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Vaikunth SS, Ortega-Legaspi JM, Conrad DR, Chen S, Daugherty T, Haeffele CL, Teuteberg J, Mclean R, MacArthur JW, Woo YJ, Maeda K, Ma M, Nasirov T, Hoteit M, Hilscher MB, Wald J, Mandelbaum T, Olthoff KM, Abt PL, Atluri P, Cevasco M, Mavroudis CD, Fuller S, Lui GK, Kim YY. Mortality and morbidity after combined heart and liver transplantation in the failing Fontan: An updated dual center retrospective study. Clin Transplant 2024; 38:e15302. [PMID: 38567883 DOI: 10.1111/ctr.15302] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION As the adult Fontan population with Fontan associated liver disease continues to increase, more patients are being referred for transplantation, including combined heart and liver transplantation. METHODS We report updated mortality and morbidity outcomes after combined heart and liver transplant in a retrospective cohort series of 40 patients (age 14 to 49 years) with Fontan circulation across two centers from 2006-2022. RESULTS The 30-day, 1-year, 5-year and 10-year survival rate was 90%, 80%, 73% and 73% respectively. Sixty percent of patients met a composite comorbidity of needing either post-transplant mechanical circulatory support, renal replacement therapy or tracheostomy. Cardiopulmonary bypass time > 283 min (4.7 h) and meeting the composite comorbidity were associated with mortality by Kaplan Meier analysis. CONCLUSION Further study to mitigate early mortality and the above comorbidities as well as the high risk of bleeding and vasoplegia in this patient population is warranted.
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Affiliation(s)
- Sumeet S Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juan M Ortega-Legaspi
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Desiree R Conrad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tami Daugherty
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christiane L Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rhondalynn Mclean
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John W MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Teimour Nasirov
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marrouf Hoteit
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Wald
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tal Mandelbaum
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Constantine D Mavroudis
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Fuller
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George K Lui
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yuli Y Kim
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Cambria G, Spelde AE, Olia SE, Biscotti M, Mackay E, Ibrahim M, Cevasco M, Bermudez C, Vernick W, Gutsche J, Usman AA. Extracorporeal Carbon Dioxide Removal to De-escalate Venovenous Extracorporeal Membrane Oxygenation in Severe COVID-19 Acute Respiratory Distress Syndrome. J Cardiothorac Vasc Anesth 2024; 38:717-723. [PMID: 38212185 PMCID: PMC10922866 DOI: 10.1053/j.jvca.2023.12.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVES In a subset of patients with COVID-19 acute respiratory distress syndrome (ARDS), there is a need for extracorporeal membrane oxygenation (ECMO) for pulmonary support. The primary extracorporeal support tool for severe COVID-19 ARDS is venovenous (VV) ECMO; however, after hypoxemic respiratory failure resolves, many patients experience refractory residual hypercarbic respiratory failure. Extracorporeal carbon dioxide removal (ECCO2R) for isolated hypercarbic type II respiratory failure can be used in select cases to deescalate patients from VV ECMO while the lung recovers the ability to exchange CO2. The objective of this study was to describe the authors' experience in using ECCO2R as a bridge from VV ECMO. DESIGN Hemolung Respiratory Assist System (RAS) is a commercially available (ECCO2R) device, and the United States Food and Drug Administration accelerated its use under its Emergency Use Authorization for the treatment of refractory hypercarbic respiratory failure in COVID-19-induced ARDS. This created an environment in which selected and targeted mechanical circulatory support therapy for refractory hypercarbic respiratory failure could be addressed. This retrospective study describes the application of Hemolung RAS as a VV ECMO deescalation platform to treat refractory hypercarbic respiratory failure after the resolution of hypoxemic COVID-19 ARDS. SETTING A quaternary-care academic medical center, single institution. PARTICIPANTS Patients with refractory hypercarbic respiratory failure after COVID-19 ARDS who were previously supported with VV ECMO. MEASUREMENTS AND MAIN RESULTS Twenty-one patients were placed on ECCO2R after VV ECMO for COVID-19 ARDS. Seventeen patients successfully were transitioned to ECCO2R and then decannulated; 3 patients required reescalation to VV ECMO secondary to hypercapnic respiratory failure, and 1 patient died while on ECCO2R. Five (23.8%) of the 21 patients were transitioned off of VV ECMO to ECCO2R, with a compliance of <20 (mL/cmH2O). Of these patients, 3 with low compliance were reescalated to VV ECMO. CONCLUSIONS Extracorporeal carbon dioxide removal can be used to continue supportive methods for patients with refractory type 2 hypercarbic respiratory failure after COVID-19 ARDS for patients previously on VV ECMO. Patients with low compliance have a higher rate of reescalation to VV ECMO.
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Affiliation(s)
- Gaetano Cambria
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Salim E Olia
- Department of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mauer Biscotti
- Department of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Emily Mackay
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael Ibrahim
- Department of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Department of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christian Bermudez
- Department of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Asad A Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA.
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Kim ST, Iyengar A, Helmers MR, Weingarten N, Rekhtman D, Song C, Shin M, Cevasco M, Atluri P. Heart Retransplantation Under the 2018 Adult Heart Allocation Policy. Ann Thorac Surg 2024; 117:603-609. [PMID: 37709159 DOI: 10.1016/j.athoracsur.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/22/2023] [Accepted: 09/05/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The purpose of the present study was to characterize the impact of the 2018 adult heart allocation policy change on waiting list and posttransplant outcomes of heart retransplantation in the United States. METHODS All adults listed for heart retransplantation from May 2015 to June 2022 were identified using the United Network for Organ Sharing database. Patients were stratified into eras (era 1 and era 2) based on the heart allocation change on October 18, 2018. Competing risks regressions and Cox proportional hazards models were used to assess differences across eras in waiting list outcomes and 1-year posttransplant survival, respectively. RESULTS The analysis included 356 repeat heart transplant recipients, with 207 (58%) receiving retransplantation during era 2. Patients who received a retransplant in era 2 were more commonly bridged with extracorporeal membrane oxygenation (21% vs 8%, P < .01) and intra-aortic balloon pump (29% vs 13%, P < .001) and had a lower likelihood of death/deterioration on the waiting list (subdistribution hazard ratio, 0.52; 95% CI, 0.33-0.82) compared with those in era 1. Rates of 30-day mortality (7% vs 7%, P = .99) and 1-year survival (82% vs 87%, P = .27) were not significantly different among retransplantation recipients across eras. After adjustment, retransplantation in era 2 was not associated with an increased hazard of mortality (adjusted hazard ratio, 1.13; 95% CI, 0.55-2.30). The gap in 1-year mortality between primary transplant and retransplant recipients increased from era 1 to 2. CONCLUSIONS Heart retransplantation candidates have experienced improved waiting list outcomes after the 2018 adult heart allocation policy, without significant changes to posttransplant survival.
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Affiliation(s)
- Samuel T Kim
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Amit Iyengar
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cindy Song
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Kwon JH, Bentley D, Cevasco M, Blumer V, Kanwar MK, Silvestry SC, Daneshmand MA, Abraham J, Shorbaji K, Kilic A. Patient Characteristics and Early Clinical Outcomes With Impella 5.5: A Systematic Review and Meta-Analysis. ASAIO J 2024:00002480-990000000-00425. [PMID: 38386980 DOI: 10.1097/mat.0000000000002169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024] Open
Abstract
Data regarding outcomes with Impella 5.5 are limited. The aim of this systematic review and meta-analysis was to summarize patient and treatment characteristics and early clinical outcomes among patients supported by Impella 5.5. A systematic literature search was conducted in PubMed, Scopus, and Cochrane databases from September 2019 to March 2023. Studies reporting outcomes in greater than or equal to 5 patients were included for review. Patient characteristics, treatment characteristics, and early clinical outcomes were extracted. Outcomes included adverse events, survival to hospital discharge, and 30 day survival. Random-effect models were used to estimate pooled effects for survival outcomes. Assessment for bias was performed using funnel plots and Egger's tests. Fifteen studies were included for qualitative review, representing 707 patients. Mean duration of support was 9.9 ± 8.2 days. On meta-analysis of 13 studies reporting survival outcomes, survival to hospital discharge was 68% (95% confidence interval [CI], 58-78%), and 30 day survival was 65% (95% CI, 56-74%) among patients with Impella devices predominantly supported by Impella 5.5 (>60%). There was significant study heterogeneity for these outcomes. Among 294 patients with Impella 5.5 only, survival to discharge was 78% (95% CI, 72-82%) with no significant study heterogeneity. This data present early benchmarks for outcomes with Impella 5.5 as clinical experience with these devices accrues.
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Affiliation(s)
- Jennie H Kwon
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence Research Network, Portland, Oregon
| | - Dana Bentley
- Principle Scientific Affairs, Abiomed, Danvers, Massachusetts
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vanessa Blumer
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Jacob Abraham
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence Research Network, Portland, Oregon
| | - Khaled Shorbaji
- From the Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Arman Kilic
- From the Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, South Carolina
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5
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Shin M, Iyengar A, Helmers MR, Song C, Rekhtman D, Kelly JJ, Weingarten N, Patrick WL, Cevasco M. Non-inferior outcomes in lower urgency patients transplanted with extended criteria donor hearts. J Heart Lung Transplant 2024; 43:263-271. [PMID: 37778527 DOI: 10.1016/j.healun.2023.09.015] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/07/2023] [Accepted: 09/24/2023] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Recent work has suggested that outcomes among heart transplant patients listed at the lower-urgency (United Network for Organ Sharing Status 4 or 6) status may not be significantly impacted by donor comorbidities. The purpose of this study was to investigate outcomes of extended criteria donors (ECD) in lower versus higher urgency patients undergoing heart transplantation. METHODS The United Network for Organ Sharing (UNOS) database was queried for all adult patients undergoing heart transplantation from October 18, 2018 through December 31, 2021. Patients were stratified by degree of urgency (higher urgency: UNOS 1 or 2 vs lower urgency: UNOS 4 or 6) and receipt of ECD hearts, as defined by donor hearts failing to meet established acceptable use criteria. Outcomes were compared using propensity score matched cohorts. RESULTS Among 9,160 patients included, 2,320 (25.4%) were low urgency. ECD hearts were used in 35.5% of higher urgency (HU) patients and 39.2% of lower urgency (LU) patients. While ECD hearts had an impact on survival among high-urgency patients (p < 0.01), there was no difference in 1- and 2-year survival (p > 0.05) found among low urgency patients receiving ECD versus standard hearts. Neither ECDs nor individual ECD criteria were independently associated with mortality in low urgency patients (p > 0.05). CONCLUSIONS Post-transplant outcomes among low urgency patients are not adversely affected by receipt of ECD vs. standard hearts. Expanding the available donor pool by optimizing use of ECDs in this population may increase transplant frequency, decrease waitlist morbidity, and improve postoperative outcomes for the transplant community at large.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Hunt ML, Crespo MM, Richards TJ, Bermudez F, Courtwright A, Usman A, Spelde AE, Diamond J, Patel N, Cantu E, Christie J, Clausen E, Cevasco M, Ahya V, Bermudez CA. Lung transplant outcomes after acute respiratory distress syndrome requiring extracorporeal life support: Lessons from the COVID-19 pandemic. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00010-2. [PMID: 38199292 DOI: 10.1016/j.jtcvs.2023.12.028] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 11/08/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE Lung transplant for acute respiratory distress syndrome in patients supported with extracorporeal membrane oxygenation was rare before 2020, but was rapidly adopted to rescue patients with COVID-19 with lung failure. This study aims to compare the outcomes of patients who underwent lung transplant for COVID-associated acute respiratory distress syndrome and non-COVID acute respiratory distress syndrome, and to assess the impact of type and duration of extracorporeal membrane oxygenation support on survival. METHODS Using the United Network for Organ Sharing database, we identified 311 patients with acute respiratory distress syndrome who underwent lung transplant from 2007 to 2022 and performed a retrospective analysis of the patients who required extracorporeal membrane oxygenation preoperatively, stratified by COVID-associated acute respiratory distress syndrome and non-COVID acute respiratory distress syndrome listing diagnoses. The primary outcome was 1-year survival. Secondary outcomes included the effect of type and duration of extracorporeal membrane oxygenation on survival. RESULTS During the study period, 236 patients with acute respiratory distress syndrome and preoperative extracorporeal membrane oxygenation underwent lung transplant; 181 patients had a listing diagnosis of COVID-associated acute respiratory distress syndrome (77%), and 55 patients had a listing diagnosis of non-COVID acute respiratory distress syndrome (23%). Patients with COVID-associated acute respiratory distress syndrome were older, were more likely to be female, had higher body mass index, and spent longer on the waitlist (all P < .02) than patients with non-COVID acute respiratory distress syndrome. The 2 groups had similar 1-year survival (85.8% vs 81.1%, P = .2) with no differences in postoperative complications. Patients with COVID-associated acute respiratory distress syndrome required longer times on extracorporeal membrane oxygenation pretransplant (P = .02), but duration of extracorporeal membrane oxygenation support was not a predictor of 1-year survival (P = .2). CONCLUSIONS Despite prolonged periods of pretransplant extracorporeal membrane oxygenation support, selected patients with acute respiratory distress syndrome can undergo lung transplant safely with acceptable short-term outcomes. Appropriate selection criteria and long-term implications require further analysis.
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Affiliation(s)
- Mallory L Hunt
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas J Richards
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | | | - Andrew Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Asad Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pa
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pa
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Namrata Patel
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Edward Cantu
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Emily Clausen
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Vivek Ahya
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Christian A Bermudez
- Divison of Cardiac Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
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7
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Song C, Weingarten N, Rekhtman D, Iyengar A, Patel M, Herbst DA, Helmers M, Cevasco M, Atluri P. Center Volume Predicts Improved Early Outcomes in Multiorgan Heart Transplantation. Transplant Proc 2024; 56:135-144. [PMID: 38177045 DOI: 10.1016/j.transproceed.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 02/21/2023] [Revised: 10/16/2023] [Accepted: 11/26/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE Center volume is associated with improved survival after isolated heart transplant, but its impact on multiorgan heart transplant (MHT) outcomes is unknown. This study examines the impact of institutional MHT volume on MHT outcomes. METHODS Adult patients undergoing first time MHT from 2011 to 2021 were identified in the United Network for Organ Sharing database. Transplant centers were annually classified as low-, medium-, or high-volume if they performed <3, 3 to 5, or ≥6 MHTs that year, respectively. Graft failure was defined as death, failure, or re-transplantation of any allograft. RESULTS A total of 1860 MHTs were performed at 104 centers, including 482 (26%) at low-, 601 (32%) at medium-, and 777 (42%) at high-MHT volume centers. Noncardiac allografts included kidney (83%), liver (16%), and lung (2%). The proportion of MHTs performed at high-volume centers increased from 10% in 2011 to 62% in 2021. Recipient age, race, and body mass index did not vary by center volume (all P > .05). Patients at high-volume centers were more likely to be in the intensive care unit pre-transplant (58% vs 44%, P < .001) and have shorter waitlist times (47 vs 92 days, P < .001) than those at low-volume centers. 30-day graft survival was higher in combined medium- and high-volume compared with low-volume centers (95% vs 92%, P = .004). Increasing center MHT volume was protective against 30-day graft failure (adjusted hazard ratio 0.93 [0.88-0.98]) on multivariate Cox regression. CONCLUSIONS Higher MHT volume is associated with improved early graft survival after MHT, which may justify centralizing the performance of MHTs to high-volume centers.
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Affiliation(s)
- Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania
| | - Mrinal Patel
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania
| | - David Alan Herbst
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania
| | - Mark Helmers
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Hospital of the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, Pennsylvania.
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8
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Bermudez C, Bermudez F, Courtwright A, Richards T, Diamond J, Cevasco M, Blumberg E, Christie J, Usman A, Crespo MM. Lung transplantation for COVID-2019 respiratory failure in the United States: Outcomes 1-year posttransplant and the impact of preoperative extracorporeal membrane oxygenation support. J Thorac Cardiovasc Surg 2024; 167:384-395.e3. [PMID: 37087098 PMCID: PMC10121065 DOI: 10.1016/j.jtcvs.2023.04.016] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/09/2023] [Accepted: 04/16/2023] [Indexed: 04/24/2023]
Abstract
OBJECTIVE Patients with end-stage respiratory failure after severe coronavirus disease 2019 (COVID-19) infection may benefit from lung transplant; however, data on transplant outcomes and the impact of prolonged circulatory support before transplant in these patients are limited. METHODS We assessed survival, postoperative complications, and the impact of pretransplant extracorporeal membrane oxygenation (ECMO) in patients undergoing lung transplant in the United States from August 2020 through March 2022 using records validated by United Network for Organ Sharing experts and extracted from the United Network for Organ Sharing database. RESULTS In 305 patients with COVID-19-related respiratory failure and validated data, survival for up to 1-year posttransplant did not differ between 188 patients with COVID-19-related acute respiratory distress syndrome and 117 patients with post-COVID-19 pulmonary fibrosis (P = .8). Pretransplant ECMO support (median 66 days) was required in 191 patients (63%), and venovenous ECMO was used in 91.2% of patients. One-, 6-, and 12-month survival was not significantly different between patients requiring ECMO and patients without ECMO (95.8% vs 99.1%, 93.1% vs 96.4%, 84.8% vs 90.9%, P = .2) In addition, 1-year survival was similar in recipients requiring ECMO for COVID-19 lung failure and recipients requiring ECMO for non-COVID-19 restrictive lung failure (84.8% vs 78.0%, P = .1). CONCLUSIONS These findings suggest that lung transplant in patients with COVID-19 respiratory failure yields acceptable 1-year outcomes. Despite an often more complex postoperative course, prolonged ECMO pretransplant in well-selected patients was associated with adequate clinical and functional status.
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Affiliation(s)
- Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.
| | | | - Andrew Courtwright
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Thomas Richards
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Joshua Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Emily Blumberg
- Division of Infectious Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Jason Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pa
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9
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Shin M, Iyengar A, Helmers MR, Weingarten N, Patrick WL, Rekhtman D, Song C, Kelly JJ, Cevasco M. Decreased survival of simultaneous heart-kidney transplant recipients in the new heart allocation era. J Heart Lung Transplant 2023; 42:1725-1734. [PMID: 37579829 DOI: 10.1016/j.healun.2023.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/16/2023] [Accepted: 08/04/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND In 2018, the United Network for Organ Sharing (UNOS) modified their heart allocation policy to reduce waitlist mortality. The rates of simultaneous heart-kidney transplant (SHKT) have dramatically increased in recent years, despite increased rates of posttransplant renal failure in the new policy era. This study sought to investigate the impact of the new allocation system on waitlist and posttransplant outcomes of simultaneous heart-kidney transplantation. METHODS Adult patients listed for SHKT between 2012 and 2021 were included. Patients were cross-validated across both Thoracic and Kidney UNOS databases to confirm accurate listing and transplant data. Patients were stratified according to listing era. The Fine and Gray model was used to assess waitlist outcomes and posttransplant renal graft function. Kaplan-Meier analysis and Cox regression were used to compare posttransplant survival. RESULTS A total of 2,588 patients were included, of whom 1,406 (54.1%) were listed between 2012 and 2018 (era 1) and 1,182 (45.9%) between 2019 and 2021 (era 2). Era 2 was associated with increased likelihood of transplant (adjusted Sub-hazard ratios (aSHR): 1.52; p < 0.01) and decreased waitlist mortality (aSHR: 0.63; p < 0.01). Posttransplant survival at 2 years was decreased in era 2 (78.8% vs 86.9%; p < 0.01). Undersized hearts (hazard ratio [HR]: 2.02; p < 0.01), use of extracorporeal membrane oxygenation (HR: 2.67; p < 0.1), and transplants performed following the policy change (HR: 1.45; p = 0.03) were associated with increased mortality. Actuarial survival (combined waitlist and posttransplant) was significantly lower in the modern era (71.6% vs 62.2%; p = 0.02). CONCLUSIONS The allocation policy change has improved waitlist outcomes in patients listed for SHKT but potentially at the cost of worsened posttransplant outcomes.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, Philadelphia, PA, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Cindy Song
- Perelman School of Medicine, Philadelphia, PA, USA
| | - John J Kelly
- Perelman School of Medicine, Philadelphia, PA, USA; Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA.
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10
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Cohen S, Patel SJ, Grosh T, Augoustides JG, Spelde AE, Vernick W, Wald J, Bermudez C, Ibrahim M, Cevasco M, Usman AA, Folbe E, Sanders J, Fernando RJ. Surgical Placement of Axillary Impella 5.5 With Regional Anesthesia and Monitored Anesthesia Care. J Cardiothorac Vasc Anesth 2023; 37:2350-2360. [PMID: 37574337 PMCID: PMC10543652 DOI: 10.1053/j.jvca.2023.07.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/19/2023] [Indexed: 08/15/2023]
Affiliation(s)
- Samuel Cohen
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Saumil Jayant Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Taras Grosh
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Audrey Elizabeth Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - William Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joyce Wald
- Department of Medicine, Division of Cardiovascular Medicine, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael Ibrahim
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Asad Ali Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Elana Folbe
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Joseph Sanders
- Department of Anesthesiology, Pain Management & Perioperative Medicine, Henry Ford Health, Detroit, MI
| | - Rohesh J Fernando
- Department of Anesthesiology, Cardiothoracic Section, Wake Forest University School of Medicine, Medical Center Boulevard, Winston Salem, NC.
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11
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Iyengar A, Rekhtman D, Weingarten N, Song C, Shin M, Helmers MR, Kelly JJ, Cevasco M, Atluri P. Comparison of Intraaortic Balloon Pump and Impella 5.5 as Heart Transplant Bridging Strategies. Ann Thorac Surg 2023; 116:811-817. [PMID: 37419173 DOI: 10.1016/j.athoracsur.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/15/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Temporary mechanical circulatory support is increasingly utilized as a bridge to heart transplantation. The Impella 5.5 (Abiomed) has achieved anecdotal success as a bridge since receiving US Food and Drug Administration approval. The purpose of the current study was to compare waitlist and posttransplant outcomes of patients bridged with intraaortic balloon pumps (IABPs) to those receiving Impella 5.5 therapy. METHODS Patients listed for heart transplantation between October 2018 and December 2021 who received IABP or Impella 5.5 at any time during waitlist course were identified from the United Network for Organ Sharing database. Propensity-matched groups of recipients with each device were created. Competing-risks regression for mortality, transplantation, and removal from waitlist for illness was performed according to the method of Fine and Gray. Posttransplant survival was censored at 2 years. RESULTS Overall, 2936 patients were identified, of whom 2484 (85%) were supported with IABP and 452 (15%) received Impella 5.5. Patients with Impella 5.5 support had more functional impairment, higher wedge pressures, higher rates of preoperative diabetes and dialysis, and more ventilator support (all P < .05). Waitlist mortality was significantly worsened in the Impella group and transplantation was less frequent (P < .001). However, survival at 2 years after transplant was similar in both complete (90% vs 90%, P = .693) and propensity-matched cohorts (88% vs 83%, P = .874). CONCLUSIONS Patients bridged with Impella 5.5 were sicker than IABP-bridged patients and less frequently transplanted; however, posttransplant outcomes were similar in propensity-matched cohorts. The role of these bridging strategies in patients listed for heart transplantation should be continually assessed with future allocation system changes.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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12
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Schurr JW, Sigal I, Usman A, Patel P, Lefebvre B, Kurcik K, Atluri P, Acker M, Bermudez C, Rame JE, Hanff T, Cevasco M, Wald J. Effect of Anesthesia Induction on Cardiac Hemodynamics in Patients Undergoing Durable Left Ventricular Assist Device Implantation: The EACH-LVAD Study. ASAIO J 2023; 69:907-914. [PMID: 37578995 DOI: 10.1097/mat.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/16/2023] Open
Abstract
Right ventricular (RV) dysfunction is common after left ventricular assist device (LVAD) implantation leading to clinical right heart failure (RHF) associated with worsened survival and quality of life. It is likely that intraoperative events such as anesthesia induction play a role in the development or unmasking of RV dysfunction in addition to known effects from hemodynamic changes that occur after LVAD implantation. The EACH-LVAD Study is a prospective, single-center, single-arm, observational cohort study of adult patients with advanced heart failure undergoing durable LVAD implantation with standard anesthesia induction. Intraoperative RV hemodynamics via central venous pressure, mean pulmonary artery pressure, pulmonary artery pulsatility index, and vasoactive-inotropic score (a simple weighted summation of standardized drug doses) and echocardiographic parameters (RV fractional area change, RV area in diastole, RV basal diameter, septum position, RV function, tricuspid regurgitation) were measured and compared at prespecified timepoints, including postinduction. Postoperative clinical RHF was determined based on published definitions. Forty-two patients receiving a first-time LVAD were included between September 2017 and March 2019. Propofol-based induction was used in 31 patients and etomidate-based induction in eight patients. A significant increase in central venous pressure (CVP; p < 0.001), mean pulmonary artery pressure (mPAP; p < 0.001), and vasoactive inotropic score (VIS; p < 0.001) with associated decrease in pulmonary artery pulsatility index (PAPi; p < 0.001) was observed. Right ventricular function worsened throughout. Right heart failure occurred in 70% of patients. Propofol-based induction was not associated with a higher risk of RHF (relative risk [RR], 1.01 [95% confidence interval {CI}, 0.64-1.61]). The EACH-LVAD study demonstrates an effect of anesthesia induction on worsened RV hemodynamics and echocardiographic changes which may have an effect on the development of RHF.
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Affiliation(s)
- James W Schurr
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ian Sigal
- From the Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Asad Usman
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Prakash Patel
- Department of Anesthesiology, Yale University, New Haven, Connecticut
| | - Benedicte Lefebvre
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kristy Kurcik
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Acker
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Thomas Hanff
- Division of Cardiovascular Medicine, University of Utah Hospital, Salt Lake City, Utah
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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13
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Courtwright AM, Doyon JB, Blumberg EA, Cevasco M, Cantu E, Bermudez CA, Crespo MM. Infectious complications associated with bronchial anastomotic dehiscence in lung transplant recipients. Clin Transplant 2023; 37:e15040. [PMID: 37248788 DOI: 10.1111/ctr.15040] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/09/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Bronchial anastomotic dehiscence (AD) is an uncommon complication following lung transplantation that carries significant morbidity and mortality. The objective of this study was to characterize fungal and bacterial infections in ADs, including whether infections following AD were associated with progression to bronchial stenosis. METHODS This was a single-center study of 615 lung transplant recipients between 6/1/2015 and 12/31/2021. Airway complications were defined according to ISHLT consensus guidelines. RESULTS 22 of the 615 recipients (3.6%) developed an AD. Bronchial ischemia or necrosis was common prior to dehiscence (68.1%). Fourteen (63.6%) recipients had bacterial airway infections, most commonly with Gram-negative rods, prior to dehiscence. Thirteen (59.1%) recipients had an associated pleural infection, most commonly with Candida species (30.8%). Post-dehiscence Aspergillus species were isolated in 4 recipients, 3 of which were de novo infections. Eleven had bacterial infections prior to dehiscence resolution, most commonly with Pseudomonas aeruginosa. Eleven recipients developed airway stenosis requiring dilation and/or stenting. Development of secondary infection prior to AD resolution was not associated with progression to stenosis (OR = .41, 95% CI = .05-3.30, p = .41). CONCLUSIONS Gram-negative bacterial infections are common before and after AD. Pleural infection should be suspected in most cases. Infections prior to healing were not associated with subsequent development of airway stenosis.
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Affiliation(s)
- Andrew M Courtwright
- Division of Pulmonology, Allergy, and Critical Care, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffery B Doyon
- Division of Infectious Diseases, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily A Blumberg
- Division of Infectious Diseases, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ed Cantu
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria M Crespo
- Division of Pulmonology, Allergy, and Critical Care, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Cevasco M, Shin M, Cohen W, Helmers MR, Weingarten N, Rekhtman D, Wald JW, Iyengar A. Impella 5.5 as a bridge to heart transplantation: Waitlist outcomes in the United States. Clin Transplant 2023; 37:e15066. [PMID: 37392194 DOI: 10.1111/ctr.15066] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/24/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVES The 2018 United Network for Organ Sharing allocation policy change has led to a significant increase in the use of mechanical circulatory support devices in patients listed for orthotopic heart transplantation. However, there has been a paucity of data regarding the newest generation Impella 5.5, which received FDA approval in 2019. METHODS The United Network for Organ Sharing registry was queried for all adults awaiting orthotopic heart transplantation who received Impella 5.5 support during their listing period. Waitlist, device, and early post-transplant outcomes were assessed. RESULTS A total of 464 patients received Impella 5.5 support during their listing period with a median waitlist time of 19 days. Among them, 402 (87%) patients were ultimately transplanted, with 378 (81%) being directly bridged to transplant with the device. Waitlist death (7%) and clinical deterioration (5%) were the most common reasons for waitlist removal. Device complications and failure were uncommon (<5%). The most common post-transplant complication was acute kidney injury requiring dialysis (16%). Survival at 1-year post-transplant survival was 89.5%. CONCLUSION Since its approval, the Impella 5.5 has been increasingly used as a bridge to transplant. This analysis demonstrates robust waitlist and post-transplant outcomes with minimal device-related and postoperative complications.
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Affiliation(s)
- Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce W Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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15
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Rekhtman D, Iyengar A, Song C, Weingarten N, Shin M, Patel M, Herbst DA, Helmers M, Cevasco M, Atluri P. Emerging Racial Differences in Heart Transplant Waitlist Outcomes for Patients on Temporary Mechanical Circulatory Support. Am J Cardiol 2023; 204:234-241. [PMID: 37556892 DOI: 10.1016/j.amjcard.2023.07.086] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 07/10/2023] [Indexed: 08/11/2023]
Abstract
Temporary mechanical circulatory support (tMCS) is increasingly used for patients awaiting heart transplantation. Although examples of systemic inequity in cardiac care have been described, biases in tMCS use are not well characterized. This study explores the racial disparities in tMCS use and waitlist outcomes. The United Network for Organ Sharing database was used to identify adults listed for first-time heart transplantation from 2015 to 2021. White and non-White patients on extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary left ventricular assist device were identified. Waitlist outcomes of mortality, transplantation, and delisting were analyzed by race using competing risks regression. The effect of the new heart allocation system was also assessed. A total of 16,811 patients were included in this study, with 10,377 self-identifying as White and 6,434 as non-White. White patients were more often male, privately ensured, and had less co-morbidities (p <0.05). tMCS use was found to be significantly higher in non-White patients (p <0.001). Among those on tMCS, non-White patients were more likely to be delisted because of illness (subhazard ratio 1.34 [1.09 to 1.63]) and less likely to die while on the waitlist (subhazard ratio 0.76 [0.61 to 0.93]). This disparity was not present before the implementation of the new heart allocation system. tMCS use was proportional to the risk factors identified in the non-White cohort. After the implementation of the new heart allocation system, White patients were more likely to die, whereas non-White patients were more likely to be delisted. Further work is needed to determine the causes of and potential solutions for disparities in the waitlist outcomes.
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Affiliation(s)
- David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mrinal Patel
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Alan Herbst
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Helmers
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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16
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Spelde AE, Usman AA, Olia SE, Ibrahim ME, Szeto WY, Cevasco M, Grimm JC, Bermudez CA, Steinberg TB, Vernick WJ, Gutsche JT. Intracannula Thrombus Formation Associated With Dual Lumen ProtekDuo Cannula in Extracorporeal Membrane Oxygenation (ECMO). ASAIO J 2023; 69:e391-e396. [PMID: 36867841 PMCID: PMC10480334 DOI: 10.1097/mat.0000000000001906] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in cases of severe respiratory failure refractory to medical management. Use of ECMO is increasing, along with new cannulation strategies including oxygenated right ventricular assist devices (oxy-RVADs). Multiple dual lumen cannulas are now available, which increase the potential for patient mobility and decrease the number of vascular access sites. However, dual lumen, single cannula flow can be limited by adequate inflow, requiring the need for an additional inflow cannula to meet patient demands. This cannula configuration may result in differential flows in the inflow and outflow limbs and altered flow dynamics, increasing the risk of intracannula thrombus. We describe a series of four patients treated with oxy-RVAD for COVID-19-associated respiratory failure complicated by dual lumen ProtekDuo intracannula thrombus.
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Affiliation(s)
- Audrey E. Spelde
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Asad A. Usman
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Salim E. Olia
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Michael E. Ibrahim
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Wilson Y. Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Joshua C. Grimm
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christian A. Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Toby B. Steinberg
- Department of Anesthesia & Perioperative Medicine, Medical University of South Carolina, Charleston, SC
| | - William J. Vernick
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Jacob T. Gutsche
- Department of Anesthesiology & Critical Care, University of Pennsylvania, Philadelphia, PA
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17
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Kim ST, Iyengar A, Helmers MR, Weingarten N, Rekhtman D, Song C, Shin M, Cevasco M, Atluri P. Outcomes of COVID-19-Positive Donor Heart Transplantation in the United States. J Am Heart Assoc 2023:e029178. [PMID: 37421286 PMCID: PMC10382108 DOI: 10.1161/jaha.122.029178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 12/19/2022] [Accepted: 05/30/2023] [Indexed: 07/10/2023]
Abstract
Background Little is known regarding the impact of donor COVID-19 status on recipient outcomes after heart transplantation. In this study, we characterize outcomes of the first 110 heart transplants from organ donors positive for COVID-19 (COVID-19+) in the United States. Methods and Results Retrospective analysis of the United Network for Organ Sharing database was performed for single-organ adult heart transplants from January 2020 to March 2022. Donor COVID-19+ status was defined as a positive nucleic acid amplification, antigen, or other COVID-19 test within 7 days of transplant. Nearest-neighbor propensity score matching used to adjust for differences between recipients of COVID-19+ and nonpositive donor hearts. Overall, 7251 heart transplants were included in analysis, with 110 using COVID-19+ donor hearts. Recipients of COVID-19+ allografts were younger (54 [interquartile range, 41-61]) versus 57 [46-64] years; P=0.02) but had similar rates of female sex and non-White race compared with those receiving allografts from negative donors. Nearest-neighbor propensity score matching resulted in 100 well-matched pairs of recipients of COVID-19+ versus nonpositive donor organs. The 2 matched groups had similar median lengths of stay (15 [11-23] days versus 15 [13-23] days; P=0.40), rates of graft failure (1% versus 0%; P=0.99), 30-day death (3% versus 3%; P=0.99), and 3-month survival (88% versus 94%; P=0.23) compared with recipients of nonpositive donors. No deaths occurred due to COVID-19 infection among the 8 (7%) total deceased recipients of COVID-19+ allografts to date. Conclusions Short-term outcomes of heart transplant recipients receiving COVID-19+ donor organs are reassuring. However, continued monitoring for long-term survival and potential complications are warranted.
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Affiliation(s)
- Samuel T Kim
- David Geffen School of Medicine University of California Los Angeles CA USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - Noah Weingarten
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - David Rekhtman
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - Cindy Song
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - Max Shin
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery University of Pennsylvania Philadelphia PA USA
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18
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Shin M, Iyengar A, Helmers MR, Patrick WL, Cohen W, Weingarten N, Rekhtman D, Song C, Atluri P, Cevasco M. Use of extended criteria donor hearts in combined heart-kidney transplant confers greater risk of mortality. J Heart Lung Transplant 2023; 42:943-952. [PMID: 36918338 DOI: 10.1016/j.healun.2023.02.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/25/2023] [Accepted: 02/10/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Extended criteria donors (ECD) hearts have demonstrated acceptable outcomes in select populations. However, their use in patients undergoing simultaneous heart-kidney transplantation (SHKT) has not been explored. This study is assessed the effect of ECD hearts in patients undergoing SHKT vs isolated heart transplants (IHT). METHODS The United Network for Organ Sharing (UNOS) database was queried for all adult patients undergoing IHT and SHKT. Patients were stratified by receipt of ECD heart, defined as donor hearts failing to meet established acceptable use criteria. Interaction effects between ECDs and simultaneous kidney transplants were generated. Postoperative outcomes, risk factors, and patient/graft survival were compared across cohorts using Fine-Gray, Kaplan Meier, and Cox Proportional Hazards analyses. RESULTS Among 26,207 patients included, 1,766 (7%) underwent SHKT. ECD hearts were used in 25% of both IHT and SHKT cohorts. Five-year survival among SHKT/ECD patients (67.3%) was reduced (p < 0.01) compared to SHKT/SDC (80.3%), IHT/ECD (78.1%) and IHT/SCD (80.0%) groups. Among SHKT patients, use of ECD hearts was associated with increased risk (SHR: 1.48; p < 0.01) of renal graft failure compared to SCD hearts. Among SHKT patients, receipt of an ECD heart, and individual ECD criteria (coronary disease and size mismatch >20%), predicted mortality. The interaction effect of receiving both ECD and SHKT predicted mortality and graft failure (HR 1.43; p < 0.01). CONCLUSIONS Patients undergoing SHKT with an ECD heart face greater risks of mortality and graft failure in comparison to those undergoing IHT with ECD hearts. Careful selection of donor organs should be applied to this high-risk cohort.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Cohen WG, Rekhtman D, Iyengar A, Shin M, Ibrahim M, Bermudez C, Cevasco M, Wald J. Extended Support With the Impella 5.5: Transplant, ECMO, and Complications. ASAIO J 2023; 69:642-648. [PMID: 37039780 DOI: 10.1097/mat.0000000000001931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/12/2023] Open
Abstract
We report midterm results of Impella 5.5 use with focus placed on bridge-outcomes, venoarterial extracorporeal membrane oxygenation (VA-ECMO) transition, complications, and risk factors for mortality. A retrospective review of patients implanted with the Impella 5.5 at our medical center was conducted. Forty patients were included with varying bridge strategies. Sixteen (40%) patients were supported for <14 days, 13 (32.5%) for 14-30 days, and 11 (27.5%) for >30 days. Thirty day mortality was 22.5% (9/40). Twenty-five (62.5%) were successfully bridged to transplant or durable left ventricular assist device (LVAD), while four (10.0%) recovered without the need for any further cardiac support. Five of 11 (60%) patients initially supported with VA-ECMO were either transitioned to durable left ventricular assist device (dLVAD; n = 3, 27.3%), transplanted (n = 1, 9.1%), or recovered (n = 1, 9.1%). Of nine patients with >moderate right ventricle (RV) dysfunction, five (55.6%) were successfully bridged to transplant or LVAD. Five (12.5%) patients required interval cannulation to VA-ECMO, often in the setting of RV dysfunction, and all (100%) were successfully transplanted. Lower pulmonary artery (PA) systolic pressure ( P = 0.029), among other factors, was associated with mortality. In summary, the Impella 5.5 may be able to effectively stabilize patients in refractory left ventricular predominant cardiogenic shock for extended durations, allowing time for mechanical circulatory support (MCS) and transplant evaluations.
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Affiliation(s)
- William G Cohen
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Rekhtman
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Max Shin
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce Wald
- From the Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Usman AA, Cevasco M, Maybauer MO, Spelde AE, Olia S, Bermudez C, Ibrahim M, Szeto W, Vernick WJ, Gutsche JT. Oxygenated right ventricular assist device as part of veno-venopulmonary extracorporeal membrane oxygenation to support the right ventricle and pulmonary vasculature. J Cardiothorac Surg 2023; 18:134. [PMID: 37041646 PMCID: PMC10088623 DOI: 10.1186/s13019-023-02264-8] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 04/03/2023] [Indexed: 04/13/2023] Open
Abstract
COVID-19 infection can lead to severe acute respiratory distress syndrome (ARDS), right ventricular (RV) failure and pulmonary hypertension. Venovenous extracorporeal membrane oxygenation (V-V ECMO) has been used for patients with refractory hypoxemia. More recently dual-lumen right atrium to pulmonary artery oxygenated right ventricular assist devices (Oxy-RVAD) have been utilized in the severe medical refractory COVID ARDS setting. Historically, animal data has demonstrated that high continuous non-pulsatile RVAD flows, leading to unregulated and unprotected circulation through the pulmonary vessels is associated with an increased risk of pulmonary hemorrhage and increased amount of extravascular lung water. These risks are heightened in the setting of ARDS with fragile capillaries, left ventricular (LV) diastolic failure, COVID cardiomyopathy, and anticoagulation. Concurrently, due to infection, tachycardia, and refractory hypoxemia, high V-V ECMO flows to match high cardiac output are often necessary to maintain systemic oxygenation. Increase in cardiac output without a concurrent increase in VV ECMO flow will result in a higher fraction of deoxygenated blood returning to the right heart and therefore resulting in hypoxemia. Several groups have suggested using a RVAD only strategy in COVID ARDS; however, this exposes the patients to the risk of pulmonary hemorrhage. We present one of the first known cases using an RV mechanical support, partial flow pulmonary circulation, oxygenated Veno-venopulmonary (V-VP) strategy resulting in RV recovery, total renal recovery, awake rehabilitation, and recovery.
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Affiliation(s)
- Asad Ali Usman
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA.
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Marc O Maybauer
- Advanced Cardiac and Critical Care, Nazih Zuhdi Transplant Institute, 24/7 Shock Service, Intergris Baptist Medical Center, Oklahoma City, OK, USA
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Critical Care Research Group, The Prince Charles Hospital, The University of Queensland, Hospital cardiac Arrest, Brisbane, Australia
| | - Audrey Elizabeth Spelde
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
| | - Salim Olia
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Ibrahim
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - William J Vernick
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA
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21
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Song C, Weingarten N, Rekhtman D, Iyengar A, Patel M, Herbst D, Helmers M, Cevasco M, Atluri P. Positive Correlative Volume-Outcome Relationship for Multiorgan Heart Transplantation. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.639] [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: 04/05/2023] Open
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22
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Sundaravel S, Wald J, Senker R, Cevasco M, Giri J, Desai N, Ortega-Legaspi J, Pieretti J, Owens A, Genuardi M, Holzhauser L. Persistent Cardiogenic Shock after Valve in Valve TAVR Rescued with Durable LVAD. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.793] [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: 04/05/2023] Open
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23
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Rekhtman D, Iyengar A, Song C, Weingarten N, Shin M, Patel M, Herbst D, Helmers M, Cevasco M, Atluri P. Emerging Racial Differences in Heart Transplant Waitlist Outcomes for Patients on Temporary Mechanical Circulatory Support. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.080] [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: 04/05/2023] Open
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24
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Iyengar A, Patrick WL, Helmers MR, Kelly JJ, Han J, Williams ML, Mackay EJ, Desai ND, Cevasco M. Neighborhood Socioeconomic Status Independently Predicts Outcomes After Mitral Valve Surgery. Ann Thorac Surg 2023; 115:940-947. [PMID: 36623633 DOI: 10.1016/j.athoracsur.2023.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 12/08/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023]
Abstract
BACKGROUND Socioeconomic status has increasingly recognized influence on outcomes after cardiac surgery. However, singular metrics fail to fully capture the socioeconomic context within which patients live, which vary greatly between neighborhoods. We sought to explore the impact of neighborhood-level socioeconomic status on patients undergoing mitral valve surgery in the United States. METHODS Adults undergoing first-time, isolated mitral valve surgery were queried from The Society of Thoracic Surgeons Adult Cardiac Surgery Database between 2012 and 2018. Socioeconomic status was quantified using the Area Deprivation Index, a weighted composite including average housing prices, household incomes, education, and employment levels. The associations between regional deprivation, access to mitral surgery, valve repair rates, and outcomes were evaluated using logistic regression. RESULTS Among 137,100 patients included, patients with socioeconomic deprivation had fewer elective presentations, more comorbidity burden, and more urgent/emergent surgery. Patients from less disadvantaged areas received operations from higher volume surgeons and had higher repair rates (highest vs lowest quintile: 72% vs 51%, P < .001, more minimally-invasive approach (33% vs 20%, P < .001), lower composite complication rate (42% vs 50%, P < .001), and lower 30-day mortality (1.8% vs 3.9%, P < .001). After hierarchical multivariable adjustment, the Area Deprivation Index significantly predicted 30-day mortality and repair rate (P < .001). CONCLUSIONS In a risk-adjusted national analysis of mitral surgery, patients from more deprived areas were less likely to undergo mitral repair and more likely to have complications. Further work at targeting neighborhood-level disparity is important to improving mitral surgical outcomes in the United States.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason Han
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew L Williams
- Division of Cardiovascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Emily J Mackay
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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25
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Jin D, Mccurry M, Friskey J, Lisowski J, Diamond J, Anderson M, Crespo M, Courtwright A, Cevasco M, Bermudez C, Gallop R, Hsu Y, Christie J, Schaubel D, Cantu E. Transplanting Candidates with Stacked Risks Negatively Affects Outcomes. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1619] [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: 04/05/2023] Open
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26
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Silvestre J, Cevasco M. Comparing Match Outcomes in a Surgical Subspecialty: Independent Versus Integrated Training Pathways. J Surg Educ 2023; 80:468-475. [PMID: 36464614 DOI: 10.1016/j.jsurg.2022.11.004] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/31/2022] [Accepted: 11/12/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE In recent years, the Thoracic Surgery Match (TSM) has become increasingly competitive. The purpose of this study was to compare recent trends in application and match rates in the TSM by training pathway. DESIGN This was a retrospective cohort study of all applicants to Integrated and Independent pathways for Thoracic Surgery training (2008-2021). Chi square tests were used to elucidate temporal trends and make comparisons by training pathway. SETTING Accreditation Council for Graduate Medical Education (ACGME)-accredited Thoracic Surgery training programs in the United States. PARTICIPANTS 1500 Independent and 1242 Integrated pathway applicants for Thoracic Surgery training. RESULTS From 2008 to 2021, the annual match rate decreased from 91% to 71% in the Independent pathway (p < 0.001). This was driven by a decrease in the number of training positions (130-101, 22% decrease) and increase in number of applicants (96-140, 46% increase). In the Integrated pathway, the annual match rate increased from 33% to 35% (p < 0.001) as did the number of training positions (3 to 46, 1430% increase) and applicants (9-129, 1333% increase). During each year, match rates in the Independent pathway exceeded those in the Integrated pathway (p < 0.001). U.S. Allopathic graduates had higher match rates than non-U.S. Allopathic graduates for both Integrated and Independent training pathways. The percentage of applicants in the Independent pathway matching at one of their top 3 choices decreased from 73% to 40% (p < 0.001). The percentage of Independent thoracic surgery training positions that went unmatched decreased from 28% to 2% (p < 0.001). This percentage was stable at an average of 1% in the Integrated pathway (p > 0.05). CONCLUSIONS The TSM has become increasingly competitive for Independent pathway applicants and remains ultracompetitive for Integrated pathway applicants. More research is needed to understand disparities in match rates by Thoracic Surgery training pathway.
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Shin M, Han JJ, Cohen WG, Iyengar A, Helmers MR, Kelly JJ, Patrick WL, Wang X, Cevasco M. Higher Rates of Dialysis and Subsequent Mortality in the New Allocation Era for Heart Transplants. Ann Thorac Surg 2023; 115:502-509. [PMID: 35926639 DOI: 10.1016/j.athoracsur.2022.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2018, a United Network for Organ Sharing (UNOS) policy change increased prioritization of patients bridged with temporary mechanical circulatory support devices, such as venoarterial ECMO, for cardiac transplantation. Considering increased waitlist acuity, we sought to characterize whether this was associated with an increased risk for development of postoperative acute renal failure requiring dialysis (AKI-D) and risk of death after transplantation. METHODS Dialysis-naive adults receiving single-organ heart transplant between November 2009 and February 2020 were stratified by receipt of AKI-D. Era 1 and era 2 were defined by the periods of UNOS allocation before and after policy change, respectively. Multivariable logistic regression was performed to determine risk factors for AKI-D. Rates of AKI-D were compared by propensity score-matched cohorts. Survival was compared by Kaplan-Meier analysis. RESULTS A total of 20 698 patients were included. Venoarterial ECMO use significantly increased in era 2 (5.6% vs 0.58%; P < .01). Overall prevalence of AKI-D was greater in era 2 (13.5% vs 10.2%; P < .01). Use of preoperative ECMO, intra-aortic balloon pump, and ventilators and longer ischemia times were identified as independent risk factors for development of AKI-D. Five- and 10-year survival rates were significantly decreased for patients with AKI-D. There was no short-term survival difference of patients with AKI-D between era 2 and the more contemporary era 1. CONCLUSIONS Patients in whom AKI-D develops after transplantation have significantly worse short- and long-term outcomes. Preoperative use of ECMO, preoperative ventilator support, and longer ischemia times are risk factors for development of AKI-D, and their prevalence has increased since the allocation policy change.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William G Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Xingmei Wang
- Biostatistics Analysis Center, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Shin M, Iyengar A, Helmers MR, Kelly JJ, Song C, Rekhtman D, Cevasco M. Modern outcomes of heart-lung transplantation: assessing the impact of the updated US allocation system. Eur J Cardiothorac Surg 2022; 63:6874542. [PMID: 36472453 DOI: 10.1093/ejcts/ezac559] [Citation(s) in RCA: 6] [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] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/10/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In 2018, the United Network for Organ Sharing modified their heart allocation policy to reduce waitlist mortality and prioritize patients with the greatest acuity. Considering declining rates of combined heart-lung transplantation, this study sought to investigate the impact of the new allocation system on waitlist and post-transplant outcomes of patients listed for combined heart-lung transplantation. METHODS Adult patients listed for combined heart-lung transplant between 2012 and 2021 were included. Patients were stratified according to listing era. Competing risk regression was used to assess waitlist outcomes. Cox proportional hazards regression was used to establish risk factors for post-transplant mortality. RESULTS A total of 511 patients were included, of whom 295 (57.8%) were listed in era 1 and 216 (42.2%) in era 2. Era 2 was associated with increased likelihood of transplant (adjusted standard hazard ratio (aSHR): 1.60 [1.23-2.07]; P < 0.01) and decreased waitlist mortality (aSHR: 0.43 [0.25-0.73]; P < 0.01). Despite longer ischaemic times and increased use of preoperative veno-arterial extracorporeal membrane oxygenation (ECMO) in era 2, early post-transplant survival was equivalent. Predicted heart mass ratio <0.8 (Hazard ratio (HR); 3.24; P = 0.01), ventilator support (HR: 3.83; P < 0.01) and greater ischaemic times (HR: 1.80; P < 0.01) independently predicted the mortality. Procedures at high centre volumes (HR: 0.36; P = 0.04) were associated with decreased mortality. Use of ECMO was not predictive of mortality in the modern era. CONCLUSIONS The allocation policy change has led to improvements in waitlist outcomes in patients listed for heart-lung transplantation. Despite increased ischaemic times and use of ECMO, early post-transplant survival was equivalent.
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Affiliation(s)
- Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Cindy Song
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David Rekhtman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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29
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Glance LG, Joynt Maddox KE, Mazzefi M, Knight PW, Eaton MP, Feng C, Kertai MD, Albernathy J, Wu IY, Wyrobek JA, Cevasco M, Desai N, Dick AW. Racial and Ethnic Disparities in Access to Minimally Invasive Mitral Valve Surgery. JAMA Netw Open 2022; 5:e2247968. [PMID: 36542380 PMCID: PMC9857175 DOI: 10.1001/jamanetworkopen.2022.47968] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Whether people from racial and ethnic minority groups experience disparities in access to minimally invasive mitral valve surgery (MIMVS) is not known. OBJECTIVE To investigate racial and ethnic disparities in the utilization of MIMVS. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study used data from the Society of Thoracic Surgeons Database for patients who underwent mitral valve surgery between 2014 and 2019. Statistical analysis was performed from January 24 to August 11, 2022. EXPOSURES Patients were categorized as non-Hispanic White, non-Hispanic Black, and Hispanic individuals. MAIN OUTCOMES AND MEASURES The association between MIMVS (vs full sternotomy) and race and ethnicity were evaluated using logistic regression. RESULTS Among the 103 753 patients undergoing mitral valve surgery (mean [SD] age, 62 [13] years; 47 886 female individuals [46.2%]), 10 404 (10.0%) were non-Hispanic Black individuals, 89 013 (85.8%) were non-Hispanic White individuals, and 4336 (4.2%) were Hispanic individuals. Non-Hispanic Black individuals were more likely to have Medicaid insurance (odds ratio [OR], 2.21; 95% CI, 1.64-2.98; P < .001) and to receive care from a low-volume surgeon (OR, 4.45; 95% CI, 4.01-4.93; P < .001) compared with non-Hispanic White individuals. Non-Hispanic Black individuals were less likely to undergo MIMVS (OR, 0.65; 95% CI, 0.58-0.73; P < .001), whereas Hispanic individuals were not less likely to undergo MIMVS compared with non-Hispanic White individuals (OR, 1.08; 95% CI, 0.67-1.75; P = .74). Patients with commercial insurance had 2.35-fold higher odds of undergoing MIMVS (OR, 2.35; 95% CI, 2.06-2.68; P < .001) than those with Medicaid insurance. Patients operated by very-high volume surgeons (300 or more cases) had 20.7-fold higher odds (OR, 20.70; 95% CI, 12.7-33.9; P < .001) of undergoing MIMVS compared with patients treated by low-volume surgeons (less than 20 cases). After adjusting for patient risk, non-Hispanic Black individuals were still less likely to undergo MIMVS (adjusted OR [aOR], 0.88; 95% CI, 0.78-0.99; P = .04) and were more likely to die or experience a major complication (aOR, 1.25; 95% CI, 1.16-1.35; P < .001) compared with non-Hispanic White individuals. CONCLUSIONS AND RELEVANCE In this cross-sectional study, non-Hispanic Black patients were less likely to undergo MIMVS and more likely to die or experience a major complication than non-Hispanic White patients. These findings suggest that efforts to reduce inequity in cardiovascular medicine may need to include increasing access to private insurance and high-volume surgeons.
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Affiliation(s)
- Laurent G. Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
| | - Karen E. Joynt Maddox
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri
- Center for Health Economics and Policy at the Institute for Public Health, Washington University in St Louis, St Louis, Missouri
| | - Michael Mazzefi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville
| | - Peter W. Knight
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Michael P. Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Changyong Feng
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine, Rochester, New York
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James Albernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins, Baltimore, Maryland
| | - Isaac Y. Wu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Julie A. Wyrobek
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Marisa Cevasco
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
| | - Nimesh Desai
- Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia
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Usman AA, Spelde AE, Cevasco M, Bermudez C, Olia S, Ibrahim M, Atluri P, Szeto W, Vernick W, Gutsche J. Technical Considerations for Percutaneous Pulmonary Artery Cannulation for Mechanical Circulatory Support. JTCVS Tech 2022; 18:65-73. [PMID: 37096080 PMCID: PMC10122133 DOI: 10.1016/j.xjtc.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 11/09/2022] [Accepted: 11/13/2022] [Indexed: 12/24/2022] Open
Abstract
Objectives Percutaneous pulmonary artery cannulas, used as inflow for left ventricular venting or as outflow for right ventricular mechanical circulatory support, are easily and rapidly deployable with transesophageal and fluoroscopic guidance. Methods We chose to review our institutional and technical experience with all right atrium to pulmonary artery cannulations. Results Based on the review, we describe 6 right atrium to pulmonary artery cannulation strategies. They are divided into total right ventricular assist support, partial right ventricular assist support, and left ventricular venting. A single limb cannula or a dual lumen cannula can be used for right ventricular support. Conclusions In the right ventricular assist device configuration, percutaneous cannulation may prove beneficial in cases of isolated right ventricular failure. Conversely, pulmonary artery cannulation can be used for left ventricular venting as drainage to a cardiopulmonary bypass or extracorporeal membrane oxygenation circuit. This article can be used as a reference for the technical aspects of cannulation, decision-making in patient selection, and management of patients in these clinical scenarios.
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Cantu E, Diamond JM, Cevasco M, Suzuki Y, Crespo M, Clausen E, Dallara L, Ramon CV, Harmon MT, Bermudez C, Benvenuto L, Anderson M, Wille KM, Weinacker A, Dhillon GS, Orens J, Shah P, Merlo C, Lama V, McDyer J, Snyder L, Palmer S, Hartwig M, Hage CA, Singer J, Calfee C, Kukreja J, Greenland JR, Ware LB, Localio R, Hsu J, Gallop R, Christie JD. Contemporary trends in PGD incidence, outcomes, and therapies. J Heart Lung Transplant 2022; 41:1839-1849. [PMID: 36216694 PMCID: PMC9990084 DOI: 10.1016/j.healun.2022.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 01/04/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We sought to describe trends in extracorporeal membrane oxygenation (ECMO) use, and define the impact on PGD incidence and early mortality in lung transplantation. METHODS Patients were enrolled from August 2011 to June 2018 at 10 transplant centers in the multi-center Lung Transplant Outcomes Group prospective cohort study. PGD was defined as Grade 3 at 48 or 72 hours, based on the 2016 PGD ISHLT guidelines. Logistic regression and survival models were used to contrast between group effects for event (i.e., PGD and Death) and time-to-event (i.e., death, extubation, discharge) outcomes respectively. Both modeling frameworks accommodate the inclusion of potential confounders. RESULTS A total of 1,528 subjects were enrolled with a 25.7% incidence of PGD. Annual PGD incidence (14.3%-38.2%, p = .0002), median LAS (38.0-47.7 p = .009) and the use of ECMO salvage for PGD (5.7%-20.9%, p = .007) increased over the course of the study. PGD was associated with increased 1 year mortality (OR 1.7 [95% C.I. 1.2, 2.3], p = .0001). Bridging strategies were not associated with increased mortality compared to non-bridged patients (p = .66); however, salvage ECMO for PGD was significantly associated with increased mortality (OR 1.9 [1.3, 2.7], p = .0007). Restricted mean survival time comparison at 1-year demonstrated 84.1 days lost in venoarterial salvaged recipients with PGD when compared to those without PGD (ratio 1.3 [1.1, 1.5]) and 27.2 days for venovenous with PGD (ratio 1.1 [1.0, 1.4]). CONCLUSIONS PGD incidence continues to rise in modern transplant practice paralleled by significant increases in recipient severity of illness. Bridging strategies have increased but did not affect PGD incidence or mortality. PGD remains highly associated with mortality and is increasingly treated with salvage ECMO.
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Affiliation(s)
- Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoshi Suzuki
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Dallara
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian V Ramon
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael T Harmon
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Michaela Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Keith M Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ann Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Gundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Jonathan Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Christian Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Vibha Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - John McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Laurie Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Scott Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matt Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Chadi A Hage
- Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan Singer
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, University of California, San Francisco, California
| | - Carolyn Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California, San Francisco, California
| | - John R Greenland
- Department of Medicine, University of California, San Francisco, California
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Russel Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert Gallop
- Department of Mathematics, West Chester University, West Chester, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Cohen WG, Han J, Shin M, Iyengar A, Wang X, Helmers MR, Cevasco M. Lack of volume-outcome association in ECMO bridge to heart transplantation. J Card Surg 2022; 37:4883-4890. [PMID: 36352776 DOI: 10.1111/jocs.17157] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a bridge to cardiac transplantation. As the 2018 United Network for Organ Sharing (UNOS) heart allocation policy change elevated waitlist status for patients receiving mechanical circulatory support (MCS), we aimed to determine if a center's annual heart transplant volume was associated with ECMO-support duration and posttransplant outcomes. METHODS Adults heart transplant candidates between January 1, 2011, and December 31, 2021, were isolated in the UNOS database. VA-ECMO use was identified at the time of listing for transplant. Average annual transplant volume was calculated by the center, with stratification as high (≥20 cardiac transplants, high volume center [HVC]) or low (<20 cardiac transplants, low volume center [LVC]) volume centers. Results are reported as mean (interquartile range) or n (%). RESULTS In total, 543 patients at HVCs and 275 at LVCs were listed for transplant supported with VA-ECMO. Those listed at HVCs were more likely to be supported by intra-aortic balloon pump (103 [19%] vs. 32 [11.6%], p = .008) and inotropes (267 [49.2%] vs. 106 [38.5%], p = .004) at time of listing. Patients at HVCs received ECMO support for 6 [4-9] days, compared to 8 [4-15] days at low-volume centers (p = .030), and but were cannulated a similar time before listing (2 [1-5] vs. 3 [1-7] days, p = .517). There were no differences in rates of transplant (p = .2126), waitlist mortality (p = .8645), delisting due to clinical deterioration (p = .8419), or recovery (p = .1773) between groups. Among transplanted patients, there were no differences in support duration (6 [4-8] vs. 6 [4-10], p = .187), or time from registration to transplant (5 [2-20] vs. 7 [3-22] days, p = .560). Posttransplant survival did not vary (p = .293). CONCLUSIONS LVCs can successfully bridge patients to transplant with VA-ECMO and achieve comparable outcomes to HVCs.
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Affiliation(s)
- William G Cohen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason Han
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xingmei Wang
- Perelman School of Medicine at the University of Pennsylvania, Biostatistics Analysis Center, Philadelphia, Pennsylvania, USA
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Koons B, Suzuki Y, Cevasco M, Bermudez CA, Harmon MT, Dallara L, Ramon CV, Nottingham A, Ganjoo N, Diamond JM, Christie JD, Localio AR, Cantu E. Cryoablation in Lung Transplantation: Its Impact on Pain, Opioid Use, and Outcomes. JTCVS Open 2022; 13:444-456. [PMID: 37063121 PMCID: PMC10091298 DOI: 10.1016/j.xjon.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/09/2022] [Accepted: 10/06/2022] [Indexed: 11/26/2022]
Abstract
Objective To assess the effect of intraoperative cryoablation on postoperative patient-reported pain, opioid use, and clinical outcomes in lung transplantation. Methods We performed a single-center retrospective cohort study of adult lung transplant recipients from August 2017 to September 2018. We compared outcomes of patients who received intraoperative cryoablation of the intercostal nerves with those who did not. Primary outcomes were postoperative patient-reported pain scores and opioid use. Secondary outcomes included postoperative sedation and agitation levels and perioperative outcomes. Data were abstracted from patients' electronic health records. Results Of the 102 patients transplanted, 45 received intraoperative cryoablation (intervention group) and 57 received the standard of care, which did not include intercostal or serratus blocks or immediate postoperative epidural placement (control group). The intervention group had significantly lower median and maximum postoperative pain scores at days 3 and 7 and significantly lower oral opioid use at days 3, 7, and 14 compared with the control group. Chronic opioid use at 3 and 6 months' posttransplant was lower in the intervention group. Differences in perioperative outcomes, including length of mechanical ventilation, sedation and agitation levels, and hospital stay, were not clinically meaningful. Survival at 30 days and 1 year was superior in the intervention compared with the control group. Conclusions Findings suggest that use of intraoperative cryoablation is an effective approach for treating pain and reducing opioid use in patients who undergo lung transplant, but a randomized study across multiple institutions is needed to confirm these findings.
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Affiliation(s)
- Brittany Koons
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, Pa
- Address for reprints: Brittany Koons, PhD, RN, M. Louise Fitzpatrick College of Nursing, Villanova University, 800 Lancaster Ave, Villanova, PA 19085.
| | - Yoshikazu Suzuki
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Christian A. Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Michael T. Harmon
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Laura Dallara
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Christian V. Ramon
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Ana Nottingham
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Nikhil Ganjoo
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Joshua M. Diamond
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Jason D. Christie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - A. Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Usman AA, Spelde AE, Olia SE, Cevasco M, Bermudez C, Haddle J, Ibrahim M, Szeto W, Vernick W, Gutsche J. First-in-man successful use of the SPECTRUM percutaneous dual-stage right ventricle and right atrium to pulmonary artery ventricular assist device. J Card Surg 2022; 37:3403-3407. [PMID: 35870174 PMCID: PMC9444884 DOI: 10.1111/jocs.16753] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/03/2022] [Accepted: 06/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Over the past decade, several minimally invasive mechanical support devices have been introduced into clinical practice to support the right ventricle (RV). Percutaneous cannulas are easy to insert, minimally invasive, and treat acute RV failure rapidly. In December 2021, the Food and Drug Administration approved a new 31 French dual lumen single cannula for use as a right ventricular assist device. AIMS Descirbe the use of the new dual lumen percutaneous right ventricular assist device (RVAD) cannula. MATERIAL AND METHODS Deployment of the RVAD can be done surgically or percutaneously. This cannula, manufactured by Spectrum, is dual staged. It has inflow ports positioned both in the right atrium (RA) as well as the RV for maximal drainage of the right heart. The distal end of the cannula which includes the outflow port is positioned in the pulmonary artery (PA). RESULTS Deployment of the Spectrum RVAD can be done percutaneously with transesophageal and flouroscopy guidence. Cannulation requires requisite wire skills in order to navigate into the main pulmonary artery. Utilization of this cannula can be done in acute RV failure secondary to ischemia, post cardiotomy shock, acute respiratory failure or other causes of isolated RV failure. DISCUSSION The dual stage drainage design optimizes venous drainage as well as limits suck-down events. Theoretically, direct RV decompression also decreases RV dilation and wall tension, and facilitates improved transmural pressure gradient to reduce RV strain. CONCLUSION Here we describe the first-in-man successful use of the dual-stage RA and RV to PA Spectrum cannula in a patient with severe COVID acute respiratory distress syndrome and acute right ventricular failure, bridged to recovery.
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Affiliation(s)
- Asad A Usman
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
| | - Audrey E Spelde
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
| | - Salim E Olia
- Department of Surgery, Division of Cardiovascular Surgery
| | - Marisa Cevasco
- Department of Surgery, Division of Cardiovascular Surgery
| | | | - John Haddle
- Department of Surgery, Division of Cardiovascular Surgery
| | | | - Wilson Szeto
- Department of Surgery, Division of Cardiovascular Surgery
| | - William Vernick
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Philadelphia, Pennsylvania, USA
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Zhao K, Wang R, Kamoun M, Callans L, Bremner R, Rame E, McLean R, Cevasco M, Olthoff KM, Levine MH, Shaked A, Abt PL. Incidence of acute rejection and patient survival in combined heart-liver transplantation. Liver Transpl 2022; 28:1500-1508. [PMID: 35247292 DOI: 10.1002/lt.26448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 07/04/2021] [Revised: 02/06/2022] [Accepted: 02/13/2022] [Indexed: 01/13/2023]
Abstract
Combined heart-liver transplantation (CHLT) is indicated for patients with concomitant end-stage heart and liver disease or patients with amyloid heart disease where liver transplantation mitigates progression. Limited data suggest that the liver allograft provides immunoprotection for heart and kidney allografts in combined transplantation from the same donor. We hypothesized that CHLT reduces the incidence of acute cellular rejection (ACR) and the development of de novo donor-specific antibodies (DSAs) compared with heart-alone transplantation (HA). We conducted a retrospective analysis of 32 CHLT and 280 HA recipients in a single-center experience. The primary outcome was incidence of ACR based on protocol and for-cause myocardial biopsy. Rejection was graded by the International Society of Heart and Lung Transplantation guidelines with Grade 2R and higher considered significant. Secondary outcomes included the development of new DSAs, cardiac function, and patient and cardiac graft survival rates. Of CHLT patients, 9.7% had ACR compared with 45.3% of HA patients (p < 0.01). Mean pretransplant calculated panel reactive antibody (cPRA) levels were similar between groups (CHLT 9.4% vs. HA 9.5%; p = 0.97). Among patients who underwent testing, 26.9% of the CHLT and 16.7% of HA developed DSA (p = 0.19). Despite the difference in ACR, patient and cardiac graft survival rates were similar at 5 years (CHLT 82.1% vs. HA 80.9% [p = 0.73]; CHLT 82.1% vs. HA 80.9% [p = 0.73]). CHLT reduced the incidence of ACR in the cardiac allograft, suggesting that the liver offers immunoprotection against cellular mechanisms of rejection without significant impacts on patient and cardiac graft survival rates. CHLT did not reduce the incidence of de novo DSA, possibly portending similar long-term survival among cardiac allografts in CHLT and HA.
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Affiliation(s)
- Kai Zhao
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Roy Wang
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Malek Kamoun
- Department of Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lauren Callans
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Remy Bremner
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eduardo Rame
- Department of Medicine, Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rhondalyn McLean
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew H Levine
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Abraham Shaked
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Han JJ, Cevasco M. An Idea Whose Time Has Come. Ann Thorac Surg 2022; 114:600. [PMID: 34166635 DOI: 10.1016/j.athoracsur.2021.05.070] [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: 05/22/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 6 Silverstein Pavilion, 3400 Spruce St, Philadelphia, PA 19104.
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 6 Silverstein Pavilion, 3400 Spruce St, Philadelphia, PA 19104
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Aranda-Michel E, Trager LE, Han JJ, Aggarwal R, Cevasco M, Kelly RF, Sultan I. Considerations for a Holistic Model in Evaluating Medical Students for Cardiothoracic Surgical Residency. Semin Thorac Cardiovasc Surg 2022; 35:705-710. [PMID: 35714822 DOI: 10.1053/j.semtcvs.2022.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 06/09/2022] [Indexed: 11/11/2022]
Abstract
Program directors are tasked with selecting whom they think will be the best fit for residency and the next leaders of the field. While numerical metrics have played a vital role in this process, recent changes to student evaluation are reducing the availability of these metrics. This poses unique challenges for both applicants and program directors. Here we discuss how this will likely shift the focus on other parts of the application and the consequences (good and bad) of doing so.
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Affiliation(s)
- Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lena E Trager
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Jason J Han
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Rishav Aggarwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Han JJ, Shin M, Patrick WL, Rao A, Olia SE, Helmers MR, Iyengar A, Kelly JJ, Smood B, Gutsche JT, Bermudez C, Cevasco M. How Should ECMO Be Used Under Conditions of Severe Scarcity? A Population Study of Public Perception. J Cardiothorac Vasc Anesth 2022; 36:1662-1669. [PMID: 34218997 PMCID: PMC8249692 DOI: 10.1053/j.jvca.2021.05.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/12/2021] [Accepted: 05/30/2021] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To assess societal preferences regarding allocation of extracorporeal membrane oxygenation (ECMO) as a rescue option for select patients with coronavirus disease 2019 (COVID-19). DESIGN Cross-sectional survey of a nationally representative sample. SETTING Amazon Mechanical Turk platform. PARTICIPANTS In total, responses from 1,041 members of Amazon Mechanical Turk crowd-sourcing platform were included. Participants were 37.9 ± 12.6 years old, generally white (65%), and college-educated (66.1%). Many reported working in a healthcare setting (22.5%) and having a friend or family member who was admitted to the hospital (43.8%) or died from COVID-19 (29.9%). MEASUREMENTS AND MAIN RESULTS Although most reported an unwillingness to stay on ECMO for >one week without signs of recovery, participants were highly supportive of ECMO utilization as a life-preserving technique on a policy level. The majority (96.7%) advocated for continued use of ECMO to treat COVID patients during periods of resource scarcity but would prioritize those with highest likelihood of recovery (50%) followed by those who were sickest regardless of survival chances (31.7%). Patients >40 years old were more likely to prefer distributing ECMO on a first-come first-served basis (21.5% v 13.3%, p < 0.05). CONCLUSION Even though participants expressed hesitation regarding ECMO in personal circumstances, they were uniformly in support of using ECMO to treat COVID patients at a policy level for others who might need it, even in the setting of severe scarcity.
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Affiliation(s)
- Jason J. Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Max Shin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William L. Patrick
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Akhil Rao
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Salim E. Olia
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Mark R. Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John J. Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Jacob T. Gutsche
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Christian Bermudez
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA,Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA,Address correspondence to Marisa Cevasco, MD, MPH, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA
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Han JJ, Patrick WL, Rao A, Smood B, Helmers M, Iyengar A, Kelly JJ, Kalva S, Atluri P, Desai N, Cevasco M. Populational Perceptions Regarding Decision to Visit the Emergency Room with Chest Pain During COVID-19. Cardiol Ther 2022; 11:269-281. [PMID: 35318609 PMCID: PMC8939398 DOI: 10.1007/s40119-022-00259-5] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION A significant decrease in emergency presentations of acute cardiac conditions has been observed during the COVID-19 pandemic. We aimed to understand perceptions that influence people's decisions whether to present to the emergency department (ED) with symptoms related to acute cardiovascular events to inform necessary medical communication. METHODS We recruited users of Amazon Mechanical Turk (Seattle, WA) to participate in a survey to elucidate perceptions of COVID-19 risk associated with a visit to the ED. A conjoint analysis was designed based on commonly reported factors associated with people's decisions to present to the ED during the pandemic to calculate preference utilities. RESULTS After exclusions, 1003 participants completed the survey between 12/5/2020 and 12/6/2020. Participants ranked the perceived risk of contracting COVID-19 at the ED as one of the highest, only second to that at bars and restaurants. Only 68% (685/1003) were willing to present to the ED immediately with severe chest pain. Fear of further transmitting the virus to loved ones was the most frequently cited reason for not presenting. Conjoint analysis demonstrated severe chest pain to be the dominant factor in the decision to present to the ED. CONCLUSIONS The risk of contracting COVID-19 while presenting to the ED for a life-threatening cardiovascular symptom is overestimated and is strongly affected by social factors.
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Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - William L Patrick
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Philadelphia, PA, USA
| | - Akhil Rao
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Helmers
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Saiesh Kalva
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nimesh Desai
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Philadelphia, PA, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA, USA.
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Zhang RS, Hanff TC, Peters CJ, Evans PT, Marble J, Rame JE, Atluri P, Urgo K, Tanna MS, Mazurek JA, Acker MA, Cevasco M, Birati EY, Wald JW. Left Ventricular Assist Device as a Bridge to Recovery: Single Center Experience of Successful Device Explantation. ASAIO J 2022; 68:822-828. [PMID: 34560718 DOI: 10.1097/mat.0000000000001574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/26/2022] Open
Abstract
Continuous-flow left ventricular assist devices (CF-LVAD) have been shown to enhance reverse remodeling and myocardial recovery in certain patients allowing for device removal. We sought to analyze the characteristics and describe outcomes of patients who underwent CF-LVAD explantation at a large academic center. We retrospectively identified all patients who underwent CF-LVAD explants due to recovery from 2006 to 2019. Patient baseline characteristics and data on pre- and postexplant evaluation were collected and analyzed. Of 421 patients who underwent CF-LVAD implantation, 13 underwent explantation (3.1%). Twelve HeartMate II and one HeartWare LVAD were explanted. All patients had nonischemic cardiomyopathy. Median time from heart failure diagnosis to LVAD implant was 12 months (interquartile range [IQR], 2-44) and the median time supported on LVAD was 22 months (IQR, 11-28). Two patients died within 30 days of explant. Three additional patients died during the follow-up period and all were noted to be nonadherent to medical therapy. After a mean follow-up duration of 5 years, overall survival was 52%. Mean pre-explant ejection fraction was 49%, which decreased at most recent follow-up to 32%. Mean pre-explant left ventricular internal diameter in diastole (LVIDD) was 4.37 cm and increased to 5.52 cm at most recent follow-up. Continuous-flow left ventricular assist device explantation is feasible and safe in select patients.
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Affiliation(s)
- Robert S Zhang
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas C Hanff
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carli J Peters
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter T Evans
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Judy Marble
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J Eduardo Rame
- Division of Cardiovascular Medicine, Jefferson Hospital University, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kimberly Urgo
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Monique S Tanna
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marisa Cevasco
- Division of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edo Y Birati
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joyce W Wald
- From the Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Wang TS, Cevasco M, Birati EY, Mazurek JA. Predicting, Recognizing, and Treating Right Heart Failure in Patients Undergoing Durable LVAD Therapy. J Clin Med 2022; 11:jcm11112984. [PMID: 35683372 PMCID: PMC9181012 DOI: 10.3390/jcm11112984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/20/2022] [Accepted: 05/20/2022] [Indexed: 12/04/2022] Open
Abstract
Despite advancing technology, right heart failure after left ventricular assist device implantation remains a significant source of morbidity and mortality. With the UNOS allocation policy change, a larger proportion of patients proceeding to LVAD are destination therapy and consist of an overall sicker population. Thus, a comprehensive understanding of right heart failure is critical for ensuring the ongoing success of durable LVADs. The purpose of this review is to describe the effect of LVAD implantation on right heart function, review the diagnostic and predictive criteria related to right heart failure, and discuss the current evidence for management and treatment of post-LVAD right heart failure.
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Affiliation(s)
- Teresa S. Wang
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +1-267-624-7276
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Edo Y. Birati
- Division of Cardiovascular Medicine, Padeh-Poriya Medical Center, Bar-Ilan University, Ramat Gan 5290002, Israel;
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
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Cohen W, Han J, Shin M, Wang X, Iyengar A, Helmers M, Cevasco M. The Utility of Concomitant ECMO and IABP as a Bridge to Heart Transplant. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1530] [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: 11/28/2022] Open
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Wilcox NS, Prenner SB, Cevasco M, Condit C, Goldstein A, Peterson JT, Resta IT, Palmer M, Lal P, Owens AT, Pieretti J, Drivas TG, Reza N. End Stage Mitochondrial Cardiomyopathy and Heart Transplantation Due to Biallelic Pathogenic C1QBP Variants. Circ Genom Precis Med 2022; 15:e003559. [PMID: 35119291 PMCID: PMC9085452 DOI: 10.1161/circgen.121.003559] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Nicholas S. Wilcox
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania
| | - Stuart B. Prenner
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania
| | - Courtney Condit
- Division of Translational Medicine and Human Genetics, Department of Medicine, University of Pennsylvania
| | - Amy Goldstein
- Mitochondrial Medicine Frontier Program, Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia
| | - James T. Peterson
- Mitochondrial Medicine Frontier Program, Division of Human Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia
| | - Isabella Tondi Resta
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Palmer
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Priti Lal
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Anjali Tiku Owens
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania
| | - Janice Pieretti
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania
| | - Theodore G. Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, University of Pennsylvania
- Department of Genetics, Perelman School of Medicine at the University of Pennsylvania
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, University of Pennsylvania
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Wang T, Cevasco M, Domsky S, Findeis S, Gnall E, Norris M, Prenner S, Wald J. The Devil is in the Details: A Case of Fulminant Giant Cell Myocarditis. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1414] [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: 11/29/2022] Open
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Cohen W, Han J, Shin M, Wang X, Iyengar A, Helmers M, Cevasco M. Higher Utilization of ECMO as a Bridge to OHT Has Not Led to Regional Variations. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.1479] [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] Open
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Bulcha NA, Kramer S, Wang T, Fiorilli P, Gutsche J, Santangeli P, Cevasco M, Bermudez C, Wald J. Outcomes of a multidisciplinary shock team utilizing an integrated medical/surgical strategy: The Penn Medicine Shock Model. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.053] [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: 11/28/2022]
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Federico L, Courtwright A, Kamoun M, Molina M, Diamond J, Ahya V, Christie J, Clausen E, Hadjiliadis D, Patel N, Salgado J, Cevasco M, Cantu E, Crespo M, Bermudez C. Change in Panel Reactive Antibodies in Patients Bridged to Lung Transplantation with Extracorporeal Membrane Oxygenation. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.711] [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] Open
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Anjum F, Pishko A, Diamond J, Ahya V, Christie J, Clausen E, Hadjiliadis D, Patel N, Salgado J, Cevasco M, Cantu E, Crespo M, Bermudez C, Courtwright A. Antiphospholipid Antibodies and Outcomes Following Lung Transplantation. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.718] [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] Open
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Ibrahim M, Spelde AE, Szeto WY, Acker MA, Atluri P, Grimm JC, Cevasco M, Vallabhajosyula P, Bavaria J, Desai ND, Williams ML. Clinical and Echocardiographic Results of Aortic Valve Replacement in the Failing Ventricle: Do Aortic Stenosis and Aortic Regurgitation Differ? Ann Thorac Surg 2022; 113:853-858. [PMID: 33631158 PMCID: PMC9774041 DOI: 10.1016/j.athoracsur.2021.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 01/04/2021] [Accepted: 02/03/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND We hypothesized that long-term clinical and echocardiographic recovery of the impaired ventricle from pressure (aortic stenosis [AS]) and volume (aortic regurgitation [AR]) overload would be different after aortic valve replacement (AVR). METHODS We compared the results of AVR in patients with a preoperative ejection fraction (EF) of 0.35 or less due to AS, AR, or mixed disease. We constructed a mixed-effects model of EF and left ventricular (LV) end-diastolic diameter (LVEDD) to understand ventricular recovery over the short- (in-hospital), intermediate- (3-6 months), and longer- (>24 months) terms. We sought to identify factors associated with clinical and echocardiographic recovery using multivariable analysis. RESULTS Between July 2011 and 2017, 136 patients with a preoperative EF of 0.35 or less and severe AS (n = 83), severe AR (n = 18), or mixed AS and AR (n = 35) underwent AVR. There were 2 (1.5%) early deaths in the AS group. Survival at 1, 2, and 5 years did not differ between groups. Baseline EF did not differ between the groups but improved with markedly different trajectory and time course in the AS, AR, and mixed groups over time. LVEDD regressed in all patient cohorts, following a different pattern for AS and AR. Baseline EF and LVEDD predicted the long-term fate of the LV but did not determine survival. We identify factors associated with long-term survival. CONCLUSIONS The pattern of LV recovery appears to be early in AS and delayed in AR. Baseline clinical factors, rather than echocardiographic status of the LV, appear to determine late survival.
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Han JJ, Cevasco M. Reply: Innovating the virtual curriculum in cardiothoracic surgical education during the pandemic. JTCVS Open 2021; 8:543. [PMID: 36004127 PMCID: PMC9390148 DOI: 10.1016/j.xjon.2021.09.018] [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] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
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