Jessica G.Y. Luc

Successful repair of donation after circulatory death lungs with large pulmonary embolus using the lung organ care system for ex vivo thrombolysis and subsequent clinical transplantation.

Successful Repair of Donation After Circulatory Death Lungs With Large Pulmonary Embolus Using the Lung Organ Care System for Ex Vivo Thrombolysis and Subsequent Clinical Transplantation Jessica G.Y. Luc, Sabin J. Bozso, Darren H. Freed, and Jayan Nagendran T boundary of marginal lung utilization is expanding with the development of ex vivo lung perfusion to improve donor lung function. We report the use of the Transmedics Lung Organ Care System (OCS) to lyse pulmonary embolus (PE) from a set of donation after circulatory death (DCD) lungs with subsequent clinical transplantation.

lung transplantation from donors after circulatory death using portable ex vivo lung perfusion

BACKGROUND Donation after circulatory death is a novel method of increasing the number of donor lungs available for transplantation. Using organs from donors after circulatory death has the potential to increase the number of transplants performed. METHODS Three bilateral lung transplants from donors after circulatory death were performed over a six-month period. Following organ retrieval, all sets of lungs were placed on a portable ex vivo lung perfusion device for evaluation and preservation. RESULTS Lung function remained stable during portable ex vivo perfusion, with improvement in partial pressure of oxygen/fraction of inspired oxygen ratios. Mechanical ventilation was discontinued within 48 h for each recipient and no patient stayed in the intensive care unit longer than eight days. There was no postgraft dysfunction at 72 h in two of the three recipients. Ninety-day mortality for all recipients was 0% and all maintain excellent forced expiratory volume in 1 s and forced vital capacity values post-transplantation. CONCLUSION The authors report excellent results with their initial experience using donors after circulatory death after portable ex vivo lung perfusion. It is hoped this will allow for the most efficient use of available donor lungs, leading to more transplants and fewer deaths for potential recipients on wait lists.

Clinical implications of physiological flow adjustment in continuous-flow left ventricular assist devices.

There is increasing evidence for successful management of end-stage heart failure with continuous-flow left ventricular assist device (CF-LVAD) technology. However, passive flow adjustment at fixed CF-LVAD speed is susceptible to flow balancing issues as well as adverse hemodynamic effects relating to the diminished arterial pulse pressure and flow. With current therapy, flow cannot be adjusted with changes in venous return, which can vary significantly with volume status. This limits the performance and safety of CF-LVAD. Active flow adjustment strategies have been proposed to improve the synchrony between the pump and the native cardiovascular system, mimicking the Frank–Starling mechanism of the heart. These flow adjustment strategies include modulation by CF-LVAD pump speed by synchrony and maintenance of constant flow or constant pressure head, or a combination of these variables. However, none of these adjustment strategies have evolved sufficiently to gain widespread attention. Herein we review the current challenges and future directions of CF-LVAD therapy and sensor technology focusing on the development of a physiologic, long-term active flow adjustment strategy for CF-LVADs.

The evolving potential for pediatric ex vivo lung perfusion

Despite the rise in the number of adult lung transplantations performed, rates of pediatric lung transplantation remain low. Lung transplantation is an accepted therapy for pediatric end‐stage lung disease; however, it is limited by a shortage of donor organs. EVLP has emerged as a platform for assessment and preservation of donor lung function. EVLP has been adopted in adult lung transplantation and has successfully led to increased adult lung transplantations and donor lung utilization. We discuss the future implications of EVLP utilization, specifically, its potential evolving role in overcoming donor shortages in smaller children and adolescents to improve the quality and outcomes of lung transplantation in pediatric patients.

Active Learning in Medical Education: Application to the Training of Surgeons

Our article defines active learning in the context of surgical education and reviews the growing body of research on new approaches to teaching. We then discuss future perspectives and the challenges faced by the trainee and surgeon in applying active learning to surgical training. As modern surgical education faces numerous challenges, we hope our article will help surgical educators in the evaluation of curriculum development, methods of instruction, and assessment.

Does Cramming Work? Impact of National Web-Based Thoracic Surgery Curriculum Login Frequency on Thoracic Surgery In-Training Exam Performance

Objective Web‐based curricula provide login data that can be advantageously used to characterize and analyze study habits. We sought to compare thoracic surgical trainee In‐Training Examination percentiles with regard to their study habits (ie, cramming), as characterized by curriculum login frequency to the national Web‐based Thoracic Surgery Curriculum. Furthermore, we then aimed to characterize the curriculum login frequency of trainees as stratified by their performance on the In‐Training Examination and their improvement on the In‐Training Examination over subsequent years. Methods We performed a retrospective review of trainees who accessed the curriculum before the 2014 In‐Training Examination, with curriculum login data collected from site analytics. Scores were compared between trainees who crammed (≥30% increase in logins in the month before the In‐Training Examination) and those who did not. Trainees were stratified on the basis of 2014 In‐Training Examination percentile and improvement in percentile from 2013 to 2014 into high, medium, and low scorers and improvers. Results Of 256 trainees who took the 2014 In‐Training Examination, 63 (25%) met criteria as crammers. Crammers increased total study sessions immediately before the In‐Training Examination (P < .001), but without impact on 2014 In‐Training Examination percentile (P = .995) or year‐to‐year improvement (P = .234). Stratification by In‐Training Examination percentile demonstrated that highest scoring trainees used the curriculum more frequently in the final month than medium‐range scorers (P = .039). When stratified by extent of year‐to‐year improvement, those who improved the most accessed the curriculum significantly more often in the last month compared with baseline (P = .040). Moreover, those with greatest improvement logged in more in the final month than those with least improvement (P = .006). Conclusions Increasing the frequency of study periods on the national Web‐based thoracic surgery curriculum before the In‐Training Examination may have a unique benefit to trainees who initially score low to allow them to significantly improve their subsequent year In‐Training Examination performance.

A Leukocyte Filter Does Not Provide Further Benefit During Ex Vivo Lung Perfusion

Normothermic ex vivo lung perfusion (EVLP) allows for assessment and reconditioning of donor lungs. Although a leukocyte filter (LF) is routinely incorporated into the EVLP circuit; its efficacy remains to be determined. Twelve pig lungs were perfused and ventilated ex vivo in a normothermic state for 12 hours. Lungs (n = 3) were allocated to four groups according to perfusate composition and the presence or absence of a LF in the circuit (acellular ± LF, cellular ± LF). Acceptable physiologic lung parameters were achieved during EVLP; however, increased amounts of pro-inflammatory cytokines (TNF-&agr; and IL-6) and leukocytes in the perfusate were observed despite the presence or absence of a LF. Analysis of cells washed off the LF demonstrates that it trapped leukocytes although being ineffective throughout perfusion as it became saturated over 12 hours of EVLP. We conclude that there is no objective evidence to support the routine incorporation of a LF during EVLP as it does not provide further benefit and its removal does not appear to cause harm. The lack of hypothesized benefit to a LF may be because of the saturation of the LF with donor leukocytes, leading to similar amounts of circulating leukocytes still present in the perfusate with and without a LF.

Utilization and Outcomes of Temporary Mechanical Circulatory Support for Graft Dysfunction After Heart Transplantation

Graft dysfunction is the main cause of early mortality after heart transplantation. In cases of severe graft dysfunction, temporary mechanical circulatory support (TMCS) may be necessary. The aim of this systematic review was to examine the utilization and outcomes of TMCS in patients with graft dysfunction after heart transplantation. Electronic search was performed to identify all studies in the English literature assessing the use of TMCS for graft dysfunction. All identified articles were systematically assessed for inclusion and exclusion criteria. Of the 5,462 studies identified, 41 studies were included. Among the 11,555 patients undergoing heart transplantation, 695 (6.0%) required TMCS with patients most often supported using venoarterial extracorporeal membrane oxygenation (79.4%) followed by right ventricular assist devices (11.1%), biventricular assist devices (BiVADs) (7.5%), and left ventricular assist devices (LVADs) (2.0%). Patients supported by LVADs were more likely to be supported longer (p = 0.003), have a higher death by cardiac event (p = 0.013) and retransplantation rate (p = 0.015). In contrast, patients supported with BiVAD and LVAD were more likely to be weaned off support (p = 0.020). Overall, no significant difference was found in pooled 30 day survival (p = 0.31), survival to discharge (p = 0.19), and overall survival (p = 0.51) between the subgroups. Temporary mechanical circulatory support is an effective modality to support patients with graft dysfunction after heart transplantation. Further studies are needed to establish the optimal threshold and strategy for TMCS and to augment cardiac recovery and long-term survival.

A Structured, Debate-Style Cardiothoracic Surgery Journal Club for Trainee Acquisition and Application of Seminal Literature

Introduction The acquisition of specialty-specific seminal literature and its application to daily, clinical patient-care decisions are critical components of clinical training. This structured, debate-style cardiothoracic surgery journal club module engages trainees in discussion of realistic patient scenarios, incorporating an extensive body of literature identified as the best evidence for the practice of cardiothoracic surgery. Methods We designed the structured, debate-style cardiothoracic surgery journal club and delivered it to University of Texas MD Anderson Cancer Center cardiothoracic surgery trainees. Overall assessment of knowledge acquisition consisted of both direct judging of debates by faculty facilitators and a year-end written test of trainee knowledge. Associated materials include guidelines and resources for faculty facilitators and trainees to prepare them for the journal club debate. Also included are cardiothoracic surgery patient cases, PowerPoint presentation slides, a debate score sheet, and multiple-choice knowledge tests with answer keys. Results Our structured, debate-style cardiothoracic surgery journal club is an effective educational intervention for cardiothoracic surgical trainees to gain practice in applying specialty-specific, literature-based evidence to particular patient problems. Discussion This resource may be used by course directors for surgery, for independent study by individuals planning to matriculate into surgical residencies, or as a review for those already in surgical training. Moreover, this curriculum can be delivered at other clinical training programs.

Social media in the mentorship and networking of physicians: Important role for women in surgical specialties

BACKGROUND Social media may be a useful supplement to physician and trainee interactions; however, its role in enhancing mentorship has not been described. METHODS A 35-item survey investigating trainee and physician social media use was distributed. Responses were analyzed using descriptive statistics. RESULTS 282 respondents completed the survey, among whom 136 (48.2%) reported careers in surgical specialties. Women in surgical specialties were more likely to describe the specialty as being dominated by the opposite sex (p < 0.001) and to be mentored by the opposite sex though wish to be mentored by individuals of the same sex (p < 0.001). Respondents in surgical specialties were also more likely to report using social media to build a network of same-sex mentorship (p = 0.031). CONCLUSIONS Social media serves as a valuable tool to enhance the networking and mentorship of surgeons, particularly for women in surgical specialties who may lack exposure to same-sex mentors at their own institution.