Dhaval Chauhan

Post-transplant survival in idiopathic pulmonary fibrosis patients concurrently listed for single and double lung transplantation.

BACKGROUND Lung transplantation is a widely accepted treatment for patients with end-stage lung disease related to idiopathic pulmonary fibrosis (IPF). However, there are conflicting data on whether double lung transplant (DLT) or single lung transplant (SLT) is the superior therapy in these patients. The purpose of this study was to determine whether actuarial post-transplant graft survival among IPF patients concurrently listed for DLT and SLT is greater for recipients undergoing the former or the latter. METHODS The United Network for Organ Sharing provided de-identified patient-level data. Analysis included lung transplant candidates with IPF listed between January 1, 2001 and December 31, 2009 (n = 3,411). The study population included 1,001 (29.3%) lung transplant recipients concurrently listed for DLT and SLT, all ≥18 years of age. The primary outcome measure was actuarial post-transplant graft survival, expressed in years. RESULTS Among the study population, 433 (43.26%) recipients underwent SLT and 568 (56.74%) recipients underwent DLT. The analysis included 2,722.5 years at risk, with median graft survival of 5.31 years. On univariate (p = 0.317) and multivariate (p = 0.415) regression analyses, there was no difference in graft survival between DLT and SLT. CONCLUSIONS Among IPF recipients concurrently listed for DLT and SLT, there is no statistical difference in actuarial graft survival between recipients undergoing DLT vs SLT. This analysis suggests that increased use of SLT for IPF patients may increase the availability of organs to other candidates, and thus increase the net benefit of these organs, without measurably compromising outcomes.

Quantitative increase in frailty is associated with diminished survival after transcatheter aortic valve replacement

BACKGROUND The purpose of this study is to assess the impact of frailty index comprised of commonly used frailty metrics on outcomes following transcatheter aortic valve replacement (TAVR) outcomes, including mortality, length of stay, and discharge destination. METHODS AND RESULTS Retrospective data collection was performed for 342 consecutive patients who underwent TAVR at a single center from May 15, 2012, to September 17, 2015. Frailty index score was calculated using 15-ft walk test, Katz activities of daily living, preoperative serum albumin, and dominant handgrip strength. Patients were given a frailty score from 0/4 to 4/4, with higher scores indicating greater levels of frailty. There were 27 patients (8%) in 0/4, 82 patients (24%) in 1/4, 129 patients (38%) in 2/4, 73 patients (21%) in 3/4, and 31 patients (9%) in 4/4 frailty group. Multivariate cox, logistic, and linear regression analyses showed that patients with frailty score of 3/4 or 4/4 had increased all-cause mortality (P = .015 and P < .001) and were more likely to be discharged to an acute care facility (P = .083 and P = .001). 4/4 frail patients had increased post-operative length of stay (P = .014) when compared to less frail patients. Individual components of the frailty score were also independent predictors of all-cause mortality. Median survival in 4/4 frail patients was 7 months. CONCLUSIONS Frailty index comprised of commonly used frailty metrics and its components are independent predictors of poor post-TAVR outcomes. There is a stepwise increase in mortality and post-TAVR length of stay with increasing frailty with dismal prognosis in extremely frail patients.

Distribution of donor lungs in the United States: a case for broader geographic sharing.

To evaluate the association between allocation of donor lungs by geographic sharing type (GST) and lung allocation score (LAS).

Evidence supports severe renal insufficiency as a relative contraindication to heart transplantation

BACKGROUND This study was conducted to determine whether survival after orthotopic heart transplant (OHT) is associated with pre-transplant estimated glomerular filtration rate (eGFR) and to define ranges of pre-OHT eGFR associated with differences in post-transplant survival. The 2006 International Society for Heart and Lung Transplantation revised listing criteria for OHT stated that chronic kidney disease, defined by an eGFR <40 ml/min is a relative contraindication for OHT alone. The committee noted that this recommendation was supported by consensus opinion of experts and not data derived from a randomized trial or non-randomized studies. METHODS The United Network for Organ Sharing provided deidentified patient-level data. The study population included 17,459 OHT recipients aged ≥18 years who received allografts between January 1, 2001, and December 31, 2009. Logistic regression was used to assess the effect of multiple variables on survival after OHT. Receiver operating characteristic curves and stratum-specific likelihood ratios were generated to compare 1-year survival at eGFR thresholds. The primary outcomes measure was actuarial post-transplant survival expressed in years. RESULTS Regression analysis showed that a lower pre-transplant eGFR is associated with worse post-transplant survival. Threshold analysis demonstrated 3 distinct survival strata: eGFR ≤ 34 ml/min, eGFR 35 to 49 ml/min, and eGFR > 49 ml/min. Graft survival at all times is decreased for patients with eGFR ≤ 34 ml/min. They are also more likely to have in-hospital and long-term complications. CONCLUSIONS eGFR is a strong predictor of post-transplant survival and should be considered when assessing patients for OHT. This analysis supports current International Society for Heart and Lung Transplantation guidelines and suggests that end-stage heart failure patients with an eGFR ≤ 34 ml/min is a relative contraindication for heart transplantation alone.

Impact of Left-Ventricular Assist Device–Related Complications on Posttransplant Graft Survival

BACKGROUND This study describes the impact of continuous-flow left-ventricular-assist device (CF-LVAD)-related complications on postoperative outcomes. METHODS The United Network for Organ Sharing (UNOS) heart transplant follow-up data from 2005 to 2015 were obtained. CF-LVAD patients who were bridged to transplant were studied. Device-related complications (DRCs) at patients last follow-up before transplantation were reported in 5 categories: device thrombosis (B1), infection (B2), device malfunction (B3), life-threatening arrhythmias (B4), and others (B5). Multivariable Cox regression models were used to evaluate the association of each category of complications and number of complications with postoperative graft survival. RESULTS Of 3,877 patients analyzed, incidence of DRCs was as following: 374 (9.65%) for thrombosis (B1), 869 (22.41%) for device-related infection (B2), 400 (10.32%) for device malfunction (B3), 135 (3.48%) for life-threatening arrhythmias (B4), and 510 (13.15%) for others (B5). A total of 2,018 (52.05%) patients did not have any DRC at last follow-up; 1,482 (38.23%) patients had 1 DRC and 377 (9.72%) patients had 2 or more DRCs. Mean time from last preoperative follow-up to transplant in patients with 0, 1, and 2 or more DRCs was 93, 18, and 11 days, respectively. Multivariate analysis showed that none of the complications (from B1 to B5) were independent risk factors for poor graft survival after cardiac transplantation. Independent predictors of postoperative graft failure were increasing donor age, inpatient status, increasing body mass index, poor functional status, ventilator dependence, and extracorporeal membrane oxygenation at the time of transplant. CONCLUSIONS DRCs are common among advanced heart failure patients bridged to transplant with CF-LVADs. Contrary to popular belief, DRCs are not associated with poor postoperative graft survival.

Resource utilization after thoracic aortic aneurysm repair: An examination of the endovascular approach in the United States

Purpose: To examine the resource utilization of the endovascular approach for thoracic aortic aneurysm (TAA) repair, and quantify the incremental effect of complications on hospital costs and length of stay (LOS). Methods: De-identified patient-level claims data on a random sample of TAA repairs performed in the US from January 1st, 2008 to December 31st, 2008 were obtained from the Nationwide Inpatient Sample (n=3,794). Risk-adjusted total hospital costs and LOS were analyzed by major complication. Results: Analysis included 989 (26.1%) people undergoing Thoracic Endovascular Aneurysm Repair (TEVAR). The median LOS was 6 days and the median cost was

Outcomes following emergent open repair for thoracic aortic dissection are improved at higher volume centers in direct admissions and transfers

46,059. There was a stepwise increase in resource utilization as function of the number of complications per patient (p<0.001); among TEVAR the most resource intensive complications on a per patient basis were myocardial infarction and venous thromboembolism. Conclusion: TEVAR patients continue to show improvements in LOS and resource utilization. However, post-operative complications resulted in compounded hospital costs and increased length of stay. Quality improvement efforts reducing the risk of these post-operative complications have the potential to provide significant cost savings.