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Gupta VF, Halpern SE, Pontula A, Krischak MK, Reynolds JM, Klapper JA, Hartwig MG, Haney JC. Short-term outcomes after third-time lung transplantation: A single institution experience. J Heart Lung Transplant 2024; 43:771-779. [PMID: 38141895 DOI: 10.1016/j.healun.2023.12.010] [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: 07/25/2023] [Revised: 12/15/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Reoperative lung transplantation (LTx) survival has improved over time such that a growing number of patients may present for third-time LTx (L3Tx). To understand the safety of L3Tx, we evaluated perioperative outcomes and 3-year survival after L3Tx at a high-volume US LTx center. METHODS This retrospective study included all patients who underwent bilateral L3Tx at our institution. Using an optimal matching technique, a primary LTx (L1Tx) cohort was matched 1:2 and a second-time LTx (L2Tx) cohort 1:1. Recipient, operative, and donor characteristics, perioperative outcomes, and 3-year survival were compared among L1Tx, L2Tx, and L3Tx groups. RESULTS Eleven L3Tx, 11 L2Tx, and 22 L1Tx recipients were included. Among L3Tx recipients, median age at transplant was 37 years and most (73%) had cystic fibrosis. L3Tx was performed median 6.0 and 10.6 years after L2Tx and L1Tx, respectively. Compared to L1Tx and L2Tx recipients, L3Tx recipients had greater intraoperative transfusion requirements, a higher incidence of postoperative complications, and a higher rate of unplanned reoperation. Rates of grade 3 primary graft dysfunction at 72 hours, extracorporeal membrane oxygenation at 72 hours, reintubation, and in-hospital mortality were similar among groups. There were no differences in 3-year patient (log-rank p = 0.61) or rejection-free survival (log-rank p = 0.34) after L1Tx, L2Tx, and L3Tx. CONCLUSIONS At our institution, L3Tx was associated with similar perioperative outcomes and 3-year patient survival compared to L1Tx and L2Tx. L3Tx represents the only safe treatment option for patients with allograft failure after L2Tx; however, further investigation is needed to understand the long-term survival and durability of L3Tx.
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Affiliation(s)
- Vikram F Gupta
- Duke University School of Medicine, Durham, North Carolina.
| | - Samantha E Halpern
- Duke University School of Medicine, Durham, North Carolina; Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Arya Pontula
- University of Manchester Medical School, Manchester, UK; Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Madison K Krischak
- Duke University School of Medicine, Durham, North Carolina; Department of Urology, University of Michigan, Ann Arbor, Michigan
| | - John M Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Zwischenberger BA, Gaca JG, Haney JC, Carr K, Glower DD. Late Outcomes of Porcine and Pericardial Bioprostheses after Mitral Valve Replacement in 1162 Patients. Ann Thorac Surg 2024:S0003-4975(24)00286-8. [PMID: 38631662 DOI: 10.1016/j.athoracsur.2024.04.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/05/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Debate continues regarding the superiority of porcine versus pericardial bioprostheses, and data relevant to this comparison are scant. We therefore compare late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. METHODS Adults undergoing mitral valve replacement with one first-generation porcine valve model and one pericardial valve line were reviewed from our prospectively-maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. RESULTS Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine 36±2%, pericardial 38±3%, P=0.5) and cumulative incidence (CI) of mitral valve structural deterioration (porcine 18±2%, pericardial 19±3%, P=0.3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35/50(70%) versus 38/106(36%), P<0.001), and more likely severe mitral regurgitation in porcine valves (80/106(75%) versus 19/50(38%), P<0.0001). After adjustment, structural deterioration was associated with younger patient age (P<0.001), but not valve type. At 10 years, porcine valves demonstrated a higher CI of mitral reoperation (19±2% vs 9±2%, P<0.001) and reoperation for structural deterioration (15±1% vs 6±2%, P=0.007). CONCLUSIONS We demonstrate similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprosthetics in mitral valve replacement. This study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. Failure mode may have greater influence on surgeon decision-making of valve choice.
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Affiliation(s)
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - John C Haney
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL
| | - Keith Carr
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Donald D Glower
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
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Tam PCK, Hardie R, Alexander BD, Yarrington ME, Lee MJ, Polage CR, Messina JA, Maziarz EK, Saullo JL, Miller R, Wolfe CR, Arif S, Reynolds JM, Haney JC, Perfect JR, Baker AW. Risk factors, management, and clinical outcomes of invasive Mycoplasma and Ureaplasma infections after lung transplantation. Am J Transplant 2024; 24:641-652. [PMID: 37657654 PMCID: PMC10902193 DOI: 10.1016/j.ajt.2023.08.019] [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: 03/06/2023] [Revised: 08/08/2023] [Accepted: 08/24/2023] [Indexed: 09/03/2023]
Abstract
Mollicute infections, caused by Mycoplasma and Ureaplasma species, are serious complications after lung transplantation; however, understanding of the epidemiology and outcomes of these infections remains limited. We conducted a single-center retrospective study of 1156 consecutive lung transplants performed from 2010-2019. We used log-binomial regression to identify risk factors for infection and analyzed clinical management and outcomes. In total, 27 (2.3%) recipients developed mollicute infection. Donor characteristics independently associated with recipient infection were age ≤40 years (prevalence rate ratio [PRR] 2.6, 95% CI 1.0-6.9), White race (PRR 3.1, 95% CI 1.1-8.8), and purulent secretions on donor bronchoscopy (PRR 2.3, 95% CI 1.1-5.0). Median time to diagnosis was 16 days posttransplant (IQR: 11-26 days). Mollicute-infected recipients were significantly more likely to require prolonged ventilatory support (66.7% vs 21.4%), undergo dialysis (44.4% vs 6.3%), and remain hospitalized ≥30 days (70.4% vs 27.4%) after transplant. One-year posttransplant mortality in mollicute-infected recipients was 12/27 (44%), compared to 148/1129 (13%) in those without infection (P <.0001). Hyperammonemia syndrome occurred in 5/27 (19%) mollicute-infected recipients, of whom 3 (60%) died within 10 weeks posttransplant. This study highlights the morbidity and mortality associated with mollicute infection after lung transplantation and the need for better screening and management protocols.
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Affiliation(s)
- Patrick C K Tam
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Rochelle Hardie
- Division of Infectious Diseases, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA; Duke University Clinical Microbiology Laboratory, Durham, North Carolina, USA
| | - Michael E Yarrington
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Mark J Lee
- Duke University Clinical Microbiology Laboratory, Durham, North Carolina, USA
| | - Chris R Polage
- Duke University Clinical Microbiology Laboratory, Durham, North Carolina, USA
| | - Julia A Messina
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Eileen K Maziarz
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer L Saullo
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rachel Miller
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sana Arif
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - John M Reynolds
- Department of Medicine, Transplant Pulmonology, Duke University School of Medicine, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - John R Perfect
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA; Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA.
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Prabhu NK, Wong MK, Klapper JA, Haney JC, Mazurowski MA, Mammarappallil JG, Hartwig MG. Computed Tomography Volumetrics for Size Matching in Lung Transplantation for Restrictive Disease. Ann Thorac Surg 2024; 117:413-421. [PMID: 37031770 DOI: 10.1016/j.athoracsur.2023.03.033] [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: 11/20/2022] [Revised: 03/08/2023] [Accepted: 03/26/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND There is no consensus on the optimal allograft sizing strategy for lung transplantation in restrictive lung disease. Current methods that are based on predicted total lung capacity (pTLC) ratios do not account for the diminutive recipient chest size. The study investigators hypothesized that a new sizing ratio incorporating preoperative recipient computed tomographic lung volumes (CTVol) would be associated with postoperative outcomes. METHODS A retrospective single-institution study was conducted of adults undergoing primary bilateral lung transplantation between January 2016 and July 2020 for restrictive lung disease. CTVol was computed for recipients by using advanced segmentation software. Two sizing ratios were calculated: pTLC ratio (pTLCdonor/pTLCrecipient) and a new volumetric ratio (pTLCdonor/CTVolrecipient). Patients were divided into reference, oversized, and undersized groups on the basis of ratio quintiles, and multivariable models were used to assess the effect of the ratios on primary graft dysfunction and survival. RESULTS CTVol was successfully acquired in 218 of 220 (99.1%) patients. In adjusted analysis, undersizing on the basis of the volumetric ratio was independently associated with decreased primary graft dysfunction grade 2 or 3 within 72 hours (odds ratio, 0.42; 95% CI, 0.20-0.87; P =.02). The pTLC ratio was not significantly associated with primary graft dysfunction. Oversizing on the basis of the volumetric ratio was independently associated with an increased risk of death (hazard ratio, 2.27; 95% CI, 1.04-4.99; P =.04], whereas the pTLC ratio did not have a significant survival association. CONCLUSIONS Using computed tomography-acquired lung volumes for donor-recipient size matching in lung transplantation is feasible with advanced segmentation software. This method may be more predictive of outcome compared with current sizing methods, which use gender and height only.
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Affiliation(s)
- Neel K Prabhu
- Duke University School of Medicine, Durham, North Carolina.
| | - Megan K Wong
- Duke University School of Medicine, Durham, North Carolina
| | - Jacob A Klapper
- Duke University School of Medicine, Durham, North Carolina; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Duke University School of Medicine, Durham, North Carolina; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Maciej A Mazurowski
- Duke University School of Medicine, Durham, North Carolina; Department of Computer Science, Duke University, Durham, North Carolina; Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina; Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph G Mammarappallil
- Duke University School of Medicine, Durham, North Carolina; Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Duke University School of Medicine, Durham, North Carolina; Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Gao Q, Pontula A, Alderete IS, DeLaura I, Kahan R, Nakata K, Haney JC, Klapper JA, Hartwig MG. Impact of simultaneous heart procurement on outcomes of donation after circulatory death lung transplantation. Am J Transplant 2024; 24:79-88. [PMID: 37673176 DOI: 10.1016/j.ajt.2023.08.012] [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: 04/04/2023] [Revised: 08/06/2023] [Accepted: 08/17/2023] [Indexed: 09/08/2023]
Abstract
Donation after circulatory death (DCD) heart procurement is done using either direct procurement (DP) or thoracoabdominal normothermic machine perfusion (TA-NRP). Both approaches could impact lung transplant outcomes with combined heart and lung procurements from the same donor. The impact of such practice on DCD lung transplant remains unstudied. We performed a retrospective analysis using the United Network for Organ Sharing (UNOS) dataset, identifying DCD lung transplants where the donor also donated the heart (cardia lung donor [CD]). A cohort of noncardiac DCD lung donors (noncardiac lung donor [NCD]) from the same era, matched for donor and recipient characteristics, was used as a comparison group. Both immediate and long-term outcomes were examined. A subanalysis was performed comparing the distinct impact of DP or TA-NRP on DCD lung transplant outcomes. Overall graft survival did not significantly differ between CD and NCD. However, recipients in the CD group trended toward a lower P/F ratio at 72 hours (CD vs NCD: 284 vs 3190; P = .054). In the subanalysis, we identified 40 DP donors and 22 TA-NRP donors. We found the both cohorts had lower P/F ratio at 72 hours than the NCD control (P = .04). Overall, 1-year graft survival was equivalent among the TA-NRP, DP, and NCD cohorts.
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Affiliation(s)
- Qimeng Gao
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Arya Pontula
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Isaac S Alderete
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Isabel DeLaura
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Riley Kahan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Kentaro Nakata
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob A Klapper
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA.
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Cai SR, Pollak A, Madsen G, McCartney S, Hashmi N, Haney JC, Nicoara A. Pulmonary Vein Systolic Flow Reversal Seen With Severe Tricuspid Regurgitation. CASE (Phila) 2023; 7:266-272. [PMID: 37546361 PMCID: PMC10403631 DOI: 10.1016/j.case.2023.03.004] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
•Systolic PVF reversal is specific to severe MR. •We report systolic PVF reversal with severe TR and TS. •This may be caused by interatrial dependence due to elevated RAP.
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Affiliation(s)
- Sunny R. Cai
- Correspondence: Sunny R. Cai, MD, ECU Health, Department of Anethesiology, 1905 Belles Ferry Court, Winterville, North Carolina 28590.
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Al-Qudsi O, Reynolds JM, Haney JC, Welsby IJ. Voxelotor as a Treatment of Persistent Hypoxia in the ICU. Chest 2023; 164:e1-e4. [PMID: 37423700 DOI: 10.1016/j.chest.2023.01.036] [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: 12/30/2022] [Revised: 01/17/2023] [Accepted: 01/23/2023] [Indexed: 07/11/2023] Open
Abstract
Hypoxia is encountered frequently in the ICU as a result of a wide range of pathologic characteristics. The oxygen-hemoglobin dissociation curve describes hemoglobin's affinity for a given Po2 and factors affecting uptake and offload. Research in manipulating this relationship between hemoglobin and oxygen is sparing. Voxelotor is a hemoglobin oxygen-affinity modulator that is approved by the US Food and Drug Association for use in the management of sickle cell disease. We present two patients without sickle cell disease who underwent treatment with this novel agent to assist with chronic hypoxia and weaning of mechanical support.
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Affiliation(s)
- Omar Al-Qudsi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - John M Reynolds
- Division of Transplant Pulmonology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - John C Haney
- Division of Thoracic Transplant Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Olive JK, Yost CC, Robinson JA, Brescia AA, Han JJ, Haney JC, Forbess JM, Varghese TK, Backhus LM, Cooke DT, Cornwell LD, Preventza OA. Demographics of Current and Aspiring Integrated Six-year Cardiothoracic Surgery Trainees. Ann Thorac Surg 2023; 115:771-777. [PMID: 35934069 DOI: 10.1016/j.athoracsur.2022.06.051] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 04/16/2022] [Accepted: 06/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The integrated 6-year thoracic surgery (I-6) residency model was developed in part to promote early interest in cardiothoracic surgery in diverse trainees. To determine gaps in and opportunities for recruitment of women and minority groups in the pipeline for I-6 residency, we quantified rates of progression at each training level and trends over time. METHODS We obtained 2015 to 2019 medical student, I-6 applicant, and I-6 resident gender and race/ethnicity demographic data from the American Association of Medical Colleges and Electronic Residency Application Service public databases and Accreditation Council for Graduate Medical Education Data Resource Books. We performed χ2, Fisher exact, and Cochran-Armitage tests for trend to compare 2015 and 2019. RESULTS Our cross-sectional analysis found increased representation of women and all non-White races/ethnicities, except Native American, at each training level from 2015 to 2019 (P < .001 for all). The greatest trends in increases were seen in the proportions of women (28% vs 22%, P = .46) and Asian/Pacific Islander (25% vs 15%, P = .08) applicants. There was also an increase in the proportions of women (28% vs 24%, P = .024) and White (61% vs 58%, P = .007) I-6 residents, with a trend for Asian/Pacific Islanders (20% vs 17%, P = .08). The proportions of Hispanic (5%) and Black/African American (2%) I-6 residents in 2019 remained low. CONCLUSIONS I-6 residency matriculation is not representative of medical student demographics and spotlights a need to foster early interest in cardiothoracic surgery among all groups underrepresented in medicine while ensuring that we mitigate bias in residency recruitment.
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Affiliation(s)
- Jacqueline K Olive
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Colin C Yost
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Justin A Robinson
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | | | - Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Joseph M Forbess
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Thomas K Varghese
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Leah M Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - David T Cooke
- Division of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, Sacramento, California
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ourania A Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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Olaso DG, Halpern SE, Krischak MK, Au S, Jamieson IR, Haney JC, Klapper JA, Hartwig MG. Same-teams versus different-teams for long distance lung procurement: A cost analysis. J Thorac Cardiovasc Surg 2023; 165:908-919.e3. [PMID: 35840431 PMCID: PMC9734279 DOI: 10.1016/j.jtcvs.2022.05.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/27/2022] [Accepted: 05/29/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE In an era of broader lung sharing, different-team transplantation (DT, procuring team from nonrecipient center) may streamline procurement logistics; however, safety and cost implications of DT remain unclear. To understand whether DT represents a safe means to reduce lung transplant (LTx) costs, we compared posttransplant outcomes and lung procurement and index hospitalization costs among matched DT and same-team transplantation (ST, procuring team from recipient center) cohorts at a single, high-volume institution. We hypothesized that DT reduces costs without compromising outcomes after LTx. METHODS Patients who underwent DT between January 2016 to May 2020 were included. A cohort of patients who underwent ST was matched 1:3 (nearest neighbor) based on recipient age, disease group, lung allocation score, history of previous LTx, and bilateral versus single LTx. Posttransplant outcomes and costs were compared between groups. RESULTS In total, 23 DT and 69 matched ST recipients were included. Perioperative outcomes and posttransplant survival were similar between groups. Compared with ST, DT was associated with similar lung procurement and index hospitalization costs (DT vs ST, procurement: median $65,991 vs $58,847, P = .16; index hospitalization: median $294,346 vs $322,189, P = .7). On average, procurement costs increased $3263 less per 100 nautical miles for DT versus ST; DT offered cost-savings when travel distances exceeded approximately 363 nautical miles. CONCLUSIONS At our institution, DT and ST were associated with similar post-LTx outcomes; DT offered cost-savings with increasing procurement travel distance. These findings suggest that DT may mitigate logistical and financial burdens of lung procurement; however, further investigation in a multi-institutional cohort is warranted.
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Affiliation(s)
- Danae G Olaso
- School of Medicine, Duke University Medical Center, Durham, NC.
| | | | | | - Sandra Au
- School of Medicine, Duke University Medical Center, Durham, NC
| | | | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Tam PC, Alexander BD, Lee MJ, Hardie RG, Reynolds JM, Haney JC, Waites KB, Baker AW. 632. Donor-Derived Mollicute Infections in Lung Transplant Recipients: a Prospective Study of Donor Respiratory Tract Screening and Recipient Outcomes. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.684] [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: 12/23/2022] Open
Abstract
Abstract
Background
Mollicutes, such as Mycoplasma hominis and Ureaplasma spp, are fastidious bacteria that can cause invasive donor-derived infections in lung transplant recipients. Best practices for donor screening and recipient surveillance for Mollicute infections are unknown. This study assessed the performance of donor respiratory tract screening for Mollicutes.
Methods
We prospectively analyzed all lung transplant surgeries performed 10/5/20 – 9/25/21 at a single transplant center. Donor bronchoalveolar lavage (BAL) performed at time of procurement was tested for presence of urogenital Mycoplasmas and Ureaplasma spp. using culture and PCR. Treating clinicians were blinded to these results.
Post-transplant recipient evaluation was performed at the discretion of the treating clinicians, who maintained a high index of suspicion for Mollicute infection. Mollicute cases were defined as recipients with any post-transplant culture or PCR that detected a Mollicute. We analyzed recipient outcomes and assessed the performance of donor BAL screening in predicting recipient Mollicute cases.
Results
In total, 115 patients underwent lung transplant. Of this cohort, 99 (86%) donors had adequate BAL samples for Mollicute testing via both culture and PCR. 8/99 (8%) donors had culture-positive samples, and 15/99 (15%) had PCR-positive samples for Mollicutes. Among the 99 corresponding recipients, 9 (9%) patients met the Mollicute case definition (Figure 1). These recipients were diagnosed a median of 6 days after transplant (IQR 4-15 days). 6 patients had pulmonary Mollicute detection alone, and 3 had invasive extrapulmonary thoracic infections. The only death was unrelated (Table 1).
Donor BAL culture sensitivity was 6/9 (67%) in predicting recipient Mollicute cases, and sensitivity of PCR was 5/9 (56%). Positive predictive value (PPV) was 6/8 (75%) for donor culture and 5/15 (33%) for PCR (Table 2). Figure 1Clinical courses of 9 lung transplant recipients who acquired post-transplant Mycoplasma hominis or Ureaplasma species.
Table 1 Characteristics of 9 lung transplant recipients who acquired post-transplant Mycoplasma hominis or Ureaplasma species.
Table 2 Performance of donor bronchoalveolar lavage screening methods in predicting Mollicute acquisition among 99 lung transplant recipients.
Conclusion
In our single center cohort, donor BAL screening via culture predicted all serious recipient Mollicute infections and had better PPV than PCR. Given limitations of either screening method, clinicians should maintain a high index of suspicion for Mollicute infection after lung transplant to facilitate early diagnosis and effective treatment.
Disclosures
Barbara D. Alexander, MD, Astellas: Advisor/Consultant|HealthtrackRx: Advisor/Consultant|HealthtrackRx: Grant/Research Support|Scynexis: Grant/Research Support|UpToDate: Advisor/Consultant Arthur W. Baker, MD, MPH, Medincell: Advisor/Consultant.
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Affiliation(s)
- Patrick C Tam
- Duke University School of Medicine , Durham, North Carolina
| | | | - Mark J Lee
- Duke University School of Medicine , Durham, North Carolina
| | | | | | - John C Haney
- Duke University School of Medicine , Durham, North Carolina
| | - Ken B Waites
- University of Alabama at Birmingham , Birmingham, Alabama
| | - Arthur W Baker
- Duke University School of Medicine , Durham, North Carolina
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11
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Halpern SE, Wright MC, Madsen G, Chow B, Harris CS, Haney JC, Klapper JA, Bottiger BA, Hartwig MG. Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension. J Heart Lung Transplant 2022; 41:1628-1637. [PMID: 35961827 PMCID: PMC10403788 DOI: 10.1016/j.healun.2022.07.015] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. METHODS Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. RESULTS Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004). CONCLUSIONS At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.
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Affiliation(s)
| | - Mary C Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Gabrielle Madsen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Bryan Chow
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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12
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Thornton SW, Hoover AC, Nellis JR, Overbey DM, Andersen ND, Haney JC, Turek JW. Minimally Invasive Approach for Cardiac Hemangioma Resection in a Teenager. Innovations (Phila) 2022; 17:358-360. [PMID: 35770608 DOI: 10.1177/15569845221107012] [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] [Indexed: 11/15/2022]
Abstract
Cardiac hemangiomas are a rare tumor traditionally resected by median sternotomy. We performed a minimally invasive right ventricular cardiac hemangioma resection via a left anterior mini-incision (LAMI). The procedure was without complication, and the patient was discharged on postoperative day 2. The LAMI has been used broadly by our team for operations involving the right ventricular outflow tract, as an alternative to median sternotomy. Here we show that it can also be used for the resection of a cardiac tumor.
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Affiliation(s)
| | | | - Joseph R Nellis
- Department of Surgery, 22957Duke University Hospitals, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
| | - Douglas M Overbey
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Cardiothoracic Surgery, 22957Duke University Hospitals, Durham, NC, USA
| | - Nicholas D Andersen
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Cardiothoracic Surgery, 22957Duke University Hospitals, Durham, NC, USA.,Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC, USA
| | - John C Haney
- Division of Cardiothoracic Surgery, 22957Duke University Hospitals, Durham, NC, USA
| | - Joseph W Turek
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Cardiothoracic Surgery, 22957Duke University Hospitals, Durham, NC, USA.,Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC, USA
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13
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Halpern SE, Kesseli SJ, Au S, Krischak MK, Olaso DG, Smith H, Tipton G, Jamieson IR, Barbas AS, Haney JC, Klapper JA, Hartwig MG. Lung transplantation after ex vivo lung perfusion versus static cold storage: An institutional cost analysis. Am J Transplant 2022; 22:552-564. [PMID: 34379885 PMCID: PMC8813879 DOI: 10.1111/ajt.16794] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 08/04/2021] [Accepted: 08/04/2021] [Indexed: 02/03/2023]
Abstract
Ex vivo lung perfusion (EVLP) is a novel lung preservation strategy that facilitates the use of marginal allografts; however, it is more expensive than static cold storage (SCS). To understand how preservation method might affect postoperative costs, we compared outcomes and index hospitalization costs among matched EVLP and SCS preserved lung transplant (LTx) recipients at a single, high-volume institution. A total of 22 EVLP and 66 matched SCS LTx recipients were included; SCS grafts were further stratified as either standard-criteria (SCD) or extended-criteria donors (ECD). Median total preservation time was 857, 409, and 438 min for EVLP, SCD, and ECD lungs, respectively (p < .0001). EVLP patients had similar perioperative outcomes and posttransplant survival compared to SCS SCD and ECD recipients. Excluding device-specific costs, total direct variable costs were similar among EVLP, SCD, and ECD recipients (median $200,404, vs. $154,709 vs. $168,334, p = .11). The median direct contribution margin was positive for EVLP recipients, and similar to that for SCD and ECD graft recipients (all p > .99). These findings demonstrate that the use of EVLP was profitable at an institutional level; however, further investigation is needed to better understand the financial implications of EVLP in facilitating donor pool expansion in an era of broader lung sharing.
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Affiliation(s)
| | - Samuel J. Kesseli
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sandra Au
- School of Medicine, Duke University, Durham, NC, USA
| | | | | | - Haley Smith
- Office of Finance, Duke Transplant Center, Durham, NC, USA
| | - Greg Tipton
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Andrew S. Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - John C. Haney
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A. Klapper
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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14
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Krischak MK, Au S, Halpern SE, Olaso DG, Moris D, Snyder LD, Barbas AS, Haney JC, Klapper JA, Hartwig MG. Textbook surgical outcome in lung transplantation: Analysis of a US national registry. Clin Transplant 2022; 36:e14588. [PMID: 35001428 DOI: 10.1111/ctr.14588] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [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: 09/16/2021] [Revised: 12/08/2021] [Accepted: 01/05/2022] [Indexed: 11/30/2022]
Abstract
Textbook surgical outcome (TO) is a novel composite quality measure in lung transplantation (LTx). Compared to one-year survival metrics, TO may better differentiate center performance, and motivate improvements in care. To understand the feasibility of implementing this metric, we defined TO in LTx using US national data, and evaluated its ability to predict post-transplant outcomes and differentiate center performance. Adult patients who underwent isolated LTx between 2016-2019 were included. TO was defined as freedom from post-transplant length of stay >30 days, 90-day mortality, intubation or extracorporeal membrane oxygenation at 72 hours post-transplant, post-transplant ventilator support lasting ≥5 days, postoperative airway dehiscence, inpatient dialysis, pre-discharge acute rejection, and grade 3 primary graft dysfunction at 72 hours. Recipient and donor characteristics and post-transplant outcomes were compared between patients who achieved and failed TO. Of 8959 lung transplant recipients, 4664 (52.1%) achieved TO. Patient and graft survival were improved among patients who achieved TO (both log-rank p<0.0001). Among 62 centers, adjusted rates of TO ranged from 27.0% to 72.4% reflecting a wide variability in center-level performance. TO defined using national data may represent a novel composite metric to guide quality improvement in LTx across US transplant centers. Summary: In this study we defined textbook outcome (TO) for lung transplantation (LTx) using US national data. We found that achievement of TO was associated with improved post-transplant survival, and wide variability in center-level LTx performance. These findings suggest that TO could be readily implemented to compare quality of care among US LTx centers. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Sandra Au
- School of Medicine, Duke University, Durham, NC, USA
| | | | - Danae G Olaso
- School of Medicine, Duke University, Durham, NC, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - John C Haney
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A Klapper
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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15
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Nellis JR, Daneshmand MA, Gaca JG, Andersen ND, Haney JC, Turek JW. A single center experience with minimally invasive approaches in congenital cardiac surgery. J Thorac Dis 2021; 13:5818-5825. [PMID: 34795930 PMCID: PMC8575860 DOI: 10.21037/jtd-21-836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 05/15/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Abstract
Background Cardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved. Methods We performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range). Results Between September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14–47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7–37.8) than those who were not (24.2, 20.8–29.3) (P=0.009). Conclusions Minimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.
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Affiliation(s)
- Joseph R Nellis
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
| | - Mani A Daneshmand
- Department of Surgery, Duke University, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Duke University, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA
| | - Nicholas D Andersen
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA.,Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC, USA
| | - John C Haney
- Department of Surgery, Duke University, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA
| | - Joseph W Turek
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA.,Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC, USA
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16
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Ghadimi K, Cappiello J, Cooter-Wright M, Haney JC, Reynolds JM, Bottiger BA, Klapper JA, Levy JH, Hartwig MG. Inhaled Pulmonary Vasodilator Therapy in Adult Lung Transplant: A Randomized Clinical Trial. JAMA Surg 2021; 157:e215856. [PMID: 34787647 DOI: 10.1001/jamasurg.2021.5856] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Inhaled nitric oxide (iNO) is commonly administered for selectively inhaled pulmonary vasodilation and prevention of oxidative injury after lung transplant (LT). Inhaled epoprostenol (iEPO) has been introduced worldwide as a cost-saving alternative to iNO without high-grade evidence for this indication. Objective To investigate whether the use of iEPO will lead to similar rates of severe/grade 3 primary graft dysfunction (PGD-3) after adult LT when compared with use of iNO. Design, Setting, and Participants This health system-funded, randomized, blinded (to participants, clinicians, data managers, and the statistician), parallel-designed, equivalence clinical trial included 201 adult patients who underwent single or bilateral LT between May 30, 2017, and March 21, 2020. Patients were grouped into 5 strata according to key prognostic clinical features and randomized per stratum to receive either iNO or iEPO at the time of LT via 1:1 treatment allocation. Interventions Treatment with iNO or iEPO initiated in the operating room before lung allograft reperfusion and administered continously until cessation criteria met in the intensive care unit (ICU). Main Outcomes and Measures The primary outcome was PGD-3 development at 24, 48, or 72 hours after LT. The primary analysis was for equivalence using a two one-sided test (TOST) procedure (90% CI) with a margin of 19% for between-group PGD-3 risk difference. Secondary outcomes included duration of mechanical ventilation, hospital and ICU lengths of stay, incidence and severity of acute kidney injury, postoperative tracheostomy placement, and in-hospital, 30-day, and 90-day mortality rates. An intention-to-treat analysis was performed for the primary and secondary outcomes, supplemented by per-protocol analysis for the primary outcome. Results A total of 201 randomized patients met eligibility criteria at the time of LT (129 men [64.2%]). In the intention-to-treat population, 103 patients received iEPO and 98 received iNO. The primary outcome occurred in 46 of 103 patients (44.7%) in the iEPO group and 39 of 98 (39.8%) in the iNO group, leading to a risk difference of 4.9% (TOST 90% CI, -6.4% to 16.2%; P = .02 for equivalence). There were no significant between-group differences for secondary outcomes. Conclusions and Relevance Among patients undergoing LT, use of iEPO was associated with similar risks for PGD-3 development and other postoperative outcomes compared with the use of iNO. Trial Registration ClinicalTrials.gov identifier: NCT03081052.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jhaymie Cappiello
- Department of Respiratory Care Services, Duke University Medical Center, Durham, North Carolina
| | - Mary Cooter-Wright
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - John M Reynolds
- Department of Medicine, Transplant Pulmonology, Duke University School of Medicine, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Jacob A Klapper
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, North Carolina
| | - Matthew G Hartwig
- Department of Surgery, Thoracic Transplant Surgery, Duke University School of Medicine, Durham, North Carolina
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17
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Halpern SE, Au S, Kesseli SJ, Krischak MK, Olaso DG, Bottiger BA, Haney JC, Klapper JA, Hartwig MG. Lung transplantation using allografts with more than 8 hours of ischemic time: A single-institution experience. J Heart Lung Transplant 2021; 40:1463-1471. [PMID: 34281776 PMCID: PMC8570997 DOI: 10.1016/j.healun.2021.05.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 02/11/2021] [Revised: 05/04/2021] [Accepted: 05/13/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Six hours was historically regarded as the limit of acceptable ischemic time for lung allografts. However, broader sharing of donor lungs often necessitates use of allografts with ischemic time >6 hours. We characterized the association between ischemic time ≥8 hours and outcomes after lung transplantation using a contemporary cohort from a high-volume institution. METHODS Patients who underwent primary isolated bilateral lung transplantation between 1/2016 and 5/2020 were included. Patients bridged to transplant with extracorporeal membrane oxygenation or mechanical ventilation, and ex-vivo perfusion cases were excluded. Recipients were stratified by total allograft ischemic time <8 hours (standard) vs ≥8 hours (long). Perioperative outcomes and post-transplant survival were compared between groups. RESULTS Of 358 patients, 95 (26.5%) received long ischemic time (≥8 hours) lungs. Long ischemic time recipients were more likely to be male and have donation after circulatory death donors than standard ischemic time recipients. On unadjusted analysis, long and standard ischemic time recipients had similar survival, and similar rates of grade 3 primary graft dysfunction at 72 hours, extracorporeal membrane oxygenation post-transplant, acute rejection within 30 days, reintubation, and post-transplant length of stay. After adjustment, long and standard ischemic time recipients had comparable risks of mortality or graft failure. CONCLUSIONS In a modern cohort, use of lung allografts with "long" ischemic time ≥8 hours were associated with acceptable perioperative outcomes and post-transplant survival. Further investigation is required to better understand how broader use impacts post-lung transplant outcomes and the implications for smarter sharing under an evolving national allocation policy.
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Affiliation(s)
| | - Sandra Au
- School of Medicine, Duke University, Durham, North Carolina
| | - Samuel J Kesseli
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Danae G Olaso
- School of Medicine, Duke University, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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18
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Jodice PGR, Michael PE, Gleason JS, Haney JC, Satgé YG. Revising the marine range of the endangered black-capped petrel Pterodroma hasitata: occurrence in the northern Gulf of Mexico and exposure to conservation threats. ENDANGER SPECIES RES 2021. [DOI: 10.3354/esr01143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The black-capped petrel Pterodroma hasitata is an Endangered seabird endemic to the western North Atlantic. Although estimated at ~1000 breeding pairs, only ~100 nests have been located at 2 sites in Haiti and 3 sites in the Dominican Republic. At sea, the species primarily occupies waters of the western Gulf Stream in the Atlantic and the Caribbean Sea. Due to limited data, there is currently no consensus on the geographic marine range of the species although no current proposed ranges include the Gulf of Mexico. Here, we report on observations of black-capped petrels during 2 vessel-based survey efforts throughout the northern Gulf of Mexico from 2010-2011 and 2017-2019. During 558 d and ~54700 km of surveys, we tallied 40 black-capped petrels. Most observations occurred in the eastern Gulf, although birds were observed over much of the east-west and north-south footprint of the survey area. Predictive models indicated that habitat suitability for black-capped petrels was highest in areas associated with dynamic waters of the Loop Current. We used the extent of occurrence and area of occupancy concepts to delimit the geographic range of the species within the northern Gulf. We suggest that the marine range for black-capped petrels be modified to include the northern Gulf of Mexico, recognizing that distribution may be more clumped in the eastern Gulf and that occurrence in the southern Gulf remains unknown due to a lack of surveys there. To date, however, it remains unclear which nesting areas are linked to the Gulf of Mexico.
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Affiliation(s)
- PGR Jodice
- US Geological Survey, South Carolina Cooperative Fish & Wildlife Research Unit, Clemson University, Clemson, SC 29634, USA
| | - PE Michael
- South Carolina Cooperative Fish & Wildlife Research Unit, Clemson University, Clemson, SC 29634, USA
| | - JS Gleason
- US Fish and Wildlife Service, Migratory Birds/Science Applications, Chiefland, FL 32626, USA
| | - JC Haney
- Terra Mar Applied Sciences, LLC, Washington, DC 20012, USA
| | - YG Satgé
- South Carolina Cooperative Fish & Wildlife Research Unit, Clemson University, Clemson, SC 29634, USA
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19
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Halpern SE, Jawitz OK, Raman V, Choi AY, Haney JC, Klapper JA, Hartwig MG. Aggressive pursuit and utilization of non-ideal donor lungs does not compromise post-lung transplant survival. Clin Transplant 2021; 35:e14414. [PMID: 34218467 DOI: 10.1111/ctr.14414] [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: 05/08/2021] [Revised: 06/06/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Organ procurement organizations (OPOs) vary in willingness to pursue and utilize non-ideal donor lungs; implications of these practices for lung transplant (LTx) recipients remain unclear. We examined associations between OPO-level behavior toward non-ideal donors and post-LTx outcomes. METHODS Adult lung donors and corresponding adult first-time LTx recipients in the 2008-2019 UNOS registry were included. Non-ideal donors had any of age > 50, smoking history ≥20 pack-years, PaO2 /FiO2 ratio ≤350, donation after circulatory death, or increased risk status. OPOs were classified as least, moderately, or most aggressive based on non-ideal donor pursuit, consent attainment, lung recovery, and transplantation. Post-transplant outcomes were compared among aggressiveness strata. RESULTS Of 22,795 recipients, 6229 (27.3%), 8256 (36.2%), and 8310 (36.5%) received lungs from least, moderately, and most aggressive OPOs, respectively. Moderately aggressive OPOs had the highest recipient rates of pre-discharge acute rejection, grade 3 primary graft dysfunction, postoperative extracorporeal membrane oxygenation, and longest lengths of stay. After adjustment, moderately and most aggressive OPOs had similar risks of recipient mortality as least aggressive OPOs. CONCLUSIONS The most and least aggressive OPOs achieve similar patient survival and short-term post-LTx outcomes. Aggressive pursuit and utilization of non-ideal donor lungs by less aggressive OPOs would likely expand the donor pool, without compromising recipient outcomes.
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Affiliation(s)
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vignesh Raman
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Ashley Y Choi
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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20
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Fitch ZW, Doberne J, Reynolds JM, Jamieson I, Haney JC, Klapper JA, Hartwig MG. Expanding donor availability in lung transplantation: A case report of 5000 miles traveled. Am J Transplant 2021; 21:2269-2272. [PMID: 33675176 DOI: 10.1111/ajt.16556] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 01/25/2023]
Abstract
We present the case of a 41-year-old female who underwent bilateral lung transplantation after the donor lungs were placed on a normothermic ex vivo lung perfusion and ventilation device and flown nearly 5000 miles from Honolulu, Hawaii to Durham, North Carolina. The patient experienced no primary graft dysfunction. One year after transplantation she has remained rejection-free and exhibits excellent pulmonary function. This case highlights the challenge that active organ preservation systems pose to questions of organ allocation and geographic sharing.
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Affiliation(s)
- Zachary W Fitch
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Julie Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - John M Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Ian Jamieson
- Duke University Hospital, Duke University, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina, USA
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21
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Wojnarski CM, Chodavadia PA, Barac YD, Armstrong JL, Vekstein AM, Haney JC, Gaca JG, Chad Hughes G, Glower DD. Long-term outcomes of aortic root replacement for endocarditis. J Card Surg 2021; 36:1969-1978. [PMID: 33651483 DOI: 10.1111/jocs.15472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented. METHODS From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk. RESULTS Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46). CONCLUSIONS In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.
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Affiliation(s)
- Charles M Wojnarski
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery, Rabin Medical Center, Petah Tikva, Israel
| | | | - Andrew M Vekstein
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - John C Haney
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey G Gaca
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - G Chad Hughes
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Donald D Glower
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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22
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Nellis JR, Haney JC, Turek JW. Commentary: Repair or replace-Potts shunt versus lung transplantation for refractory pediatric pulmonary hypertension. J Thorac Cardiovasc Surg 2020; 161:1153-1154. [PMID: 33419532 DOI: 10.1016/j.jtcvs.2020.11.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 11/21/2020] [Accepted: 11/23/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Joseph R Nellis
- Duke Congenital Heart Surgery Research & Training Laboratory, Duke University, Durham, NC
| | - John C Haney
- Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC
| | - Joseph W Turek
- Duke Congenital Heart Surgery Research & Training Laboratory, Duke University, Durham, NC; Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC; Duke Children's Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC.
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23
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Manning MW, Li YJ, Linder D, Haney JC, Wu YH, Podgoreanu MV, Swaminathan M, Schroder JN, Milano CA, Welsby IJ, Stafford-Smith M, Ghadimi K. Conventional Ultrafiltration During Elective Cardiac Surgery and Postoperative Acute Kidney Injury. J Cardiothorac Vasc Anesth 2020; 35:1310-1318. [PMID: 33339661 DOI: 10.1053/j.jvca.2020.11.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/08/2020] [Accepted: 11/18/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Conventional ultrafiltration (CUF) during cardiopulmonary bypass (CPB) serves to hemoconcentrate blood volume to avoid allogeneic blood transfusions. Previous studies have determined CUF volumes as a continuous variable are associated with postoperative acute kidney injury (AKI) after cardiac surgery, but optimal weight-indexed volumes that predict AKI have not been described. DESIGN Retrospective cohort. SETTING Single-center university hospital. PARTICIPANTS A total of 1,641 consecutive patients who underwent elective cardiac surgery between June 2013 and December 2015. INTERVENTIONS The CUF volume was removed during CPB in all participants as part of routine practice. The authors investigated the association of dichotomized weight-indexed CUF volume removal with postoperative AKI development to provide pragmatic guidance for clinical practice at the authors' institution. MEASUREMENTS AND MAIN RESULTS Primary outcomes of postoperative AKI were defined by the Kidney Disease: Improving Global Outcomes staging criteria and dichotomized, weight-indexed CUF volumes (mL/kg) were defined by (1) extreme quartiles (<Q1 v >Q3) and (2) Youden's criterion that best predicted AKI development. Multivariate logistic regression models were developed to test the association of these dichotomized indices with AKI status. Postoperative AKI occurred in 827 patients (50.4%). Higher CUF volumes were associated with AKI development by quartiles (CUF >Q3 = 32.6 v CUF < Q1 = 10.4 mL/kg; odds ratio [OR] = 1.68, 95% CI: 1.19-2.3) and Youden's criterion (CUF ≥ 32.9 v CUF <32.9 mL/kg; OR = 1.60, 95% CI: 1.21-2.13). Despite similar intraoperative nadir hematocrits among groups (p = 0.8), higher CUF volumes were associated with more allogeneic blood transfusions (p = 0.002) and longer lengths of stay (p < 0.001). CONCLUSIONS Removal of weight-indexed CUF volumes > 32 mL/kg increased the risk for postoperative AKI development. Importantly, CUF volume removal of any amount did not mitigate allogeneic blood transfusion during elective cardiac surgery. Prospective studies are needed to validate these findings.
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Affiliation(s)
- Michael W Manning
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC.
| | - Yi-Ju Li
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Dean Linder
- Oschner Medical Center, Jefferson Parish, LA
| | - John C Haney
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Mihai V Podgoreanu
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Madhav Swaminathan
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Cardiothoracic Division, Duke University School of Medicine, Durham, NC
| | - Ian J Welsby
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Mark Stafford-Smith
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Duke University School of Medicine, Durham, NC
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Halpern SE, Olaso DG, Krischak MK, Reynolds JM, Haney JC, Klapper JA, Hartwig MG. Lung transplantation during the COVID-19 pandemic: Safely navigating the new "normal". Am J Transplant 2020; 20:3094-3105. [PMID: 32894641 PMCID: PMC9800716 DOI: 10.1111/ajt.16304] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 01/25/2023]
Abstract
In the United States, an overall national decline in organ transplants has accompanied the substantial burden of COVID-19. Amidst significant regional variations in COVID-19, lung transplantation (LTx) remains a critical life-saving operation. Our LTx practice during the early pandemic may provide a blueprint for managing LTx in an era of continued community prevalence. Patients who underwent LTx at our institution between March 1 and May 20, 2020 were included. Recipient, operative, and donor characteristics were compared to those from our program in 2019, and COVID-19 testing practices were evaluated for March, April, and May to understand how our practice adapted to the pandemic. Our program performed 36 LTx, 33% more than the same period in 2019. Recipient, operative, and donor characteristics during COVID-19 were similar to those in 2019. By April 1, all donors and recipients underwent pretransplant COVID-19 testing, all returning negative results. To date, no recipients have developed posttransplant COVID-19. At our institution, pretransplant COVID-19 testing, use of local donor lungs, and avoidance of donors from areas of increased community penetration supported a safe and effective LTx practice during the early COVID-19 pandemic. Continued follow-up is required to ensure the long-term safety of these newly transplanted patients.
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Key Words
- asts, american society of transplant surgeons
- bal, bronchoalveolar lavage
- covid-19, coronavirus disease 2019
- ct, computed tomography
- ecmo, extracorporeal membrane oxygenation
- evlp, ex-vivo lung perfusion
- fev1, forced expiratory volume in 1 second
- fvc, forced vital capacity
- icu, intensive care unit
- iqr, interquartile range
- ird, increased risk for disease transmission
- ishlt, international society for heart and lung transplantation
- las, lung allocation score
- los, length of stay
- ltx, lung transplantation
- opo, organ procurement organization
- p/f, pao2/fio2
- pcr, polymerase chain reaction
- pgd, primary graft dysfunction
- sars-cov-2, severe acute respiratory syndrome coronavirus 2
- unos, united network for organ sharing
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Affiliation(s)
- Samantha E. Halpern
- School of Medicine, Duke University, Durham, NC, USA,Correspondence Samantha E. Halpern
| | | | | | - John M. Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - John C. Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob A. Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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25
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Brockbank B, Nicoara A, Klinger RY, Swaminathan M, Haney JC, Maisonave Y. Transesophageal Echocardiographic Evaluation of Novel Extracellular Matrix Valve for Tricuspid Valve Endocarditis. ACTA ACUST UNITED AC 2020; 4:429-432. [PMID: 33117943 PMCID: PMC7581605 DOI: 10.1016/j.case.2020.05.018] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intravenous drug abuse is a common cause of infective TV endocarditis. The use of a novel ECM valve is a surgical alternative to TV replacement. TEE evaluation is a useful tool to evaluate the unique valve appearance and function.
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Affiliation(s)
- Benjamin Brockbank
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Rebecca Y Klinger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Yasmin Maisonave
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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26
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Bryner BS, Haney JC. Commentary: A longer agonal period in lungs donated after circulatory determination of death is a gamble worth taking. J Thorac Cardiovasc Surg 2020; 161:1559-1560. [PMID: 32713638 DOI: 10.1016/j.jtcvs.2020.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 05/25/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Benjamin S Bryner
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, NC.
| | - John C Haney
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University, Durham, NC
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27
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Black-Maier E, Piccini JP, Bishawi M, Pokorney SD, Bryner B, Schroder JN, Fowler VG, Katz JN, Haney JC, Milano CA, Nicoara A, Hegland DD, Daubert JP, Lewis RK. Lead Extraction for Cardiovascular Implantable Electronic Device Infection in Patients With Left Ventricular Assist Devices. JACC Clin Electrophysiol 2020; 6:672-680. [PMID: 32553217 DOI: 10.1016/j.jacep.2020.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The goal of this study was to assess the utility of transvenous lead extraction for cardiovascular implantable electronic device (CIED) infection in patients with a left ventricular assist device (LVAD). BACKGROUND The use of transvenous lead extraction for the management CIED infection in patients with a durable LVAD has not been well described. METHODS Clinical and outcomes data were collected retrospectively among patients who underwent lead extraction for CIED infection after LVAD implantation at Duke University Hospital. RESULTS Overall, 27 patients (n = 6 HVAD; n = 15 HeartMate II; n = 6 Heartmate III) underwent lead extraction for infection. Median (interquartile range) time from LVAD implantation to infection was 6.1 (2.5 to 14.9) months. Indications included endocarditis (n = 16), bacteremia (n = 9), and pocket infection (n = 2). Common pathogens were Staphylococcus aureus (n = 10), coagulase-negative staphylococci (n = 7), and Enterococcus faecalis (n = 3). Sixty-eight leads were removed, with a median lead implant time of 5.7 (3.6 to 9.2) years. Laser sheaths were used in all procedures, with a median laser time of 35.0 s (17.5 to 85.5s). Mechanical cutting tools were required in 11 (40.7%) and femoral snaring in 4 (14.8%). Complete procedural success was achieved in 25 (93.6%) patients and clinical success in 27 (100%). No procedural failures or major adverse events occurred. Twenty-one patients (77.8%) were alive without persistent endovascular infection 1 year after lead extraction. Most were treated with oral suppressive antibiotics after extraction (n = 23 [82.5%]). Persistent infection after extraction occurred in 4 patients and was associated with 50% 1-year mortality. CONCLUSIONS Transvenous lead extraction for LVAD-associated CIED infection can be performed safely with low rates of persistent infection and 1-year mortality.
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Affiliation(s)
- Eric Black-Maier
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Benjamin Bryner
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Disease, Duke University Medical Center, Durham, North Carolina, USA
| | - Jason N Katz
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Alina Nicoara
- Division of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Donald D Hegland
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - James P Daubert
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert K Lewis
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA.
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28
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Nellis JR, Vekstein AM, Meza JM, Andersen ND, Haney JC, Turek JW. Left Anterior Mini-Incision for Pulmonary Valve Replacement Following Tetralogy of Fallot Repair. Innovations�(Phila) 2020; 15:106-110. [DOI: 10.1177/1556984520911025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pulmonary insufficiency is a known complication following Tetralogy of Fallot repair. With over 90% of patients now surviving to adulthood, surgeons are once again faced with the question of when, and more importantly, how to reintervene. We developed a novel approach to pulmonary valve replacement in this population through a 5-cm left anterior mini-incision. The incision is optimized for exposing and operating on the right ventricular outflow tract and the main pulmonary artery in patients with a history of median sternotomy. Early outcomes are reassuring, and we believe our approach is a safe and reliable alternative to median sternotomy within this patient population, with the ability to quickly convert intraoperatively when needed.
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Affiliation(s)
- Joseph R. Nellis
- Department of Surgery, Duke University Hospitals, Durham, NC, USA
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
| | - Andrew M. Vekstein
- Department of Surgery, Duke University Hospitals, Durham, NC, USA
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
| | - James M. Meza
- Department of Surgery, Duke University Hospitals, Durham, NC, USA
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
| | - Nicholas D. Andersen
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
- Pediatric & Congenital Heart Center, Duke Children’s Hospital, Durham, NC, USA
| | - John C. Haney
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
| | - Joseph W. Turek
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
- Pediatric & Congenital Heart Center, Duke Children’s Hospital, Durham, NC, USA
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29
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Vekstein AM, Nellis JR, Meza JM, Andersen ND, Haney JC, Turek JW. Left Anterior Mini-Incision for Pulmonary Valve Replacement in a 12-Year-Old. Innovations�(Phila) 2020; 15:111-113. [DOI: 10.1177/1556984520911026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 12-year-old, 32 kg male with history of Tetralogy of Fallot status post repair at 8 days of life presented with progressive pulmonary insufficiency and left pulmonary artery stenosis. Surgical options were discussed, and the patient and his family elected to pursue minimally invasive pulmonary valve replacement with left pulmonary artery augmentation through a 5-cm left anterior mini-incision. The procedure was performed without complication, and he was discharged on postoperative day 3. At the time of his last follow-up, the patient was recovering well without evidence of pulmonary stenosis or insufficiency.
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Affiliation(s)
- Andrew M. Vekstein
- Department of Surgery, Duke University Hospitals, Durham, NC, USA
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
| | - Joseph R. Nellis
- Department of Surgery, Duke University Hospitals, Durham, NC, USA
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
| | - James M. Meza
- Department of Surgery, Duke University Hospitals, Durham, NC, USA
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
| | - Nicholas D. Andersen
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
- Pediatric & Congenital Heart Center, Duke Children’s Hospital, Durham, NC, USA
| | - John C. Haney
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
| | - Joseph W. Turek
- Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
- Division of Cardiothoracic Surgery, Duke University Hospitals, Durham, NC, USA
- Pediatric & Congenital Heart Center, Duke Children’s Hospital, Durham, NC, USA
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30
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Haney JC, Hemming JM, Tuttle P. Pelagic seabird density and vulnerability in the Gulf of Mexico to oiling from the Deepwater Horizon/MC-252 spill. Environ Monit Assess 2020; 191:818. [PMID: 32185528 PMCID: PMC7078140 DOI: 10.1007/s10661-019-7921-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 10/23/2019] [Indexed: 06/10/2023]
Abstract
Using ship-based surveys, the Natural Resource Damage Assessment (NRDA) Trustees assessed the external oiling of offshore and pelagic marine birds inhabiting the northern Gulf of Mexico (Gulf) in the year following the Deepwater Horizon oil spill (DWH spill). Study objectives were to (1) collect data on pelagic seabirds that were visibly oiled, (2) collect data to estimate abundance of seabirds in offshore and pelagic waters, and 3) document the location and condition of any bird carcasses encountered. Methods employed included strip line transects and station point counts. Surveys were conducted within a study area bound by the Texas-Mexico border and the Dry Tortugas of Florida to the south, and the nearshore coastal waters of the northern Gulf of Mexico. A total of 5665 strip line transects and 386 station point-counts of variable duration were collected during the study. More than 23,000 individual seabirds comprising 45 estuarine, coastal, offshore, and pelagic species were tallied. Average daily abundance of seabirds detected varied from a low of approximately 7 birds/day in November 2010 along regions of the mid- and outer continental shelf to a high of more than 580 birds/day in June 2011 within the near-shore, coastal waters of the northern Gulf.
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Affiliation(s)
- J C Haney
- Terra Mar Applied Sciences, LLC, 1370 Tewkesbury Place NW, Washington, DC, 20012, USA.
| | - J M Hemming
- U.S. Fish and Wildlife Service, 341 Greeno Rd., Suite A, Fairhope, AL, 36532, USA
| | - P Tuttle
- U.S. Fish and Wildlife Service, 341 Greeno Rd., Suite A, Fairhope, AL, 36532, USA
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31
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Barac YD, Bryner B, Bonadonna D, Wolfe C, Reynolds J, Haney JC, Daneshmand MA. Bilateral pneumonectomy with veno-arterial extracorporeal membrane oxygenation as a bridge to lung transplant. J Heart Lung Transplant 2019; 38:1231-1232. [DOI: 10.1016/j.healun.2019.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/22/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022] Open
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32
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Ansari A, Cobert J, Navuluri N, Cheng G, Haney JC, Welsby I. Intrapulmonary Activated Factor VII for Hemoptysis Complicating Pulmonary Thromboendarterectomy. Ann Thorac Surg 2019; 109:e243-e245. [PMID: 31470015 DOI: 10.1016/j.athoracsur.2019.06.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/12/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 11/29/2022]
Abstract
Massive hemoptysis represents a life-threatening disorder that has numerous different causes. The development of recombinant factor concentrates has allowed for novel treatments in this emergency setting. This report describes a patient with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy. The postoperative course was complicated by massive hemoptysis resulting in severe hypoxemia that required extracorporeal membrane oxygenation and multiple daily blood transfusions. After failure of conservative and interventional approaches, recombinant factor VII was administered by bronchial isolation. After treatment, the patient's hemoptysis dramatically resolved, with eventual hospital discharge and excellent function at follow-up. This case presents the use of intrapulmonary activated factor VII to control massive hemoptysis.
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Affiliation(s)
- Andrea Ansari
- Duke University School of Medicine, Durham, North Carolina
| | - Julien Cobert
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
| | - Neelima Navuluri
- Department of Pulmonology and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - George Cheng
- Division of Interventional Pulmonology, Department of Pulmonology and Critical Care, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ian Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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33
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Nasir BS, Mulvihill MS, Barac YD, Bishawi M, Cox ML, Megna DJ, Haney JC, Klapper JA, Daneshmand MA, Hartwig MG. Single lung transplantation in patients with severe secondary pulmonary hypertension. J Heart Lung Transplant 2019; 38:939-948. [PMID: 31495410 DOI: 10.1016/j.healun.2019.06.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 03/01/2019] [Revised: 05/26/2019] [Accepted: 06/14/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The optimal transplant strategy for patients with end-stage lung disease complicated by secondary pulmonary hypertension (PH) is controversial. The aim of this study is to define the role of single lung transplantation in this population. METHODS We performed a retrospective study of lung transplant recipients using the Organ Procurement and Transplantation Network/United Network for Organ Sharing Standard Transplant Analysis and Research registry. Adult recipients that underwent isolated lung transplantation between May 2005 and June 2015 for end-stage lung disease because of obstructive or restrictive etiologies were identified. Patients were stratified by mean pulmonary artery pressure ([mPAP] ≥ or < 40 mm Hg) and by treatment-single (SOLT) or bilateral (BOLT) orthotopic lung transplantation. The primary outcome measure was overall survival (OS), which was estimated using the Kaplan-Meier method and compared by the log-rank test. To adjust for donor and recipient confounders, Cox proportional hazards models were developed to estimate the adjusted hazard ratio of mortality associated with elevated mPAP in SOLT and BOLT recipients. RESULTS A total of 12,392 recipients met inclusion criteria. Of recipients undergoing SOLT, those with mPAP ≥40 were shown to have lower survival, with 5-year OS of 43.9% (95% confidence interval 36.6-52.7; p = 0.007). Of recipients undergoing BOLT, OS was superior to SOLT, and no difference in 5-year OS between mPAP ≥ and <40 was observed (p = 0.15). In the adjusted analysis, mPAP ≥40 mm Hg was found to be an independent predictor for mortality in SOLT, but not BOLT recipients. This finding remained true on multivariable analysis. In patients undergoing SOLT, mPAP ≥40 was associated with an adjusted hazard ratio for mortality of 1.31 (1.08-1.59, p = 0.07). In BOLT, mPAP was not associated with increased hazard (adjusted hazard ratio 1.04, p = 0.48). CONCLUSIONS There is a reduced survival when a patient with severe secondary PH undergoes SOLT. This increased mortality hazard is not seen in BOLT. It appears that a BOLT may negate the adverse effect that severe PH has on OS, and may be superior to SOLT in patients with mPAP over 40 mm Hg.
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Affiliation(s)
- Basil S Nasir
- Division of Thoracic Surgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada.
| | - Michael S Mulvihill
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Muath Bishawi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Morgan L Cox
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Dominick J Megna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Fierro MA, Dunne B, Ranney DN, Daneshmand MA, Haney JC, Klapper JA, Hartwig MG, Bonadonna D, Manning MW, Bartz RR. Perioperative Anesthetic and Transfusion Management of Veno-Venous Extracorporeal Membrane Oxygenation Patients Undergoing Noncardiac Surgery: A Case Series of 21 Procedures. J Cardiothorac Vasc Anesth 2019; 33:1855-1862. [DOI: 10.1053/j.jvca.2019.01.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Indexed: 12/12/2022]
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Sigurdsson MI, Brockbank B, Haney JC, Andrews J, MacLeod DB, Vaslef SN, Brooks KR, Manning EL, Nicoara A. Abdominal Gunshot Causing Ventricular Septal Injury Without Perforation into the Pericardium. J Cardiothorac Vasc Anesth 2019; 33:772-775. [DOI: 10.1053/j.jvca.2018.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 11/11/2022]
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Waldron NH, Cooter M, Haney JC, Schroder JN, Gaca JG, Lin SS, Sigurdsson MI, Fudim M, Podgoreanu MV, Stafford-Smith M, Milano CA, Piccini JP, Mathew JP. Temporary autonomic modulation with botulinum toxin type A to reduce atrial fibrillation after cardiac surgery. Heart Rhythm 2018; 16:178-184. [PMID: 30414840 DOI: 10.1016/j.hrthm.2018.08.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery and is associated with worse outcomes. The cardiac autonomic nervous system is implicated in the pathogenesis of POAF. OBJECTIVE The purpose of this study was to determine the efficacy and safety of selective cardiac autonomic modulation in preventing POAF. METHODS In this randomized, double-blind, placebo-controlled trial, adults undergoing cardiac surgery were randomized 1:1 to intraoperative injection of 250 units onabotulinumtoxinA (botulinum toxin type A [BoNTA]) or placebo into epicardial fat pads. The study was powered to detect a 40% reduction in relative risk of POAF. Time to first episode of in-hospital POAF was the primary outcome, evaluated in patients receiving injection. Additionally, incidence of POAF, length of stay (LOS), and adverse events were examined. RESULTS The trial assigned 145 patients to injection, 15 of whom were dropped before treatment, leaving 130 patients for analysis. Overall, 36.5% (23/63) of BoNTA-treated patients developed POAF compared with 47.8% (32/67) of placebo-treated patients. The time-to-event analysis revealed a hazard ratio of 0.69 (95% confidence interval 0.41-1.19; P = .18) for the BoNTA vs placebo arm. There were no significant differences in postoperative hospital LOS (median [interquartile range] 6.0 [3.4] vs 6.2 [3.7] days; P = .51) or adverse events prolonging LOS (27/63 [42.9%] vs 30/67 [44.8%]; P = .83) in patients receiving BoNTA vs placebo. CONCLUSION Epicardial injection of onabotulinumtoxinA was without discernible adverse effects, but we failed to detect a significant difference in risk of POAF. Future large-scale studies of epicardial onabotulinumtoxinA injection as a potential POAF prevention strategy should be designed to study smaller, but clinically meaningful, treatment effects.
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Affiliation(s)
- Nathan H Waldron
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Shu S Lin
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina; Department of Immunology, Duke University Medical Center, Durham, North Carolina; Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Martin I Sigurdsson
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine (Cardiology), Duke University Medical Center, Durham, North Carolina
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine (Cardiology), Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Waldron NH, Haney JC, Suarez A, Swaminathan M. The Value of Echocardiography in Unexpected Valve Disease in a Patient With Ischemic Cardiomyopathy: Less Is Not Always the Right Answer. J Cardiothorac Vasc Anesth 2018; 32:389-392. [DOI: 10.1053/j.jvca.2017.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 11/11/2022]
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Barac YD, Zwischenberger B, Schroder JN, Daneshmand MA, Haney JC, Gaca JG, Wang A, Milano CA, Glower DD. Using a Regent Aortic Valve in a Small Annulus Mitral Position Is a Viable Option. Ann Thorac Surg 2017; 105:1200-1204. [PMID: 29258732 DOI: 10.1016/j.athoracsur.2017.11.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Outcome of mitral valve replacement in extreme scenarios of small mitral annulus with the use of the Regent mechanical aortic valve is not well documented. METHODS Records were examined in 31 consecutive patients who underwent mitral valve replacement with the use of the aortic Regent valve because of a small mitral annulus. RESULTS Mean age was 60 ± 14 years. Mitral stenosis or mitral annulus calcification was present in 30 of 31 patients (97%). Concurrent procedures were performed in 17 of 31 patients (55%). Median valve size was 23 mm. Mean mitral gradient coming out of the operating room was 4.2 ± 1.5 mm Hg and at follow-up echocardiogram performed at a median of 32 months after the procedure was 5.8 ± 2.4 mm Hg. CONCLUSIONS A Regent aortic mechanical valve can be a viable option with a larger orifice area than the regular mechanical mitral valve in a problematic situation of a small mitral valve annulus. Moreover, the pressure gradients over the valve are acceptable intraoperatively and over time.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Donald D Glower
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
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Ranney DN, Benrashid E, Meza JM, Keenan JE, Bonadonna DK, Bartz R, Milano CA, Hartwig MG, Haney JC, Schroder JN, Daneshmand MA. Central Cannulation as a Viable Alternative to Peripheral Cannulation in Extracorporeal Membrane Oxygenation. Semin Thorac Cardiovasc Surg 2017; 29:188-195. [DOI: 10.1053/j.semtcvs.2017.02.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 12/20/2022]
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Worni M, Castleberry AW, Gloor B, Pietrobon R, Haney JC, D’Amico TA, Akushevich I, Berry MF. Trends and outcomes in the use of surgery and radiation for the treatment of locally advanced esophageal cancer: a propensity score adjusted analysis of the surveillance, epidemiology, and end results registry from 1998 to 2008. Dis Esophagus 2014; 27:662-9. [PMID: 23937253 PMCID: PMC3923844 DOI: 10.1111/dote.12123] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We examined outcomes and trends in surgery and radiation use for patients with locally advanced esophageal cancer, for whom optimal treatment isn't clear. Trends in surgery and radiation for patients with T1-T3N1M0 squamous cell or adenocarcinoma of the mid or distal esophagus in the Surveillance, Epidemiology, and End Results database from 1998 to 2008 were analyzed using generalized linear models including year as predictor; Surveillance, Epidemiology, and End Results doesn't record chemotherapy data. Local treatment was unimodal if patients had only surgery or radiation and bimodal if they had both. Five-year cancer-specific survival (CSS) and overall survival (OS) were analyzed using propensity-score adjusted Cox proportional-hazard models. Overall 5-year survival for the 3295 patients identified (mean age 65.1 years, standard deviation 11.0) was 18.9% (95% confidence interval: 17.3-20.7). Local treatment was bimodal for 1274 (38.7%) and unimodal for 2021 (61.3%) patients; 1325 (40.2%) had radiation alone and 696 (21.1%) underwent only surgery. The use of bimodal therapy (32.8-42.5%, P = 0.01) and radiation alone (29.3-44.5%, P < 0.001) increased significantly from 1998 to 2008. Bimodal therapy predicted improved CSS (hazard ratios [HR]: 0.68, P < 0.001) and OS (HR: 0.58, P < 0.001) compared with unimodal therapy. For the first 7 months (before survival curve crossing), CSS after radiation therapy alone was similar to surgery alone (HR: 0.86, P = 0.12) while OS was worse for surgery only (HR: 0.70, P = 0.001). However, worse CSS (HR: 1.43, P < 0.001) and OS (HR: 1.46, P < 0.001) after that initial timeframe were found for radiation therapy only. The use of radiation to treat locally advanced mid and distal esophageal cancers increased from 1998 to 2008. Survival was best when both surgery and radiation were used.
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Affiliation(s)
- Mathias Worni
- Department of Surgery, Duke University Medical Center, Durham NC, USA,Department of Visceral Surgery and Medicine, University of Bern, Inselspital, Bern, Switzerland
| | | | - Beat Gloor
- Department of Visceral Surgery and Medicine, University of Bern, Inselspital, Bern, Switzerland
| | - Ricardo Pietrobon
- Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - John C. Haney
- Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Thomas A. D’Amico
- Department of Surgery, Duke University Medical Center, Durham NC, USA
| | - Igor Akushevich
- Center for Population Health and Aging, Duke University, Durham NC, USA
| | - Mark F. Berry
- Department of Surgery, Duke University Medical Center, Durham NC, USA
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Barbas AS, Haney JC, Henry BV, Heflin MT, Lagoo SA. Development and implementation of a formalized geriatric surgery curriculum for general surgery residents. Gerontol Geriatr Educ 2014; 35:380-394. [PMID: 24447092 DOI: 10.1080/02701960.2013.879444] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Despite the growth of the elderly population, most surgical training programs lack formalized geriatric education. The authors' aim was to implement a formalized geriatric surgery curriculum at an academic medical center. Surgery residents were surveyed on attitudes toward the care of elderly patients and the importance of various geriatric topics to daily practice. A curriculum consisting of 16 didactic sessions was created with faculty experts moderating. After curriculum completion, residents were surveyed to assess curriculum impact. Residents expressed increased comfort in accessing community resources. A greater percentage of residents recognized the significance of delirium and acute renal failure in elderly patients. Implementing a geriatric surgery curriculum geared toward surgery residents is feasible and can increase resident comfort with multidisciplinary care and recognition of clinical conditions pertinent to elderly surgical patients. This initiative also provided valuable experience for geriatric surgery curriculum development.
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Affiliation(s)
- Andrew S Barbas
- a Department of Surgery , Duke University , Durham , North Carolina , USA
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Haney JC, Hanna JM, Berry MF, Harpole DH, D'Amico TA, Tong BC, Onaitis MW. Differential prognostic significance of extralobar and intralobar nodal metastases in patients with surgically resected stage II non-small cell lung cancer. J Thorac Cardiovasc Surg 2014; 147:1164-8. [PMID: 24507984 DOI: 10.1016/j.jtcvs.2013.12.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 10/11/2013] [Accepted: 12/09/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVES We sought to determine the prognostic significance of extralobar nodal metastases versus intralobar nodal metastases in patients with lung cancer and pathologic stage N1 disease. METHODS A retrospective review of a prospectively maintained lung resection database identified 230 patients with pathologic stage II, N1 non-small cell lung cancer from 1997 to 2011. The surgical pathology reports were reviewed to identify the involved N1 stations. The outcome variables included recurrence and death. Univariate and multivariate analyses were performed using the R statistical software package. RESULTS A total of 122 patients had extralobar nodal metastases (level 10 or 11); 108 patients were identified with intralobar nodal disease (levels 12-14). The median follow-up was 111 months. The baseline characteristics were similar in both groups. No significant differences were noted in the surgical approach, anatomic resections performed, or adjuvant therapy rates between the 2 groups. Overall, 80 patients developed recurrence during follow-up: 33 (30%) of 108 in the intralobar and 47 (38%) of 122 in the extralobar cohort. The median overall survival was 46.9 months for the intralobar cohort and 24.4 months for the extralobar cohort (P < .001). In a multivariate Cox proportional hazard model that included the presence of extralobar nodal disease, age, tumor size, tumor histologic type, and number of positive lymph nodes, extralobar nodal disease independently predicted both recurrence-free and overall survival (hazard ratio, 1.96; 95% confidence interval, 1.36-2.81; P = .001). CONCLUSIONS In patients who underwent surgical resection for stage II non-small cell lung cancer, the presence of extralobar nodal metastases at level 10 or 11 predicted significantly poorer outcomes than did nodal metastases at stations 12 to 14. This finding has prognostic importance and implications for adjuvant therapy and surveillance strategies for patients within the heterogeneous stage II (N1) category.
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Affiliation(s)
- John C Haney
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jennifer M Hanna
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mark F Berry
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - David H Harpole
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Thomas A D'Amico
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Betty C Tong
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mark W Onaitis
- Division of Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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Turley RS, Czito BG, Haney JC, Tyler DS, Mantyh CR, Migaly J. Intraoperative pelvic brachytherapy for treatment of locally advanced or recurrent colorectal cancer. Tech Coloproctol 2012; 17:95-100. [PMID: 22986843 DOI: 10.1007/s10151-012-0892-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [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: 02/20/2012] [Accepted: 08/22/2012] [Indexed: 01/12/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the efficacy and morbidity of intraoperative radiation therapy (IORT) for advanced colorectal cancer. METHODS All patients undergoing IORT for locally advanced rectal cancer from 2001-2009 were reviewed for cancer recurrence, survival, and procedure-related morbidity. Cumulative event rates were estimated using the method of Kaplan and Meier. RESULTS Twenty-nine patients with locally advanced (n = 8) or recurrent (n = 21) rectal cancers were treated with IORT and resection. Surgical interventions included low anterior resection, abdominoperineal resection, pelvic exenteration, and a variety of non-anatomic resections of pelvic recurrences. R(0) resections were achieved in 16 patients, while R(1) resections were achieved in 10, and margins were grossly positive in 3 patients. IORT was delivered to all patients over a median area of 48 (42-72) cm(2) at a median dose of 12 (12-15) Gy. Local and overall recurrence rates were 24 % (locally advanced group) and 45 % (recurrent group). Median disease-free and overall survival were 25 and 40 months respectively at a median follow-up of 26 (18-42) months. The short-term (≤30 days) complication rate was 45 %. Eight patients developed local wound complications, 5 of which required operative intervention. Four patients developed intra-abdominal abscesses requiring drainage. Long-term (>30 days) complications were identified in 11 patients (38 %) and included long-term wound complications (n = 3), ureteral obstruction requiring stenting (n = 1), neurogenic bladder (n = 3), enteric fistulae (n = 2), small bowel obstruction (n = 1), and neuropathic pain (n = 1). CONCLUSIONS Intraoperative brachytherapy is a viable IORT option during pelvic surgery for locally advanced or recurrent colorectal cancer but is associated with high postoperative morbidity. Whether intraoperative brachytherapy can improve local recurrence rates for locally advanced or recurrent colorectal cancer will require further prospective investigation.
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Affiliation(s)
- R S Turley
- Department of General Surgery, Duke University Medical Center, DUMC 2817, Durham, NC, 27710, USA.
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Abstract
ALK-1 is a transforming growth factor beta (TGF-beta) superfamily receptor that is predominantly expressed in endothelial cells and is essential for angiogenesis, as demonstrated by the embryonic lethal phentoype when targeted for deletion in mice and its mutation in the human disease hereditary hemorrhagic telangiectasia. Although ALK-1 and the endothelial-specific TGF-beta superfamily coreceptor, endoglin, form a heteromeric complex and bind similar TGF-beta superfamily ligands, their signaling mechanisms remain poorly characterized. Here we report the identification of CK2beta, the regulatory subunit of protein kinase CK2, as a novel enhancer of ALK-1 signaling. The cytoplasmic domain of ALK-1 specifically binds to CK2beta in vitro and in vivo. NAAIRS mutagenesis studies define amino acid sequences 181-199 of CK2beta and 207-212 of ALK-1 as the interaction domains, respectively. The ALK-1/CK2beta interaction specifically enhanced Smad1/5/8 phosphorylation and ALK-1-mediated reporter activation in response to TGF-beta1 and BMP-9 treatment. In a reciprocal manner, siRNA-mediated silencing of endogenous CK2beta inhibited TGF-beta1 and BMP-9-stimulated Smad1/5/8 phosphorylation and ALK-1-mediated reporter activation. Functionally, CK2beta enhanced the ability of activated or ligand-stimulated ALK-1 to inhibit endothelial cell migration. Similarly, ALK-1 and CK2beta antagonized endothelial tubule formation in Matrigel. These studies support CK2beta as an important regulator of ALK-1 signaling and ALK-1-mediated functions in endothelial cells.
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Affiliation(s)
- Nam Y Lee
- Department of Medicine, Duke University, Durham, NC, USA
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Haney JC, Shortell CK, McCann RL, Lawson JH, Stirling MJ, Stone DH. Congenital jugular vein phlebectasia: a case report and review of the literature. Ann Vasc Surg 2008; 22:681-3. [PMID: 18462919 DOI: 10.1016/j.avsg.2008.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2007] [Revised: 01/16/2008] [Accepted: 02/13/2008] [Indexed: 01/25/2023]
Abstract
Fusiform dilation of the jugular vein, or jugular venous phlebectasia, is a rare clinical entity, with an etiology of cervical swelling. We present a case of a 15-year-old male with no antecedent history of trauma and an enlarging right neck mass. Pertinent literature and relevant diagnostic and therapeutic modalities are reviewed. While conservative management is usually prescribed, ligation and resection may be performed safely when intervention is warranted.
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Affiliation(s)
- John C Haney
- Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Abstract
Necrotizing pancreatitis is a severe disease characterized by gland necrosis and a destructive systemic inflammatory response. Early management involves aggressive resuscitative and supportive measures. Outcomes are primarily determined by the presence of late secondary bacterial infection of the necrotic gland. Early empiric antibiotics and late surgical necrosectomy in the appropriate setting are the keys to managing these sick patients. With appropriate management, mortality can be minimized and long-term quality of life may be restored.
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Affiliation(s)
- John C Haney
- Duke University Medical Center, Duke University School of Medicine, Durham, NC 27710, USA
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Petersen RP, Hanish SI, Haney JC, Miller CC, Burfeind WR, Tyler DS, Seigler HF, Wolfe W, D'Amico TA, Harpole DH. Improved survival with pulmonary metastasectomy: an analysis of 1720 patients with pulmonary metastatic melanoma. J Thorac Cardiovasc Surg 2007; 133:104-10. [PMID: 17198792 DOI: 10.1016/j.jtcvs.2006.08.065] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [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: 04/28/2006] [Revised: 07/18/2006] [Accepted: 08/07/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The outcomes of patients with metastatic melanoma are poor. Although prognostic models have been developed to predict the occurrence of pulmonary metastasis from cutaneous melanoma, few data exist to define the outcomes of these patients once metastasis has occurred. The objective of this study was to discriminate predictors of survival for patients with pulmonary metastatic melanoma. METHODS We found 1720 patients with pulmonary metastasis listed in a prospective comprehensive cancer center database of 14,057 consecutive patients with melanoma (Jan 1, 1970-June 1, 2004). Demographic and histopathologic data, time and location of recurrences, number of pulmonary nodules, and subsequent therapies were collected. Univariate and multivariate Cox proportional hazards models were used to identify predictors of survival for patients with pulmonary metastatic melanoma. RESULTS The median survival was 7.3 months after development of pulmonary metastasis. Significant predictors of survival from the multivariate model included nodular histologic type (P = .033), disease-free interval (P < .001), number of pulmonary metastases (P = .012), presence of extrathoracic metastasis (P < .001), and performance of pulmonary metastasectomy (P < .001). Interactions were identified between metastasectomy and disease-free interval and presence of extrathoracic metastasis. Surgery was associated with a survival advantage of 12 months for patients with a disease-free interval longer than 5 years (19 vs 7 months, P < .01) and of 10 months for patients without extrathoracic metastasis (18 vs 8 months, P < .01). CONCLUSIONS When all other identified risk factors were controlled for mathematically, metastasectomy maintained a significant survival advantage for patients with pulmonary metastatic melanoma. These data support the role of surgery for a select subset of patients with pulmonary metastasis.
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Affiliation(s)
- Rebecca P Petersen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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White RR, Kattan MW, Haney JC, Clary BM, Pappas TN, Tyler DS, Brennan MF. Evaluation of preoperative therapy for pancreatic cancer using a prognostic nomogram. Ann Surg Oncol 2006; 13:1485-92. [PMID: 17013688 DOI: 10.1245/s10434-006-9104-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [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: 06/02/2006] [Revised: 06/02/2006] [Accepted: 06/02/2006] [Indexed: 12/17/2022]
Abstract
BACKGROUND Theoretical benefits of preoperative chemoradiation therapy (preop CRT) for pancreatic cancer include improved efficacy, resectability, and patient selection. The goal of this study was to evaluate the applicability of a nomogram, which was developed for patients undergoing resection without preop CRT and which incorporates several post-resection pathological factors, to a population of patients who received preop CRT prior to resection. METHODS From 1994 to 2004, 82 patients with biopsy-proven, radiographically localized adenocarcinoma of the pancreatic head underwent preop CRT followed by pancreaticoduodenectomy (PD); 50 concurrent patients underwent PD without preop CRT. Mean nomogram-predicted disease-specific survival (DSS) rates were compared with observed DSS rates from the time of resection. RESULTS Despite having more locally advanced tumors on initial staging (21 vs. 8%; P < .05), patients who received preop CRT had smaller resected tumors (mean 2.3 vs. 3.1 cm; P < .01), were less likely to have T3 tumors (54 vs. 80%, P < .01), were less likely to have positive lymph nodes (29 vs. 58%, P < .01), and had fewer positive lymph nodes (mean .4 vs. 1.9, P < .01), all factors that imply treatment effect and favorably impact on nomogram-predicted DSS. Observed DSS was similar to predicted DSS in both groups. CONCLUSIONS The similarity in observed and predicted DSS following resection in patients who received preop CRT suggests that the effects of preop CRT-whether treatment, selection, or no effect-are reflected by the nomogram. The ability of the nomogram to evaluate the effects of preop CRT on survival is limited by the potential effects of preop CRT on factors within the nomogram.
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Affiliation(s)
- Rebekah R White
- Department of Surgical Oncology, Memorial Sloan-Kettering Cancer Center, New York 10021, USA
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Affiliation(s)
- John C Haney
- Duke University Medical Center, Durham, NC 27710, USA
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