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Objectives This study sought to explore the long-term arrhythmic outcomes of bilateral cardiac sympathetic denervation (BCSD). Background BCSD has been associated with improved arrhythmic outcomes in patients with refractory ventricular arrhythmias. However, whether BCSD antiarrhythmic effects are sustained long after the procedure is still uncertain. Methods We included consecutive patients who underwent BCSD because of refractory ventricular tachycardia (VT) and had at least 18 months of follow-up. VT recurrence after BCSD was evaluated to assess arrhythmic outcomes. The occurrence of VT episodes within the first 12 weeks after the procedure was assessed to explore the impact of early VT recurrence on late arrhythmia-free survival. Results Twenty patients (42 ± 16 years; 55% male) were included in the analysis. Nineteen (95%) patients had structural heart disease (left ventricular ejection fraction: 0.46 ± 0.14). Class I or class III drugs failed for all patients, and the mean number of VT ablation procedures was 2.5 ± 1.6. Over a mean follow-up of 1,300 ± 321 days (median: 1,276 days [Interquartile range (IQR): 1,181 to 1,480 days), 11 (55%) patients remained VT free after sympathectomy. Freedom from sustained VT or implantable cardioverter-defibrillator shock was 60% (95% confidence interval: 0.35 to 0.77) and 54.5% (95% confidence interval: 0.31 to 0.73) after BCSD at 1 and 4 years. Early VT recurrence was not associated with worse late arrhythmia-free survival rates. Conclusions BCSD was associated with longstanding antiarrhythmic effects in patients with refractory ventricular arrhythmias. The occurrence of VT episodes early after the procedure was not associated with worse late arrhythmic outcomes.

Purpose:Neoadjuvant PD-1 blockade is a promising treatment for resectable non–small cell lung cancer (NSCLC), yet immunologic mechanisms contributing to tumor regression and biomarkers of response are unknown. Using paired tumor/blood samples from a phase II clinical trial (NCT02259621), we explored whether the peripheral T-cell clonotypic dynamics can serve as a biomarker for response to neoadjuvant PD-1 blockade.Experimental Design:T-cell receptor (TCR) sequencing was performed on serial peripheral blood, tumor, and normal lung samples from resectable NSCLC patients treated with neoadjuvant PD-1 blockade. We explored the temporal dynamics of the T-cell repertoire in the peripheral and tumoral compartments in response to neoadjuvant PD-1 blockade by using the TCR as a molecular barcode.Results:Higher intratumoral TCR clonality was associated with reduced percent residual tumor at the time of surgery, and the TCR repertoire of tumors with major pathologic response (MPR; Conclusions:Our study suggests that exchange of T-cell clones between tumor and blood represents a key correlate of pathologic response to neoadjuvant immunotherapy and shows that the periphery may be a previously underappreciated originating compartment for effective antitumor immunity.See related commentary by Henick, p. 1205

Background The purpose of this study was to evaluate outcomes in people with cystic fibrosis (CF) who underwent lung transplant (LT) at a transplant center with an accredited Cystic Fibrosis Care Center (CFCC) in the United States. Methods We reviewed the Scientific Registry of Transplant Recipients for all adult patients with CF who received a first-time LT from 2005 to 2018. The primary outcome was graft failure. Unadjusted Kaplan-Meier analysis and adjusted multilevel Cox proportional hazards models were used to evaluate outcomes in CF patients undergoing lung transplantation at a CFCC. Results 2,573 patients with CF underwent a first time LT during the study period. Of the 68 lung transplantation centers, 50 were CFCCs (73.5%). After adjustment for potential confounders, patients who underwent lung transplantation at a hospital with an accredited CFCC had a 33% reduction in risk of death or re-transplantation compared to those transplanted at a hospital without an accredited CFCC (HR: 0.67, 95% CI: 0.56-0.82, p Conclusion People with CF who undergo LT at a transplant center with a CFCC have improved graft survival and decreased need for re-transplantation compared to those who undergo LT at a non-CFCC, independent of volume.

PD-1 blockade unleashes CD8 T cells1, including those specific for mutation-associated neoantigens (MANA), but factors in the tumour microenvironment can inhibit these T cell responses. Single-cell transcriptomics have revealed global T cell dysfunction programs in tumour-infiltrating lymphocytes (TIL). However, the majority of TIL do not recognize tumour antigens2, and little is known about transcriptional programs of MANA-specific TIL. Here, we identify MANA-specific T cell clones using the MANA functional expansion of specific T cells assay3 in neoadjuvant anti-PD-1-treated non-small cell lung cancers (NSCLC). We use their T cell receptors as a ‘barcode’ to track and analyse their transcriptional programs in the tumour microenvironment using coupled single-cell RNA sequencing and T cell receptor sequencing. We find both MANA- and virus-specific clones in TIL, regardless of response, and MANA-, influenza- and Epstein–Barr virus-specific TIL each have unique transcriptional programs. Despite exposure to cognate antigen, MANA-specific TIL express an incompletely activated cytolytic program. MANA-specific CD8 T cells have hallmark transcriptional programs of tissue-resident memory (TRM) cells, but low levels of interleukin-7 receptor (IL-7R) and are functionally less responsive to interleukin-7 (IL-7) compared with influenza-specific TRM cells. Compared with those from responding tumours, MANA-specific clones from non-responding tumours express T cell receptors with markedly lower ligand-dependent signalling, are largely confined to HOBIThigh TRM subsets, and coordinately upregulate checkpoints, killer inhibitory receptors and inhibitors of T cell activation. These findings provide important insights for overcoming resistance to PD-1 blockade., Single-cell RNA sequencing and T cell receptor sequencing are combined to identify transcriptional programs specific to mutation-associated neoantigen-specific T cells in non-small cell lung cancers treated with anti-PD-1, providing insights into resistance to PD-1 blockade.

Background Lung volume reduction surgery (LVRS) is treatment option for chronic obstructive pulmonary disease, the second most common indication for lung transplantation (LTx) in the United States. Lung volume reduction surgery before LTx is controversial. Single-institution studies report contradicting results, and the impact of undergoing LVRS before LTx on outcomes after LTx is unclear. Methods We reviewed the United Network for Organ Sharing database for all adults (aged more than 18 years) who underwent first-time LTx for chronic obstructive pulmonary disease in the lung allocation score era. We used patient demographic and clinical characteristics and lung allocation score to propensity match patients who did and patients who did not undergo LVRS before LTx. The primary exposure was prior LVRS. The primary outcome was graft failure after LTx. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards models were used to assess outcomes. Results A total of 4905 patients with chronic obstructive pulmonary disease underwent LTx between May 2005 and March 2017. Of them, 107 patients (2.2%) underwent LVRS before LTx. Propensity matching generated 212 matches (106 LVRS+LTx, and 106 LTx only). Median survival was significantly longer in the LTx only cohort (6.5 vs 3.4 years, P = .034). Lung volume reduction surgery before lung transplantation was associated with significantly increased risk of graft failure after lung transplant (hazard ratio 1.72; 95% confidence interval, 1.13 to 2.60; P = .01). Conclusions In this national, propensity-matched analysis of LVRS before LTx, we show that LVRS is associated with a significantly increased risk of graft failure. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed postoperatively.

BackgroundWe conducted the first trial of neoadjuvant PD-1 blockade in resectable non-small cell lung cancer (NSCLC), finding nivolumab monotherapy to be safe and feasible with an encouraging rate of pathologic response. Building on these results, and promising data for nivolumab plus ipilimumab (anti-CTLA-4) in advanced NSCLC, we expanded our study to include an arm investigating neoadjuvant nivolumab plus ipilimumab.MethodsPatients with resectable stage IB (≥4 cm)–IIIA (American Joint Committee on Cancer Tumor Node Metastases seventh edition), histologically confirmed, treatment-naïve NSCLC received nivolumab 3 mg/kg intravenously plus ipilimumab 1 mg/kg intravenously 6 weeks prior to planned resection. Nivolumab 3 mg/kg was given again approximately 4 and 2 weeks preoperatively. Primary endpoints were safety and feasibility with a planned enrollment of 15 patients. Pathologic response was a key secondary endpoint.ResultsWhile the treatment regimen was feasible per protocol, due to toxicity, the study arm was terminated early by investigator consensus after 9 of 15 patients were enrolled. All patients received every scheduled dose of therapy and were fit for planned surgery; however, 6 of 9 (67%) experienced treatment-related adverse events (TRAEs) and 3 (33%) experienced grade ≥3 TRAEs. Three of 9 patients (33%) had biopsy-confirmed tumor progression precluding definitive surgery. Of the 6 patients who underwent resection, 3 are alive and disease-free, 2 experienced recurrence and are actively receiving systemic treatment, and one died postoperatively due to acute respiratory distress syndrome. Two patients who underwent resection had tumor pathologic complete responses (pCRs) and continue to remain disease-free over 24 months since surgery. Pathologic response correlated with pre-treatment tumor PD-L1 expression, but not tumor mutation burden. Tumor KRAS/STK11 co-mutations were identified in 5 of 9 patients (59%), of whom two with disease progression precluding surgery had tumor KRAS/STK11/KEAP1 co-mutations.ConclusionsThough treatment was feasible, due to toxicity the study arm was terminated early by investigator consensus. In light of this, and while the long-term disease-free status of patients who achieved pCR is encouraging, further investigation of neoadjuvant nivolumab plus ipilimumab in patients with resectable NSCLC requires the identification of predictive biomarkers that enrich for response.

Background Concern has been raised over inferior lung transplantation survival associated with traumatic brain injury (TBI) organ donors. Our purpose was to explore the relationship between TBI donors and lung transplantation survival in the lung allocation score (LAS) era. Methods We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients and identified all adult (≥18 years) lung transplantations performed from May 4, 2005, to December 31, 2015. Recipients were dichotomized based on donor cause of death, TBI versus non-TBI, propensity score across eight variables (final LAS, intensive care unit admission before transplantation, extracorporeal membrane oxygenation before transplantation, donor age 50 years or older, cytomegalovirus antibody recipient−/donor+, ischemia time, annual center transplantation volume, single versus double lung transplantation), and matched 1:1 without replacement. Our primary outcomes were survival at 1, 3, and 5 years by Kaplan-Meier method. Results A total of 17,610 patients underwent isolated lung transplantation over the study period at 75 different transplantation centers. TBI was the leading cause of death in the donor population: 47% of all donors. Propensity score matching generated 6,782 well-matched donor TBI versus non-TBI pairs (all covariate p > 0.2). Risk-adjusted survival was similar between recipients of TBI donors versus non-TBI donors at 1 year (86% versus 86%, log-rank p = 0.27), 3 years (68% versus 68%, log-rank p = 0.47), and 5 years (55% versus 54%, log-rank p = 0.40). Conclusions In the largest analysis of TBI donors and the impact on lung transplantation survival to date, we found similar survival out to 5 years in lung transplant recipients of TBI versus non-TBI donors, alleviating concerns over continued transplantation with this unique donor population.

We examined the utility of serial liquid biopsies to monitor clonal dynamics and predict pathologic response in patients with esophageal/gastroesophageal junction (E/GEJ) cancer undergoing treatment with neoadjuvant immunotherapy and concurrent chemoradiation (CA209-906; NCT03044613). Methods: Using Targeted Error Correction sequencing (TEC-Seq), we performed high-depth next generation sequencing on 79 serial plasma samples from 16 patients with operable stage II/III E/GEJ cancer undergoing treatment with neoadjuvant nivolumab, followed by nivolumab plus chemo-radiation and surgery as part of the CA209-906 trial. Liquid biopsies were evaluated pre-treatment, after each of two cycles of neoadjuvant nivolumab, and after concurrent nivolumab and chemoradiation immediately prior to surgery, for an average of 4 time points per patient. Deep sequencing of matched leukocyte DNA and whole exome sequencing (WES) of pre-treatment tumors was performed. The origin of plasma variants was determined by comparison to tumor WES (tumor-derived) and leukocyte TEC-Seq (clonal hematopoiesis (CH)-derived or germline) and their clonal dynamics over time were evaluated. Resected tumors were reviewed by central pathology and percent residual tumor was estimated. Patients were followed for an average of 2 years post-surgery. Results: Eight of 16 patients had detectable circulating tumor-derived DNA (ctDNA) at any time point. Additionally, 13 CH-derived mutations were detected in plasma of 8 patients. The number of CH-derived mutations was correlated with increasing patient age. Identification and removal of CH-derived mutations via comparison to matched leukocyte sequencing allowed for accurate assessment of kinetics of bona fide tumor-derived mutations in plasma. Tumor mutation burden as determined by tumor WES was not associated with pathological response (mean baseline mutations per exome 90 vs 81 for patients with residual disease >20% and 20% (50% vs 23% with or without detectable ctDNA respectively). ctDNA clearance, defined as detectable ctDNA at one or more earlier time points that subsequently becomes undetectable before surgery, occurred in 5 patients and was associated with improved pathologic response (80% of patients with ctDNA clearance had residual tumor Conclusion: Comprehensive analyses of ctDNA from E/GEJ patients undergoing neoadjuvant immunotherapy with concurrent chemoradiation revealed ctDNA dynamics that were associated with pathologic response and disease recurrence. These approaches may be used to identify patients at high risk for disease progression. Citation Format: Jenna VanLiere Canzoniero, Vincent Lam, Zineb Belcaid, Mara Lanis, Lamia Rhymee, Blair Landon, Archana Balan, Kristen Marrone, Patrick Forde, Benjamin Levy, David Ettinger, Heather Schneider, Hanika Rodavia, Richard Battafarano, Stephen Yang, Stephen Broderick, Jinny Ha, Blair Jobe, Ali Zaidi, Elizabeth Thompson, Julie Brahmer, Victor Velculescu, Ronan Kelly, Josephine Feliciano, Valsamo Anagnostou. Liquid biopsy approaches for determining pathologic response to neoadjuvant immunotherapy in esophageal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 538.

4042 Background: Improving immunotherapy efficacy remains an unmet need in esophagogastric cancer and a deeper understanding of tumor and immune system dynamics during therapy may tailor immuno-oncology approaches. Methods: We performed whole exome sequencing (WES) and bulk RNA sequencing (RNAseq) of 70 serial tumor samples from 23 patients with stage II/III esophageal/gastroesophageal junction (E/GEJ) cancer treated on a phase 1B clinical trial with neoadjuvant nivolumab with or without relatlimab (anti-LAG-3) and chemoradiation followed by surgery (NCT03044613; CA209-906). Pathologic response was measured by tumor regression at the time of resection. Median follow up was 23 months post-surgery. Serial tumor samples were collected prior to therapy, after 2 cycles of induction immune checkpoint blockade (ICB), and at the time of resection. Twenty-two baseline tumor/normal DNA pairs were analyzed by WES and 48 serial tumor samples were analyzed by RNAseq. WES data was analyzed to identify somatic mutations, generate tumor mutation burden (TMB) estimates and assess the fraction of expressed mutations in conjunction with RNAseq data. Immune cell subset composition was determined by RNAseq data deconvolution by CIBERSORT and gene set enrichment analyses were performed utilizing GSEA. B-cell density was inferred by immunoglobulin rearrangements detected by RNAseq. Results: Gene set enrichment expression analyses revealed an upregulation of effector pro-inflammatory cytokines after induction ICB. Interferon-gamma, interferon-alpha and TNF-alpha related genes were significantly upregulated after induction ICB compared to baseline (p < 0.0001). In contrast, significant downregulation of E2F targets (p = 0.002), G2M checkpoint genes (p = 0.005) and DNA damage repair genes (p = 0.004) was observed post ICB; enrichment analyses were independent of response to therapy and treatment arm. While TMB was not predictive of pathologic response (p = 0.22), patients with tumors harboring a higher number of expressed mutations were more likely to achieve a pathologic complete response (pCR; p = 0.026). RNAseq deconvolution analyses revealed a higher B-cell density post ICB induction in tumors with pCR (p = 0.018). Furthermore, an increased baseline content of intra-tumoral activated M1 macrophages differentiated tumors from patients achieving a pCR (p = 0.0034), which was further exemplified post induction ICB. Conclusions: Neoadjuvant immunotherapy induces an inflammatory immune response in the tumor microenvironment that is linked with tumor elimination and pathologic response. Our findings highlight the importance of nuanced multi-omics analyses to understand the wiring of response to immunotherapy and guide therapy for E/GEJ cancer.

Background Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period. Methods Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation. Results The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively ( p p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p Conclusions Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling.

Purpose Lung volume reduction surgery (LVRS) is a therapeutic option in the treatment of chronic obstructive pulmonary disease (COPD), the most common indication for lung transplantation (LTx). LVRS prior to LTx is controversial. Single institution studies report contradicting results, and the impact of undergoing LVRS prior to LTx on outcomes after LTx is unclear. We performed a propensity-matched analysis of outcomes after LTx in patients who underwent LVRS using a national database of LTx. Methods We reviewed the Scientific Registry of Transplant Recipients for all adults (age>18) who underwent first-time LTx for COPD in the Lung Allocation Score (LAS) era. We used patient demographics and LAS to match patients who did and did not undergo LVRS. The primary exposure was prior LVRS. We used multivariate logistic regression modeling to evaluate the primary outcome, one-year mortality, and secondary outcomes, chronic rejection by one year requiring treatment and prolonged ventilation (>5 days). Long-term survival was compared using Kaplan Meier testing. Results A total of 5,061 patients underwent LTx between January 2005 and March 2017. The average patient age at transplant was 60.7±6.0 years, and 2,591 (51.2%) patients were male. The mean LAS at transplant was 34.9±6.1. A total of 111 (2.2%) patients underwent LVRS prior to LTx. Propensity matching generated 111 matches. Multivariate logistic regression modeling in this group revealed a 16% increased risk of mortality at one year among patients who underwent LVRS prior to LTx (OR: 1.16, 95% CI: 1.01-1.32, p=0.03). There was no statistically significant difference in risk of chronic rejection by one year requiring treatment (p=0.5) or prolonged ventilator support (p=0.5) among the two groups. The Kaplan Meier survival analysis demonstrated a significant survival deficit between patients who received LVRS and those who did not at five years post-transplant (52.3% vs. 66.3% p=0.01). Conclusion In this national, propensity matched analysis of LVRS prior to LTx, we show that LVRS is associated with a significantly increased risk of mortality. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed post-operatively. Further studies are necessary to identify why these patients may be at increased risk of adverse outcomes after LTx.

Purpose Clinical outcomes remain extremely poor for children with cystic fibrosis undergoing lung transplantation. Since 1961, the Cystic Fibrosis Foundation has maintained a network of accredited Cystic Fibrosis Care Centers (CFCC) designated to deliver specialized, multidisciplinary care for people with cystic fibrosis (CF). While this integrated clinical approach is thought to be beneficial in patients undergoing transplantation, it remains unknown whether lung transplantation at a CFCC is associated with improved long-term outcomes among children with CF. Methods We used the Scientific Registry of Transplant Recipients to identify all children (age Results We included 336 children with CF who underwent lung transplantation during the study period. Of these patients, 229 (68%) were transplanted at CFCCs. During a median follow-up time of 2.5 person-years, 35 (10%) children experienced graft failure or underwent retransplantation, and 7 (2%) children were lost to follow-up. In our multivariable Cox proportional hazards model, there was no significant difference in graft survival (HR 1.13, 95% CI 0.82-1.56) or overall survival (HR 1.10, 95% CI 0.77-1.57). Conclusion In children with CF, lung transplantation at a designated CFCC was not associated with a significant improvement in overall or graft survival. While treatment at a CFCC may not be associated with improved survival after pediatric lung transplantation, specialized care at a CFCC may result in improvements in other aspects of care which could not be assessed in this analysis.

Purpose We aimed to assess the prognostic value of Neutrophil to Lymphocyte Ratio (NLR) on long-term outcomes and graft dysfunction after lung transplantation. Methods We retrospectively reviewed all patients receiving a lung transplant at our institution from 2011 to 2014. The primary exposure was elevated NLR at the time of transplant, defined by NLR>4. The primary outcomes were graft failure and three-year all-cause mortality. Multivariate logistic regression and Kaplan-Meier survival analysis were used to analyze outcomes. Results 95 patients were included. 40 patients (42%) had an elevated NLR. Elevated NLR was associated with graft failure (OR: 4.7 [1.2–18.8], p = 0.02), and three-year mortality (OR: 5.4 [1.3–23.2], p = 0.03) on multivariate logistic regression. Patients with elevated NLR demonstrated significantly lower survival on Kaplan-Meier analysis (50% versus 74%, p = 0.02). The c-statistic for our multivariate model was 0.91. Conclusion Elevated neutrophil to lymphocyte ratio is associated with poor long-term survival and graft failure after lung transplantation.

To assess the rate and effect of anastomotic leak among patients who undergo esophagectomy with either thoracic or cervical anastomosis after neoadjuvant chemoradiation.We conducted a retrospective cohort study using data from the National Surgical Quality Improvement Program Esophagectomy Data File. We included adult patients who underwent esophagectomy for esophageal cancer (2016-2017) after neoadjuvant chemoradiation. We used inverse probability of treatment weighted regression adjustment to compare 30-day anastomotic leak and mortality rates among patients with cervical or thoracic anastomoses. We accounted for confounding due to patient-, surgeon-, and procedure-related variables.Of the 908 patients who met inclusion criteria, 528 (58%) had a thoracic anastomosis and 119 (13%) experienced anastomotic leak. There was no statistically significant difference in leak rate for patients who underwent thoracic (12%) compared with cervical anastomoses (14%) in the inverse probability of treatment weighted regression adjustment analysis (P = .09). Although overall 30-day mortality was low (2.3%), it was significantly higher among patients who had an anastomotic leak (8.4% vs 1.4%; P .01). Among patients with a leak, there was no significant difference in length of stay, mortality, or type of required intervention for patients with cervical versus thoracic anastomoses.Anastomosis type does not affect leak rates or mortality after esophagectomy in patients who have undergone neoadjuvant chemoradiation. Patient risk factors and surgeon experience should determine the ideal surgical approach for each patient.

Background Ventricular arrhythmias (VAs) in cardiac sarcoidosis (CS) are frequently refractory to both antiarrhythmic drug (AAD) therapy and catheter ablation (CA). Cardiac sympathetic denervation (CSD) has been shown to reduce VA burden and implantable cardioverter-defibrillator (ICD) shocks in patients with nonischemic cardiomyopathy. Objective We aimed to report our center's preliminary experience with CSD in patients with known or presumed CS and refractory VAs. Methods Patients with CS and refractory VAs who underwent CSD at our institution were included. Patient characteristics, procedural outcomes, and number of arrhythmic events including ICD shocks pre- and post-CSD are reported. Results Five patients with CS (mean age 53 ± 11 years; 2 men [40%]; mean left ventricular ejection fraction 38% ± 11%) underwent CSD for VA refractory to AAD therapy and CA. Four of 5 patients underwent bilateral CSD; 1 patient underwent right-sided sympathectomy only because of poor intraoperative visualization on the left. Procedural complications included hemothorax in 1 patient and azygous vein injury in 1 patient. The median number of ICD shocks in the 6 months pre-CSD was 5. During a median follow-up of 26 months (range 5–29 months), the median number of ICD shocks post-CSD was 0; 1 patient had sustained VA that was below the threshold for device therapy, and 1 patient had symptomatic premature ventricular contractions; both underwent repeat CA. In addition, 1 patient required cardiac transplantation for progressive heart failure. Conclusion CSD may be a feasible therapeutic adjunct for patients with CS and VA refractory to AAD therapy and CA.

Purpose Patients who undergo repeat lung transplantation (LT) are at high risk for perioperative complications. The complexity of their care requires specialized multidisciplinary collaboration, particularly among people with cystic fibrosis (CF). Since 1961, the Cystic Fibrosis Foundation has established a network of accredited Cystic Fibrosis Care Centers (CFCCs) dedicated to the treatment of people with CF, including LT. We hypothesize that patients undergoing repeat lung transplantation at CFCCs will have improved postoperative outcomes compared to those at non-CFCC centers. Methods Using the Scientific Registry of Transplant Recipients, we identified adults with cystic fibrosis who received a repeat LT at a CFCC between 2005 and 2018. We compared clinical, demographic, and donor characteristics between groups. We then used multivariable Cox proportional hazards modeling to compare graft survival (defined as freedom from death, graft failure, or further retransplantation) in people with CF treated at CFCCs and non-CFCC centers during the study period. Results Our cohort included 303 people with CF who underwent repeat LT from 2005-2018. Median age at repeat transplantation was 30 years (SD 8) and 50% were male. During 877 person-years of observation, 159 (53%) patients died, 7 (2%) underwent another transplant, and 4 (1%) were lost to follow-up. In a multivariable model, graft survival was significantly improved at CFCC centers compared to non-CFCCs (adjusted HR 0.62, 95% CI 0.42-0.94). Median survival was 4.2 years among people treated at CFCCs and 2.8 years among those treated at non-CFCCs. Conclusion In people with CF, repeat LT at CFCCs is associated with improved graft and overall survival compared to repeat LT at non-CFCCs. Treatment at a CFCC provides specialized, multidisciplinary care for people with CF and can lead to improved outcomes even among high acuity patient subgroups.

Purpose Since 1961 the Cystic Fibrosis Foundation has designated certain institutions devoted to treating cystic fibrosis (CF) as Cystic Fibrosis Care Centers (CFCC). Little is known about the benefits of undergoing lung transplantation (LT) at a transplant center with an accredited CFCC. The purpose of this study was to evaluate outcomes in people with CF who undergo LT at a transplant center with an accredited CFCC. Methods We reviewed the Scientific Registry of Transplant Recipients for all adult (18 and older) patients with CF who received a first-time LT from 2005 to present. The primary exposure was whether a patient received LT at a designated CFCC. The primary outcome was death or re-transplantation within ten years of LT. Kaplan-Meier analysis and multivariate Cox proportional hazards regression were used to assess outcomes. Results From January 2005 to February 2019, 2,887 patients with CF underwent LT. Of the cohort, there were 1,403 (49%) females. The mean (SD) age at transplant was 32.0 (9.9) years. Out of 72 centers in the US performing LT, 53 (74%) were CFCCs, and most patients (88%) were transplanted at a CFCC. A total of 1,009 (35%) patients died over the study period, and 158 (6%) patients underwent a second transplant. The most common cause of death was infection (n=209, 21%). On adjusted Cox modeling, patients transplanted at a CFCC had a 36% reduced risk of death or re-transplantation compared to those transplanted at a non-CFCC (HR: 0.64, 95% CI: 0.54-0.75, p Conclusion People with CF who undergo LT at a CFCC have improved survival and longer freedom from re-transplantation compared to those transplanted at non-CFCCs. These patients suffering from CF likely have greater access to specialized CF care at CFCCs which may contribute to improved post-transplant survival.

Purpose Ex vivo lung perfusion (EVLP) is a contemporary tool which aims to improve the utilization of marginal donor lungs. Little is known about the impact of EVLP on the utilization of potential donor organs on a national scale in the United States. This study examines whether EVLP is associated with increased lung utilization among potential donors in a contemporary cohort of United States patients. Methods We used the Organ Procurement and Transplantation Network database to identify all adult potential deceased organ donors, including donors after brain death (DBD) and donors after circulatory determination of death (DCD) in the modern era of EVLP (2015-2018). Our main covariate of interest was use of EVLP, defined by perfusion of either or both lungs prior to transplantation. The primary study endpoint was lung utilization, defined as successful single or double lung transplantation of a potential organ donor. Our analysis was performed using a multivariable logistic regression model adjusted for donor demographics, clinical characteristics, and risk factors. We evaluated the association between EVLP and lung utilization separately among the DCD and DBD potential donor populations. Results We identified 11,857 potential donors of whom 1,608 (14%) were DCDs. EVLP use increased from 2% to 4% annually during the study period. Among DBD potential donors, EVLP was used in 2% (n=22). Lung utilization was 62% (n=6188) in grafts recovered without EVLP and 49% (n=108) with EVLP. Recovery with EVLP was associated with significantly lower lung utilization (adjusted OR 0.6, 95% CI 0.4-0.8) among DBD potential donors. Among DCD potential donors, EVLP was used in 6% (n=100). Lung utilization was 15% (n=234) without EVLP and 49% (n=49) with EVLP. Recovery with EVLP was associated with significantly improved lung utilization among DCD potential donors (adjusted OR 2.8, 95% CI 1.7-4.6). Conclusion EVLP is associated with significantly higher lung utilization among potential DCD donors in the United States. In DBD donors, use of EVLP was likely a surrogate for unmeasured high-risk features and appeared to represent attempted salvage of organs that would otherwise have been discarded. EVLP can be a valuable tool to improve lung utilization among DCD donors and if employed more widely, may increase the pool of organs available for transplantation.

Purpose Some surgeries performed during the weekend have worse outcomes. Lung transplantation is frequently performed on weekends despite a lack of evidence for its safety. We hypothesized that weekend lung transplants have worse outcomes than those performed during weekdays. Methods We conducted a retrospective analysis using the Scientific Registry of Transplant Recipients (SRTR) to characterize the safety of weekend lung transplantation. We evaluated adult lung transplantations performed in the USA between 1987 and 2019. Baseline donor and recipient characteristics were stratified by weekday (Monday-Friday) versus weekend (Saturday-Sunday) transplantation and compared using appropriate parametric and non-parametric tests. The primary outcomes were 10-year patient survival, overall graft survival, and death-censored graft survival. Secondary outcomes included post-operative complications, hospital length of stay, readmission, and acute rejection within the first year. Cox proportional hazards and competing risks regression models were used to evaluate the impact of weekend surgery on outcomes. Results Of the 38,963 lung transplants performed in the United States between 1987 and 2019, 10,286 (36%) were performed during the weekend and 28,677 (64%) during the week. Recipients transplanted during the weekend were slightly older (50.6 years vs. 49.9 years, p=0.0002), more likely to be male (57.8% vs 55.2%, p=0.006), and spent less time on the waitlist (100 days vs 105 days, p=0.0008). There were no other significant differences in baseline characteristics, comorbidities, or transplant indication. There were no differences in donor characteristics. No significant association was found between weekend transplant and 10-year overall patient survival, allograft survival, or death-censored graft survival in the adjusted analyses. (HR 1.0, (95% CI 0.99-1.01), 1.01 (95% CI 0.99-1.02), 1.0). Additionally, no association was found between weekend transplant and secondary outcomes. Conclusion Outcomes for lung transplantation in the USA are not affected by day of surgery, and weekends do not confer an increased risk for mortality, graft failure, or post-operative complications. This is the first study investigating lung transplant outcomes during the weekend. Further study is needed to evaluate differences in outcomes of surgical procedures that occur over the weekend.

Parathyroid cysts (PCs) are relatively rare entities, with an even smaller proportion that functionally produce parathyroid hormone (PTH). Given associated hypercalcemia, often symptomatic, as well as potentially related osteoporosis and/or nephrolithiasis, resection of these functional cysts is often indicated. This case report details the management course for a patient who presented with primary hyperparathyroidism and was ultimately found to have a functional intrathymic PC. During initial workup, 4-dimensional computed tomography (4D-CT) of the neck demonstrated enlarged left upper and right lower parathyroid glands; however, the patient’s hyperparathyroid state persisted even after bilateral neck exploration and resection of these two glands. Subsequent postoperative imaging of the mediastinum revealed a large (11 cm) thymic cyst. The patient consequently underwent uneventful robotic-assisted thoracoscopic excision of the mediastinal cyst. Intraoperative blood PTH levels dropped from 734 pg/mL preoperatively to 86 pg/nL 10 minutes following resection, consistent with surgical cure by the Miami Criteria. At two months postoperatively, the patient’s serum total calcium (STC) was normal at 9.2 mg/dL. Final surgical pathology noted a 15-gram parathyroid gland, with cystic degeneration. As the robot becomes further integrated into the everyday practice of thoracic surgery, we believe this approach offers advantages over conventional video-assisted thoracoscopic surgery (VATS) for mediastinal resections. Advantages include better visualization and finer, more precise dissection, especially important in this case, given the proximity of vital structures and the small, but real, risk of parathyromatosis associated with intraoperative cyst rupture.

Background Previous studies have demonstrated an association between pretransplantation renal dysfunction (PRD) and increased mortality after lung transplantation (LT). The purpose of this study was to determine whether PRD impacts survival after LT in patients with cystic fibrosis (CF). Methods We queried the United Network for Organ Sharing (UNOS) database to identify all adult (≥18 years) recipients with CF who underwent isolated LT from May 4, 2005 to December 31, 2014. We separated recipients into those with and those without PRD (glomerular filtration rate [GFR] ≤60 mL/min). We excluded patients who required dialysis before transplantation. Kaplan-Meier analysis was used to assess unadjusted survival differences. Cox proportional hazards modeling was then performed across 26 variables to assess the risk-adjusted impact of PRD on 1-, 3-, and 5-year mortality. Results Isolated LT was performed on 1,830 patients with CF; 17 patients were excluded because of pretransplantation dialysis. Eighty-two of 1,813 patients (4.5%) had PRD (GFR ≤60 mL/min). Kaplan-Meier analysis revealed no survival differences between PRD and non-PRD groups at 1 year (85.3% versus 89.5%; log-rank p = 0.23), 3 years (71.0% versus 72.5%; p = 0.57), or 5 years (63.3% versus 59.8%; p = 0.95). After risk adjustment, PRD was not independently associated with an increased hazard for mortality at 1 year (hazard ratio [HR], 1.38 [95% confidence interval [CI], 0.74–2.58]; p = 0.31), 3 years (HR, 1.44 [95% CI, 0.92–2.24]; p = 0.11), or 5 years (HR, 1.30 [95% CI, 0.86–1.94]; p = 0.29). Conclusions Although PRD has historically served as a relative contraindication to LT, our study is the first to suggest that among CF recipients, PRD was not associated with increased hazard for mortality out to 5 years after LT.

Purpose While recipients who are critically ill at the time of lung transplantation are at increased risk of post-transplant mortality and complications, it is unclear whether outcomes for inpatient recipients without critical care needs are any worse than those of patients who are admitted from home prior to transplant. Methods The United Network for Organ Sharing database was queried for adult lung transplants between 2005 and 2017. Patients were classified as either inpatient or outpatient at the time of transplant. Patients requiring life support or critical care were excluded. Patients were stratified by Lung Allocation Score (LAS) and functional status, and propensity score matching was performed on demographics and risk factors. Post-transplant survival, graft function, forced expiratory volume (FEV1), and functional status were analyzed with the Kaplan-Meier method and Cox proportional hazard, linear, and logistic regression. Results Of the 12,198 patients included in the study, 6140 were inpatient at the time of transplant (50.3%). Stratification and propensity score matching yielded 4760 well-matched pairs. Post-transplant survival was 85.6% at 1 year and 68.5% at 3 years for outpatients and 85.8% at 1 year and 67.3% at 3 years for inpatients (p = 0.700 by log-rank test). Graft function was 73.1% at 1 year and 39.0% at 3 years for outpatients and 72.0% at 1 year and 31.5% at 3 years for inpatients (p = 0.001). In Cox regression, inpatient status was not associated with post-transplant mortality (hazard ratio: 1.00, p = 0.892), but was associated with increased risk of graft failure (HR = 1.16, p = 0.005). In logistic regression, inpatient status was associated with increased risk of graft failure at 3 years (odds ratio: 1.39, p = 0.003) and worse FEV1 (p Conclusion When controlling for LAS score, functional status, and risk factors, patients who required hospitalization prior to lung transplant had similar survival, but worse long-term outcomes.

166 Background: Esophagogastrectomy following neoadjuvant chemo-radiation therapy for the treatment of locally advanced esophageal cancer is associated with significant morbidity and mortality. We hypothesized that the avoidance of neck anastomoses unless absolutely necessary to achieve negative margins and standardization of the anastomotic technique among surgeons would significantly decrease perioperative morbidity and potential mortality and improve oncologic outcomes for these patients. Methods: A HIPAA-compliant, prospectively maintained data base was retrospectively analyzed on 115 patients who underwent esophagogastrectomy following chemo-RT from 2007-2017 performed via a laparotomy and right thoracotomy using a standardized anastomotic technique. These procedures were performed by 5 different attending surgeons at 2 different academic medical centers. Peri-operative morbidity was assessed by standard measures and post-operative survival was assessed using Kaplan-Meyer survival. Results: There was 1 anastomotic leak and 1 mortality at 30 and 90 days. The overall 5-year survival was 40%. Major morbidity, defined as re-operation for bleeding, anastomotic leak, pneumonia, reintubation, chyle leak, and initial mechanical ventilation > 48 hours was 26% (30/113). Conclusions: Low anastomotic complication rates are associated with decreased perioperative morbidity and prolonged oncologic survival when compared to historical controls.

We have evaluated a biomaterial to serve as a scaffold for the propagation and amplification of chondrocytes that promotes the original cellular phenotype of these cells. The goal of the present study was to investigate the use of thermally reversible polymer gels poly(NiPAAm-co-AAc), as a biocompatible supporting scaffold for the propagation of chondrocytic cells. The polymer gels at temperatures above its lower critical solution temperature whereas liquefying at temperatures below its lower critical solution temperature of 34.5°C. Hence, the polymer, in its gelled form, has the ability to hold cells in situ, forming a matrix similar to the natural cellular environment or the extracellular matrix that comprises cartilage. We tested the hypothesis that the polymer gel promotes cell viability and function. Human osteoblast-like cells, nasal chondrocytes, and articular chondrocytes (1 × 105/150 μL) were resuspended in enriched Dulbecco's minimal essential media and were plated onto control (without gel) and gel containing 24-well plates. The plates were reincubated at 37°C, 5% CO2 for the time point of interest. Additional media was added to the plates and exchanged as needed. After cell culture, cells were retrieved, enumerated, and cell viability was determined. Other aliquots of the cells were stained for morphological analysis whereas expression of chondrocyte markers including collagen type II and aggrecan were determined using reverse transcriptase–polymerase chain reaction. The polymer gel was not cytotoxic because the cell number retrieved from three-dimensional culture gel was found to be one to two times higher than that retrieved from monolayer culture. Chondrocytes propagated in the thermo-reversible polymers expressed enhanced or maintained expression of collagen type II and aggrecan. Collagen type I expression was decreased or unaltered. The N-isopropylacrylamide and acrylic acid copolymer gel has potential use as a cell culture substrate and as a cell delivery vehicle. © 2003 Wiley Periodicals, Inc. J Biomed Mater Res 67A: 1310–1319, 2003

Over the last decades, there has been a paradigm shift regarding the management of peritoneal dissemination of intra-abdominal malignancies. Previously believed to be an end-stage disease amenable only to palliative management, several studies have reported achieving significant survival advantage by applying cytoreduction of the tumour load with or without intraoperative hyperthermic intraperitoneal chemotherapy administration. It is hard to classify this procedure as curative despite the reported good results in achieving a reasonable 5-years survival. However, its ability to control the disease process is clearly recognized in different types of intra-abdominal malignancies and its role is better understood within the new concept of treating advanced cancer as a chronic disease. The aim of this review is to discuss the concept, techniques, results and complications of this approach. Current indications and future directions will also be emphasized.