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Aim To review the indications, complications and outcomes of extracorporeal membrane oxygenation (ECMO) in major trauma patients. Methods Single centre, retrospective, cohort study. Results Over a ten year period, from 13,420 major trauma patients, 11 were identified from our institutional trauma registry as having received ECMO. These patients were predominantly younger (mean 39 +/- 17 years), male (91%) and severely traumatised (median ISS 50, IQR 34 - 54). Veno-venous (VV) ECMO was used predominantly (n = 7, 64%), to treat hypoxic respiratory failure (mean PaO2/FiO2 ratio 69.7 +/- 38.6), secondary to traumatic lung injury. Veno-arterial (VA) ECMO was used less frequently, primarily to treat massive pulmonary embolism following trauma. Major bleeding complications occurred in four patients, however only one patient died from haemorrhage. Heparin free (2/11), delayed (3/11) or low dose heparin (2/11) therapy was frequently utilised. The median time from injury to ECMO initiation was 1 day (IQR 0.5 - 5.5) and median ECMO duration 9 days (IQR 6.5 - 10.5). ECMO was initiated72 hours in 6 patients, with survival to discharge 67%, compared to 20% in those initiated72 hours. Overall survival to discharge was 45%, and was higher with VV ECMO (64%), than other configurations (25%). Conclusion ECMO was rarely used in major trauma, the most common indication being severe hypoxaemic respiratory failure secondary to lung injury. In this severely injured cohort, overall survival was poor but better in VV compared to VA and better if initiated early (72 hours), compared to late.

Background: Emphysema is characterised by airflow obstruction, hyperinflation, and resultant dyspnoea. It is worth investigating whether decompression improves lung mechanics and enhances quality of life (QoL). Objectives: The purpose of this study was to describe the feasibility and safety of creating a transthoracic pneumostoma to enable lung reduction. Methods: A transthoracic 10-mm diameter Portaero Access Tube (Portaero™, Cupertino, CA, USA) was implanted via a third intercostal space incision in 15 severe emphysema patients [mean age 63 years, forced expiratory volume in 1 s 54% predicted, diffusing capacity for carbon monoxide 31% predicted, residual volume 246% predicted, Six-Minute Walk Test 296 m]. Four weeks later, an 8-mm Portaero Disposable Tube (3-8 cm in length) was substituted and changed daily thereafter. The targeted primary endpoints were a ≥12% increase in forced expiratory volume in 1 s and a decrease of ≥4 points in Saint George's Respiratory Questionnaire score at 6 months. Results: Sixteen procedures were performed on 15 patients, complicated by 1 intercostal haemorrhage, 1 pneumothorax, and universal mild surgical emphysema. Early patency issues were common, but often responded to external endoscopic debridement or argon plasma laser. Three-month patency was achieved in 9 of 15 patients, and 6 of these had long-term patency (mean of 4 years). Patency was associated with potentially useful long-term improvements or stability in spirometry, residual volume, and QoL. However, the primary endpoints were not met at 6 months. Conclusion: The creation and maintenance of a transthoracic pneumostoma appears feasible and safe in patients with severe emphysema. Further studies refining patient selection (perhaps via chest computed tomography collateral ventilation and fissure assessments), techniques, and tube materials are suggested.

AATD is a common inherited disorder associated with an increased risk of developing pulmonary emphysema and liver disease. Many people with AATD‐associated pulmonary emphysema remain undiagnosed and therefore without access to care and counselling specific to the disease. AAT augmentation therapy is available and consists of i.v. infusions of exogenous AAT protein harvested from pooled blood products. Its clinical efficacy has been the subject of some debate and the use of AAT augmentation therapy was recently permitted by regulators in Australia and New Zealand, although treatment is not presently subsidized by the government in either country. The purpose of this position statement is to review the evidence for diagnosis and treatment of AATD‐related lung disease with reference to the Australian and New Zealand population. The clinical efficacy and adverse events of AAT augmentation therapy were evaluated by a systematic review, and the GRADE process was employed to move from evidence to recommendation. Other sections address the wide range of issues to be considered in the care of the individual with AATD‐related lung disease: when and how to test for AATD, changing diagnostic techniques, monitoring of progression, disease in heterozygous AATD and pharmacological and non‐pharmacological therapy including surgical options for severe disease. Consideration is also given to broader issues in AATD that respiratory healthcare staff may encounter: genetic counselling, patient support groups, monitoring for liver disease and the need to establish national registries for people with AATD in Australia and New Zealand.

Mucormycosis carries a high mortality rate with few therapeutic options available. We describe a man with pulmonary/splenic mucormycosis complicating hypoplastic myelodysplastic syndrome on a background of chronic kidney disease, who achieved a complete response with salvage isavuconazole therapy following intolerance of consecutive courses of liposomal amphotericin and posaconazole therapy.

We present a case of intraoperative coronary artery vasospasm during thoracic surgery causing profound hemodynamic instability. A 68-year-old man undergoing completion right pneumonectomy exhibited intraoperative widespread ST elevation with associated hypotension. Transesophageal echocardiography performed by the anesthetist revealed hypokinetic apical and lateral walls, prompting transportation to the catheterization laboratory, with angiography demonstrating widespread coronary artery spasm. Intracoronary nitroglycerin relieved the vasospasm; however, heparin administration caused significant postoperative bleeding, resulting in cardiac arrest requiring resuscitation and return to the operating room. He ultimately recovered and was discharged to a rehabilitation facility 3 weeks later.

Scedosporium is an important pathogen in cystic fibrosis (CF) and post-transplant but rarely causes invasive infection. Treatment remains challenging, particularly due to inherent resistance to multiple antifungal agents. We present a young man with CF who developed invasive sternal and rib infection 10-months following lung transplant. The infection has been clinically and radiologically cured with extensive surgery and triazole therapy. This case highlights the importance of adjunctive surgery in addition to prolonged triazole treatment to manage invasive Scedosporium infections in immunosuppressed patients.

Bronchoscopic Lung Volume Reduction (BLVR) and Surgical Lung Volume Reduction (SLVR) and are two different approaches used to remodel severely emphysematous lungs to improve lung function and quality-of-life. We present a case initially referred for lung transplantation, where sequential left upper lobe BLVR and 7 years later right upper lobe SLVR, providing enduring physiological and functional improvement. The potential for sustained benefit via sequential unilateral lung volume reduction is under-appreciated.

Background Primary graft dysfunction (PGD) remains a significant problem after lung transplantation. Data from animal and clinical studies suggest that remote ischemic conditioning (RIC) may reduce ischemia-reperfusion injury in solid organ transplantation. Methods A pilot randomized controlled trial of 60 patients undergoing bilateral sequential lung transplantation assessed the utility of RIC in attenuating PGD. Treated recipients underwent 3 cycles of lower limb ischemic conditioning before allograft reperfusion. The primary outcome measure was a comparison of the partial pressure of arterial oxygen/fraction of inspired oxygen ratio (P/F ratio) between treatment groups. Results No adverse effects of tourniquet application were observed. The mean lowest P/F ratio during the first 24 hours after transplantation was 271.3 mm Hg in the treatment arm vs 256.1 mm Hg in the control arm ( p = 0.46). PGD grade and severity and the rate of acute rejection also showed a tendency to favor the treatment arm. Sub-group analysis demonstrated a significant benefit of treatment in patients with a primary diagnosis of restrictive lung disease, a group at high risk for the development of PGD. RIC was not accompanied by systemic release of high-molecular-weight group box 1. Levels of cytokines, high-molecular-weight group box 1, and endogenous secretory receptor for advanced glycation end products peaked within 2 hours after reperfusion and likely reflected donor organ quality rather than an effect of RIC. Conclusions RIC did not significantly improve P/F ratios or PGD in this randomized controlled trial. However, encouraging results in this small study warrant a large multicenter trial of RIC in lung transplantation.

This case reports the successful management of chylothorax in a non-transplanted patient with pulmonary lymphangioleiomyomatosis (pLAM). Prolonged initial therapy failed, including total parenteral nutrition, pleural drainage, surgical pleurodesis, and pleurectomy. Commencement of sirolimus 2 mg daily (2 mg alternating days had failed) led to resolution of chylothorax after 20 days. Discontinuation of sirolimus for abdominal surgery led to recurrence of the chylothorax. Reinstitution of sirolimus led to rapid resolution of the effusion, stabilization of lung function, and there has been no recurrence in the ensuing 4 years. We conclude that sirolimus should be considered in the management of pLAM-related chylothorax, perhaps before surgical intervention.

Background Xenotransplantation could provide a solution to the donor shortage that is currently the major barrier to solid-organ transplantation. The ability to breed pigs with multiple genetic modifications provides a unique opportunity to explore the immunologic challenges of pulmonary xenotransplantation. Methods Explanted lungs from wild-type and 3 groups of genetically modified pigs were studied: (i) α1,3-galactosyltransferase gene knockout (GTKO); (ii) GTKO pigs expressing the human complementary regulatory proteins CD55 and CD59 (GTKO/CD55-59); and (iii) GTKO pigs expressing both CD55-59 and CD39 (GTKO/CD55-59/CD39). The physiologic, immunologic and histologic properties of porcine lungs were evaluated on an ex vivo rig after perfusion with human blood. Results Lungs from genetically modified pigs demonstrated stable pulmonary vascular resistance and better oxygenation of the perfusate, and survived longer than wild-type lungs. Physiologic function was inversely correlated with the degree of platelet sequestration into the xenograft. Despite superior physiologic profiles, lungs from genetically modified pigs still showed evidence of intravascular thrombosis and coagulopathy after perfusion with human blood. CONCLUSIONS The ability to breed pigs with multiple genetic modifications, and to evaluate lung physiology and histology in real-time on an ex vivo rig, represent significant advances toward better understanding the challenges inherent to pulmonary xenotransplantation.

Background The use of lobar transplantation and other size reduction techniques has allowed larger donor lungs to be utilized for smaller recipients who tend to have longer waiting times for transplantation. However, despite these advantages, the techniques have not been widely adopted. We outline the surgical and sizing issues associated with this technique. Methods A retrospective review of 23 consecutive patients who received lung transplantation with anatomic lobar reduction was performed, focusing on surgical technique and outcomes. Results All 23 patients received an anatomic lobar reduction of between 1 and 3 lobes. Survival analysis showed no difference between the lobar reduction cohort and the other historically comparable lung transplant patients from our institution ( p = 0.115). Percent predicted forced vital capacity and forced expiratory volume in 1 second at 3 months correlated with transplanted donor to recipient total lung capacity ratio, confirming the importance of correct sizing. Conclusions Anatomic lobar reduction in lung transplantation is a safe and effective means of transplanting pediatric and small adult recipients, and urgently listed patients.

Background: A common surgical incision for bilateral lung transplantation is the ‘clam shell’ approach via bilateral anterior thoracotomies and a transverse sternotomy to allow for the replacement of the lungs sequentially (Macchiarini et al, 1999; Karnak et al, 2006 ). Although popular, the clam shell incision (CSI) can be associated with significant postoperative pain, bony overriding or disruptions at the sternotomy site in 32%-60% of patients (Macchiarini et al, 1999; Venuta et al, 2003 ; Richards et al, 2004 ; Karnak et al, 2006 ). The subsequent non-union and sternal instability cause significant morbidity and mortality with reported rates of 34% and 26%, respectively ( Karnak et al, 2006 ). Content: The literature revealed a myriad of surgical approaches to this clinical problem, but a paucity of conservative external chest bracing solutions for transverse sternal instability. This case series describes the clinical management of three post bilateral sequential lung transplant (BSLTX) recipients that necessitated the design and development of a custom made external chest orthosis (brace) with input from a multidisciplinary team. Conclusion: This brace is offered as a solution for transverse sternal instability and pain following lung transplantation.

Improvements in pre-hospital care and the development of integrated Trauma Systems have streamlined access for the severely injured to sophisticated, specialist Trauma Centre reception and resuscitation. We describe the initial care of a survivor of combined ruptures of the left ventricle and left atrium secondary to blunt injury. This case emphasises the contribution of such a Trauma System in achieving a favourable outcome for a severely injured trauma patient with injuries previously considered non-survivable.

In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.

s S237 Therapy (BTT) may include either medical or social criteria. We sought to find the rate at which patients who were originally implanted as DT candidates changed their classification to BTT. Methods: We reviewed charts of patients who received LVADS at our center as Destination Therapy between February, 2012 and September, 2014. There was a cohort of 56 patients during this timeframe. Patients who were implanted at other centers were not included in this review. Results: Of the fifty-six DT LVAD patients, six of twenty-two with elevated Body Mass Index eventually were listed for heart transplant (conversion rate 27%); five of thirteen patients who had active/recent smoking or other tobacco use were eventually listed (38%); two out of four patients with uncontrolled diabetes mellitus (50%) eventually met transplant criteria and were listed; two of three patients initially not candidates due to active or recent malignancy were cleared for listing; one of four patients with active or recent drug use (25%) later were listed; one of two patients within insufficient support established support after LVAD and were listed for transplant (50%); one patient who did not originally have sufficient insurance coverage did acquire it and was listed for transplant. Those DT patients who were implanted due to age, pulmonary hypertension or other end-organ dysfunction have not been listed for transplant. One patient transferred care after LVAD placement and was lost to followup. The average time from LVAD implant to listing was 150 days. Two of the patients who were listed after LVAD implant are currently inactive due to elevated BMI. Conclusion: For those with controllable factors such as elevated BMI, smoking, or diabetes control, there is an assumption that the patients can quickly modify these factors to enable transplant listing. This review showed that a large percentage of these patients do not. It also showed that some patients temporarily modify behaviors in order to be listed for transplant, but then later again become ineligible.

To describe our experience to date of four children with end-stage lung disease who have been bridged with ECMO to successful lung transplantation in our institution. Between March 2006 and June 2012, a total of 21 pediatric patients successfully underwent lung transplantation within The Alfred's lung transplantation program. This included four children who were bridged on ECMO prior to transplantation according to the "ECMO bridge to transplant" protocol and whose clinical notes and outcomes were reviewed. Lung transplantation is an established life-saving treatment for patients with severe lung disease, but remains limited due to scarcity of suitable donor organs. This is a particular issue in the pediatric setting, where the smaller child waits disproportionately longer compared with adult patients for size-matched donor lungs. As ECMO has become more widely accepted, its use as a bridge to lung transplantation in pediatric patients with severe acute lung injury or end-stage chronic lung disease has been considered. The medical notes from the four pediatric patients were retrospectively reviewed. Our report describes excellent short- and medium-term outcomes in a small number of children who have been bridged to transplant on ECMO.

ters to further investigate and potentially improve donor organ function. doi:10.1016/j.hlc.2010.10.036 Accuracy in Staging Lung Cancer using Ebus Transbronchial Needle Aspiration Shoane Ip ∗, Julian Gooi, Simon Knight, Siven Seevanayagam Austin Hospital, Melbourne, Victoria, Australia Introduction:Pathologicdiagnosis ofmediastinal lymph nodes is often required for lung cancer staging and decisions regarding treatment. In those without histological diagnosis it can also be used to obtain a diagnosis. Previously, the standardmethods for interrogatingmediastinal lymph nodes were through invasive procedures including mediastinoscopy, mediastinotomy, V.A.T.S, E.U.S or blind transbronchial biopsy. Endobronchial ultrasound is a new technique for biopsy of mediastinal lymph nodes that is less invasive. This allows the lymph node to be sampled under real time ultrasound guidance. This presentation looks at our first 18 months experience using EBUS for mediastinal lymphnodebiopsy in suspected lung cancers. Methods: Prospectively collected data on all EBUS biopsy procedures at the Austin Hospital in Melbourne from January 2008 to June 2009 were analysed. The decis C b p n l W e p d i f 5 a o l o c w w a 5 p a l r i m a n experience is needed to evaluate the role of EBUS in other diseases involving the mediastinal lymph nodes. doi:10.1016/j.hlc.2010.10.037 Pulmonary Lobectomy for NSCLC in Octogenarians Shoane Ip ∗, Bing Teh, Zeng Yap, Julian Gooi, Simon Knight, Siven Seevanayagam Austin Hospital, Melbourne, Victoria, Australia Introduction: The world population is aging as a result of increasing life expectancy and advances in health care. The mean age that lung cancer is diagnosed in Australia is also increasing and is now above 70. Currently, surgical resection with clear margin is the treatment of choice for early disease. However, octogenarians have been associated with high complication rates and mortality due to co-morbidities. Surgerymay have been denied due to perceived lower life expectancy and hence lower quality of life. However, studies have shown that lung resections in the elderly can be performed safely withminimalmorbidity [1]. Theaimof this study is to assessmorbidity andmortality of lobectomies for non-small cell lung cancer in octogenarians and whether we should be less stringent in selecting octogenarians for pulmonary lobectomy. Methods: This is a retrospective data analysis of all pulm a f g o i o f m s y a b ( w ( w u ( p d w v w N m p a i r ion to biopsy lymphnodeswas based on a combination of T, PET and clinical findings. Funding for EBUS has only een provided for those cases where lung cancer was susected. Data recorded included size and location of lymph odesbiopsied,whether nodeswerepositive and the cytoogical diagnosis, length of stay and procedures avoided. hen samples were negative, follow up was carried out ither by clinical monitoring via CT or further diagnostic rocedures to confirm the diagnosis. Results: In the first 18 months, 86 EBUS biopsy proceures were done. There were 55 in the first year and 31 n the subsequent 6 months. There were 56 male and 29 emale patients.Mean agewas 64 years.Of the 86 patients, 4 (63%) were admitted as a day case and 79 (92%) were dmitted on the day of surgery. Positive diagnosis was btained in 47 (54%). Of the positive biopsies, 41 were ung cancers and 6 were other cancers. Negative biopsies ccurred in 39 cases (45%). True negatives occurred in 18 ases (21%), false negatives in 7 cases (8%) and 14 cases ere still pending follow-up. The accuracy of diagnosis as 72–92%. In the 47 positive cases there were 26 medistinoscopy, 5mediastinotomy, 6VATS, 5 thoracotomyand EUS procedures avoided. There were no instances of rocedure associated pneumothorax or bleeding. Discussion: Endobronchial ultrasound is emerging as n accurate technique for interrogation of mediastinal ymphnodes. There is a learning curve involvedwith accuately identifying and sampling the target lymph nodes. It s a safe procedure, which is less invasive, with minimal orbidity, low risk of complications and can be done as day procedure. In the setting of lung cancer the diagostic yield and accuracy are very good, however, further onary lobectomies for NSCLC performed in patients ged 80 and above at the Austin Hospital, Melbourne rom 1992 to 2008. Over this period, 26 patients in this age roup underwent lobectomy for NSCLC. Information was btained from the medical records. Where records were ncomplete or follow-upwas inadequate, informationwas btained by contacting the local medical officer, patient or amily.Theendpointsmeasuredwere in-hospital or 30day ortality, 1 year survival and 5 year survival. KaplanMeier urvival curves were used to estimate 5 year survival. Results:All patients were between the ages of 80 and 85 ears. The mean age was 81.88 years. There were 19 male nd 7 female patients. There were an increasing numer of lobectomies being performed in more recent years 14 in the past 5 years). In-hospital and 30 day mortality as 3.8% (1 of 26). Morbidity included atrial fibrillation 6), pneumonia (4) and prolonged air leak (3). One patient as admitted to ICU post operatively for respiratory failre. Median length of stay was 11 days. Three patients 11%) required rehabilitation before returning home. One atient was discharged to respite care and one patient was ischarged to a peripheral hospital. Eventual return home as achieved in 25 patients (96%). Overall one year surivalwas84%,5year survivalwas64%andmediansurvival as greater than 7 years. Discussion: In conclusion, pulmonary lobectomy for SCLC in octogenarians can be performed safely with inimal increase in morbidity in properly selected atients. Survival at 1 and 5 years is comparable to other ge groups undergoing lobectomy. Comparative studes are needed to follow-up patients who had surgically esectable disease butwere not offered or did not undergo A B S T R A C T S 52 Heart, Lung and Circulation Abstracts 2011;20:35–67 resections. It may be that we should not be as selective when offering surgical treatment for NSCLC in patients between the ages of 80 and 85 years.

ObjectiveThe aims of this study were first to analyze neurocognitive outcomes of patients after open-chamber cardiac surgery to determine whether carbon dioxide pericardial insufflation reduces incidence of neurocognitive decline (primary end point) as measured 6 weeks postoperatively and second to assess the utility of carbon dioxide insufflation in cardiac chamber deairing as assessed by transesophageal echocardiography.MethodsA multicenter, prospective, double-blind, randomized, controlled trial compared neurocognitive outcomes in patients undergoing open-chamber (left-sided) cardiac surgery who were assigned carbon dioxide insufflation or placebo (control group) in addition to standardized mechanical deairing maneuvers.ResultsOne hundred twenty-five patients underwent surgery and were randomly allocated. Neurocognitive testing showed no clinically significant differences in z scores between preoperative and postoperative testing. Linear regression was used to identify factors associated with neurocognitive decline. Factors most strongly associated with neurocognitive decline were hypercholesterolemia, aortic atheroma grade, and coronary artery disease. There was significantly more intracardiac gas noted on intraoperative transesophageal echocardiography in all cardiac chambers (left atrium, left ventricle, and aorta) at all measured times (after crossclamp removal, during weaning from cardiopulmonary bypass, and at declaration of adequate deairing by the anesthetist) in the control group than in the carbon dioxide group (P

Prolonged Ex-Vivo Pulmonary Xenograft Function Using GeneticallyModified Porcine Donor Lungs G.P. Westall, B. Levvey, J. Gooi, M. Silvana, R. McEgan, M. Mennen, F. Rosenfeldt, G. Snell, P. Cowan. Lung Transplant Unit, Alfred Hospital, Melbourne, VIC, Australia; Department of Immunology, St Vincent’s Hospital, Melbourne, VIC, Australia; Department of Immunology, The University of Adelaide, Adelaide, SA, Australia.

Introduction We investigated the relationship between predominant subtype, according to the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society International Multidisciplinary Lung Adenocarcinoma Classification; mutation status; and patient outcome in stage III (N2) lung adenocarcinoma. Methods We identified 69 patients with stage III (N2) lung adenocarcinoma operated on with curative intent between 1993 and 2011 who had adequate tumor tissue for molecular analysis and adequate follow-up time for survival analysis. DNA was isolated and tested for mutations using Sequenom's OncoCarta Panel (v1.0; Sequenom, San Diego, CA). Results The majority of tumors were acinar (26 of 69 tumors; 38%), solid (24 of 69 tumors; 35%), and micropapillary predominant (13 of 69 tumors; 19%) subtypes. EGFR and KRAS mutations were identified in 17 of 59 tumors (29%) and 13 of 59 tumors (22%), respectively. EGFR mutations occurred most often in acinar (11 of 25 tumors; 44%) and micropapillary predominant tumors (five of 13 tumors; 38%) ( p = 0.009), whereas KRAS mutations occurred most often in solid predominant tumors (nine of 21 tumors; 43%) ( p = 0.016). Patients with acinar predominant tumors had significantly improved overall survival compared with those with non-acinar predominant tumors (hazard ratio: 0.45; 95% confidence interval: 0.22–0.91; p = 0.026), which remained significant after adjustment for EGFR status, T-stage, sex, and age. Patients with EGFR -mutant micropapillary predominant tumors had similar survival to those with EGFR -mutant acinar predominant tumors. The predominant subtype in the primary tumor was most often seen in the N2 node in micropapillary and solid predominant tumors but not in acinar predominant tumors. Conclusions The predominant subtype in the primary tumor was associated with overall survival in resected stage III (N2) lung adenocarcinoma and was independent of mutation status. Histologic subtyping provides important prognostic information and potentially molecular correlates.