Grayson Wheatley

Study design and rationale of the heterotopic implantation of the Edwards-Sapien XT transcatheter valve in the inferior VEna cava for the treatment of severe tricuspid regurgitation (HOVER) trial.

Tricuspid regurgitation (TR) is an under treated disease. Although surgery for TR remains an effective therapy, many patients are considered to be at a high risk or otherwise inoperable. Caval valve implant (CAVI) offers an alternative to surgery in these patients. Trials assessing the safety and efficacy of caval valve implant are lacking. Methods: The Heterotopic Implantation Of the Edwards‐Sapien XT Transcatheter Valve in the Inferior VEna cava for the treatment of severe Tricuspid Regurgitation (HOVER) trial is an FDA approved, physician initiated, prospective, non‐blinded (open label), non‐randomized safety and feasibility study to determine the safety and efficacy of the heterotopic implantation of the Edwards‐Sapien XT valve in the inferior vena cava for the treatment of severe TR in patients who are at high risk or inoperable. Patients with severe TR in the absence of severe pulmonary hypertension will be recruited. They will be evaluated by a multi‐disciplinary team who will agree by consensus that the patients’ symptoms are from TR. They will undergo imaging to assess the size of the inferior vena cava (IVC) to determine feasibility of the procedure. If patients meet the inclusion criteria and are free from exclusion criteria, after informed consent they will be eligible for enrollment in the study. A total of 30 patients will be enrolled. The primary objective of the study will be to demonstrate procedural success at 30‐days and patient success at 1‐year. Conclusion: Caval valve implant may present an alternative for patients who are at high risk or inoperable for tricuspid valve surgery (TVS) for TR.

The Impact of Alemtuzumab and Basiliximab Induction on Patient Survival and Time to Bronchiolitis Obliterans Syndrome in Double Lung Transplantation Recipients

We examined the effect of alemtuzumab and basiliximab induction therapy on patient survival and freedom from bronchiolitis obliterans syndrome (BOS) in double lung transplantation. The United Network for Organ Sharing database was reviewed for adult double lung transplant recipients from 2006 to 2013. The primary outcome was risk‐adjusted all‐cause mortality. Secondary outcomes included time to BOS. There were 6117 patients were identified, of whom 738 received alemtuzumab, 2804 received basiliximab, and 2575 received no induction. Alemtuzumab recipients had higher lung allocation scores compared with basiliximab and no‐induction recipients (41.4 versus 37.9 versus 40.7, p < 0.001) and were more likely to require mechanical ventilation before to transplantation (21.7% versus 6.5% versus 6.2%, p < 0.001). Median survival was longer for alemtuzumab and basiliximab recipients compared with patients who received no induction (2321 versus 2352 versus 1967 days, p = 0.001). Alemtuzumab (hazard ratio 0.80, 95% confidence interval 0.67–0.95, p = 0.009) and basiliximab induction (0.88, 0.80–0.98, p = 0.015) were independently associated with survival on multivariate analysis. At 5 years, alemtuzumab recipients had a lower incidence of BOS (22.7% versus 55.4 versus 55.9%), and its use was independently associated with lower risk of developing BOS on multivariate analysis. While both induction therapies were associated with improved survival, patients who received alemtuzumab had greater median freedom from BOS.

Endoanchor stenting for the repair of a Type I endoleak in the aortic arch following the endovascular repair of a Kommerrell's diverticulum

As more challenging aortic arch anatomy is being treated using aortic stent‐grafts, there is an increased risk for proximal Type I endoleaks at the proximal seal zone or subsequent graft migration. We report a case of an endoanchor‐assisted thoracic endovascular aneurysm repair of a patient with an aberrant right subclavian artery (ARSA) and aortic arch aneurysm who developed a proximal Type I endoleak in the aortic arch which was subsequently treated with endoanchors.

Long-term outcomes in heart transplantation using donors with a history of past and present cocaine use

OBJECTIVES Organ donors with a history of cocaine use are thought to be less favourable for orthotopic heart transplantation (OHT). This study examined long-term survival in OHT using donors with a history of cocaine use. METHODS The United Network for Organ Sharing (UNOS) database was examined for primary, adult heart transplants from 2000 to 2010. Cox proportional hazards analysis using covariates associated with mortality was used to examine survival. RESULTS There were 19 636 total OHTs with 2274 (11.6%) using donors with a history of dependent cocaine use (DCU). Of these, 1008 (44.3%) donors were current cocaine users. Recipients of DCU were more likely to be male (79.0 vs 75.7%, P < 0.001), more likely diabetic (16.5 vs 14.8%, P = 0.003) and were less likely to be sex mismatched (23.0 vs 28.6%, P < 0.001). DCU donors were older (32.5 vs 31.4 years, P < 0.001), more likely male (79.7 vs 69.8%, P < 0.001) and had higher ischaemic times (3.27 vs 3.20 h, P = 0.001). On multivariate analysis, DCU was not associated with mortality [hazard ratio (HR): 0.95, 95% CI: 0.87-1.03, P = 0.22]. Variables associated with mortality included recipient body mass index, sex mismatch, race mismatch, black race, ischaemic time, recipient creatinine, donor age, donor smoking history and mechanical ventilation or extracorporeal membrane oxygen as a bridge to transplantation. On subset analysis, CCU was not associated with mortality (HR: 0.97, 95% CI: 0.89-1.05, P = 0.42). On Kaplan-Meier analysis, median survival was not different when comparing current (3890.0 days), past (3,889.0 days) and non-cocaine using donors (4165.0 days); P = 0.54. CONCLUSIONS Use of carefully selected donors with a history of past and current cocaine use does not result in worse outcomes.

Use of Heavy Drinking Donors in Heart Transplantation is Not Associated With Worse Mortality.

Background Although orthotopic heart transplantation (OHT) remains the preferred treatment for end-stage heart failure, there continues to be a critical shortage of organ donors. The goal of this study is to examine outcomes after orthotopic OHT using heavy drinking donors (HDDs) in a large, national database. Methods The United Network for Organ Sharing database was examined for all primary, adult OHT carried out from 2005 to 2012. Results There were 14,928 total OHT performed during the study period with 2,274 (15.2%) using HDD. Recipients of HDD were older (53.4 vs. 51.9 years, P < 0.001), more likely men (80.7 vs 74.4%, P < 0.001), less likely sex mismatched (21.5 vs 27.5%, P < 0.001), more likely race mismatched (57.4 vs 52.4%, P < 0.001), and had less total HLA mismatches (4.55 vs 4.65, P < 0.001). The HDD were older (37.0 vs 30.5 years, P < 0.001), more likely men (82.2 vs 69.9%, P < 0.001), and more likely to have heavy cigarette use (38.1 vs 13.2%, P < 0.001). Length of stay was not different (20.3 vs 19.7 days, P = 0.02). On multivariate analysis, use of HDD was not associated with mortality at 30 days (hazards ratio [HR], 1.12; 95% confidence interval [95% CI], 0.90–1.39; P = 0.30), 1 year (HR, 0.96; 95% CI, 0.83–1.11; P = 0.56), and at 5 years (HR, 1.02; 95% CI, 0.91–1.13; P = 0.79). Variables associated with mortality at 5 years included increasing donor age, prolonged ischemic time, worsening recipient creatinine, recipient black race, sex mismatch, and extracorporeal membrane oxygenation or mechanical ventilation as a bridge to transplantation. Conclusion Heart transplantation can be performed using carefully selected HDDs with good outcomes.

Examining Mortality and Rejection in Combined Heart–Lung Transplantations

Background There is a paucity of data on outcomes related to combined heart‐lung transplantations (HLTs). Our objective was to identify variables associated with mortality and rejection in HLT. Methods The United Network for Organ Sharing database was reviewed for HLT performed between 1993 and 2008. Long‐term survivors (survival > 5 years) were compared with short‐term survivors (survival < 5 years). Factors associated with rejection were examined. Risk‐adjusted multivariable Coxs proportional hazards regression analysis was performed to examine variables associated with mortality and rejection. Results Multivariable analysis revealed that recipient male gender was associated with mortality at 1 year (hazard ratio [HR]: 1.68, 95% confidence interval [CI]: 1.11‐2.54, p = 0.01) and 5 years (HR: 1.41, 95% CI: 1.05‐1.89, p = 0.02). Preoperative extracorporeal membrane oxygenation (ECMO) was associated with mortality at 1 year (HR: 7.55, 95% CI: 2.55‐22.30, p < 0.01) and 5 years (HR: 3.14, 95% CI: 1.19‐8.32, p = 0.02). Preoperative mechanical ventilation (MV) was associated with mortality at 1 year (HR: 3.51, 95% CI: 1.77‐6.98, p < 0.01) and at 5 years (HR: 2.70, 95% CI: 1.51‐4.85, p < 0.01). Multivariable analysis showed that male gender (HR: 1.78, 95% CI: 1.03‐3.09, p = 0.04) and cytomegalovirus (CMV) positivity in the recipient and donor (HR: 3.09, 95% CI: 1.59‐6.01, p < 0.01) were associated with rejection. Clinical infection in the donor (HR: 2.05, 95% CI: 1.16‐3.61, p = 0.01) was also associated with rejection. Conclusion Survival was affected by recipient male sex and need for preoperative ECMO or MV. Risk factors for rejection included male sex, CMV positivity in the donor and recipient, and donor with clinical infection.

The butterfly effect: From Seldinger technique to endovascular arch repair

From the Division of Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, Pa. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication June 30, 2016; accepted for publication July 1, 2016. Address for reprints: Grayson H. Wheatley III, MD, FACS, Division of Cardiovascular Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad St, 3rd Floor, Zone C, Suite 301, Philadelphia, PA 19147 (E-mail: grayson.wheatley@tuhs.temple.edu). J Thorac Cardiovasc Surg 2016;-:1-2 0022-5223/

Where there's smoke, there's fire: Chimney stent grafts for hybrid repair of the aortic arch

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.07.007

Eskimos, elephants, and endovascular: Body floss technique for hybrid arch procedures

From the Division of Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, Pa. Disclosures: Author has nothing to disclose with regard to commercial support. Received for publication June 21, 2016; accepted for publication June 21, 2016; available ahead of print July 28, 2016. Address for reprints: Grayson H.Wheatley III, MD, FACS, Temple University School of Medicine, 3401 N Broad St, 3rd Floor, Zone C, Suite 301, Philadelphia, PA 19147 (E-mail: grayson.wheatley@tuhs.temple.edu). J Thorac Cardiovasc Surg 2016;152:1194 0022-5223/

Burning bridges: Endovascular therapies for acute traumatic aortic transection

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2016.06.033