A. Iyengar

Heart transplantation in children with intellectual disability: An analysis of the UNOS database

Heart transplantation in children with intellectual disability (ID) is an issue of debate due to the shortage of available donor organs. We sought to perform the first large‐scale retrospective cohort study describing the prevalence and outcomes of heart transplantation in this population. The United Network of Organ Sharing database was queried from 2008 to 2015 for pediatric patients (age <19 years) receiving first, isolated heart transplant. Recipients were divided into three subgroups: definite ID, probable ID, and no ID. The chi‐square test was used to compare patients’ baseline characteristics. Kaplan‐Meier and Cox proportional hazard regression analyses were used to estimate the association between ID and death‐censored graft failure and patient survival. Over the study period, 565 pediatric patients with definite (131) or probable (434) ID received first heart transplant, accounting for 22.4% of all first pediatric heart transplants (n=2524). Recipients with definite ID did not significantly differ from those without ID in terms of gender, ethnicity, ischemia time, severity of pretransplant condition (waitlist status, mechanical ventilation, inotrope dependence, ECMO, VAD, PVRI, infection prior to transplant), or incidents of acute rejection within the first year. ID was associated with prolonged waitlist time (P<.001). Graft and patient survival at 3 years was equivalent between children with and without ID (P=.811 and .578, respectively). We conclude that intellectual disability is prevalent in children receiving heart transplants, with 22.4% of recipients over the study period having definite or probable ID. ID does not appear to negatively affect transplantation outcomes. Future studies are needed to assess long‐term outcomes of transplantation in this population.

Lung transplantation and concomitant cardiac surgery: Is it justified?

OBJECTIVE Increasing numbers of lung transplant candidates have cardiac conditions that affect their survival after transplantation. Our objective was to determine if patients who undergo concomitant cardiac surgery (CCS) during the lung transplant procedure have similar outcomes, as a cohort of isolated lung transplant recipients. METHODS This was a retrospective, observational, matched-cohort analysis. The records of lung transplant recipients who underwent CCS from August 2000 to August 2013 were reviewed. A cohort of isolated lung transplant recipients, matched on the basis of age, lung allocation score, diagnosis, type of procedure, and era, was identified. The primary endpoint of this trial was 5-year survival. The secondary endpoints were primary graft dysfunction, grade III, at 72 hours, intensive care unit and hospital length of stay, and 5-year major adverse cardiac event rates. RESULTS A total of 120 patients underwent lung transplantation and CCS. Compared with the isolated lung transplant group, the donor, recipient, and operation characteristics were similar. No difference was found in the survival of the 2 groups for up to 5 years, or in the incidence of primary graft dysfunction Grade III at 72 hours, intensive care unit length of stay, invasive ventilation, hospital length of stay, or incidence of 5-year major adverse cardiac events. CONCLUSIONS Lung transplant recipients undergoing CCS have early and midterm clinical outcomes similar to those of isolated lung transplant recipients. Given that this report is the largest published experience, offering cardiac surgery at the time of lung transplantation, to selected patients, remains justified.

Impact of an Institutional Antimicrobial Stewardship Program on Bacteriology of Surgical Site Infections in Cardiac Surgery.

Surgical site infections (SSIs) occur in 1% to 4% of cardiac surgery patients and are associated with significantly reduced survival. The present study evaluated trends in the incidence and bacteriology of SSIs before and after the implementation of an antimicrobial stewardship program.

Predictors of cardiogenic shock in cardiac surgery patients receiving intra-aortic balloon pumps

Background: Cardiogenic shock after cardiac surgery leads to severely increased mortality. Intra‐aortic balloon pumps may be used during the preoperative period to increase coronary perfusion. The purpose of this study was to characterize predictors of postoperative cardiogenic shock in cardiac surgery patients with and without intra‐aortic balloon pumps support. Methods: We performed a retrospective analysis of our institutional database of the Society of Thoracic Surgeons for patients operated between January 2008 to July 2015. Multivariable logistic regression was used to model postoperative cardiogenic shock in both the intra‐aortic balloon pumps and matched control cohorts. Results: Overall, 4,741 cardiac surgery patients were identified during the study period, of whom 192 (4%) received a preoperative intra‐aortic balloon pump. Intra‐aortic balloon pumps patients had a greater prevalence of diabetes, previous cardiac surgery, congestive heart failure, and an urgent/emergent status (P < .001). Intra‐aortic balloon pumps patients also had greater 30‐day mortality and more postoperative cardiogenic shock (9% vs 3%, P < .001). On multivariable analysis of the matched control cohort, postoperative cardiogenic shock remained multifactorial. Among the intra‐aortic balloon pumps cohort, only sex, previous percutaneous coronary intervention and preoperative arrhythmia remained significant on multivariable analysis (all P < .05). Conclusion: Factors associated with cardiogenic shock among postcardiac surgery patients differ between those patients receiving intra‐aortic balloon pumps and those who do not. Further analysis of the effects of prophylactic intra‐aortic balloon pumps support is warranted. (Surgery 2017;160:XXX‐XXX.)

Heparin-Coated Grafts Reduce Mortality in Pediatric Patients Receiving Systemic-to-Pulmonary Shunts

We aimed to evaluate the outcomes of systemic-to-pulmonary (SP) shunt procedures utilizing heparin-coated (HC) polytetrafluoroethylene (PTFE) vascular grafts compared to uncoated (non-HC) grafts, in order to observe any benefits in pediatric patients. Our institution switched from using non-HC grafts to HC grafts in March 2011. We conducted a retrospective review of consecutive pediatric patients receiving SP shunts from May 2008 to December 2015. Perioperative variables including baseline characteristics, morbidity, mortality, and blood product utilization were evaluated between the HC and non-HC groups. A total of 142 pediatric patients received SP shunts during the study period: 69 patients received HC shunts and 73 patients received non-HC shunts. The HC group had significantly fewer desaturation or arrest events (P < 0.01), fewer shunt occlusions/thromboses (P < 0.01). There was no statistically significant difference in unplanned reoperations between groups (P = 0.18). The HC group demonstrated significantly lower overall 30-day mortality (P < 0.01), as well as shunt-related mortality (P < 0.01). The HC group had significantly lower postoperative packed red blood cell utilization as compared to the non-HC group (P < 0.01). In this study, pediatric patients receiving HC PTFE grafts in SP shunts demonstrated significantly lower shunt-related mortality. The majority of HC grafts remained patent. These findings suggest that HC grafts used in SP shunt procedures may benefit pediatric patients in terms of efficacy and outcomes.

Lung transplantation in the Lung Allocation Score era: Medium-term analysis from a single center

In 2005, the Lung Allocation Score (LAS) was implemented as the allocation system for lungs in the US. We sought to compare 5‐year lung transplant outcomes before and after the institution of the LAS. Between 2000 and 2011, 501 adult patients were identified, with 132 from January 2000 to April 2005 (Pre‐LAS era) and 369 from May 2005 to December 2011 (Post‐LAS era). Kruskal‐Wallis or chi‐squared test was used to determine significance between groups. Survival was censored at 5 years. Overall, the post‐LAS era was associated with more restrictive lung disease, higher LAS scores, shorter wait‐list times, more preoperative immunosuppression, and more single lung transplantation. In addition, post‐LAS patients had higher O2 requirements with greater preoperative pulmonary impairment. Postoperatively, 30‐day mortality improved in post‐LAS era (1.6% vs 5.3%, P = .048). During the pre‐ and post‐LAS eras, 5‐year survival was 52.3% and 55.3%, respectively (P = .414). The adjusted risk of mortality was not different in the post‐LAS era (P = .139). Freedom from chronic lung allograft dysfunction was significantly higher in the post‐LAS era (P = .002). In this single‐center report, implementation of the LAS score has led to allocation to sicker patients without decrement in short‐ or medium‐term outcomes. Freedom from CLAD at 5 years is improving after LAS implementation.

Comparison of Frequency of Late Gastrointestinal Bleeding with Transcatheter Versus Surgical Aortic Valve Replacement

Improvements in technology and operator experience have led to exponential growth of transcatheter aortic valve implantation (TAVI) programs. Late bleeding complications were recently highlighted after TAVI with a high impact on morbidity. The purpose of the present study was to assess the incidence and financial impact of late Gastrointestinal (GI) bleeding after TAVI, and compare with the surgical cohort. Retrospective analysis of the National Readmissions Database was performed from January 2011 to December 2014, and patients who underwent TAVI or surgical aortic valve replacement (SAVR) were identified. Incidence of readmission with a diagnosis of GI bleeding was utilized as the primary end point. Overall, 43,357 patients were identified who underwent TAVI, whereas 310,013 patients underwent SAVR. Compared with SAVR, TAVI patients were older (81 vs 68y, p < 0.001), more women (48% vs 36%, p < 0.001), and had higher Elixhauser Comorbidity Index (6 vs 5, p < 0.001). Hospital stay was shorter with TAVI (5 vs 8 days, p < 0.001), but raw in-hospital mortality rates were similar (4.2% vs 3.8%, p = 0.022). In the TAVI cohort, 3.3% of patients were rehospitalized for GI bleeding compared with 1.5% of the SAVR cohort (p < 0.001). Average time to bleeding readmission was similar between cohorts (92 vs 84 days, p = 0.049). After multivariable adjustment, TAVI remained significantly associated with readmissions for GI bleeding compared with SAVR Adjusted Odds Ratio (AOR 1.54 [1.38 to 1.71], p < 0.001). In this national cohort study, TAVI was associated with more frequent readmissions for late GI bleeding compared with SAVR. In conclusion, strategies to reduce late GI bleeding may serve as important targets for improvement in overall quality of care.