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Objective: Lung transplantation remains limited by the shortage of healthy organs. Cross-circulation with a healthy swine recipient provides a durable physiologic environment to recover injured donor lungs. In a clinical application, a recipient awaiting lung transplantation could be placed on cross-circulation to recover damaged donor lungs, enabling eventual transplantation. Our objective was to assess the ability of recipient swine with respiratory compromise to tolerate cross-circulation and support recovery of donor lungs subjected to extended cold ischemia., Methods: Swine donor lungs (n = 6) were stored at 4 °C for 24 hours while recipient swine (n = 6) underwent gastric aspiration injury before cross-circulation. Longitudinal multiscale analyses (blood gas, bronchoscopy, radiography, histopathology, cytokine quantification) were performed to evaluate recipient swine and extracorporeal lungs on cross-circulation., Results: Recipient swine lung injury resulted in sustained, impaired oxygenation (arterial oxygen tension/inspired oxygen fraction ratio 205 ± 39 mm Hg vs 454 ± 111 mm Hg at baseline). Radiographic, bronchoscopic, and histologic assessments demonstrated bilateral infiltrates, airway cytokine elevation, and significantly worsened lung injury scores. Recipient swine provided sufficient metabolic support for extracorporeal lungs to demonstrate robust functional improvement (0 hours, arterial oxygen tension/inspired oxygen fraction ratio 138 ± 28.2 mm Hg; 24 hours, 539 ± 156 mm Hg). Multiscale analyses demonstrated improved gross appearance, aeration, and cellular regeneration in extracorporeal lungs by 24 hours., Conclusions: We demonstrate that acutely injured recipient swine tolerate cross-circulation and enable recovery of donor lungs subjected to extended cold storage. This proof-of-concept study supports feasibility of cross-circulation for recipients with isolated lung disease who are candidates for this clinical application., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Right heart remodeling and tricuspid regurgitation (TR) are common in patients with chronic thromboembolic pulmonary hypertension. This study aimed to investigate the significance of right heart remodeling and TR after pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension., Methods: Patients who underwent PEA with preoperative and postoperative transthoracic echocardiograms at our center between June 2010 and July 2019 were retrospectively reviewed. The composite end point was defined as death or hospitalization due to worsening heart failure, bleeding, or recurrent pulmonary embolism., Results: In total, 158 patients were included for analysis. Right ventricular basal (48 [45-52] vs 43 [39-47] mm, P < .001), midcavitary (46 [42-50] vs 38 [34-42] mm, P < .001), and longitudinal dimensions (87 [83-93] vs 80 [75-84] mm, P < .001), along with the right atrial volume index (37 [25-51] vs 24 [18-34] mL/m 2 , P < .001), significantly decreased, whereas left ventricular and atrial sizes and left ventricular ejection fraction increased after PEA. Overall, 78 patients (49%) showed significant TR on preoperative transthoracic echocardiograms, and 33 (21%) had significant residual TR after PEA. Fourteen patients died, and 24 patients met the composite end point. Residual TR after PEA was independently associated with mortality (P = .005) and the composite end point (P = .003). Patients with residual TR had significantly worse survival (log-rank P < .001) and greater event rates (log-rank P = .003) than those without residual TR., Conclusions: Significant improvements in right heart remodeling were seen following PEA. However, residual TR was a poor prognostic marker., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Refractory hypoxemia can occur in patients with acute respiratory distress syndrome from COVID-19 despite support with venovenous (VV) extracorporeal membrane oxygenation (ECMO). Parallel ECMO circuits can be used to increase physiologic support. We report our clinical experience using ECMO circuits in parallel for select patients with persistent severe hypoxemia despite the use of a single ECMO circuit., Methods: We performed a retrospective cohort study of all patients with COVID-19-related acute respiratory distress syndrome who received VV-ECMO with an additional circuit in parallel at Vanderbilt University Medical Center between March 1, 2020, and March 1, 2022. We report demographic characteristics and clinical characteristics including ECMO settings, mechanical ventilator settings, use of adjunctive therapies, and arterial blood gas results after initial cannulation, before and after receipt of a second ECMO circuit in parallel, and before removal of the circuit in parallel, and outcomes., Results: Of 84 patients with COVID-19 who received VV-ECMO during the study period, 22 patients (26.2%) received a circuit in parallel. The median duration of ECMO was 40.0 days (interquartile range, 31.6-53.1 days), of which 19.0 days (interquartile range, 13.0-33.0 days) were spent with a circuit in parallel. Of the 22 patients who received a circuit in parallel, 16 (72.7%) survived to hospital discharge and 6 (27.3%) died before discharge., Conclusions: In select patients, the additional use of an ECMO circuit in parallel can increase ECMO blood flow and improve oxygenation while allowing for lung-protective mechanical ventilation and excellent outcomes., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Despite advances in treatment of idiopathic pulmonary arterial hypertension (IPAH), there remains no medical cure, and patients can experience disease progression leading to right heart failure, progressive exercise intolerance, and death. The reversed Potts shunt (left pulmonary artery to descending aorta) was reintroduced for treatment of end-stage IPAH to permit decompression of the suprasystemic right ventricle by right to left shunting, with preservation of upper body oxygenation. The shunt has the potential to delay the need for lung transplantation and offer a treatment for those who are transplant ineligible. To optimize shunt design and avoid the potential complications of bidirectional shunting, we developed a novel approach using a unidirectional-valved shunt (UVS) in patients with IPAH with suprasystemic pulmonary arterial pressure and poor right ventricular function., Methods: A single-center retrospective review was performed of UVS cases done at Columbia University Medical Center-New York Presbyterian between November 1, 2016, and May 1, 2019., Results: Five patients (4 female; ages 12-22 years) underwent UVS. All had suprasystemic pulmonary arterial pressure, poor right ventricular function, and World Health Organization functional class IV symptoms at baseline. All patients are alive and transplant-free at latest follow-up (range 3-33 months; median 6 ± 11 months)., Conclusions: The UVS may offer an alternative solution to lung transplantation in adolescents and young adults with IPAH. Longer-term follow-up is needed to determine the ultimate impact of unidirectional unloading of the right ventricle in these patients and to determine whether the UVS will enable a broader approach to the treatment of patients with IPAH., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Lung remains the least-utilized solid organ for transplantation. Efforts to recover donor lungs with reversible injuries using ex vivo perfusion systems are limited to <24 hours of support. Here, we demonstrate the feasibility of extending normothermic extracorporeal lung support to 4 days using cross-circulation with conscious swine., Methods: A swine behavioral training program and custom enclosure were developed to enable multiday cross-circulation between extracorporeal lungs and recipient swine. Lungs were ventilated and perfused in a normothermic chamber for 4 days. Longitudinal analyses of extracorporeal lungs (ie, functional assessments, multiscale imaging, cytokine quantification, and cellular assays) and recipient swine (eg, vital signs and blood and tissue analyses) were performed., Results: Throughout 4 days of normothermic support, extracorporeal lung function was maintained (arterial oxygen tension/inspired oxygen fraction >400 mm Hg; compliance >20 mL/cm H 2 O), and recipient swine were hemodynamically stable (lactate <3 mmol/L; pH, 7.42 ± 0.05). Radiography revealed well-aerated lower lobes and consolidation in upper lobes of extracorporeal lungs, and bronchoscopy showed healthy airways without edema or secretions. In bronchoalveolar lavage fluid, granulocyte-macrophage colony-stimulating factor, interleukin (IL) 4, IL-6, and IL-10 levels increased less than 6-fold, whereas interferon gamma, IL-1α, IL-1β, IL-1ra, IL-2, IL-8, IL-12, IL-18, and tumor necrosis factor alpha levels decreased from baseline to day 4. Histologic evaluations confirmed an intact blood-gas barrier and outstanding preservation of airway and alveolar architecture. Cellular viability and metabolism in extracorporeal lungs were confirmed after 4 days., Conclusions: We demonstrate feasibility of normothermic maintenance of extracorporeal lungs for 4 days by cross-circulation with conscious swine. Cross-circulation approaches could support the recovery of damaged lungs and enable organ bioengineering to improve transplant outcomes., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Extracorporeal membrane oxygenation (ECMO) is used to provide support for patients with cardiopulmonary failure. Best available medical management often fails in these patients and referring hospitals have no further recourse for escalating care apart from transfer to a tertiary facility. In severely unstable patients, the only option might be to use ECMO to facilitate safe transport. This study aimed to examine the characteristics and outcomes of patients transported while receiving ECMO., Methods: Statistical analysis was performed on data gathered retrospectively from the electronic medical records of adult patients transported while receiving ECMO to Columbia University Medical Center between January 1, 2008, and December 31, 2017., Results: Two hundred sixty five adult patients were safely transported while receiving ECMO with no transport-related complications that adversely affected outcomes. Transport distance ranged from 0.2 to 7084 miles with a median distance of 16.9 miles. One hundred eighty-three (69%) received on veno-venous, 72 (27%) veno-arterial, and 10 (3.8%) veno-venous arterial or veno-arterial venous configurations. Two hundred ten (79%) cannulations were performed at our institution at the referring hospital. Sixty-four percent of patients transported while receiving ECMO survived to hospital discharge., Conclusions: Interfacility transport during ECMO was shown to be safe and effective with minimal complications and favorable outcomes when performed at an experienced referral center using stringently applied protocols., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: This study compared differences in patient outcomes and operative parameters for extracorporeal membrane oxygenation (ECMO) versus cardiopulmonary bypass (CPB) in patients undergoing lung transplants., Methods: Between January 1, 2008, and July 13, 2013, 316 patients underwent lung transplants at our institution, 102 requiring intraoperative mechanical cardiopulmonary support (CPB, n=55; ECMO, n=47). We evaluated survival, blood product transfusions, bleeding complications, graft dysfunction, and rejection., Results: Intraoperatively, the CPB group required more cell saver volume (1123±701 vs 814±826 mL; P=.043), fresh-frozen plasma (3.64±5.0 vs 1.51±3.2 units; P=.014), platelets (1.38±1.6 vs 0.43±1.25 units; P=.001), and cryoprecipitate (4.89±6.3 vs 0.85±2.8 units; P<.001) than the ECMO group. Postoperatively, the CPB group received more platelets (1.09±2.6 vs 0.13±0.39 units; P=.013) and was more likely to have bleeding (15 [27.3%] vs 3 [6.4%]; P=.006) and reoperation (21 [38.2%] vs 7 [14.9%]; P=.009]. The CPB group had higher rates of primary graft dysfunction at 24 and 72 hours (41 [74.5%] vs 23 [48.9%]; P=.008; and 42 [76.4%] vs 26 [56.5%]; P=.034; respectively). There were no differences in 30-day and 1-year survivals., Conclusions: Relative to CPB, the ECMO group required fewer transfusions and had less bleeding, fewer reoperations, and less primary graft dysfunction. There were no statistically significant survival differences at 30 days or 1 year., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Respiratory failure develops in many patients on lung transplant waiting lists before a suitable donor organ becomes available. Extracorporeal membrane oxygenation may be used to bridge such patients to recovery or lung transplantation., Methods: This is a review of a single-institution's experience with placing patients on extracorporeal membrane oxygenation with the intention of bridging them to lung transplantation. End points included successful bridging, duration of extracorporeal membrane oxygenation support, extubation, weaning from extracorporeal membrane oxygenation, overall survival, and extracorporeal membrane oxygenation-related complications. During an approximate 5-year period, acute respiratory failure developed in 18 patients (median age, 34 years) on the institution's lung transplant waiting list (8 hypoxemic, 9 hypercarbic, and 1 combined) who were placed on extracorporeal membrane oxygenation (13 venovenous and 5 venoarterial)., Results: All patients achieved appropriate extracorporeal membrane oxygenation blood flow rates (median, 4.05 L/min) and good gas exchange (median, on extracorporeal membrane oxygenation partial pressure of arterial carbon dioxide 43 mm Hg and partial pressure of arterial oxygen 196 mm Hg). Thirteen patients (72%) were successfully bridged: 10 to transplant and 3 returned to baseline function. Eleven patients (61%) survived beyond 3 months, including the 10 (56%) who underwent transplantation and are still alive. The median duration of extracorporeal membrane oxygenation support for patients who underwent transplantation was 6 days (3.5-31 days) versus 13.5 days (11-19 days) for those who did not undergo transplantation (P = .45). Six patients (33%) were extubated on extracorporeal membrane oxygenation, 4 of whom underwent transplantation. Four patients (22%) who were too unstable for conventional interhospital transfer were transported on extracorporeal membrane oxygenation to Columbia University Medical Center. This subgroup had a 75% bridge to transplant or recovery rate and 100% survival in transplanted patients., Conclusions: Extracorporeal membrane oxygenation is a safe and effective means of bridging well-selected patients with refractory respiratory failure to lung transplantation or return to their baseline condition., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Uncertainty exists among surgeons as to whether minimally invasive esophagectomy (MIE) is a comparable operation to open esophagectomy (OE). The surgical technique and oncologic dissection should not be degraded when using a minimally invasive approach., Methods: We reviewed a single hospital's experience with both OE and MIE. From 2000 to 2010, 257 patients underwent esophagectomy by 1 of 3 surgical techniques: transhiatal, Ivor Lewis, or 3-hole., Results: Of the 257 patients (median age, 67 years; range, 58-74), 92 underwent MIE. Both groups were comparable in terms of gender, age, comorbidities, surgical technique, and induction chemotherapy and radiotherapy. The overall median follow-up was 29.5 months (range, 9.9-61.5). The MIE group had a significantly shorter operative time (MIE vs OE, 330 vs 365 minutes, P = .04), length of stay (MIE vs OE, 9 vs 12 days, P < .01), intensive care unit admission rate (MIE vs OE, 55% vs 81%, P < .01), intensive care unit length of stay (MIE vs OE, 1 vs 2 days, P < .01), and estimated blood loss (MIE vs OE, 100 vs 400 mL, P < .01). More lymph nodes were harvested in the MIE group than in the OE group (17 vs 11 nodes, P < .01). There were insignificant differences in 30-day mortality (MIE vs OE, 2.2% vs 3.0%; P = .93) and overall survival (P = .19), as well as in the rates of all complications, except pneumonia (MIE vs OE, 2% vs 13%; P = .01)., Conclusions: A thoracic surgeon can safely tailor the MIE to a patient's anatomy and oncologic demands while maintaining equivalent survival., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Total aortic arch replacement typically requires hypothermic circulatory arrest, carrying risks of cerebral ischemia. We recently introduced left carotid-subclavian bypass before total aortic arch replacement with thoracic stent grafting to achieve hybrid arch reconstruction with short periods of selective antegrade cerebral perfusion., Methods: From 2004 to 2009, 332 patients underwent ascending aorta or arch replacements. Of these, 37 underwent total aortic arch replacement. In 2008, we began performing left carotid-subclavian bypass before subtotal arch replacement, with side-graft anastomoses to innominate and left carotid arteries. Patients then underwent aortic graft stent deployment to complete arch reconstruction. Twenty-eight patients underwent conventional arch replacement (group I); 9 underwent hybrid arch replacement (group II)., Results: Selective antegrade cerebral perfusion time in group I was 33.3 +/- 13.7 minutes versus 18.9 +/- 9.2 minutes in group II (P = .007). Among group I patients, 82% required hypothermic circulatory arrest (vs 0% in group II, P < .001). Mean cardiopulmonary bypass and aortic crossclamp times were longer in group I than group II (P < .05). Incidence of neurologic complications was 14% in group I (4/28) versus 0% (0/9) in group II, although this finding did not reach statistical significance (P = .55)., Conclusions: Left carotid-subclavian bypass before arch replacement with staged thoracic stent grafting to achieve hybrid arch reconstruction was associated with decreased selective antegrade cerebral perfusion, cardiopulmonary bypass, and aortic crossclamp times and eliminated hypothermic circulatory arrest. This technique may minimize neurologic complications associated with arch replacement and provide a viable hybrid approach to patients with arch aneurysms and dissections., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: The purpose of this study was to create a preoperative risk stratification score (RSS) based on pretransplant recipient characteristics that could be used to predict mortality following lung transplantation., Methods: United Network for Organ Sharing provided de-identified patient-level data. The study population included 8780 adult recipients (age > 12 years) having lung transplantation from January 1, 1999, to December 31, 2006. Multivariate logistic regression (backward, P > .10) was performed. Using the odds ratio for each identified variable, an RSS was devised. The RSS included only pretransplant recipient variables and excluded donor variables., Results: The strongest negative predictors of 1-year survival included extracorporeal membrane oxygenation, decreased estimated glomerular filtration rate, total bilirubin >2.0 mg/dL, recipient age, hospitalization at time of transplant, O(2) dependence, cardiac index <2, steroid dependence, donor:recipient weight ratio <0.7, all non-cystic fibrosis/chronic obstructive pulmonary disease etiologies, and female donor-to-male recipient. Threshold analysis identified 4 discrete groups: low risk, moderate, elevated risk, and high risk. The 1-year actuarial survival was 80.4% for the entire group, compared with 56.8% in the high-risk group (RSS > 7.2, n = 490; 6%)., Conclusion: Pretransplant recipient variables significantly influence both early and late survival following lung transplantation. Some patients face a higher than average risk of mortality during their first year posttransplant, which challenges the goals of equitable organ allocation. RSS may improve organ allocation strategies by avoiding the potential negative impact of performing transplantation in extremely high-risk candidates.