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Ezzelarab MB, Zhang H, Sasaki K, Lu L, Zahorchak AF, van der Windt DJ, Dai H, Perez-Gutierrez A, Bhama JK, Thomson AW. Ex Vivo Expanded Donor Alloreactive Regulatory T Cells Lose Immunoregulatory, Proliferation, and Antiapoptotic Markers After Infusion Into ATG-lymphodepleted, Nonhuman Primate Heart Allograft Recipients. Transplantation 2021; 105:1965-1979. [PMID: 33587433 PMCID: PMC8239063 DOI: 10.1097/tp.0000000000003617] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Regulatory T cell (Treg) therapy is a promising approach to amelioration of allograft rejection and promotion of organ transplant tolerance. However, the fate of infused Treg, and how this relates to their therapeutic efficacy using different immunosuppressive regimens is poorly understood. Our aim was to analyze the tissue distribution, persistence, replicative activity and phenotypic stability of autologous, donor antigen alloreactive Treg (darTreg) in anti-thymocyte globulin (ATG)-lymphodepleted, heart-allografted cynomolgus monkeys. METHODS darTreg were expanded ex vivo from flow-sorted, circulating Treg using activated donor B cells and infused posttransplant into recipients of major histocompatibility complex-mismatched heart allografts. Fluorochrome-labeled darTreg were identified and characterized in peripheral blood, lymphoid, and nonlymphoid tissues and the graft by flow cytometric analysis. RESULTS darTreg selectively suppressed autologous T cell responses to donor antigens in vitro. However, following their adoptive transfer after transplantation, graft survival was not prolonged. Early (within 2 wk posttransplant; under ATG, tacrolimus, and anti-IL-6R) or delayed (6-8 wk posttransplant; under rapamycin) darTreg infusion resulted in a rapid decline in transferred darTreg in peripheral blood. Following their early or delayed infusion, labeled cells were evident in lymphoid and nonlymphoid organs and the graft at low percentages (<4% CD4+ T cells). Notably, infused darTreg showed reduced expression of immunoregulatory molecules (Foxp3 and CTLA4), Helios, the proliferative marker Ki67 and antiapoptotic Bcl2, compared with preinfusion darTreg and endogenous CD4+CD25hi Treg. CONCLUSIONS Lack of therapeutic efficacy of infused darTreg in lymphodepleted heart graft recipients appears to reflect loss of a regulatory signature and proliferative and survival capacity shortly after infusion.
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Affiliation(s)
- Mohamed B. Ezzelarab
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Hong Zhang
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kazuki Sasaki
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lien Lu
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alan F. Zahorchak
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Dirk J. van der Windt
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Helong Dai
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Angelica Perez-Gutierrez
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jay K. Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Angus W. Thomson
- Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Immunology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Bhama JK. Commentary: A riddle wrapped in a mystery inside an enigma. J Thorac Cardiovasc Surg 2021; 164:1818-1819. [PMID: 33894994 DOI: 10.1016/j.jtcvs.2021.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Jay K Bhama
- Division of Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Ark; Department of Cardiothoracic Surgery, Baptist Heart Failure and Transplant Institute, Baptist Health Medical Center, Little Rock, Ark.
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Bhama JK. Commentary: MANTAstic! JTCVS Tech 2020; 6:84. [PMID: 34318151 PMCID: PMC8300907 DOI: 10.1016/j.xjtc.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 12/13/2020] [Accepted: 12/21/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jay K Bhama
- Department of Cardiothoracic Surgery and Baptist Heart Failure and Transplant Institute, Baptist Health Medical Center, Little Rock, Ark.,Division of Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Ark
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Bhama JK. Commentary: Not Everything That Matters Can Be Measured…. Semin Thorac Cardiovasc Surg 2020; 32:811-812. [PMID: 32610190 DOI: 10.1053/j.semtcvs.2020.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jay K Bhama
- Department of Cardiothoracic Surgery & Baptist Heart Failure and Transplant Institute, Baptist Health Medical Center, Little Rock, Arkansas; Division of Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas.
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Balasubramanian V, Bhama JK. Technique for "open sternal" chest closure in patients with assist devices and transplant recipients. JTCVS Tech 2020; 2:77-79. [PMID: 34317759 PMCID: PMC8298878 DOI: 10.1016/j.xjtc.2020.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 01/18/2020] [Accepted: 02/25/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Velu Balasubramanian
- Division of Cardiothoracic Surgery, Department of Surgery, Carver College of Medicine, University of Iowa Health Care, Iowa City, Iowa
| | - Jay K Bhama
- Heart Failure and Transplant Institute, Baptist Health Medical Center-Little Rock, Little Rock, Ark.,Division of Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Ark
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Bhama JK. Commentary: Good information is the best medicine. J Thorac Cardiovasc Surg 2020; 162:549-550. [PMID: 32014327 DOI: 10.1016/j.jtcvs.2019.12.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/06/2019] [Accepted: 12/08/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Jay K Bhama
- Department of Cardiothoracic Surgery & Baptist Heart Failure and Transplant Institute, Baptist Health Medical Center, Little Rock, Ark; Division of Cardiovascular Surgery, University of Arkansas for Medical Sciences, Little Rock, Ark.
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Bansal A, Chan J, Bansal A, Carter-Thompson WP, Akhtar F, Parrino PE, Bhama JK. Preoperative Vitamin K Reduces Blood Transfusions at Time of Left Ventricular Assist Device Implant. Ann Thorac Surg 2019; 109:787-793. [PMID: 31470010 DOI: 10.1016/j.athoracsur.2019.06.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 05/04/2019] [Accepted: 06/25/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Congestive heart failure patients have hepatic congestion and abnormal coagulation profiles, increasing perioperative bleeding at time of ventricular assist device implantation. This study examined the impact of the preoperative administration of vitamin K on perioperative blood transfusion requirements. METHODS Retrospectively, 190 patients met inclusion criteria. Patients received no vitamin K (n = 62) or two 10-mg doses of intravenous vitamin K (n = 128) in the 24 hours before assist device implantation. Primary end points included transfusion requirements and reexploration rates for bleeding. Secondary outcomes were pump thrombosis and in-hospital mortality. RESULTS Baseline characteristics were similar between the 2 groups, with slight differences (not statistically significant) noted in the Interagency Registry for Mechanically Assisted Circulatory Support profile and total bilirubin levels. The only significant difference noted was the year of implantation (P < .001). Blood product usage was significantly lower in the vitamin K group compared to the no vitamin K group (P < .001). Higher rates of reexploration for bleeding (29.7% vs 13.6%, P = .023) and death at hospital discharge (16.2% vs 2.8%, P = .004) were noted for the no vitamin K group compared with the vitamin K group. After adjusting for age, sex, race, body mass index, Interagency Registry for Mechanically Assisted Circulatory Support profile, total bilirubin, surgeon, and year of operation, reexploration rates and death did not achieve statistical significance. No statistically significant difference was observed in stroke and pump thrombosis rates between the 2 groups. CONCLUSIONS Preoperative vitamin K administration may help reduce blood product use without any increased risk for strokes or pump thrombosis.
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Affiliation(s)
- Aditya Bansal
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana.
| | - Jessica Chan
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Arnav Bansal
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana
| | | | - Faisal Akhtar
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Patrick E Parrino
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, Louisiana; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Jay K Bhama
- Department of Cardiothoracic Surgery, University of Iowa Health Care, Iowa City, Iowa
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Bhama JK. Commentary: A tale of two valves. J Thorac Cardiovasc Surg 2019; 159:908-909. [PMID: 31256968 DOI: 10.1016/j.jtcvs.2019.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 05/14/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Jay K Bhama
- Department of Cardiothoracic Surgery, Baptist Heart Failure and Transplant Institute, Baptist Health Medical Center, Little Rock, Ark.
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Bhama JK, Singh G, Ratner A. Commentary: Go with the flow…dynamics! J Thorac Cardiovasc Surg 2019; 159:e211. [PMID: 31176548 DOI: 10.1016/j.jtcvs.2019.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Jay K Bhama
- Department of Cardiothoracic Surgery & Baptist Heart Failure and Transplant Institute, Baptist Health Medical Center, Little Rock, Ark; Department of Mechanical Engineering, College of Engineering, University of Iowa, Iowa City, Iowa.
| | - Gurjap Singh
- Department of Mechanical Engineering, College of Engineering, University of Iowa, Iowa City, Iowa
| | - Albert Ratner
- Department of Mechanical Engineering, College of Engineering, University of Iowa, Iowa City, Iowa
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Sharafuddin MJ, Bhama JK, Bashir M, Aboul-Hosn MS, Man JH, Sharp AJ. Distal landing zone optimization before endovascular repair of aortic dissection. J Thorac Cardiovasc Surg 2018; 157:88-98. [PMID: 30557960 DOI: 10.1016/j.jtcvs.2018.06.095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/08/2018] [Accepted: 06/24/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The general goals of endovascular management in chronic distal thoracic aortic dissection are optimizing the true lumen, maintaining branch patency, and promoting false lumen (FL) thrombosis. Distal seal can be challenging in chronic distal thoracic aortic dissection due to the well-established secondary fenestrations and fibrotic septum. We describe our approach of distal landing zone optimization (DLZO) to enable full-diameter contact of the distal endoprosthesis. MATERIALS AND METHODS Our experience includes 19 procedures in 16 patients (12 male, age 68 ± 8 years) between May 2014 and November 2017. A history of previous ascending repair for type A dissection was present in 8 patients. Treatment indication was enlarging aneurysm in all subjects, and 4 patients had associated chronic visceral or distal ischemia. Point septal fenestrations were expanded by serial balloon dilation and/or wire-pull approaches. Balloon molding was used to ensure complete endograft apposition and FL collapse. RESULTS One death occurred due to aortic perforation during wire-pull fenestration in a patient with heavily calcified and angulated aorta. The remaining procedures were accomplished safely and successfully. Balloon fenestration was used in 16 procedures, alone or in combination with a limited wire pull component. Adjunct procedures for distal seal included surgeon-modified fenestrated stent graft (3), iliac branch device (3), parallel superior mesenteric artery stent-graft (1), renal artery or superior mesenteric artery stent-graft (4), iliac stent (3), and plug obliteration of FL (5). Reintervention was required in 3 patients due to delayed loss of seal after the initial procedure (3, 8, and 12 months). Two were managed by repeat DLZO and distal extension. The third had distal extension via a surgeon-modified fenestrated stent-graft component. Follow-up imaging was available in 14 patients (16.0 ± 12.5 months, range: 1-33), with stable or regressed sac diameter with complete or near-complete thrombosis of the FL in all patients. CONCLUSIONS DLZO enabled creation of a distal seal zone in all patients. Residual retrograde filling of the FL is a marker of procedure failure, especially when seal segment length or feasible endoprosthesis oversizing are marginal. Insufficient landing segment can be circumvented with the use of a fenestrated or branched device to accomplish seal in the visceral aorta or iliac bifurcation. Adjunct FL ablation is also a valuable technique to promote FL thrombosis.
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Affiliation(s)
- Mel J Sharafuddin
- Department of Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa; Division of Vascular Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa.
| | - Jay K Bhama
- Department of Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa; Division of Cardiothoracic Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa
| | - Mohammad Bashir
- Department of Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa; Division of Cardiothoracic Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa
| | - Maen S Aboul-Hosn
- Department of Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa; Division of Vascular Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa
| | - Jeanette H Man
- Department of Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa; Division of Vascular Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa
| | - Alexandra J Sharp
- Department of Surgery, The University of Iowa Roy and Lucille Carver College of Medicine, Iowa City, Iowa
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Voruganti DC, Briasoulis A, Chaudhry M, Alvarez P, Cotarlan V, Bhama JK, Giudici M. Cardiac resynchronization therapy and outcomes in patients with left ventricular assist devices: a systematic review and meta-analysis. Heart Fail Rev 2018; 24:229-236. [DOI: 10.1007/s10741-018-9740-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Voruganti D, Gajurel K, Bhama JK, Cotarlan V. Ruptured Intracranial Mycotic Aneurysm in Infective Endocarditis With Left Ventricular Assist Device and Implantable Cardiac Defibrillator Device: A Clinical Course. Transplant Proc 2018; 50:4064-4066. [PMID: 30577316 DOI: 10.1016/j.transproceed.2018.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/29/2018] [Indexed: 01/16/2023]
Abstract
We report the first case of a ruptured intracranial aneurysm-related Staphylococcus epidermidis bacteremia in a patient supported by a continuous flow left ventricular assist device (LVAD). Mycotic aneurysms (MAs) are aneurysmal degeneration of the arterial wall as a result of infection. Current recommendations for management of intracranial mycotic aneurysms are based on a few retrospective case studies. There are only a few cases of intracranial MA reported in patients with LVAD infections caused by Pseudomonas aeruginosa and Klebsiella rhinos. Here, we describe the first case of a ruptured intracranial aneurysm caused by a less virulent organism (Staphylococcus epidermidis) and conclude that screening for asymptomatic MA should be strongly considered in patients with persistent LVAD- and implantable cardiac defibrillator pacemaker-associated infections.
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Affiliation(s)
- D Voruganti
- Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA.
| | - K Gajurel
- Division of Infectious Diseases, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - J K Bhama
- Department of Surgery, Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - V Cotarlan
- Division of Cardiovascular Diseases, Section of Heart Failure and Transplant, University of Cincinnati Hospitals, Cincinnati, OH
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13
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Bhama JK. Salt of the earth, or just salt? J Thorac Cardiovasc Surg 2018; 157:626-627. [PMID: 30174129 DOI: 10.1016/j.jtcvs.2018.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/13/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Jay K Bhama
- Section of Adult Cardiac Surgery, Department of Surgery, Carver College of Medicine, and University of Iowa Health Care, Iowa City, Iowa.
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14
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Bhama JK, Bansal U, Winger DG, Teuteberg JJ, Bermudez C, Kormos RL, Bansal A. Clinical experience with temporary right ventricular mechanical circulatory support. J Thorac Cardiovasc Surg 2018; 156:1885-1891. [PMID: 29861112 DOI: 10.1016/j.jtcvs.2018.04.094] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to determine if indication for support affects the outcomes after temporary right ventricular mechanical circulatory support after postcardiotomy cardiogenic shock, cardiac transplant, or left ventricular assist device placement. METHODS A retrospective review was performed on 80 patients receiving a right ventricular assist device. Data were collected from a prospectively maintained database. Kaplan-Meier survival analysis was performed to compare survival between groups. Multivariate regression analysis was performed to identify risk factors for failure to wean from support. RESULTS The indication for support was postcardiotomy cardiogenic shock in 13 patients (16%), cardiac transplant in 25 patients (31%), and left ventricular assist device in 42 patients (53%). Median support time was 6 days. Device was successfully weaned in 6 postcardiotomy cardiogenic shock cases (46%), 21 cardiac transplant cases (84%), and 35 left ventricular assist device cases (83%). Survival was worse for patients with postcardiotomy cardiogenic shock compared with patients with a left ventricular assist device. Survival up to 3 months was better for patients who received immediate (n = 43) versus delayed (n = 37) support (79% vs 46%, P = .003). Weaning and survival remained static across implant era. Risk factor analysis identified postcardiotomy cardiogenic shock indication (odds ratio, 0.161; P = .007; confidence interval, 0.043-0.600) as an independent negative predictor of weaning from mechanical support. CONCLUSIONS Temporary right ventricular mechanical support remains an effective treatment strategy after left ventricular assist device placement with immediate support resulting in superior short-term survival. Caution should be applied in postcardiotomy cardiogenic shock when weaning and survival are poor. Overall survival outcomes have remained relatively static over time.
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Affiliation(s)
- Jay K Bhama
- Division of Cardiothoracic Surgery, University of Iowa Health Care, Iowa City, Iowa.
| | - Utsav Bansal
- University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa
| | - Jeffrey J Teuteberg
- Heart and Vascular Institute, Artificial Heart Program, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Christian Bermudez
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Robert L Kormos
- Heart and Vascular Institute, Artificial Heart Program, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Aditya Bansal
- Division of Cardiothoracic Surgery, Ochsner Clinic, New Orleans, La
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Shah PR, Boisen ML, Winger DG, Marquez J, Bermudez CA, Bhama JK, Shigemura N, D'Cunha J, Subramaniam K. Corrigendum to 'Extracorporeal Support During Bilateral Sequential Lung Transplantation in Patients with Pulmonary Hypertension: Risk factors and Outcomes' [Journal of Cardiothoracic and Vascular Anesthesia volume 31/2 (2017) 418-425]. J Cardiothorac Vasc Anesth 2018; 32:2034. [PMID: 29567039 DOI: 10.1053/j.jvca.2018.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Pranav R Shah
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Daniel G Winger
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Jose Marquez
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jay K Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Bashir MA, Davis TA, Bhama JK, Calcaterra D, Parekh KR. Predicting Outcomes and Mortality for Critically Ill Patients with Infective Endocarditis. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rasmussen TP, Goldsmith G, Zahr F, Bhama JK, Bhave PD. Percutaneous extraction of a pulmonary artery catheter inadvertently sewn to the right atrial wall. HeartRhythm Case Rep 2017; 2:511-513. [PMID: 28491748 PMCID: PMC5419990 DOI: 10.1016/j.hrcr.2016.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Tyler P Rasmussen
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Gary Goldsmith
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Firas Zahr
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Jay K Bhama
- Division of Cardiothoracic Surgery, Department of General Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Prashant D Bhave
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Shah PR, Boisen ML, Winger DG, Marquez J, Bermudez CA, Bhama JK, Shigemura N, D’Cunha J, Subramaniam K. Extracorporeal Support During Bilateral Sequential Lung Transplantation in Patients With Pulmonary Hypertension: Risk Factors and Outcomes. J Cardiothorac Vasc Anesth 2017; 31:418-425. [DOI: 10.1053/j.jvca.2016.08.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Indexed: 11/11/2022]
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Bush RL, Bhama JK, Lin PH, Lumsden AB. Transient Ischemic Attack Due to Early Carotid Stent Thrombosis: Successful Rescue with Rheolytic Thrombectomy and Systemic Abciximab. J Endovasc Ther 2016; 10:870-4. [PMID: 14656189 DOI: 10.1177/152660280301000504] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To describe a successful neurorescue technique in a patient with generalized seizures followed by hemiparesis immediately after carotid artery stenting (CAS) for a postsurgical restenosis. Case Report: A 65-year-old man with a symptomatic recurrent high-grade carotid stenosis after carotid endarterectomy was treated with CAS. The procedure was complicated by sudden transient ischemic attack caused by acute carotid stent thrombosis with clot propagation into the cerebral circulation. Percutaneous mechanical thrombectomy was performed with adjunctive infusion of intravenous abciximab, resulting in complete thrombus dissolution and resolution of neurological symptoms. Conclusions: Access to a mechanical thrombectomy device was essential for rapid thrombus extraction, and adjunctive abciximab aided in residual clot dissolution. As a result of this combined method of clot removal, a disastrous outcome was averted.
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Affiliation(s)
- Ruth L Bush
- Division of Vascular Surgery & Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine and The Methodist Hospital, Houston, Texas 77030, USA.
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Murthy R, Bajona P, Bhama JK, Cooper DK. Heart Xenotransplantation: Historical Background, Experimental Progress, and Clinical Prospects. Ann Thorac Surg 2016; 101:1605-13. [DOI: 10.1016/j.athoracsur.2015.10.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/14/2015] [Accepted: 10/01/2015] [Indexed: 12/29/2022]
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Bansal A, Bhama JK, Patel R, Desai S, Mandras SA, Patel H, Collins T, Reilly JP, Ventura HO, Parrino PE. Using the Minimally Invasive Impella 5.0 via the Right Subclavian Artery Cutdown for Acute on Chronic Decompensated Heart Failure as a Bridge to Decision. Ochsner J 2016; 16:210-216. [PMID: 27660567 PMCID: PMC5024800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Outcomes of traditional mechanical support paradigms (extracorporeal membrane oxygenation, intraaortic balloon pump [IABP], and permanent left ventricular assist device [LVAD]) in acute decompensated heart failure have generally been suboptimal. Novel approaches, such as minimally invasive LVAD therapy (Impella 5.0 device), promise less invasive but equivalent hemodynamic support. However, it is yet unknown whether the outcomes with such devices support widespread acceptance of this new technology. We recently started utilizing the right subclavian artery (RSA) for Impella 5.0 implantation and report our early experience and outcomes with this novel approach. METHODS A single-center retrospective review was performed of 24 patients with acute on chronic decompensated heart failure who received the Impella 5.0 via the RSA from June 2011 to May 2014. The device was implanted via a cutdown through an 8-mm vascular graft sewn to the RSA. The device was positioned with fluoroscopy and transesophageal echocardiography. RESULTS The mean age of the patients was 51.29 years, and 75% were male. At implantation, all patients were mechanically ventilated on at least 2 inotropes with persistent cardiogenic shock, and 17 (70.8%) were on IABP support. Postimplantation, 21 (87.5%) tolerated extubation, and all 17 of the patients with IABPs tolerated discontinuation of IABP support. The reduction in the Model for End-Stage Liver Disease score preimplantation vs postimplantation was statistically significant (21.17 vs 14.88, P=0.0014), suggesting improvement in end organ function. A significant decrease was also seen in creatinine levels before and after implantation (2.17 mg/dL vs 1.50 mg/dL, P=0.0043). The endpoint of support included recovery in 6 patients (25.0%), permanent LVAD in 9 (37.5%), and heart transplantation in 2 (8.3%). Death occurred in 7 patients (29.2%) as a result of multisystem organ failure, infection, or patient withdrawal of care. CONCLUSION Minimally invasive LVAD therapy using the Impella 5.0 via the RSA cutdown is an attractive option in acute on chronic decompensated heart failure. Improvement in end organ function allows for transition to recovery or to advanced surgical therapies such as permanent LVAD and heart transplantation. Significant advantages to this approach include improved left ventricular unloading, lower anticoagulation need, and the potential for ambulation and physical therapy.
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Affiliation(s)
- Aditya Bansal
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
| | - Jay K. Bhama
- Department of Cardiothoracic Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | - Rajan Patel
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Sapna Desai
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Stacy A. Mandras
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Hamang Patel
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Tyrone Collins
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - John P. Reilly
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - Hector O. Ventura
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA
| | - P. Eugene Parrino
- Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA
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Iwase H, Ekser B, Zhou H, Liu H, Satyananda V, Humar R, Humar P, Hara H, Long C, Bhama JK, Bajona P, Wang Y, Wijkstrom M, Ayares D, Ezzelarab MB, Cooper DKC. Further evidence for sustained systemic inflammation in xenograft recipients (SIXR). Xenotransplantation 2015; 22:399-405. [PMID: 26292982 DOI: 10.1111/xen.12182] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/02/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION In pig-to-baboon heart/artery patch transplantation models, adequate costimulation blockade prevents a T-cell response. After heart transplantation, coagulation dysfunction (thrombocytopenia, reduced fibrinogen, increased D-dimer) and inflammation (increased C-reactive protein [CRP]) develop. We evaluated whether coagulation dysfunction and/or inflammation can be detected following pig artery patch transplantation. METHODS Baboons received heart (n = 8) or artery patch (n = 16) transplants from genetically engineered pigs and a costimulation blockade-based regimen. Heart grafts functioned for 15-130 days. Artery recipients were euthanized after 28-84 days. Platelet counts, fibrinogen, D-dimer, and CRP were measured. RESULTS Thrombocytopenia and reduced fibrinogen developed only in recipients of hearts not expressing a coagulation-regulatory protein (n = 4), but not in other heart or patch recipients. However, in heart recipients (n = 8), there were sustained increases in D-dimer (<0.5 to 1.9 ug/ml [P < 0.01]) and CRP (0.26-2.2 mg/dl [P < 0.01]). In recipients of artery patches, there were also sustained increases in D-dimer (<0.5 to 1.4 ug/ml [P < 0.01]) and CRP (0.26 to 1.5 mg/dl [P < 0.001]). An IL-6R antagonist suppressed the increase in CRP, but not D-dimer. CONCLUSION The pig artery patch model has proved valuable for determining immunosuppressive regimens that prevent sensitization to pig antigens. This model also provides information on the sustained systemic inflammation in xenograft recipients (SIXR). An IL-6R antagonist may help suppress this response.
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Affiliation(s)
- Hayato Iwase
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Burcin Ekser
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Surgery Transplantation and Advanced Technologies, Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Huidong Zhou
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.,Center for Kidney Transplantation, Second Affiliated Hospital of the University of South China, Hengyang, Hunan, China
| | - Hong Liu
- Department of General Surgery, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Vikas Satyananda
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rishab Humar
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pooja Humar
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hidetaka Hara
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Cassandra Long
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay K Bhama
- Department of Cardiac Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pietro Bajona
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yi Wang
- Center for Kidney Transplantation, Second Affiliated Hospital of the University of South China, Hengyang, Hunan, China
| | - Martin Wijkstrom
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Mohamed B Ezzelarab
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - David K C Cooper
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Tanaka Y, Noda K, Isse K, Tobita K, Maniwa Y, Bhama JK, D'Cunha J, Bermudez CA, Luketich JD, Shigemura N. A novel dual ex vivo lung perfusion technique improves immediate outcomes in an experimental model of lung transplantation. Am J Transplant 2015; 15:1219-30. [PMID: 25777770 DOI: 10.1111/ajt.13109] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/10/2014] [Accepted: 11/16/2014] [Indexed: 01/25/2023]
Abstract
The lungs are dually perfused by the pulmonary artery and the bronchial arteries. This study aimed to test the feasibility of dual-perfusion techniques with the bronchial artery circulation and pulmonary artery circulation synchronously perfused using ex vivo lung perfusion (EVLP) and evaluate the effects of dual-perfusion on posttransplant lung graft function. Using rat heart-lung blocks, we developed a dual-perfusion EVLP circuit (dual-EVLP), and compared cellular metabolism, expression of inflammatory mediators, and posttransplant graft function in lung allografts maintained with dual-EVLP, standard-EVLP, or cold static preservation. The microvasculature in lung grafts after transplant was objectively evaluated using microcomputed tomography angiography. Lung grafts subjected to dual-EVLP exhibited significantly better lung graft function with reduced proinflammatory profiles and more mitochondrial biogenesis, leading to better posttransplant function and compliance, as compared with standard-EVLP or static cold preservation. Interestingly, lung grafts maintained on dual-EVLP exhibited remarkably increased microvasculature and perfusion as compared with lungs maintained on standard-EVLP. Our results suggest that lung grafts can be perfused and preserved using dual-perfusion EVLP techniques that contribute to better graft function by reducing proinflammatory profiles and activating mitochondrial respiration. Dual-EVLP also yields better posttransplant graft function through increased microvasculature and better perfusion of the lung grafts after transplantation.
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Affiliation(s)
- Y Tanaka
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; Division of Thoracic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Barnes L, Reed RM, Parekh KR, Bhama JK, Pena T, Rajagopal S, Schmidt GA, Klesney-Tait JA, Eberlein M. MECHANICAL VENTILATION FOR THE LUNG TRANSPLANT RECIPIENT. Curr Pulmonol Rep 2015; 4:88-96. [PMID: 26495241 DOI: 10.1007/s13665-015-0114-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx)-recipients. There are no randomized-controlled trials of LTx-recipient MV strategies; however there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low-tidal-volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx-recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however this donor-characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.
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Affiliation(s)
- Lindsey Barnes
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland
| | - Kalpaj R Parekh
- Department of Thoracic and Cardiovascular Surgery, University of Iowa Hospitals and Clinics
| | - Jay K Bhama
- Department of Thoracic and Cardiovascular Surgery, University of Iowa Hospitals and Clinics
| | - Tahuanty Pena
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Pennsylvania
| | | | - Gregory A Schmidt
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
| | - Julia A Klesney-Tait
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
| | - Michael Eberlein
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
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D'Angelo A, Bhama JK, Crespo M, Pilewski J, Shigemura N, Bermudez C, Luketich JD, D'Cunha J. Bronchopleural fistula after bilateral sequential lobar lung transplantation: Technical details of a successful repair. J Thorac Cardiovasc Surg 2015; 149:e67-8. [DOI: 10.1016/j.jtcvs.2014.12.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Revised: 12/08/2014] [Accepted: 12/12/2014] [Indexed: 12/01/2022]
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26
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Iwase H, Ekser B, Satyananda V, Zhou H, Hara H, Bajona P, Wijkstrom M, Bhama JK, Long C, Veroux M, Wang Y, Dai Y, Phelps C, Ayares D, Ezzelarab MB, Cooper DKC. Initial in vivo experience of pig artery patch transplantation in baboons using mutant MHC (CIITA-DN) pigs. Transpl Immunol 2015; 32:99-108. [PMID: 25687023 PMCID: PMC4368496 DOI: 10.1016/j.trim.2015.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 02/03/2015] [Accepted: 02/05/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND In the pig-to-nonimmunosuppressed baboon artery patch model, a graft from an α1,3-galactosyltransferase gene-knockout pig transgenic for human CD46 (GTKO/CD46) induces a significant adaptive immune response (elicited anti-pig antibody response, increase in T cell proliferation on MLR, cellular infiltration of the graft), which is effectively prevented by anti-CD154mAb-based therapy. METHODS As anti-CD154mAb is currently not clinically applicable, we evaluated whether it could be replaced by CD28/B7 pathway blockade or by blockade of both pathways (using belatacept + anti-CD40mAb [2C10R4]). We further investigated whether a patch from a GTKO/CD46 pig with a mutant human MHC class II transactivator (CIITA-DN) gene would allow reduction in the immunosuppressive therapy administered. RESULTS When grafts from GTKO/CD46 pigs were transplanted with blockade of both pathways, a minimal or insignificant adaptive response was documented. When a GTKO/CD46/CIITA-DN graft was transplanted, but no immunosuppressive therapy was administered, a marked adaptive response was documented. In the presence of CD28/B7 pathway blockade (abatacept or belatacept), there was a weak adaptive response that was diminished when compared with that to a GTKO/CD46 graft. Blockade of both pathways prevented an adaptive response. CONCLUSION Although expression of the mutant MHC CIITA-DN gene was associated with a reduced adaptive immune response when immunosuppressive therapy was inadequate, when blockade of both the CD40/CD154 and CD28/B7 pathways was present, the response even to a GTKO/CD46 graft was suppressed. This was confirmed after GTKO/CD46 heart transplantation in baboons.
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Affiliation(s)
- H Iwase
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - B Ekser
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA; Department of Surgery, Transplantation and Advanced Technologies, Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - V Satyananda
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - H Zhou
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA; Center for Kidney Transplantation, Second Affiliated Hospital of the University of South China, Hengyang, Hunan, China
| | - H Hara
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - P Bajona
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Wijkstrom
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - J K Bhama
- Department of Cardiac Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - C Long
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Veroux
- Department of Surgery, Transplantation and Advanced Technologies, Vascular Surgery and Organ Transplant Unit, University Hospital of Catania, Catania, Italy
| | - Y Wang
- Center for Kidney Transplantation, Second Affiliated Hospital of the University of South China, Hengyang, Hunan, China
| | - Y Dai
- Revivicor, Blacksburg, VA, USA
| | | | | | - M B Ezzelarab
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - D K C Cooper
- Thomas E Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, PA, USA.
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27
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Hayanga AJ, Aboagye JK, Hayanga HE, Morrell M, Huffman L, Shigemura N, Bhama JK, D'Cunha J, Bermudez CA. Contemporary analysis of early outcomes after lung transplantation in the elderly using a national registry. J Heart Lung Transplant 2014; 34:182-8. [PMID: 25447584 DOI: 10.1016/j.healun.2014.09.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 08/02/2014] [Accepted: 09/18/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND With an increasing number of potential recipients and a comparatively static number of donors, lung transplantation (LT) in the elderly has come under significant scrutiny. Previous studies have been limited by single-center experiences with small population sizes and often mixed results. Using a national registry, we sought to evaluate the following: (1) differences in survival outcomes in septuagenarians compared with sexagenarians; and (2) the effect of temporal trends on the development of other comorbidities in this population. METHODS We analyzed the Scientific Registry of Transplant Recipients (SRTR) data files from the United Network for Organ Sharing (UNOS) database to identify recipients who underwent LT between the years 2000 and 2013. The study period was divided into two equal eras. Using Kaplan-Meier analysis, we compared the 30-day, 3-month, 1-year, 3-year and 5-year patient survival between septuagenarians and sexagenarians in both eras. Separate multivariate analyses were performed to estimate the risk of renal failure, risk of rejection and length of hospital stay (LOS) post-LT in each of these time periods. RESULTS A total of 6,596 patients were identified comprising 1,726 (26.2%) during 2000 to 2005 and 4,870 (73.8%) during 2006 to 2012. In the "early era," 32 (1.9%) septuagenarians and 1,694 (98.1%) sexagenarians underwent LT, whereas 543 (11.1%) septuagenarians and 4,327 (88.9%) sexagenarians underwent transplantation in the "latter era." A comparison of patient survival between the two groups in the early era revealed no difference at 30 days (95.7% vs 93.8%, p = 0.65). However, 3-month (91.2% vs 75%, p = 0.04) and 1-year patient survival (79.5% vs 62.5%, p = 0.048) were both lower in the septuagenarian group. In the later era, however, there were no differences in 30-day (96.2% vs 96.8, p = 0.5), 3-month (92.7% vs 91.9%, p = 0.56) or 1-year (81.7% vs 78.6%, p = 0.12) patient survival between the two age groups. Survival rates at 3 years (63.7% vs 49.3%, p < 0.001) and 5 years (47.5% vs 28.2%, p < 0.001) were each significantly lower in the septuagenarian group. CONCLUSION Overall, LT outcomes for the elderly have improved significantly over time and early outcomes in the modern era rival those found in younger recipients.
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Affiliation(s)
- Awori J Hayanga
- DeVos Heart and Lung Transplantation Program, Spectrum Health-Michigan State University, Grand Rapids, Michigan.
| | | | - Heather E Hayanga
- Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Matthew Morrell
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lynn Huffman
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jay K Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Bermudez CA, Shiose A, Esper SA, Shigemura N, D'Cunha J, Bhama JK, Richards TJ, Arlia P, Crespo MM, Pilewski JM. Outcomes of intraoperative venoarterial extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation. Ann Thorac Surg 2014; 98:1936-42; discussion 1942-3. [PMID: 25443002 DOI: 10.1016/j.athoracsur.2014.06.072] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND The intraoperative use of cardiopulmonary bypass (CPB) in lung transplantation has been associated with increased rates of pulmonary dysfunction and bleeding complications. More recently, extracorporeal membrane oxygenation (ECMO) has emerged as a valid alternative method of support and has been our preferred method of support since March 2012. We compared early and midterm outcomes of these 2 support methods. METHODS Between July 2007 and April 2013, 271 consecutive patients underwent lung transplant using CPB (n = 222) or ECMO (n = 49). We retrospectively reviewed the outcomes of these patients requiring CPB or ECMO during lung transplant. RESULTS The CPB and ECMO groups had comparable demographic and operative characteristics; however, the ECMO group had higher mean lung allocation scores (73 vs 52, p < 0.001). In the CPB group, more patients required reintubation (35.6% vs 20.4%, p = 0.04) or temporary tracheostomy (44.6% vs 28.6%, p = 0.05). Patients in the CPB group had a higher rate of renal failure requiring dialysis than the ECMO group (22.1% vs 8.2 %, p = 0.028). There were no differences in severe PGD requiring postoperative circulatory support (p = 0.83) or the need for perioperative red blood cell transfusions (p = 0.64) between the groups. No differences in 30-day (5% CPB vs 4.1% ECMO) or 6-month mortality (14.4% CPB vs 14.3% ECMO) were noted. CONCLUSIONS The use of ECMO in lung transplant is safe and in our experience was associated with decreased rates of pulmonary and renal complications, as compared with CPB. Extracorporeal membrane oxygenation has become our preferred method of intraoperative support during lung transplantation.
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Affiliation(s)
- Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Akira Shiose
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jay K Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Thomas J Richards
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Peter Arlia
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Hayanga AJ, Yang J, Aboagye J, Kaiser HE, Shigemura N, Bhama JK, Luketich JD, D'Cunha J. Lung transplantation in patients with high lung allocation scores: using national data to estimate prognosis. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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30
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Hayanga AJ, Aboagye J, Esper S, Shigemura N, Bermudez CA, D'Cunha J, Bhama JK. Extracorporeal membrane oxygenation as a bridge to lung transplantation in the United States: an evolving strategy in the management of rapidly advancing pulmonary disease. J Thorac Cardiovasc Surg 2014; 149:291-6. [PMID: 25524684 DOI: 10.1016/j.jtcvs.2014.08.072] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 08/13/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Improvements in technology have led to a resurgence in the use of extracorporeal membrane oxygenation as a bridge to lung transplantation. By using a national registry, we sought to evaluate how short-term survival has evolved using this strategy. METHODS With the use of the United Network for Organ Sharing database, we analyzed data from 12,458 adults who underwent lung transplantation between 2000 and 2011. Patients were categorized into 2 cohorts: 119 patients who were bridged to transplantation using extracorporeal membrane oxygenation and 12,339 patients who were not. The study period was divided into four 3-year intervals: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. With Kaplan-Meier analysis, 1-year survival was compared for the 2 cohorts of patients in each of the time periods. A propensity score-adjusted Cox regression model was used to estimate the risk of 1-year mortality. RESULTS Of the total number of recipients, 4 (3.4%) were bridged between 2000 and 2002, 17 (14.3%) were bridged between 2003 and 2005, 31 (26.1%) were bridged between 2006 and 2008, and 67 were bridged (56.3%) between 2009 and 2011. Recipients bridged using extracorporeal membrane oxygenation were more likely to be younger and diabetic and to have higher serum creatinine and bilirubin levels. The 1-year survival for those bridged with extracorporeal membrane oxygenation was significantly lower in subsequent periods: 25.0% versus 81.0% (2000-2002), 47.1% versus 84.2% (2006-2008), and 74.4% versus 85.7% (2009-2011). However, this survival progressively increased with each period, as did the number of patients bridged using extracorporeal membrane oxygenation. CONCLUSIONS Short-term survival with the use of extracorporeal membrane oxygenation as a bridge to lung transplantation has significantly improved over the past few years.
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Affiliation(s)
- Awori J Hayanga
- DeVos Heart and Lung Transplantation Program Spectrum Health, Michigan State University, Grand Rapids, Mich
| | | | - Stephen Esper
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Christian A Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jay K Bhama
- Heart and Vascular Center, Department of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
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George MP, Novelli EM, Shigemura N, Simon MA, Feingold B, Krishnamurti L, Morrell MR, Gries CG, Haider S, Johnson BA, Crespo MM, Bhama JK, Bermudez C, Yousem SA, Toyoda Y, Champion HC, Pilewski JM, Gladwin MT. First successful lung transplantation for sickle cell disease with severe pulmonary arterial hypertension and pulmonary veno-occlusive disease. Pulm Circ 2014; 3:952-8. [PMID: 25006411 DOI: 10.1086/674749] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 06/30/2013] [Indexed: 01/14/2023] Open
Abstract
Little is known about the use of lung transplantation in the management of sickle cell disease-associated pulmonary arterial hypertension (SCD-PAH). We present clinical and pathological data and report the first successful outcome of bilateral lung transplantation in a patient with severe SCD-PAH and pulmonary veno-occlusive disease (PVOD). We discuss the complexities of multidisciplinary planning and management of lung transplantation in patients with SCD-associated pulmonary vascular complications. This case reports the first documented successful lung transplant and first case of PVOD in a patient with SCD-PAH.
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Affiliation(s)
- M Patricia George
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Enrico M Novelli
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Norihisa Shigemura
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marc A Simon
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brian Feingold
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA ; Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lakshmanan Krishnamurti
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA ; Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew R Morrell
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cynthia G Gries
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Syed Haider
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Bruce A Johnson
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maria M Crespo
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jay K Bhama
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christian Bermudez
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Samuel A Yousem
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yoshiya Toyoda
- Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hunter C Champion
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joseph M Pilewski
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark T Gladwin
- Departments of Medicine, Pediatrics, Pathology, and Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Woolley JR, Kormos RL, Teuteberg JJ, Bermudez CA, Bhama JK, Lockard KL, Kunz NM, Wagner WR. Preoperative liver dysfunction influences blood product administration and alterations in circulating haemostatic markers following ventricular assist device implantation. Eur J Cardiothorac Surg 2014; 47:497-504. [PMID: 24810756 DOI: 10.1093/ejcts/ezu183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Preoperative liver dysfunction may influence haemostasis following ventricular assist device (VAD) implantation. The Model for End-stage Liver Disease (MELD) score was assessed as a predictor of bleeding and levels of haemostatic markers in patients with currently utilized VADs. METHODS Sixty-three patients (31 HeartMate II, 15 HeartWare, 17 Thoratec paracorporeal ventricular assist device) implanted 2001-11 were analysed for preoperative liver dysfunction (MELD) and blood product administration. Of these patients, 21 had additional blood drawn to measure haemostatic marker levels. Cohorts were defined based on high (≥18.0, n = 7) and low (<18.0, n = 14) preoperative MELD scores. RESULTS MELD score was positively correlated with postoperative administration of red blood cell (RBC), platelet, plasma and total blood product units (TBPU) , as well as chest tube drainage and cardiopulmonary bypass time. Age and MELD were preoperative predictors of TBPU by multivariate analysis. The high-MELD cohort had higher administration of TBPU, RBC and platelet units and chest tube drainage postimplant. Similarly, patients who experienced at least one bleeding adverse event were more likely to have had a high preoperative MELD. The high-MELD group exhibited different temporal trends in F1 + 2 levels and platelet counts to postoperative day (POD) 55. D-dimer levels in high-MELD patients became elevated versus those for low-MELD patients on POD 55. CONCLUSIONS Preoperative MELD score predicts postoperative bleeding in contemporary VADs. Preoperative liver dysfunction may also alter postoperative subclinical haemostasis through different temporal trends of thrombin generation and platelet counts, as well as protracted fibrinolysis.
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Affiliation(s)
- Joshua R Woolley
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert L Kormos
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Cardiovascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey J Teuteberg
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christian A Bermudez
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Cardiovascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay K Bhama
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Cardiovascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen L Lockard
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nicole M Kunz
- The Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - William R Wagner
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA Department of Cardiovascular Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Noda K, Shigemura N, Tanaka Y, Bhama JK, D'Cunha J, Luketich JD, Bermudez CA. Successful prolonged ex vivo lung perfusion for graft preservation in rats. Eur J Cardiothorac Surg 2014; 45:e54-60. [DOI: 10.1093/ejcts/ezt598] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bansal A, Shigemura N, Toyoda Y, Bhama JK. Successful lung transplantation from a donor with persistent lobar atelectasis. Ochsner J 2014; 14:266-269. [PMID: 24940140 PMCID: PMC4052597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Over the past 15 years, the number of recipients waiting for a lung transplant has increased and now far exceeds the number of available donors. Liberalization of donor criteria to include the use of extended donors remains an attractive option for expanding the donor pool. Numerous centers, including the authors' own, have begun exploring this relatively unknown territory of lung transplantation. CASE REPORT Successful bilateral lung transplantation was performed for a patient with emphysema utilizing lungs from a donor with persistent lobar atelectasis. CONCLUSION This report demonstrates that an acceptable outcome is possible from a donor with persistent lobar atelectasis if other parameters are acceptable. Larger studies would help further our understanding of the impact of donor radiographic abnormalities on outcomes following lung transplantation.
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Affiliation(s)
- Aditya Bansal
- Department of Surgery, Section of Cardiothoracic Surgery, Ochsner Clinic Foundation, New Orleans, LA
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yoshiya Toyoda
- Department of Surgery, Section of Cardiovascular Surgery, Temple University School of Medicine, Philadelphia, PA
| | - Jay K. Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Rocha RV, Zaldonis D, Badhwar V, Wei LM, Bhama JK, Shapiro R, Bermudez CA. Long-term patient and allograft outcomes of renal transplant recipients undergoing cardiac surgery. J Thorac Cardiovasc Surg 2014. [DOI: 10.1016/j.jtcvs.2012.10.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Lampert BC, Eckert C, Weaver S, Scanlon A, Lockard K, Allen C, Kunz N, Bermudez C, Bhama JK, Shullo MA, Kormos RL, Dew MA, Teuteberg JJ. Blood Pressure Control in Continuous Flow Left Ventricular Assist Devices: Efficacy and Impact on Adverse Events. Ann Thorac Surg 2014; 97:139-46. [DOI: 10.1016/j.athoracsur.2013.07.069] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/15/2013] [Accepted: 07/18/2013] [Indexed: 11/30/2022]
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Woolley JR, Teuteberg JJ, Bermudez CA, Bhama JK, Lockard KL, Kormos RL, Wagner WR. Temporal leukocyte numbers and granulocyte activation in pulsatile and rotary ventricular assist device patients. Artif Organs 2013; 38:447-55. [PMID: 24571597 DOI: 10.1111/aor.12200] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Individual ventricular assist device (VAD) design may affect leukocytes and impact immunity. Few studies have presented leukocyte and infection profiles in VAD patients over the course of the implant period. CD11b (MAC-1) expression on granulocytes is an indicator of activation during inflammation, mediating extravasation and the release of reactive oxygen species in tissue. No reported studies have presented MAC-1 expression on circulating granulocytes in VAD patients. Fifty-six patients implanted at a single center with a HeartMate II (HMII; n = 32), HeartWare (HW; n = 12), or Thoratec pneumatic VAD (PVAD; n = 12) between 1999 and 2011 were followed for 120 days of support. The leukocyte profiles and infectious events of all patients were evaluated; additionally, a subset had MAC-1 expression on circulating granulocytes was measured (HMII n = 9; HW n = 7; PVAD n = 4). All groups exhibited a significant peak in leukocyte numbers at postoperative day (POD) 14 while simultaneously experiencing a significant decrease in hematocrit. HMII patients exhibited a 3.2-fold increase in granulocyte MAC-1 expression at POD 14, and the temporal trend over the implant period differed from that experienced by HW patients. Further, HW patients experienced significantly fewer infection events. Alterations in leukocyte profiles and granulocyte activation experienced by VAD patients appear to be device-specific. Elevations in leukocyte activation may be related to an increased risk for infection, although the specific relationship between these phenomena in this patient group is not known.
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Affiliation(s)
- Joshua R Woolley
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
A simple technique for reconstructing a short recipient left atrial cuff during lung transplantation is described. After opening the confluence of the pulmonary veins, the cut ends of the pulmonary veins are sutured together, posteriorly and anteriorly. This effectively lengthens the cuff allowing safe left atrial anastomosis. This technique has been applied in 3 patients with no technique-related complications.
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Affiliation(s)
- Jay K Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aditya Bansal
- Department of Cardiothoracic Surgery, Ochsner Clinic, New Orleans, LA, USA
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yoshiya Toyoda
- Department of Cardiothoracic Surgery, Temple University Hospital, Philadelphia, PA, USA
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Bhama JK. Leveling the playing field in adult heart transplantation. J Heart Lung Transplant 2013; 32:1052-3. [PMID: 24135039 DOI: 10.1016/j.healun.2013.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 08/21/2013] [Accepted: 09/10/2013] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jay K Bhama
- Heart & Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Marco MRL, Dons EM, van der Windt DJ, Bhama JK, Lu LT, Zahorchak AF, Lakkis FG, Cooper DKC, Ezzelarab MB, Thomson AW. Post-transplant repopulation of naïve and memory T cells in blood and lymphoid tissue after alemtuzumab-mediated depletion in heart-transplanted cynomolgus monkeys. Transpl Immunol 2013; 29:88-98. [PMID: 24120957 DOI: 10.1016/j.trim.2013.10.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 10/02/2013] [Accepted: 10/02/2013] [Indexed: 11/19/2022]
Abstract
Repopulation of memory T cells (Tmem) in allograft recipients after lymphodepletion is a major barrier to transplant tolerance induction. Ineffective depletion of naïve T cells (Tn) and Tmem may predispose to repopulation of Tmem after transplantation. Cynomolgus macaque monkeys given heart allografts were lymphodepleted using Alemtuzumab (Campath-1H; anti-CD52). Peripheral blood (PB) and lymph nodes (LN) were analyzed for CD95(-) (Tn) and CD95(+) cells (Tmem), one day, one month and up to three months after Alemtuzumab infusion. CD52 expression, susceptibility to Alemtuzumab cytotoxicity and pro-apoptotic caspase-3 were evaluated in Tn and Tmem. In vivo, Alemtuzumab induction profoundly depleted lymphocytes in PB (99% reduction) but exerted a lesser effect in LN (70% reduction), with similar depletion of Tn and Tmem subsets. After transplantation, Tmem comprised the majority of lymphocytes in PB and LN. In vitro, LN T cells were more resistant to Alemtuzumab-mediated cytotoxicity than PB lymphocytes. CD4(+) Tn and Tmem were equally susceptible to Alemtuzumab-mediated cytotoxicity, whereas CD8(+) Tn were more resistant than CD8(+) Tmem. However, no significant differences in CD52 expression between lymphocyte subsets in PB and LN were observed. Caspase-3 expression was higher in PB than LN T cells. CD4(+) and CD8(+) Tn expressed lower levels of Caspase-3 than Tmem, in both PB and LN. Thus, after Alemtuzumab infusion, residual Tn in secondary lymphoid tissue may predispose to rapid recovery of Tmem in allograft recipients.
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Affiliation(s)
- M R L Marco
- Thomas E. Starzl Transplantation Institute, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
Airway fire is a well-documented event during airway surgery with devastating outcomes. Individuals involved in the care of these patients should be aware of this possible complication and precautions needed to prevent this complication.
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Affiliation(s)
- Aditya Bansal
- Section of Cardiothoracic Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
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Shields RK, Clancy CJ, Minces LR, Shigemura N, Kwak EJ, Silveira FP, Abdel-Massih RC, Bhama JK, Bermudez CA, Pilewski JM, Crespo M, Toyoda Y, Nguyen MH. Epidemiology and outcomes of deep surgical site infections following lung transplantation. Am J Transplant 2013; 13:2137-45. [PMID: 23710593 DOI: 10.1111/ajt.12292] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/18/2013] [Accepted: 04/04/2013] [Indexed: 01/25/2023]
Abstract
We conducted a retrospective study of deep surgical site infections (SSIs) among consecutive patients who underwent lung transplantation (LTx) at a single center from 2006 through 2010. Thirty-one patients (5%) developed SSIs at median 25 days after LTx. Empyema was most common (42%), followed by surgical wound infections (29%), mediastinitis (16%), sternal osteomyelitis (6%), and pericarditis (6%). Pathogens included Gram-positive bacteria (41%), Gram-negative bacteria (41%), fungi (10%) and Mycobacterium abscessus, Mycoplasma hominis and Lactobacillus sp. (one each). Twenty-three percent of SSIs were due to pathogens colonizing recipients' native lungs at time of LTx, suggesting surgical seeding as a source. Patient-related independent risk factors for SSIs were diabetes and prior cardiothoracic surgery; procedure-related independent risk factors were LTx from a female donor, prolonged ischemic time and number of perioperative red blood cell transfusions. Mediastinitis and sternal infections were not observed among patients undergoing minimally invasive LTx. SSIs were associated with 35% mortality at 1 year post-LTx. Lengths of stay and mortality in-hospital and at 6 months and 1 year were significantly greater for patients with SSIs other than empyema. In conclusion, deep SSIs were uncommon, but important complications in LTx recipients because of their diverse microbiology and association with increased mortality.
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Affiliation(s)
- R K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Bhama JK, Bansal A, Shigemura N, Bermudez CA, Toyoda Y. Sternal-sparing approach for reoperative bilateral lung transplantation. Interact Cardiovasc Thorac Surg 2013; 17:835-7. [PMID: 23847280 DOI: 10.1093/icvts/ivt305] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES A sternal-sparing approach for bilateral lung transplantation was recently applied to reoperative lung transplant cases and is compared with the traditional clamshell approach. METHODS A retrospective analysis of 15 consecutive reoperative bilateral lung transplants performed from January 2008 to April 2011 was conducted. Outcomes were compared between the first 11 patients who underwent the traditional clamshell and the most recent 4 patients who underwent the sternal-sparing approach. RESULTS The indication for retransplantation was obliterative bronchiolitis in all patients. Both groups were similar with regard to age, allograft ischaemic time and operative time. Cardiopulmonary bypass was more frequent in the sternal-sparing group although required for a shorter period of time. The need for postoperative extracorporeal membrane oxygenation for primary graft dysfunction was similar in both groups. The length of ICU care and total hospitalization length of stay were similar for the sternal-sparing group compared with the traditional clamshell approach. Operative mortality and overall survival also did not differ. CONCLUSIONS Reoperative bilateral lung transplantation with a sternal-sparing approach is feasible and may yield outcomes similar to those in the traditional clamshell approach. Further analysis with larger numbers of patients is warranted to delineate the benefits of this approach for patients requiring reoperative lung transplantation.
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Affiliation(s)
- Jay K Bhama
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Bhama JK, Shulman J, Bermudez CA, Bansal A, Ramani R, Teuteberg JJ, Shullo M, McNamara DM, Kormos RL, Toyoda Y. Heart transplantation for adults with congenital heart disease: Results in the modern era. J Heart Lung Transplant 2013; 32:499-504. [DOI: 10.1016/j.healun.2013.01.1047] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 01/07/2013] [Accepted: 01/25/2013] [Indexed: 11/28/2022] Open
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Toyoda Y, Bhama JK, Shigemura N, Zaldonis D, Pilewski J, Crespo M, Bermudez C. Efficacy of extracorporeal membrane oxygenation as a bridge to lung transplantation. J Thorac Cardiovasc Surg 2013; 145:1065-1071. [PMID: 23332185 DOI: 10.1016/j.jtcvs.2012.12.067] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 12/04/2012] [Accepted: 12/18/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Preoperative extracorporeal membrane oxygenation (ECMO) is a risk factor for poor outcome and currently considered a contraindication to lung transplantation. The lung allocation score system was introduced in May 2005 and prioritizes lung allocation to those with the greatest respiratory impairment. The purpose of this study is to determine whether ECMO as a bridge to lung transplantation is an acceptable option to support those in respiratory failure until donor lungs become available in the lung allocation score era. METHOD A retrospective review of 715 consecutive lung transplants performed between May 2005 and September 2011 was conducted using a prospectively collected institutional registry database. Twenty-four lung transplants (3.4%) were performed in the 31 patients with attempted pretransplant ECMO; 7 patients who received ECMO patients did not survive or were deemed unfit for transplantation. These patients were compared with a control group of 691 patients who did not receive pretransplant ECMO. RESULTS The duration of pretransplant ECMO was 171 ± 242 hours (median, 91 hours). Venovenous ECMO was used for respiratory failure in 15 patients, whereas venoarterial ECMO was used for circulatory collapse due to pulmonary hypertension in 9 patients. Patients in the retransplant ECMO group were younger (46 ± 15 years vs 57 ± 14 years, P < .01) compared with the control group, with no difference in recipient gender (male/female: 10/14 vs 380/311), donor age (33 ± 14 years vs 36 ± 15 years), or donor gender (male/female: 10/14 vs 352/339). Emphysema was less common (1, 4% vs 260, 38%, P < .01), and cystic fibrosis (5, 21% vs 72, 10%, P = .09), redo lung transplant (3, 13% vs 28, 4%, P = .08), and bronchiectasis (2, 8% vs 6, 1%, P = .03) were more common in the pretransplant ECMO group. Patients in the pretransplant ECMO group had a significantly higher lung allocation score (87 ± 9 vs 44 ± 15, P < .01). All patients in the pretransplant ECMO group underwent double lung transplants on pump (cardiopulmonary bypass/ECMO), and single lung transplants were performed in 171 patients (25%) and pump was used in 243 patients (35%) in the control group. The cardiopulmonary bypass time was longer in the pretransplant ECMO group (277 ± 69 minutes vs 225 ± 89 minutes, P = .02), with no difference in ischemic time (343 ± 93 minutes vs 330 ± 98 minutes, P = .54). Cadaveric lobar lung transplants were performed because of the urgency to overcome size mismatch with an oversized donor more frequently in 25% (n = 6, no mortality with the longest follow-up at 6 years) of patients in the pretransplant ECMO group versus 0.3% (n = 2) of patients in the control group (P < .01). Post-transplant ECMO was used for primary graft dysfunction in 13 patients (54%) in the pretransplant ECMO group and 41 patients (6%) in the control group (P < .01). The median hospital stay was 46 days in the pretransplant ECMO group versus 27 days in the control group (P = .16). The actuarial survivals after lung transplants at 1, 3, 6, 12, and 24 months were 96%, 88%, 83%, 74%, and 74%, respectively, in the pretransplant ECMO group, and 97%, 94%, 90%, 83%, and 74%, respectively, in the control group (P = .787). CONCLUSIONS Although the incidence of primary graft dysfunction requiring post-transplant ECMO is higher and the hospital stay is longer in patients receiving pretransplant ECMO, the graft survival is good (2-year survival, 74%). ECMO is efficacious as a bridge to lung transplantation with good post-lung transplant outcomes.
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Affiliation(s)
- Yoshiya Toyoda
- University of Pittsburgh, Pittsburgh, Pa; Temple University, Philadelphia, Pa.
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Shields RK, Clancy CJ, Minces LR, Kwak EJ, Silveira FP, Abdel Massih RC, Toyoda Y, Bermudez C, Bhama JK, Shigemura N, Pilewski JM, Crespo M, Hong Nguyen M. Staphylococcus aureus infections in the early period after lung transplantation: epidemiology, risk factors, and outcomes. J Heart Lung Transplant 2012; 31:1199-206. [PMID: 22986156 DOI: 10.1016/j.healun.2012.08.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 06/07/2012] [Accepted: 08/04/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Staphylococcus aureus infections among lung transplant recipients are poorly studied. METHODS We conducted a 5-year retrospective study of the epidemiology, clinical manifestations, risk factors, and outcomes of patients infected with S aureus within the first 90 days after lung transplantation. RESULTS An S aureus infection developed in 109 of 596 lung transplant (18%) recipients. Methicillin-susceptible S aureus (MSSA; 62%) was more common than methicillin-resistant S aureus (MRSA; 38%); however, the proportion of infections caused by MRSA increased over time. Pneumonia (48%) was the most common infection, followed by tracheobronchitis (26%), bacteremia (12%), intrathoracic infections (7%), and skin/soft tissue infections (7%). Risk factors included mechanical ventilation for > 5 days and isolation of S aureus from recipients' sterility cultures. Patients with MRSA cultured from the nares or respiratory tract at the time of transplant were at an increased risk for MRSA infection (p < 0.0001 and p = 0.02, respectively). Infected patients required longer hospital and intensive care unit stays (p < 0.0001 for both), but the 30- and 90-day mortality rates from the onset of infection were only 7% and 12%, respectively. However, infected patients had higher rates of acute and chronic rejection at 1 (p = 0.048) and 3 years (p = 0.002), and higher rates of mortality at 1 (p = 0.058) and 3 years (p = 0.009). CONCLUSIONS S aureus infections within the first 90 days of lung transplant were associated with low short-term mortality but increased long-term rates of mortality and acute and chronic rejection. Future studies are needed to explore the utility of S aureus eradication strategies in reducing disease burden and improving outcomes.
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Affiliation(s)
- Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Shields RK, Nguyen MH, Shullo MA, Silveira FP, Kwak EJ, Abdel Massih RC, Toyoda Y, Bermudez CA, Bhama JK, Kormos RL, Clancy CJ. Invasive aspergillosis among heart transplant recipients is rare but causes rapid death due to septic shock and multiple organ dysfunction syndrome. ACTA ACUST UNITED AC 2012; 44:982-6. [PMID: 22830948 DOI: 10.3109/00365548.2012.705018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Between 2000 and 2011, proven or probable invasive aspergillosis (IA) was diagnosed in 1.7% (8/455) of heart transplant (HTx) recipients at our center, in the absence of antifungal prophylaxis. All patients had invasive pulmonary infections and 75% (6/8) were diagnosed during 2 separate 3-month periods. Cases were notable for their association with septic shock and multiple organ dysfunction syndrome (MODS) (75%, 6/8 each), non-specific clinical and radiographic findings, and rapid mortality despite mould-active antifungal therapy (88%, 7/8; occuring at a median 11 days after diagnosis). All patients had predisposing conditions known to be risk factors for IA. For patients with early IA (within 90 days of HTx), conditions included hemodialysis, thoracic re-operation, and the presence of another case in the institution within the preceding 3 months. For late-onset IA, conditions included hemodialysis and receipt of augmented immunosuppression. Clinicians should suspect IA in HTx recipients with risk factors who present with non-specific and unexplained respiratory syndromes, including those in septic shock and MODS, and institute prompt antifungal therapy without waiting for the results of cultures or other diagnostic tests.
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Affiliation(s)
- Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, USA
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Mitsani D, Nguyen MH, Shields RK, Toyoda Y, Kwak EJ, Silveira FP, Pilewski JM, Crespo MM, Bermudez C, Bhama JK, Clancy CJ. Prospective, observational study of voriconazole therapeutic drug monitoring among lung transplant recipients receiving prophylaxis: factors impacting levels of and associations between serum troughs, efficacy, and toxicity. Antimicrob Agents Chemother 2012; 56:2371-7. [PMID: 22330924 PMCID: PMC3346665 DOI: 10.1128/aac.05219-11] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 12/24/2011] [Indexed: 12/28/2022] Open
Abstract
Voriconazole prophylaxis is common following lung transplantation, but the value of therapeutic drug monitoring is unknown. A prospective, observational study of lung transplant recipients (n = 93) receiving voriconazole prophylaxis was performed. Serum voriconazole troughs (n = 331) were measured by high-pressure liquid chromatography. The median initial and subsequent troughs were 1.91 and 1.46 μg/ml, respectively. The age of the patient directly correlated with initial troughs (P = 0.005). Patients that were ≥ 60 years old and cystic fibrosis patients were significantly more likely to have higher and lower initial troughs, respectively. In 95% (88/93) of patients, ≥ 2 troughs were measured. In 28% (25/88) and 32% (28/88) of these patients, all troughs were ≤ 1.5 μg/ml or >1.5 μg/ml, respectively. Ten percent (10/93) and 27% (25/93) of the patients developed invasive fungal infection (tracheobronchitis) and fungal colonization, respectively. The median troughs at the times of positive and negative fungal cultures were 0.92 and 1.72 μg/ml (P = 0.07). Invasive fungal infections or colonization were more likely with troughs of ≤ 1.5 μg/ml (P = 0.01) and among patients with no trough of >1.5 μg/ml (P = 0.007). Other cutoff troughs correlated less strongly with microbiologic outcomes. Troughs correlated directly with aspartate transferase levels (P = 0.003), but not with other liver enzymes. Voriconazole was discontinued due to suspected toxicity in 27% (25/93) of the patients. The troughs did not differ at the times of suspected drug-induced hepatotoxicity, central nervous system (CNS) toxicity, or nausea/vomiting and in the absence of toxicity. Voriconazole prophylaxis was most effective at troughs of >1.5 μg/ml. A cutoff for toxicity was not identified, but troughs of >4 μg/ml were rare. The data support a target range of >1.5 to 4 μg/ml.
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Affiliation(s)
| | | | | | - Yoshiya Toyoda
- Department of Cardiothoracic Surgery, University of Pittsburgh
| | | | | | | | | | | | - Jay K. Bhama
- Department of Cardiothoracic Surgery, University of Pittsburgh
| | - Cornelius J. Clancy
- Divisions of Infectious Diseases
- V.A. Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Bonde P, Ku NC, Genovese EA, Bermudez CA, Bhama JK, Ciarleglio MM, Cong X, Teuteberg JJ, Kormos RL. Model for End-Stage Liver Disease Score Predicts Adverse Events Related to Ventricular Assist Device Therapy. Ann Thorac Surg 2012; 93:1541-7; discussion 1547-8. [DOI: 10.1016/j.athoracsur.2012.02.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 02/02/2012] [Accepted: 02/06/2012] [Indexed: 12/24/2022]
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Bermudez CA, Rocha RV, Toyoda Y, Zaldonis D, Sappington PL, Mulukutla S, Marroquin OC, Toma C, Bhama JK, Kormos RL. Extracorporeal Membrane Oxygenation for Advanced Refractory Shock in Acute and Chronic Cardiomyopathy. Ann Thorac Surg 2011; 92:2125-31. [DOI: 10.1016/j.athoracsur.2011.07.029] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Revised: 07/08/2011] [Accepted: 07/15/2011] [Indexed: 10/16/2022]
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