Jeffrey H. Shuhaiber

Antegrade or retrograde cerebral perfusion as an adjunct during hypothermic circulatory arrest for aortic arch surgery.

Surgery of the aortic arch is a great challenge in cardiovascular surgery. Its partial or total replacement demands the temporary interruption of normal cerebral perfusion, with associated potential for neurological injury. Three methods of cerebral protection have been applied between 1975 and today: hypothermic circulatory arrest as a basic method, either alone or with antegrade cerebral perfusion (ACP), or retrograde cerebral perfusion (RCP) as an adjunctive method. After extensive research regarding the controversies that surround the ideal method of cerebral protection, it is obvious that ACP is superior to RCP for brain protection. ACP obtains a near-physiologic brain perfusion, with homogenous distribution of blood throughout the capillary beds, and extends the safe time of hypothermic circulatory arrest to 80 min, allowing the completion of whatever aortic arch work is necessary. By contrast, RCP perfuses a smaller brain territory than ACP, approximately 10–20%. Hence, RCP is, in our opinion, a ‘smaller adjunct’ to brain protection than ACP. Detailed evidence and future directions for further research are discussed.

Survival of Primary and Repeat Lung Transplantation in the United States

BACKGROUNDnThis study was undertaken to compare survival between primary and repeat lung transplant recipients and to identify survival predictors after repeat lung transplantation.nnnMETHODSnData for 10,846 primary and 354 repeat lung transplant patients were extracted from the United Network for Organ Sharing registry. Propensity score matching was used to examine balance in the distribution of potential observed confounders and to match the sample in terms of the probability of repeat lung transplantation given pretransplant characteristics alone. Matching based on the propensity score was used to compare survival between the primary and repeat lung transplant groups. A Cox regression model was used to identify risk factors for death in the cohort of patients receiving lung transplant.nnnRESULTSnConsiderable bias between the primary and repeat lung transplant groups was found in the sample. Patients with high propensity scores tended to carry high-risk profiles. Propensity score matching revealed incomplete overlap of covariate distributions between primary and repeat transplant groups. For those subjects who could be matched for the set of potential confounding variables, no difference in survival time was observed between primary and repeat lung transplant patients. Functional status and serum creatinine level were the two clinically important risk factors for predicting the survival of repeat transplant patients.nnnCONCLUSIONSnThe current study revealed that direct comparison of the survival of primary and repeat lung transplant patients is biased by nonoverlap in the distribution of potential confounders. Using propensity score matching we adjusted for this bias and found that there was no significant difference in survival between first and second transplants.

Repeat Heart–Lung Transplantation Outcome in the United States

OBJECTIVESnThis study compared risk-adjusted survival between primary and repeat heart-lung transplantation.nnnMETHODSnData for 799 primary heart-lung and 19 repeat heart-lung transplants were extracted from the United Network Organ Sharing (UNOS) registry. Analyses were based on propensity score matching in which 1, 2, and 3 primary transplant patients were matched with 19 repeat transplant patients. The matching variables were sex of recipient and donor, ethnicity, race, age of recipient and donor, cytomegalovirus status, ABO match, human leukocyte antigen mismatch, medical condition (hospitalized), ventilator, employment status, functional status, UNOS transplant status, and ischemic time.nnnRESULTSnPropensity score matching revealed incomplete overlap of covariate distributions between primary and repeat transplant patients. The 19 repeat heart-lung transplant patients were more severely impaired at the time of transplant, and 4 did not have an adequate primary transplant match. For 15 repeat transplant patients, survival time was not significantly different from matched primary transplant controls. For repeat transplant patients, being Hispanic, having longer ischemic time, poor functional status (needing assistance), being hospitalized, and requiring ventilator support were all associated with decreased survival time; however, only being on a ventilator was statistically significant. By contrast, being female, and younger were associated with increased survival, but were not statistically significant.nnnCONCLUSIONSnWhen matched for a set of potential confounding variables, no difference in survival benefit was observed between primary and repeat heart-lung transplant patients. The only predictor significantly associated with decreased survival time among repeat transplant patients was being on a ventilator.

Pseudoaneurysm of Ascending Aorta After Biventricular Assist Device Support

Presentation of an isolated ascending aortic pseudoaneurysm after heart transplantation is a rare adverse event. We describe the surgical management of aortic pseudoanuerysm in a recipient who was bridged to heart transplantation with biventricular assist device support for refractory ventricular tachycardia.

Letter Regarding Article by Gammie et al, “Influence of Hospital Procedural Volume on Care Process and Mortality for Patients Undergoing Elective Surgery for Mitral Regurgitation”

To the Editor:nnWe read with interest the article by Gammie et al1 in the February issue of Circulation . The authors elegantly emphasize the known volume-outcome2 effect and inverse relationship …

Tribute to our fallen comrades

S ix individuals who were part of the human organ retrieval program at the University of Michigan lost their lives in June 2007, one year ago, after an airplane crash into Lake Michigan. The team included 2 cardiac surgeons, Drs Martinus Spoor, an attending surgeon, and David Ashburn, a fellow in training; 2 transplant donation specialists with the University, Richard Chenault II and Richard Lapensee; and 2 pilots, Dennis Hoyes and Bill Serra. There is no greater gift than for one person to lay down his or her life for another, and the University of Michigan transplant team did just that. On that unforgettable day, the tragic news rattled through the hearts of all those involved in medicine, specifically transplantation, and widespread mourning began with an endless number of personal condolences from across the nation. This collective loss was by far the worst outcome during an organ harvest, reminding us that the risks of transplantation are for all and not for one. During that month, as a fellow in transplantation, I came to realize the risks we take to achieve our missions are far beyond the training it takes to become a thoracic surgeon. The advances in medicine and surgery that have been achieved so far at a human or non-human related risk may not be apparent when first assessed. The most important, however, is risk to human life. In the content of transplantation, the apparent safety gap between risk and benefit can be mistakenly underestimated as weather changes and technology woves can create an unpredictable dynamic hazardous environment for everyone. The extent of which can reach as far as loss of life. We should be prepared to meet the demands of our new age and its associated hazards. Our first objective is to treat and heal the sick, and we drive selflessly for our patients and are willing to accept the known, as well as the unknown, without hesitation. Every day and night, hundreds of teams worldwide are prepared to procure organs for transplantation. Risk has always been directed toward our patients; however, with such incidents, we have to include all members of the harvest team because several have made the ultimate sacrifice during the performance of their duty. Nearly 60,000 patients in the United States have enjoyed longer lives because they received new hearts through transplant programs at approximately 150 medical centers around the country. Organ retrieval remains an important extension of our services away from our hospital base. The Aviation Safety Information Analysis and Sharing Office provided information on prior medical aviation accidents. This office covers the National Transplantation Safety Board Aviation Accident and Incident Data System and is the primary source for aircraft accident information. From 1983 through the present, 209 medical incident aircraft flights have been recorded, and 76 have resulted in fatal outcomes, claiming the lives of those on board, including patients. Although air transportation is safer than ground transportation, the merits of each organ harvest need to be placed in the context of the team, as well as the patient. At the first anniversary of this tragedy, our hearts continue to be filled with sadness. We honor the team who lost their lives trying to save one, and their sacrifice, courage, and commitment to serve those in need will stay with us forever. From the Department of Surgery, Loyola University Stritch School of Medicine, Chicago, Ill.