Matthew C. Black

Left ventricular assist devices: current controversies and future directions

Advanced heart failure is a growing epidemic that leads to significant suffering and economic losses. The development of left ventricular assist devices (LVADs) has led to improved quality of life and long-term survival for patients diagnosed with this devastating condition. This review briefly summarizes the short history and clinical outcomes of LVADs and focuses on the current controversies and issues facing LVAD therapy. Finally, the future directions for the role of LVADs in the treatment of end-stage heart failure are discussed.

High sensitivity for lung cancer detection using analysis of exhaled carbonyl compounds.

OBJECTIVE Several volatile carbonyl compounds in exhaled breath have been identified as cancer-specific markers. The potential for these markers to serve as a screening test for lung cancer is reported. METHODS Patients with computed tomography-detected intrathoracic lesions and healthy control participants were enrolled from 2011 onward. One liter of breath was collected from a single exhalation from each participant. The contents were evacuated over a silicon microchip, captured by oximation reaction, and analyzed by mass spectrometry. Concentrations of 2-butanone, 3-hydroxy-2-butanone, 2-hydroxyacetaldehyde, and 4-hydroxyhexanal were measured. The overall population was divided into 3 groups: those with lung cancer, benign disease, and healthy controls. An elevated cancer marker was defined as ≥1.5 SDs above the mean concentration of the control population. One or more elevated cancer markers constituted a positive breath test. RESULTS In all, 156 subjects had lung cancer, 65 had benign disease, and 194 were healthy controls. A total of 103 (66.0%) lung cancer patients were early stage (stage 0, I, and II). For ≥1 elevated cancer marker, breath analysis showed a sensitivity of 93.6%, and a specificity of 85.6% for lung cancer patients. Additionally, 83.7% of stage I tumors ≤2 cm were detected; whereas only 14% of the control population tested positive. In a comparison of cancer to benign disease, specificity was proportional to the number of elevated cancer markers present. CONCLUSIONS Screening using a low-dose CT scan is associated with high cost, repeated radiation exposure, and low accrual. The high sensitivity, convenience, and low cost of breath analysis for carbonyl cancer markers suggests that it has the potential to become a primary screening modality for lung cancer.

Double Lung Transplants Have Significantly Improved Survival Compared With Single Lung Transplants in High Lung Allocation Score Patients

BACKGROUND Historically, double lung transplantation survival rates are higher than those of single lung transplantation, but in critically ill patients a single lung transplant, with less associated operative morbidity, could afford a better outcome. This article evaluates how survival is affected in patients who have a high lung allocation score (LAS) and receive a single versus a double lung transplant. METHODS The UNOS Thoracic Transplant Database for lung transplants from January 2005 to June 2012 was used for analysis. Propensity matching was used to minimize differences between the high and low LAS groups and between single and double lung transplants in the high LAS group. RESULTS Within this database, there were 8,778 patients, of whom 8,050 had an LAS less than 75 and 728 had an LAS greater than or equal to 75. Kaplan-Meier survival curves stratified by high and low LAS, and by single versus double lung transplants, showed a marked decrease in survival (p<0.001) in those with a high LAS who received a single lung transplant when compared with those with a high LAS who received a double lung transplant. This was a much greater difference in survival than was present in the low LAS patient population. CONCLUSIONS Despite a higher operative morbidity, patients who had a high LAS did substantially better in terms of survival if two lungs were transplanted rather than only one, with a larger difference in survival than for patients with a lower LAS.

Normalization of Exhaled Carbonyl Compounds After Lung Cancer Resection

Background Quantitative analysis of specific exhaled carbonyl compounds (ECCs) has shown promise for the detection of lung cancer. The purpose of this study is to demonstrate the normalization of ECCs in patients after lung cancer resection. Methods Patients from a single center gave consent and were enrolled in the study from 2011 onward. Breath analysis was performed on lung cancer patients before and after surgical resection of their tumors. One liter of breath from a single exhalation was collected and evacuated over a silicon microchip. Carbonyls were captured by oximation reaction and analyzed by mass spectrometry. Concentrations of four cancer-specific ECCs were measured and compared by using the Wilcoxon test. A given cancer marker was considered elevated at 1.5 or more standard deviations greater than the mean of the control population. Results There were 34 cancer patients with paired samples and 187 control subjects. The median values after resection were significantly lower for all four ECCs and were equivalent to the control patient values for three of the four ECCs. Conclusions The analysis of ECCs demonstrates reduction to the level of control patients after surgical resection for lung cancer. This technology has the potential to be a useful tool to detect disease after lung cancer resection. Continued follow-up will determine whether subsequent elevation of ECCs is indicative of recurrent disease.

Proactive or reactive? Best approach to limb ischemia in peripheral venoarterial extracorporeal life support.

From the Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, Ky. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Nov 30, 2015; accepted for publication Nov 30, 2015; available ahead of print Jan 15, 2016. Address for reprints: Mark S. Slaughter, MD, Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY (E-mail: mark.slaughter@louisville.edu). J Thorac Cardiovasc Surg 2016;151:1745-6 0022-5223/

Sunshine Heart C-Pulse: device for NYHA Class III and ambulatory Class IV heart failure

36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.11.064

Hybrid Endovascular Aortic Arch Reconstruction for Acute Aortic Dissection: An Endovascular Bridge Technique for Complex Anatomy:

Advanced heart failure (HF) patients not meeting criteria for ventricular assist device or heart transplant with life-limiting symptoms are limited to medical and resynchronization therapy. The Sunshine Heart C-Pulse, based on intra-aortic balloon pump physiology, provides implantable, on-demand, extra-aortic counterpulsation, which reduces afterload and improves cardiac perfusion in New York Heart Association Class III and ambulatory Class IV HF. The C-Pulse reduces New York Heart Association Class, improves 6-min walk distances, inotrope requirements and HF symptom questionnaires. Advantages include shorter operative times without cardiopulmonary bypass, no reported strokes or thrombosis and no need for anticoagulation. Driveline exit site infections, inability to provide full circulatory support and poor function with intractable arrhythmias remain concerns. Current randomized controlled studies will evaluate long-term efficacy and safety compared with medical and resynchronization therapy.

Donor Oversizing Results in Improved Survival in Patients with Left Ventricular Assist Device.

Acute type A aortic dissections starting at the arch pose a challenge for cardiac surgeons. Open surgical repair requires deep hypothermic circulatory arrest for arch reconstruction and is associated with significant morbidity and mortality. Hybrid aortic repair techniques, with open arch debranching and thoracic endovascular aortic repair, have been employed in high-risk cases and challenging aortic pathology. Herein, we present a case of a 33-year-old African American male with a history of open thoracoabdominal aortic reconstruction and femoral–femoral artery bypass for a type B dissection who subsequently presented with new-onset chest pain and was found to have a retrograde type A dissection of a bovine arch with multiple dissection flaps and possible contrast extravasation on chest computed tomography. Endovascular reconstruction of the aortic arch using a hybrid technique was utilized and proved to be feasible and further should be considered when complex anatomy limits traditional surgical options.

Single Versus Double Lung Retransplantation Does Not Affect Survival Based on Previous Transplant Type

Donor to recipient undersizing can result in diminished graft survival. The United Network for Organ Sharing database was retrospectively queried from January 2008 to December 2013 to identify adult patients who underwent heart transplantation. This population was divided into those without and with a left ventricular assist device (LVAD) at the time of transplant. Both groups were further subdivided into three groups: donor:recipient body mass index (BMI) ratio <0.8 (undersized), ≥0.8 and ⩽1.2 (matched), and >1.2 (oversized). Kaplan–Meier analysis was used to compare graft survival. Cox regression analysis was used to identify factors affecting graft survival time. There was no difference in mean graft survival between undersized, matched, and oversized groups in patients without an LVAD (p = 0.634). Mean graft survival was significantly worse for undersized patients with an LVAD when compared with matched and oversized patients (p = 0.032). Cox regression revealed age, creatinine, waitlist time, United Network for Organ Sharing status, BMI ratio, and total bilirubin as significant factors affecting graft survival time. A donor to recipient BMI ratio of ≥1.2 results in significantly improved long-term graft survival for patients with an LVAD at the time of heart transplantation compared with patients with a BMI ratio of <1.2. An oversized organ should be considered for patients supported with an LVAD.