Eric S. Weiss

Impact of U.S. Lung Allocation Score on Survival After Lung Transplantation

BACKGROUNDnThe Lung Allocation Score (LAS) dramatically changed organ allocation in lung transplantation. The impact of this change on patient outcomes is unknown. The purpose of the study was to examine early mortality after lung transplantation under the LAS system.nnnMETHODSnAll patients undergoing first-time lung transplantation during the period from May 1, 2005 through April 30, 2008 were included in the study. The cohort was divided into quintiles by LAS. A high-risk group (LAS >46) was comprised of the highest quintile, Quintile 5, and a low-risk group (LAS < or =46) included the lower quintiles, Quintiles 1 through 4. A time-to-event analysis was performed for risk of death after transplantation using Kaplan-Meier survival and Cox proportional hazards models.nnnRESULTSnThere were 4,346 patients who underwent lung transplantation during the study period. Patients in the high-risk group (LAS >46) were more likely to have idiopathic pulmonary fibrosis (IPF; 52.9% vs 23.8%, p < 0.001) and diabetes (25.8% vs 16.8%, p < 0.001) and to require mechanical ventilatory support (15.4% vs 2.2%, p < 0.001) at the time of transplant as compared with patients in the low-risk group. One-year survival using the Kaplan-Meier product limit estimator was significantly worse in the high-risk group (75% vs 83%, p < 0.001 by log-rank test). Patients in the high-risk group were also found to have increased risk of death (hazard ratio 1.46, 95% confidence interval 1.24 to 1.73) compared with the low-risk group.nnnCONCLUSIONSnOverall 1-year survival under the new LAS system appears to be similar to that in historic reports. However, risk of death was significantly increased among patients with LAS >46.

Outcomes in Patients Older Than 60 Years of Age Undergoing Orthotopic Heart Transplantation: An Analysis of the UNOS Database

BACKGROUNDnPatients 60 years and older have traditionally not been considered candidates for orthotopic heart transplantation (OHT). Recent studies have shown equivalent survival between older and younger patients, leading many to question this traditional ethos. As these studies may lack significant power to draw meaningful conclusions, the United Network for Organ Sharing (UNOS) database provides a unique opportunity to examine the effects of age on OHT.nnnMETHODSnWe retrospectively reviewed the UNOS dataset to identify 14,401 first-time OHT recipients between the years 1999 and 2006. Stratification was by age into those >or=60 years and younger patients aged 18 to 59 years. Baseline demographic and clinical factors were recorded. The primary end-point was all-cause mortality during the study period. Secondary outcomes included length of hospital stay (LOS), post-operative stroke, post-operative infections, acute renal failure (ARF) and rejection within 1 year of transplant. Post-transplant survival was modeled using the Kaplan-Meier method and compared between groups using Cox proportional hazard regression.nnnRESULTSnOf the 14,401 patients who met the inclusion criteria, 30% (n = 4,273) were >or=60 years of age. The elderly group had higher serum creatinine levels (1.5 vs 1.3, p < 0.001), longer waitlist times (255 vs 212 days, p < 0.001), and were more likely to have hypertension (HTN; 46% vs 37%, p < 0.001) or diabetes mellitus (DM; 25% vs 20%, p < 0.001). Survival at 30 days, 1 year and 5 years was 94%, 87% and 75% for the young group, and 93%, 84% and 69% for the older group (p < 0.001). Multivariate analysis revealed age >or=60 years, donor age, ischemic time, creatinine, HTN and DM to be independent predictors of mortality. Older patients had more infections (26% vs 23%, p < 0.001), ARF (9% vs 7%, p < 0.001) and longer LOS (21 vs 19 days, p < 0.001), but had lower rates of rejection (34% vs 43%, p < 0.001) as compared with younger recipients.nnnCONCLUSIONSnThe UNOS database has provided a large multi-institutional sample examining OHT in the elderly. Although our analysis shows lower survival in patients >or=60 years of age, the cumulative 5-year survival in these patients of close to 70% is acceptable. OHT should not be restricted based on age, as encouraging long-term results exist.

Outcomes in Bicaval Versus Biatrial Techniques in Heart Transplantation: An Analysis of the UNOS Database

BACKGROUNDnDespite 40 years of heart transplantation, the optimal atrial anastomotic technique remains unclear. The United Network for Organ Sharing (UNOS) database provides a unique and novel opportunity to address this question by examining survival in a large cohort of patients undergoing orthotopic heart transplantation (OHT). We hypothesized that, when examining the issue on a large scale, no difference in survival would exist between techniques.nnnMETHODSnWe retrospectively reviewed first-time adult OHT in the UNOS database to identify 14,418 patients undergoing OHT between the years 1999 and 2005. Primary stratification was between those who underwent bicaval vs biatrial techniques. Baseline demographic and clinical factors were also recorded. The primary end-point was mortality from all causes during the study period. Secondary outcomes included length of hospital stay (LOS), and need for permanent pacemaker placement (PP). Post-transplant survival was compared between groups using a Cox proportional hazard regression model.nnnRESULTSnOf the 11,931 patients who met inclusion criteria between 1999 and 2005, 5,207 (44%) underwent the bicaval anastomotic technique. Bicaval and biatrial groups were well matched for gender, donor age, ischemic time, pulmonary vascular resistance, transpulmonary gradient, cardiac index, body mass index and pre-operative creatinine. Technique was not associated with survival during the study period (hazard ratio 1.06, p = 0.31). On multivariate analysis, age, gender, donor age and ischemic time were independent predictors of mortality. The bicaval technique was associated with less need for post-operative PP (2.0% vs 5.3%, p < 0.001) and shorter LOS (19 vs 21 days, p < 0.001).nnnCONCLUSIONSnThis study is the single largest series examining bicaval vs biatrial anastamotic techniques for OHT. We found no difference in survival between the two groups, although the bicaval technique was associated with shorter LOS and pacemaker placement. Both techniques lead to equivalent survival in OHT.

Preoperative Recipient Cytokine Levels Are Associated With Early Lung Allograft Dysfunction

BACKGROUNDnPrimary graft dysfunction (PGD) is a morbid complication after lung transplant (LTx). Recipient before and after cytokine and chemokine profiles may be associated with a recipients propensity to have PGD.nnnMETHODSnSerum samples were obtained from adult (more than 17 years old) primary LTx recipients (2002 to 2007) at two time points: (1) pre-reperfusion of transplanted lungs, and (2) within 24 hours after reperfusion. Interleukin (IL)-6, IL-8, IL-10, chemokine ligand (CCL)-2, and matrix metalloproteinase (MMP)-9 levels were determined. A PaO2/FiO2 ratio less than 300 at 48 hours (International Society for Heart and Lung Transplantation PGD grade 2 or more) was used to stratify patients. Follow-up was obtained through August 2009. Cytokine levels at both time points and the change in levels were assessed for association with PGD grade 2 or more. Outcomes and clinical characteristics were analyzed.nnnRESULTSnOf 28 patients, 8 (28.6%) had PGD grade 2 or more. Median follow-up was 23 months (interquartile range, 16 to 31). Demographics, clinical data, and pre-LTx diagnoses did not differ between the groups. Patients who had PGD grade 2 or more had higher baseline levels of IL-10, IL-8, IL-6, and CCL-2 (all p<0.05). Within 24 hours, PGD grade 2 or more patients had higher IL-10 (p=0.02) and CCL-2 (p=0.04) levels. The PGD grade 2 or more patients were more likely to have had cardiopulmonary bypass during LTx (p=0.002) and blood products administered: platelets (p=0.004), plasma (p=0.05), and packed red blood cells (p=0.03)]. The PGD grade 2 or more patients had longer length of stay, duration of mechanical ventilation, and total intensive care unit days.nnnCONCLUSIONSnHigher before and after transplant cytokine/chemokine levels were found in LTx recipients who subsequently had PGD grade 2 or more. Our study demonstrates that the recipients inflammatory state at the time of LTx may impact early allograft function. That could represent a potential target for pretransplant pharmacologic intervention.

Ruptured Dissecting Intramural Duodenal Hematoma Following Endoscopic Retrograde Cholangiopancreatography

A 34-year-old woman with schizophrenia developed abdominal pain. Ultrasound demonstrated cholelithiasis and a dilated biliary tree. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), sphincterotomy, and extraction of gallstones from the common bile duct. She developed post-procedure fever, tachycardia, and abdominal pain and was taken to the operating room for urgent cholecystectomy with intraoperative cholangiogram. At laparotomy, an intramural dissecting duodenal hematoma was discovered, which extended the length of the duodenum and ruptured. She underwent gastric pyloric exclusion, gastrojejunostomy, and healed uneventfully. ERCP is not without risks, and a degree of vigilance should be maintained in patients who develop new symptomatology following the procedure.

Left anterior descending coronary aneurysm.

A 19-year-old man presented with gradual onset of retrosternal chest pain and hemodynamic instability. Echocardiography and computed tomography showed substantial anterior and posterior pericardial effusion with tamponade. At surgery, a 3-cm ruptured aneurysm of the left anterior descending coronary artery was identified. It was successfully bypassed using a saphenous vein graft anastomosed to the ascending aorta.

2005: DISSECTING INTRAMURAL DUODENAL HEMATOMA FOLLOWING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) severe alkalosis with a serum chloride level of 64 mmol/L and bicarbonate elevated at 40 mmol/L. Fluid losses of 350–400 mL from the fistula was reported daily. The fluid was sent for electrolyte analysis; results showed a chloride level of 129 mmol/L and the bicarbonate level was below the limit of detection. She was treated with normal saline infusion and the metabolic alkalosis and electrolyte disturbance normalized. Surgical repair of the fistula was planned, however the patient was not stable for surgery. The patient continued to deteriorate and subsequently died from shock. Results: In this patient with duodenal enterocutaneous fistula we would anticipate a metabolic acidosis to develop from bicarbonate loss. However, this patient presented with severe metabolic alkalosis. We hypothesize that decreased stimulation of pancreatic exocrine function resulted in very minimal bicarbonate secretion and instead hydrogen and chloride ions were lost and metabolic alkalosis developed.

Molecular and biochemical basis of brain injury following heart surgery - Interventions for the future

Cardiac surgical procedures such as coronary artery bypass grafting (CABG), valvular replacement and heart transplantation, as well as many others are life-saving procedures for hundreds of thousands of US patients each year. However, despite this clinical utility, many patients who undergo cardiac surgery suffer neurological injury as a result. In addition to the morbidity and mortality caused by neurological injury, these complications are associated with increases in hospital length of stays, costs, and admissions to rehabilitation facilities.