Mauricio A. Villavicencio

Teaching operative cardiac surgery in the era of increasing patient complexity: Can it still be done?

Objective: Teaching the next generation operative cardiac surgery while maintaining the highest level of patient care is an ever‐increasing challenge given the growing proportion of patients with multiple comorbidities, the loss of more straightforward cases to percutaneous interventions, and the pressure of public reporting. No study to date has compared the outcomes of similar cases performed entirely (“skin‐to‐skin”) by the resident with those performed entirely by the staff to confirm the safety of this practice. Methods: A total of 100 consecutive cardiac cases performed skin‐to‐skin by the resident (group R) were matched by procedure 1:1 to nonconsecutive cases performed by a single attending surgeon (group A). Patients were excluded from the analysis if there was overlap in any portion of the procedure by the trainee or the attending. Results: Patients in group A were similar to those in group R with respect to age, gender, body mass index, American Society of Anesthesiologists classification, left ventricular ejection fraction, and diabetes mellitus. Mean operative times were longer in group R (4.6 vs 2.7 hours, P < .001), as were cardiopulmonary bypass times (96 vs 50 minutes, P < .001) and aortic crossclamp times (78 vs 39 minutes, P < .001). There were no significant differences in red blood cell transfusions, reexplorations, stroke, length of stay, or wound infections. There were no in‐hospital or 30‐day deaths. Conclusions: Our data indicate that trainees can be educated in operative surgery under the current paradigm, despite longer operative times, without sacrificing outcome quality. It is reasonable to expect academic programs to continue providing trainees significant experience as primary operating surgeons.

Is Functional Independence Associated With Improved Long Term Survival After Lung Transplantation

BACKGROUNDnExisting research demonstrates superior short-term outcomes (length of stay, 1-year survival) after lung transplantation in patients with preoperative functional independence. The aim of this study was to determine whether advantages remain significant in the long-term.nnnMETHODSnThe United Network for Organ Sharing database was queried for adult, first-time, isolated lung transplantation records from January 2005 to December 2015. Stratification was performed based on Karnofsky Performance Status Score (3 groups) and on employment at the time of transplantation (2 groups). Kaplan-Meier and Cox analyses were performed to determine the association between these factors and survival in the long-term.nnnRESULTSnOf 16,497 patients meeting criteria, 1,581 (9.6%) were almost completely independent at the time of transplant vs 5,662 (34.3%) who were disabled (completely reliant on others for activities of daily living). Cox models adjusting for recipient, donor, and transplant factors demonstrated a statistically significant association between disability at the time of transplant and long-term death (hazard ratio, 1.26; 95% confidence interval, 1.14 to 1.40; p < 0.001). There were 15,931 patients with available data on paid employment at the time of transplantation. Multivariable analysis demonstrated a statistically significant association between employment at the time of transplantation and death (hazard ratio, 0.86; 95% confidence interval, 0.75 to 0.91; p < 0.001).nnnCONCLUSIONSnPreoperative functional independence and maintenance of employment are associated with superior long-term outcomes in lung recipients. The results highlight potential benefits of pretransplant functional rehabilitation for patients on the waiting list for lungs.

Quantifying the learning curve for pulmonary thromboendarterectomy

BackgroundPulmonary thromboendarterectomy (PTE) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but is a technically challenging operation for cardiothoracic surgeons. Starting a new program allows an opportunity to define a learning curve for PTE.MethodsA retrospective case review was performed of 134 consecutive PTEs performed from 1998 to 2016 at a single institution. Outcomes were compared using either a two-tailed t-test for continuous variables or a chi-squared test for categorical variables according to experience of the program by terciles (T).ResultsThe 30-day mortality was 3.7%. The mean length of hospital stay, length of ICU stay, and duration on a ventilator were 12.6xa0days, 4.6xa0days, and 2.0xa0days, respectively. The mean decrease in systolic pulmonary artery pressure (sPAP) was 41.3xa0mmHg. Patients with Jamieson type 2 disease had a greater change in mean sPAP than those with type 3 disease (pxa0=u20090.039). The mean cardiopulmonary bypass time was 180xa0min (T1–198xa0min, T3–159xa0min, pxa0=u2009<0.001), and the mean circulatory arrest time was 37xa0min (T1-44xa0min, T3-31xa0min, pxa0<u20090.001). Plotting circulatory arrest times as a running sum compared to the mean demonstrated 2 inflection points, the first at 22 cases and the second at 95 cases.ConclusionsPTE is a challenging procedure to learn, and good outcomes are a result of a multi-disciplinary effort to optimize case selection, operative performance, and postoperative care. Approximately 20 cases are needed to become proficient in PTE, and nearly 100 cases are required for more efficient clearing of obstructed pulmonary arteries.

Lung Transplantation from Donors after Circulatory Death: United States and Single Center Experience

BACKGROUNDnLung transplants from donation after circulatory death (DCD) have been scarcely used in the United States. Concerns about the warm ischemic injury, resource mal-utilization due to the uncertain timing of death, and public scrutiny may be some factors involved.nnnMETHODSnSurvival for recipients of a donation after brain death (DBD) versus DCD was analyzed by using the United Network for Organ Sharing and our institutional database. A propensity-matching and Cox regression analysis was performed for 25 characteristics. Primary graft dysfunction metrics were compared.nnnRESULTSnA total of 389 of 20,905 lung transplantations (2%) were performed by using DCDs in the United States, and 15 of 128 (12%) at our institution. Five and 10-year survival for DBDs was 55% and 30% and 59% and 33% for DCDs, respectively. Propensity-matched analysis of 311 DBD/DCD pairs did not demonstrate any difference in survival. On Cox regression, DCD was not associated with impaired survival. Male sex, Karnofsky class greater than 50, double lung transplantation, and transplantation year were predictors of improved survival. Age, creatinine, pulmonary fibrosis, retransplantation, extracorporeal membrane oxygenation, allocation score, and donor age were predictors of worse survival. Primary graft dysfunction at time 0 was worse for recipients of DCDs (pxa0= 0.005) but equivalent at 24, 48, and 72 hours.nnnCONCLUSIONSnDCD lung transplants remain underused in the United States. Nevertheless, survival is similar to DBD. Primary graft dysfunction metrics for DCDs are worse than DBDs on intensive care arrival but improved subsequently.

Single- Versus Double-Lung Transplantation in Pulmonary Fibrosis: Impact of Age and Pulmonary Hypertension

BACKGROUNDnDouble-lung transplantation (DLT) has better long-term outcomes compared with single-lung transplantation (SLT) in pulmonary fibrosis. However, controversy persists about whether older patients or patients with high lung allocation scores would benefit from DLT. Moreover, the degree of pulmonary hypertension in which SLT should be avoided is unknown.nnnMETHODSnA retrospective analysis using the United Network for Organ Sharing database was performed in all recipients of lung transplants for pulmonary fibrosis. Kaplan-Meier survival for SLT versus DLT was compared and stratified by age, allocation score, and mean pulmonary artery pressure. Cox regression and propensity-matching analyses were performed.nnnRESULTSnBetween 1987 and 2015; 9,191 of 29,779 lung transplants were performed in pulmonary fibrosis. Ten-year survival rates were 55% for DLT and 32% for SLT (p < 0.001). When stratified by age, DLT recipients had improved survival at all age cutoffs, except age ≥70 years. In addition, DLT recipients had improved survival across all lung allocation scores (<45, ≥45, ≥60, ≥75) and all pulmonary artery pressure categories (<25, ≥25, ≥30, ≥40 mm Hg). Among DLT recipients, pulmonary artery pressure and allocation score did not affect survival. Among SLT recipients, a pressure ≥25 mm Hg did not influence survival. Conversely, patients with a pressure ≥30 mm Hg and an allocation score ≥45 had decreased survival. On Cox regression and on propensity matching, DLT had improved survival compared with SLT.nnnCONCLUSIONSnIn pulmonary fibrosis, DLT has improved survival compared with SLT and should be considered the procedure of choice in patients younger than 70 years of age. SLT in patients with mean pulmonary artery pressure ≥30 mm Hg and an allocation score ≥45 should be discouraged.

Impella Placement Guided by Echocardiography Can Be Used as a Strategy to Unload the Left Ventricle During Peripheral Venoarterial Extracorporeal Membrane Oxygenation

OBJECTIVEnAt the authors institution, before 2015, patients cannulated for peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) did not undergo left ventricular (LV) decompression with the use of an LV vent. After 2015, the authors institution began using the Impella device to vent the left ventricle in patients on VA-ECMO. The authors hypothesized that survival outcomes would improve in patients on VA-ECMO with the use of an Impella for LV venting.nnnDESIGNnRetrospective, chart based review study.nnnSETTINGnSingle center, university-based hospital.nnnPARTICIPANTSnAll adult patients at the authors institution who required VA-ECMO between January 2015 and May 2017.nnnINTERVENTIONnAn Impella (Abiomed, Danvers, MA) device was placed percutaneously in patients cannulated for VA-ECMO as a mechanism to provide LV venting and decompression, therefore unloading the heart.nnnMEASUREMENTS AND MAIN RESULTSnManual chart review was conducted, and a survival analysis was performed. It was observed that patients on VA-ECMO in whom an Impella was implanted had improved survival and an improvement in LV function as demonstrated by echocardiography compared with patients maintained on VA-ECMO alone.nnnCONCLUSIONSnPatients on VA-ECMO plus Impella implantation demonstrated improved survival compared with patients treated with VA-ECMO alone. Key echocardiographic characteristics such as improved LV function after Impella placement and LV cavity size reduction during therapy may help predict those patients who may benefit most from this cannulation strategy.

Extracorporeal Membrane Oxygenation Is a Team Sport: Institutional Survival Benefits of a Formalized ECMO Team

OBJECTIVESnAt the authors institution, prior to 2014, patients requiring care in the peri-extracorporeal membrane oxygenation (ECMO) period were treated by intensivists with specific training in ECMO but worked independently. This isolated form of care was addressed in late 2013 with the formal initiation of an ECMO team. The authors wanted to assess the difference in overall mortality for ECMO patients cared for prior to the initiation of a multidisciplinary team compared to after its establishment.nnnDESIGNnThis was a retrospective chart review-based study.nnnSETTINGnThis was a single-center university-based hospital setting.nnnPARTICIPANTSnThe study included all adult patients at the authors institution who required ECMO support between the years 2009 and 2017.nnnINTERVENTIONSnThe new multidisciplinary ECMO team established a set of protocols and guidelines to care for ECMO patients. The formal ECMO team consisted of cardiac surgery, cardiac anesthesia, intensivists, cardiology heart failure specialist, intensive care unit nursing (NP/RN), perfusion services, respiratory therapy, nutrition, physical and occupational therapy, and an ethics committee member.nnnMEASUREMENTS AND MAIN RESULTSnManual chart review was conducted and survival to discharge was collected and separated into 2 groups, 2009 to 2013 (pre-ECMO team) and 2014 to 2017 (post-ECMO team). In a total of 279 charts reviewed, patients required ECMO support. Survival to discharge for patients between 2009 and 2013 was 37.7% compared to a survival to discharge of 52.3% between 2014 and 2017 (p valueu202f=u202f0.02).nnnCONCLUSIONSnPatients cared for after the initiation of an ECMO team showed improved survival compared to patients cared for prior to the creation of the ECMO team.

Echocardiographic Assessment of Biventricular Function in 249 Patients During the Peri-Extracorporeal Membrane Oxygenation Period

OBJECTIVESnAt a quaternary care center that regularly performs and cares for patients undergoing extracorporeal membrane oxygenation (ECMO), a database of all adult patients since 2009 was assembled with echocardiographic parameters of left (LV) and right (RV) ventricular function. From the database, 175 venoarterial (VA) and 74 venovenous (VV) ECMO patients were analyzed to compare the decannulation echocardiographic assessments of biventricular function before, during, and after ECMO in survivors and nonsurvivors.nnnDESIGNnRetrospective chart review-based study.nnnSETTINGnA single quaternary care center.nnnPARTICIPANTSnAll adult patients who received ECMO from 2009 to 2017 with both survival data and echographic studies were included in this retrospective study.nnnINTERVENTIONSnWhen indicated, transthoracic and transesophageal echocardiograms were performed for ECMO patients. The results of these echocardiograms were reviewed retrospectively, and differences between survivors and nonsurvivors were examined.nnnMEASUREMENTS AND MAIN RESULTSnA retrospective chart review of before, during cannulation, and after decannulation echocardiographic assessments of biventricular function was performed. On average, VA ECMO survivors had better post-decannulation LV function than did nonsurvivors by a full clinical grade-mild impairment versus moderate impairment (p < 0.001). RV function comparison was similar-mild impairment in survivors versus moderate impairment in nonsurvivors (pu202f=u202f0.007). LV and RV function before and during ECMO in survivors was not different from that of nonsurvivors. The change in biventricular function from before to after cannulation and during cannulation to post-cannulation was approximately a full clinical grade better in survivors than nonsurvivors (p < 0.01 in all cases). In VV ECMO patients, post-decannulation RV function was significantly worse in nonsurvivors (moderate dysfunction vs borderline normal function) (pu202f=u202f0.013).nnnCONCLUSIONSnRetrospective chart review of 249 patients suggests that echocardiographic assessment of biventricular function before ECMO cannulation is not prognostic in VA or VV ECMO patients. Post-decannulation assessment of biventricular function may aid in triaging more at risk patients because nonsurvivors have significantly worse biventricular function after decannulation. The failure to improve biventricular function from the before to after ECMO phases and the during to after ECMO phases is concerning for a poor prognosis.

The effect of donor age on posttransplant mortality in a cohort of adult cardiac transplant recipients aged 18-45

Hearts from older donors are increasingly utilized for transplantation due to unmet demand. Conflicting evidence exists regarding the prognosis of recipients of advanced age donor hearts, especially in young recipients. A retrospective analysis was performed on 11 433 patients aged 18 to 45 who received a cardiac transplant from 2000 to 2017. Overall, 10 279 patients received hearts from donors less than 45 and 1145 from donors greater than 45. Recipients of older donors were older (37 vs. 34 years, P < .01) and had higher rates of inotropic dependence (48% vs. 42%, P < .01). However, groups were similar in terms of comorbidities and dependence on mechanical circulatory support. Median survival for recipients of older donors was reduced by 2.6 years (12.6 vs. 15.2, P < .01). Multivariable analysis demonstrated donor age greater than 45 to be a predictor of mortality (HR 1.18 [1.05‐1.33], P = .01). However, when restricting the analysis to patients who received a donor with a negative preprocurement angiogram, donor age only had a borderline association with mortality (HR 1.20 [0.98‐1.46], P = .06). Older donor hearts in young recipients are associated with decreased long‐term survival, however this risk is reduced in donors without atherosclerosis. The long‐term hazard of this practice should be carefully weighed against the risk of waitlist mortality.