Gabriel Loor

Bridging to lung transplantation with extracorporeal circulatory support: when or when not?

Patients with end-stage lung disease who are candidates for lung transplantation may acutely decompensate before a donor organ becomes available. In this scenario, extracorporeal life support (ECLS) may be considered as a bridge to transplant or as a bridge to decision. In the current chapter, we review the indications, techniques, and outcomes for bridging to lung transplantation with ECLS.

Giant Mediastinal Liposarcoma: A Rare Yet Distinct Clinical Entity

Mediastinal liposarcomas are rare tumors that occasionally present as unusually large and rapidly growing mediastinal masses resulting in compressive symptoms. We present a case of a 48-year-old woman undergoing resection of a mediastinal liposarcoma of massive proportion and propose that giant mediastinal liposarcomas be identified as a distinct clinical entity.

Successful Use of Sternal-Sparing Minimally Invasive Surgery for Proximal Ascending Aortic Pathology

BACKGROUNDnA sternal-sparing approach to surgery of the proximal aorta could decrease postoperative morbidity.nnnMETHODSnTo determine the potential benefits of using a minimally invasive right thoracotomy approach for the treatment of ascending aortic pathology, we retrospectively reviewed our experience in patients who required circulatory arrest for the treatment of ascending aortic pathology (with or without aortic valve involvement) between January 2009 and November 2014 (Nxa0= 177). We compared baseline characteristics, intraoperative characteristics, and postoperative clinical outcomes between those who underwent a sternotomy (nxa0= 103) and those who underwent a minimally invasive right thoracotomy approach (nxa0= 74). All surgical procedures were performed by a single surgeon. Propensity score matching was performed to account for baseline differences between groups.nnnRESULTSnMore patients in the minimally invasive group had bicuspid aortic valve, degenerative aortic valve, or aortic insufficiency than in the sternotomy group, but other baseline characteristics were similar between groups. No strokes occurred. In the unmatched cohort, 30-day mortality was 2.7% for the minimally invasive group compared with 1.9% for the sternotomy group (pxa0= 1.00). In the propensity score-matched cohort, 30-day mortality was 3.2% for both groups; circulatory arrest times were longer in the minimally invasive group than in the sternotomy group (p < 0.0001), but the minimally invasive group had fewer red blood cell transfusions, shorter ventilation times, and shorter intensive care unit and hospital length ofxa0stay.nnnCONCLUSIONSnA sternal-sparing approach to surgery of the proximal aorta is safe when performed by an experienced surgeon and conserves hospital resources.

EVLP: Ready for Prime Time?

Ex vivo lung perfusion implies perfusion and ventilation of a donor lung outside of the human body. The 2 most clinically relevant and commercially available devices currently in clinical trials are XVIVO Perfusion System (XPS Perfusion, Goteborg, Sweden) and Organ Care System (Transmedics, Andover, MA). Our review focuses on the needs met by ex vivo lung perfusion, and the clinical literature on both devices.

LVAD Surgical Implant Technique: Extraperitoneal Approach

As the number of LVAD implantations continues to rise and the technology advances, alternate approaches and new techniques have continued to develop. This chapter aims to not only summarize the steps common to the traditional LVAD implantation approach but also to introduce, explore, and summarize the increasing minimally invasive approaches, the variants in outflow graft (OG) anastomosis sites and their perceived benefits, and the varying approaches to “off-pump” LVAD implantation that circumvent the operative risks associated with the use of cardiopulmonary bypass (CPB).

Frequency and Consequences of Right Sided Heart Failure after Continuous-Flow Left Ventricular Assist Device Implantation

Postoperative right-sided heart failure (RHF) is a common complication after continuous-flow left ventricular assist device implantation. Studies have examined RHF in the perioperative period, but few have assessed late-onset RHF. We analyzed the incidence of early and late RHF in patients with HeartMate II and HeartWare left ventricular assist devices and associated morbidity, mortality, and independent predictors of RHF. We retrospectively analyzed records of 526 patients with chronic heart failure who underwent continuous-flow left ventricular assist device implantation; 147 (27.9%) developed RHF (early RHF, nu2009=u200987, 16.5%; late RHF, nu2009=u200974, 14.4%). We examined demographics, postoperative complications, and long-term survival rate. Patients with RHF or late RHF had higher mortality (pu2009<0.001) than those without RHF. Patients with RHF had a higher incidence of acute kidney injury (20.4% vs 11.9%, pu2009=u20090.01). Device type did not affect the incidence of early, late, or overall RHF. Patients with severe RHF requiring right ventricular assist device support had a low success of bridge to transplantation (11.1% vs 33.3%, pu2009=u20090.02). In Cox regression models, RHF was an independent predictor of mortality (hazard ratiou2009=u20091.69, 95% confidence intervalu2009=u20091.28 to 2.22, pu2009<0.001), but no predictive variables of RHF were identified. RHF was significantly associated with increased mortality and a higher incidence of postoperative acute kidney injury. RHF decreased the success rate of bridging patients to transplantation when a right ventricular assist device was required.

Lung Procurement After Cardiac Death in a Donor With Previous Median Sternotomy

The shortage of lungs for organ donation is problematic, and meeting the demand by expanding the donor pool in lung transplantation is critical. Donation after cardiac death (DCD) is an under-used approach that could be a valuable source of organs. However, procuring lungs from donors with a previous median sternotomy is technically difficult and is usually avoided. Here, we describe the procurement of lungs from a DCD patient with a previous median sternotomy.