30 mg) was implanted onto the surface of the right atrium. Three days after implantation, we measured tissue amiodarone concentrations (n = 5), the AF threshold, and the atrial effective refractory period of the left atrium by using the Langendorff apparatus. The incidences of induced AF evoked by rapid pacing were measured and compared.The right atrial concentration of amiodarone was far higher than that in the lungs, ventricles, or other organs (p0.01). The blood concentration of amiodarone was below detectable levels. The amiodarone biodegradable disc significantly increased the AF threshold (amiodarone group, 6.9 ± 4.6 mA versus control group, 0.5 ± 0.6 mA; p0.01) and the effective refractory period (amiodarone group, 53.9 ± 8.9 milliseconds versus control group, 43.9 ± 9.5 milliseconds; p = 0.035) of the left atrium, indicating the electrophysiologic effect of the amiodarone biodegradable disc on the left atrium. Further, the amiodarone group was significantly less likely to experience AF, as compared with the control group (p0.01).This approach may be a less invasive and effective therapeutic option for preventing postoperative AF.

There are an estimated 8 million practicing Jehovah's Witness'(JW) worldwide, many of whom refuse blood transfusions based on religious beliefs. Given the medical, ethical and legal implications surrounding these preferences hospitals have sought to offer alternatives, both in emergency and peri

Cardiopulmonary bypass (CPB) may induce systemic inflammatory responses causing acute lung injury. Recombinant human soluble thrombomodulin (rTM) is reported to attenuate the secretion of inflammatory cytokines and the high-mobility group box 1 (HMGB1) protein, which is critical in controlling systemic inflammation and apoptosis. We investigated the protective effects of rTM on CPB-induced lung injury in a rat model.Eighteen male Sprague-Dawley rats were divided into 3 groups: sham, control (CPB alone), and rTM (CPB + rTM). CPB was conducted in the control group and the rTM group. A bolus of rTM (3 mg/kg) was administered to the rTM group rats before CPB establishment.The ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen only dropped markedly from before CPB in the control group (P .001). Serum tumor necrosis factor α, interleukin (IL) 6, and HMGB1 levels were significantly higher in the control group after CPB. Pathologic study revealed significantly more severe congestion, alveolar hemorrhage, neutrophil accumulation, and edema, and the number of lung cells expressing HMGB1 increased in the control group. The mRNA expression levels of tumor necrosis factor α, IL-6, IL-1β, and HMGB1 in the control group were significantly higher than those in other groups. According to Western blot analysis, nuclear factor-κB p65 in lung tissue was significantly downregulated in the rTM group. The number of apoptotic cells and the protein of cleaved Caspase-3 were reduced in the rTM group.These results suggest that rTM prevents acute lung injury through attenuating inflammation and apoptosis during and after CPB in a rat model.

Symptomatic pediatric patients with obstructive hypertrophic cardiomyopathy (HCM) have a higher death rate (6% annually) compared with adults. Transaortic left ventricular septal myectomy provides excellent outcomes for adults with obstructive HCM. We sought to assess the effect of septal myectomy on late survival and outcome in pediatric patients with obstructive HCM.From 1975 to 2003, 56 pediatric patients underwent septal myectomy for obstructive HCM. Mean age at diagnosis was 6.3 +/- 5.4 years. Ages at operation ranged from 2 months to 20 years (mean 11 +/- 5.6 years). Concomitant procedures included mitral valve repair (n = 7), closure of atrial septal defect (n = 3), and other (n = 5).After myectomy, mean left ventricular outflow tract (LVOT) gradient decreased from 103 +/- 34 to 16 +/- 12 mm Hg and mean degree of mitral regurgitation decreased from 2.0 +/- 1.0 to 1.0 +/- 0.3 (both p0.0001). There were no early deaths. Four patients underwent elective cardioverter defibrillator implantation and 1 patient received a permanent pacemaker. Follow-up ranged up to 29 years (mean, 8.6 +/- 6.2). Cardiac reoperations were required in 8 patients: heart transplantation (n = 2), repeat myectomy (n = 2), mitral valve repair-replacement (n = 2), Konno-Rastan procedure (n = 1), and aortic valve replacement (n = 1). Age 14 years or less at operation was the only predictor of late reoperation (p = 0.017). Two patients died late; one suddenly without residual LVOT obstruction and one from chronic rejection after heart transplantation. Ninety-six percent of surviving patients were in New York Heart Association functional class I or II. Survival estimates at 5 and 10 years were 97% and 93%, respectively.Septal myectomy is safe and effective in symptomatic pediatric patients with obstructive HCM. Late survivorship compares very favorably with the natural history of this disease.

Objective To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation. Methods We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 ± 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%). Results There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively. Conclusions Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.

Current guidelines generally recommend the strategy of watchful waiting for aortic valve replacement (AVR) until symptoms emerge in asymptomatic patients with severe aortic stenosis (AS). However, there is no previous large-scale study evaluating the impact of symptomatic status on the long-term

ObjectiveBecause microRNA-145 (miR-145) is a specific mediator in the regulation of the proliferation and differentiation of smooth muscle cells, we investigated the effect of miR-145 on the intimal hyperplasia in the rabbit model of vein graft disease using electroporation-mediated gene transfer.MethodsThe right jugular vein of male Japanese white rabbits was harvested and transduced with miR-145–encoding plasmids using an electroporator and then interposed in the carotid artery. At 2 or 4 weeks postoperatively, the venous graft was explanted, and the intimal thickness and intima/media area ratio were evaluated. Furthermore, 3 days after implantation, the myocardin and serum response factors were measured using real-time polymerase chain reaction. At 2 weeks after implantation, immunohistochemical investigations using mature smooth muscle markers, myosin heavy chain smooth muscle-1 and -2, and proliferation marker Ki-67 were performed.ResultsMiR-145 transduction significantly reduced the neointimal thickness at both 2 and 4 weeks (2 weeks, 52.1 ± 15.7 vs 113.2 ± 26.9 μm, P

We report a 24-year-old man with mitral valve endocarditis complicated by acute myocardial infarction due to coronary embolism. Percutaneous transluminal coronary angioplasty and subsequent mitral valve replacement were performed. Postoperative coronary angiography revealed formation of a mycotic aneurysm of the left anterior descending coronary artery at the site of balloon inflation. The patient then underwent successful resection of the aneurysm with coronary artery bypass grafting.