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Objective The aim of this study was to evaluate the effect of center volume on the incidence of postoperative complications and their impact on survival after lung transplantation (LTx). Methods United Network for Organ Sharing data were used to identify adult patients undergoing LTx between 1999 and 2009. Center volume was modeled as both a continuous and a categorical variable. Postoperative complications included infection, rejection, stroke, reoperation, and renal failure requiring dialysis. Multivariable Cox regression and Kaplan-Meier analyses were conducted after stratification on the basis of center volume and type of complication. Results A total of 12,565 LTx recipients were included in the study. Overall rates of postoperative complications were 5.4% for renal failure requiring dialysis, 1.9% for stroke, 19.9% for reoperation, 42.8% for infection, and 10.0% for rejection. High volume centers did not have significantly reduced rates of postoperative complications. Risk-adjusted multivariable Cox analysis demonstrated that in patients with a complication, low volume center was a significant risk factor for increased 90-day, 1-year, and 5-year mortality. Kaplan-Meier analyses similarly demonstrated reduced posttransplant survival in lower volume centers, a finding that persisted after stratification based on individual complication type except for stroke. Conclusions Although high volume centers do not have significantly lower incidences of individual postoperative complications after LTx, they are best able to minimize the adverse effects of these complications on short- and long-term survival. These data suggest that identifying and implementing the institutional practices that lead to better management of postoperative complications after LTx in high volume centers may be prudent to improving outcomes in lower volume hospitals.

ObjectiveThe objective of the present study was to evaluate whether the outcomes of lung transplantation in patients aged 70 years or older have changed after implementation of the lung allocation score in May 2005.MethodsPatients aged 70 years or older undergoing primary lung transplantation from 1995 to 2009 were identified from the United Network for Organ Sharing registry. The primary stratification was the pre-lung allocation score era versus lung allocation score era. Risk-adjusted multivariate Cox regression and Kaplan-Meier analyses were conducted to evaluate the effect of age 70 years or older on 1-year post-transplant mortality compared with a reference cohort of patients aged 60 to 69 years.ResultsOf the overall 15,726 adult lung transplantation patients in the study period, 225 (1.4%) were 70 years old or older and 4634 (29.5%) were 60 to 69 years old. The patients aged 70 years or older were a larger cohort of overall lung transplantation patients in the lung allocation score era compared with before the lung allocation score era (3.1% vs 0.3%, P

ObjectivesThe purpose of this study was to determine whether acute renal injury develops more frequently in women than in men after cardiac surgery and whether this complication is associated with operative mortality in women.MethodsProspectively collected data were evaluated from 9461 patients undergoing coronary artery bypass graft surgery, cardiac valve surgery, or both (3080 women) and not receiving preoperative dialysis. The glomerular filtration rate was estimated by using the Modification of Diet in Renal Disease equations with the last plasma creatinine level before surgical intervention (baseline) and the highest level of the first postoperative week. The primary renal injury outcome was the composite end point of renal injury according to RIFLE criteria (estimated glomerular filtration rate decrease >50% from baseline value) or failure.ResultsThirty-day operative mortality and renal injury were more common in women than in men (5.9% vs 2.8%, P = .01; 5.1% vs 3.6%, P

Background Despite evidence that bilateral internal thoracic arteries (ITAs) improve long-term survival after coronary artery bypass grafting (CABG), uptake of this technique remains low. We directly compared bilateral ITA graft configurations and examined long-term outcomes. Methods We reviewed 762 patients who underwent CABG using bilateral ITA grafts at our institution between 1997 and 2014. The outcomes were mortality and a composite revascularization end point defined as need for percutaneous coronary intervention or repeat CABG. Adjusted subgroup analyses were performed using propensity score-adjusted Cox proportional hazards modeling. Results The cohort was divided into 4 groups: in situ (left ITA [LITA] anastomosed to the left anterior descending artery [LAD] with in situ right ITA [RITA] anastomosed to the left coronary circulation [239 patients]); in situ LITA-LAD and in situ RITA-right coronary circulation (239 patients); in situ RITA-LAD with in situ LITA-left coronary circulation (185 patients); and in situ LITA-LAD with a free RITA as a composite graft with inflow from the LITA or a saphenous vein graft (99 patients). Over a median follow-up of 1128 days, there were 47 deaths, 58 late percutaneous coronary interventions, and 7 repeat CABG procedures. Unadjusted Kaplan-Meier analysis revealed a difference in need for repeat revascularization among the 4 groups (log rank P = .049). However, after statistical adjustment, graft configuration was not an independent predictor of repeat revascularization or death. Conclusions Bilateral ITA graft configuration has no independent effect on need for repeat revascularization or long-term survival. Therefore, the simplest technique, determined by individual patient characteristics, should be selected.

Objective: Limitations in clinical understanding of right ventricular relaxation can be attributed to the paucity of information from basic studies in animal models of right ventricular disease. This study examined, in the conscious state, right ventricular relaxation dynamics under normal conditions (n = 15) and in subacute (2-5 weeks) canine models of right ventricular pressure overload (n = 6), volume overload (n = 7), and free wall ischemia (n = 7). Methods: Right-heart micromanometric measurements were obtained by using multisensor catheters. A new algorithm was developed to obtain representative ensemble averages of hemodynamic waveform data sets. Right ventricular relaxation was analyzed by using an exponential model with 3 parameters: P 0 , τ, and P b . Significant changes versus control values were determined by means of analysis of variance and the Student unpaired t test with Bonferroni's adjustment. Results: In the state of pressure overload, right ventricular pressure decay exhibits an increased P 0 (56.2 ± 19.1 vs 13.1 ± 5.1 mm Hg [mean ± SD]) and prolonged τ (57.1 ± 2.8 vs 27.8 ± 3.9 ms); there is also a decreased P b (−7.9 ± 1.5 vs 0.28 ± 1.8 mm Hg). The only significant change in volume overload is an increased asymptote, P b (5.3 ± 2.9 mm Hg). In right ventricular ischemia, prolongation of τ (41.4 ± 13.0 ms) and decreased P b (−1.95 ± 1.1 mm Hg) attain high significance. Conclusions: Distinctive abnormalities in right ventricular relaxation dynamics accompany pressure overload, volume overload, and ischemia and may contribute to clinical right ventricular dysfunction. J Thorac Cardiovasc Surg 2002;124:964-72

We sought to determine whether a pilot goal-directed perfusion initiative could reduce the incidence of acute kidney injury after cardiac surgery.On the basis of the available literature, we identified goals to achieve during cardiopulmonary bypass (including maintenance of oxygen delivery300 mL O2/min/mWe used the goal-directed perfusion initiative in 88 patients and matched these to 88 control patients who were similar across all variables, including mean age (61 years in controls vs 64 years in goal-directed perfusion initiative patients, P = .12) and preoperative glomerular filtration rate (90 vs 83 mL/min, P = .34). Controls received more phenylephrine on cardiopulmonary bypass (mean 2.1 vs 1.4 mg, P .001) and had lower nadir oxygen delivery (mean 241 vs 301 mL O2/min/mThe goal-directed perfusion initiative was associated with reduced acute kidney injury incidence after cardiac surgery in this pilot study.

ObjectivesThis study derived and validated a risk index for postoperative renal failure after orthotopic heart transplantation.MethodsAdult orthotopic heart transplantations performed between 2000 and 2010 were identified in the United Network for Organ Sharing database. Patients were randomly divided 4:1 into derivation and validation cohorts. The primary outcome was new-onset postoperative renal failure requiring dialysis. A multivariable model was created incorporating variables associated with renal failure in univariate analysis, with significant risk factors assigned points based on odds ratios. A simple guide was generated to demonstrate ranges of risk scores associated with clinically meaningful renal failure rates.ResultsA total of 14,635 orthotopic heart transplantation recipients were included. New-onset postoperative renal failure occurred in 1128 patients (7.7%). A 100-point risk score was generated using 13 significant risk factors. There was a high degree of correlation between actual renal failure rates in the validation cohort and predicted rates in the derivation cohort based on risk scores (r = 0.91, P 20% risk, score ≥40). The actual renal failure rates in the validation cohort for these risk score ranges corresponded to the risk category they were assigned to: score 0 to 15 (4.1% rate), score 16 to 26 (6.8% rate), score 27 to 39 (13.2% rate), and score 40 or more (20.2% rate).ConclusionsThis 100-point risk index incorporating 13 risk factors is highly predictive of new-onset postoperative renal failure after orthotopic heart transplantation. Prospective assessment of orthotopic heart transplant recipients using the risk categories that were generated on the basis of score ranges may help in tailoring perioperative management.

Introduction: Calcitonin gene-related peptide, a potent vasodilating inotropic agent, increases coronary artery perfusion when administered exogenously and reduces ischemic injury in nonmyocardial tissue. However, it is unclear whether this agent improves recovery of myocardial performance after reversible myocardial ischemia. Methods: Nine dogs underwent complete occlusion of the left anterior descending coronary artery for 15 minutes and were monitored during 24 hours of reperfusion. Calcitonin gene–related peptide (0.07 μg · kg –1 · min –1 ), nitroglycerin (65 μg · kg –1 · min –1 ), or saline solution placebo was infused intravenously during initial reperfusion. Ischemia/reperfusion was repeated in concurrent 24-hour periods until all animals received infusions in random order. Micromanometry and sonomicrometry determined left ventricular pressure and myocardial segment length. Myocardial performance, based on the linear relationship between stroke work and end-diastolic segment length, was estimated with the preload recruitable work area.Results were analyzed as percent control and compared statistically with the use of repeated measures analysis of variance. Results: Recovery of myocardial performance was augmented during reperfusion with calcitonin gene–related peptide infusion relative to placebo ( P = .005; mean preload recruitable work area ± SE after calcitonin gene–related peptide infusion, 2484 ± 705 mm Hg at 90 minutes of reperfusion versus 1473 ± 300 mm Hg for placebo. Recovery of performance after nitroglycerin infusion was similar to recovery after placebo. Conclusions: Calcitonin gene–related peptide infusion improves recovery of contractile function in stunned myocardium. Unlike inotropic agents that impair recovery from reversible ischemia, calcitonin gene–related peptide may confer cardioprotective effects on ischemic myocardium. (J Thorac Cardiovasc Surg 2000;119:1246-54)

BackgroundThis study was undertaken to examine interhospital variability in inpatient costs of coronary artery bypass grafting (CABG).MethodsThe Nationwide Inpatient Sample was used to identify isolated CABGs performed between 2005 and 2008 in the United States. Charges for inpatient care were supplied by the data set, and hospital charge-to-cost ratios were used to derive inpatient costs for each patient and aggregated at the hospital level. Mixed-effect linear regression models were created to evaluate variability in costs between hospitals adjusting for 34 patient, operative, complication, and hospital-related variables.ResultsA total of 633 hospitals performed isolated CABG in 183,973 patients. In unadjusted analysis, there was significant baseline variability in average inpatient costs of CABG between hospitals (SD, $12,130; P

ObjectiveThe aim of the present study was to review nationwide outcomes of surgical embolectomy for acute pulmonary embolism.MethodsAdult patients undergoing surgical embolectomy for acute pulmonary embolism from 1999 to 2008 were identified in the weighted Nationwide Inpatient Sample. The primary endpoint was inpatient mortality. Multivariate logistic regression analysis incorporating significant univariate predictors (P

ObjectiveThe impact of Society of Thoracic Surgeons predicted mortality risk score on resource use has not been previously studied. We hypothesize that increasing Society of Thoracic Surgeons risk scores in patients undergoing aortic valve replacement are associated with greater hospital charges.MethodsClinical and financial data for patients undergoing aortic valve replacement at The Johns Hopkins Hospital over a 10-year period (January 2000 to December 2009) were reviewed. The current Society of Thoracic Surgeons formula (v2.61) for in-hospital mortality was used for all patients. After stratification into risk quartiles, index admission hospital charges were compared across risk strata with rank-sum and Kruskal–Wallis tests. Linear regression and Spearman’s coefficient assessed correlation and goodness of fit. Multivariable analysis assessed relative contributions of individual variables on overall charges.ResultsA total of 553 patients underwent aortic valve replacement during the study period. Average predicted mortality was 2.9% (±3.4) and actual mortality was 3.4% for aortic valve replacement. Median charges were greater in the upper quartile of patients undergoing aortic valve replacement (quartiles 1–3, $39,949 [interquartile range, 32,708–51,323] vs quartile 4, $62,301 [interquartile range, 45,952–97,103], P

ObjectivesIschemia–reperfusion injury remains a devastating complication of lung transplantation. Phosphodiesterase inhibitors have been shown to precondition tissues against ischemia–reperfusion injury. Little is known, however, about the utility of phosphodiesterase inhibition in reperfusion injury after lung transplantation. We evaluated the long-acting phosphodiesterase-5 inhibitor, tadalafil, in an ex vivo lung transplant model.MethodsNew Zealand White rabbits (4 kg), were given oral tadalafil (n = 11) 24 hours before lung harvest and compared with rabbits given oral vehicle alone (n = 11). Lungs were recovered with Perfadex solution (Vitrolife, Kungsbacka, Sweden) and cold stored for 18 hours. After storage, lung blocks were reperfused with donor rabbit blood in an ex vivo apparatus. Pulmonary artery pressures were recorded with serial arterial and venous blood gas sampling and animals served as their own controls. Phosphodiesterase-5 and protein kinase G tissue activity assays confirmed drug effects. Luminol chemiluminescence assay was used to measure reactive oxygen species and levels of endothelial and inducible nitric oxide synthase were measured.ResultsExtended cold storage, followed by reperfusion produced a consistent reproducible decrease in oxygenation and increase in pulmonary pressure. Tadalafil-treated animals exhibited greater Pao2 throughout the course of reperfusion (P = .001) Mean pulmonary artery pressure was lower in tadalafil-treated animals (22 vs 40 mm Hg; P = .04). Phosphodiesterase-5 activity was decreased (143 ± 8 vs 205 ± 32 mP; P < .001) with protein kinase G activity increased (25 ± 12 vs 12 ± 2.4 fU/μg; P = .01) in the experimental group confirming that oral pretreatment resulted in active phosphodiesterase inhibition in the lung tissue. Reactive oxygen species (as measured by luminol activity) were decreased in tadalafil-treated animals (7.8 ± 1.5 vs 10.2 ± 1.2 relative light units; P = .003).ConclusionsOur experimental model demonstrates that oral donor pretreatment with a long-acting phosphodiesterase inhibitor is an effective strategy for improving pulmonary performance after reperfusion. Importantly, phosphodiesterase enzymes and their downstream effectors may play a critical role in reperfusion injury after lung transplantation.

In recent years, apical-aortic bypass surgery has been used for patients with a heavily calcified or ‘‘porcelain’’ ascending aorta or hostile mediastinum because these patients would be at high risk for cerebrovascular events during crossclamping of the calcified ascending aorta. In this case, we describe a previously unreported complication of apical aortic bypass and illustrate the role of cardiac catheterization and ventriculography in the hemodynamic evaluation of this patient.

Objective Abrupt increases in right ventricular afterload occur after cardiac transplantation and pulmonary artery banding, which can result in right ventricular hypertrophy and dilatation. Right ventricular dysfunction is also accompanied by β-adrenergic receptor desensitization. We sought to determine whether selective right ventricular expression of a transgene encoding a β-adrenergic receptor kinase inhibitor can improve right ventricular remodeling early after pulmonary artery banding. Methods Rabbits underwent pulmonary artery banding 3 days after percutaneous right coronary artery injection of empty adenovirus (n = 19), a control adenovirus containing the β-galactosidase transgene (n = 10), or an adenovirus containing the β-adrenergic receptor kinase inhibitor transgene (n = 14). Sham-operated animals (n = 7) underwent instrumentation without deployment of the pulmonary artery band. Right ventricular function was assessed in each rabbit before and 7 days after pulmonary artery banding. Right ventricular mass and dimensions (surface area and volume) were obtained, and biochemical analysis was performed to confirm transgene expression and to characterize β-adrenergic receptor signaling. Results Right ventricular mass was increased in animals treated with adenovirus containing the β-adrenergic receptor kinase inhibitor transgene, adenovirus containing the β-galactosidase transgene, and empty adenovirus after banding when compared with results in sham-operated animals. However, right ventricular volume and surface area, as measures of dilatation, were significantly lower in pulmonary artery banded rabbits pretreated with adenovirus containing the β-adrenergic receptor kinase inhibitor transgene when compared with those treated with empty adenovirus or adenovirus containing the β-galactosidase transgene. Right ventricular contractility and defective β-adrenergic receptor signaling were significantly enhanced in rabbits expressing the β-adrenergic receptor kinase inhibitor after pulmonary artery banding. Conclusions Right ventricular preconditioning with the β-adrenergic receptor kinase inhibitor transgene can attenuate the early right ventricular dilatation and dysfunction associated with pulmonary artery banding. Thus β-adrenergic receptor kinase inhibition might represent a novel target for limiting ventricular remodeling after increased right ventricular afterload.

ObjectiveWe evaluated the combined effect of hospital and surgeon volume on operative outcomes of mitral valve surgery in the United States.MethodsThe Nationwide Inpatient Sample was used to identify adult patients undergoing isolated mitral valve surgery for mitral regurgitation from 2003 to 2008. Hospitals and surgeons were separately stratified into equal-size tertiles according to annual overall mitral valve operative volumes. Multivariate logistic regression analysis was conducted, adjusting for multiple patient, hospital, and operative data, to determine the separate and combined effects of hospital and surgeon volume on operative outcomes.ResultsA total of 50,152 eligible patients were identified during the study period. Although both hospital and surgeon volume correlated significantly with operative mortality in separate risk-adjusted analyses, only lower surgeon volume persisted as a significant risk factor in the combined risk-adjusted analysis. Moreover, although hospital volume only accounted for 10.7% of the surgeon volume effect on increased mortality for low-volume surgeons, surgeon volume accounted for 74.5% of the hospital volume effect on increased mortality in low-volume hospitals. Surgeon, but not hospital, volume correlated with inpatient costs. Also, significant trends were seen with repair rates, with increasing surgeon volume demonstrating a relatively stronger correlation with the odds of repair (P

ObjectivesThe aim of the present study was to identify the predictors of 5-year survival in elderly patients undergoing orthotopic heart transplantation (OHT).MethodsA review of the United Network for Organ Sharing database was conducted of recipients 60 years old or older undergoing OHT from 1995 to 2004. The variables were compared between the 5-year survivors and the patients who died within 5 years of OHT. A multivariate logistic regression model was constructed using the covariates significantly associated with 5-year survival on univariate analysis.ResultsA total of 5330 elderly patients underwent OHT during the study period. Of these patients, 3492 (65.5%) were 5-year survivors, 1580 (29.6%) had died within 5 years of OHT and were considered controls, and 258 (4.8%) were lost to follow-up. The predictors of improved 5-year survival included younger age (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95–1.00; P = .03), lower creatinine (OR, 0.92; 95% CI, 0.87–0.98; P = .01), white race (OR, 1.23; 95% CI, 1.02–1.49; P = .03), shorter ischemic time (OR, 0.93; 95% CI, 0.87–0.99; P = .02), and younger donor age (OR, 0.99; 95% CI, 0.99–1.00; P = .03). The following significantly reduced the odds of surviving to 5 years: mechanical ventilation (OR, 0.48; 95% CI, 0.33–0.71; P

Objective Lung transplantation has been increasingly applied to patients over the age of 60 years. Importantly, the procedure of choice, single versus bilateral lung transplantation, remains unclear. Therefore, the purpose of this study was to examine short- and midterm outcomes in this age group with particular attention to procedure type. Methods All first lung transplant recipients, 60 years of age or older, reported to the United Network for Organ Sharing from 1998 to 2004 were divided into two groups: bilateral and single lung transplantation. A retrospective review of pertinent baseline characteristics, clinical parameters, and outcomes was performed. Kaplan–Meier methodology was used to estimate and Cox proportional hazards regression modeling was used to compare posttransplant survival between these groups. Additionally, propensity scores analysis was performed. Results During the study period, 1656 lung transplant recipients were 60 years of age or older (mean 62.7 ± 2.4 years, median 62 years). Of these, 364 (28%) had bilateral and 1292 (78%) had single lung transplantation. Survival was not statistically different between the two groups. In the multivariate analysis, bilateral versus single lung transplantation was not a predictor of mortality. Idiopathic pulmonary fibrosis and a donor tobacco history of more than 20 pack-years were significantly associated with mortality ( P = .003, CI 1.12–1.76; and P = .006, CI 1.09–1.63; respectively). Conclusions The survival of lung transplant recipients 60 years of age or older who underwent bilateral versus single lung transplantation is comparable. These data suggest that type of procedure is not a predictor of mortality in this age group. Idiopathic pulmonary fibrosis and donor cigarette use of more than 20 pack-years were independently associated with mortality.

Objectives: Ex vivo perfusion of the cardiac allograft during organ procurement is an ideal environment for adenoviral vectors with transgenes that target improving graft contractility. One such target is the β-adrenergic receptor–signaling system, in which alterations in transgenic mice have elucidated novel means to improve the function of the heart in vivo. The purpose of the current study was to determine the functional consequences of β-adrenergic receptor manipulation in a rabbit model of cardiac allograft transplantation. Methods: New Zealand White rabbits weighing 3 kg served as recipients to 1-kg outbred donors. Donor hearts were arrested and harvested, and 1 of 3 adenoviral constructs was administered into the aortic root perfusing the graft. Transgenes delivered encoded either the human β 2 -adrenergic receptor, a peptide inhibitor of β-adrenergic receptor densensitization, or the marker transgene β-galactosidase. Results: Five days after cervical heterotopic transplantation, left ventricular performance was measured on a Langendorff apparatus. A moderate pattern of rejection was seen in all grafts. Biventricular myocyte expression of β-galactosidase was observed, and β 2 -adrenergic receptor density was elevated 10-fold in grafts that received adeno-β 2 -adrenergic receptor. Left ventricular systolic and diastolic performance was significantly increased in grafts transfected with either adeno-β 2 -adrenergic receptor or adeno-β-adrenergic receptor densensitization compared with control grafts that received adeno-β-galactosidase. Conclusions: Ex vivo adenovirus-mediated gene transfer is feasible in a rabbit allograft model and, more important, genetic manipulation of β-adrenergic receptor signaling either by increasing β 2 -adrenergic receptor density or blocking endogenous receptor desensitization improves graft function acutely in this allograft model. (J Thorac Cardiovasc Surg 2000;120:581-8)

BackgroundTo evaluate trends and outcomes of descending thoracic aortic aneurysm (DTAA) repair in the United States.MethodsAdults undergoing DTAA repair between 1998 and 2008 were identified in the Nationwide Inpatient Sample. To limit confounding, patients with connective tissue disorders, aortic dissection, or thoracoabdominal aneurysms were excluded. Stratification was based on intact versus ruptured DTAA and open versus endovascular approach. Standardized annual rates of repair were calculated based on US Census Bureau population estimates. Logistic regression analysis incorporating multiple patient, operative, and hospital variables was used for risk adjustment.ResultsA total of 20,568 DTAA patients (intact, 17,780; ruptured, 2788) underwent repair (open, 15,265; endovascular, 5303). Patients undergoing repair in the more recent era had higher comorbidity burdens than those undergoing repair in the earlier era. Despite this, annual rates of repair for both intact and ruptured DTAAs increased significantly during the study period (intact, 2.2-10.6 per 1 million; ruptured, 0.8-1.3 per 1 million; P

Objective: Right ventricular dysfunction is a poorly understood but persistent clinical problem. This study was undertaken to evaluate ventricular performance and β-adrenergic receptor signaling in a tricuspid regurgitation model of right ventricular overload. Methods: Seventeen dogs were chronically instrumented with epicardial dimension transducers. By means of the shell-subtraction model, right ventricular pressure-volume relationships were evaluated in normal and right ventricular overload states. Right ventricular chamber performance was quantified by the stroke work at an end-diastolic volume relationship. Results: Right ventricular volume overload caused a 28% ± 11% and 31% ± 9% decline in chamber performance acutely and at 1 week, respectively, whereas end-diastolic volume increased from 45 ± 21 to 60 ± 30 mL ( P =.019). β-Adrenergic receptor signaling in myocardial samples was assessed, examining adenylyl cyclase and G-protein–coupled receptor kinase activity. Stimulated adenylyl cyclase activity significantly decreased, and G-protein–coupled receptor kinase activity significantly increased in both left and right ventricular samples caused by increased levels of β-adrenergic receptor kinase 1. No change in β-adrenergic receptor density was seen at 1 week. Conclusions: Early right ventricular overload is associated with impaired right ventricular chamber contractility, dilation, and, importantly, a biventricular alteration of β-adrenergic receptor signaling. (J Thorac Cardiovasc Surg 2000;119:342-9)

ObjectivePreformed anti-human leukocyte antigen antibodies have been associated with prolonged wait times and increased mortality in orthotopic heart transplantation. We used United Network for Organ Sharing data to examine panel reactive antibody titers in patients bridged to transplant with left ventricular assist devices.MethodsThis was a retrospective review of the United Network for Organ Sharing dataset for all patients bridged to orthotopic heart transplantation with a HeartMate II or HeartMate XVE (Thoratec Corp, Pleasanton, Calif) from January 2004 to December 2009. Patients were primarily stratified by device type and secondarily grouped for comparisons by high (>25%) versus low (0%) panel reactive antibody activity (class I and II). Outcomes included survival (30-day and 1-year), treated rejection in the year after orthotopic heart transplantation, and primary graft dysfunction. Cox proportional hazards regression examined 30-day and 1-year survival.ResultsA total of 871 patients (56.1%) received the HeartMate II device, and 673 patients (43.9%) received the HeartMate XVE device. Patients with high panel reactive antibody had longer duration on the wait list (205 days [interquartile range, 81–344] vs 124 days [interquartile range, 51–270], P = .01). High panel reactive antibody class II was more common in patients with the HeartMate XVE device (51/547 [9.3%] vs 42/777 [5.4%], P

ObjectiveWe developed a validated 50-point recipient risk index predicting short-term mortality after orthotopic heart transplant (OHT). This study examined the relationship between institutional volume and recipient risk on post-OHT mortality.MethodsWe used United Network for Organ Sharing (UNOS) data to identify primary OHT recipients between January 2000 and April 2010. Centers were stratified by mean annual volume. Preoperative Index for Mortality Prediction After Cardiac Transplantation risk scores were calculated for each patient with our validated 50-point system. Primary outcomes were 30-day and 1-year survivals. Multivariable logistic regression analysis included interaction terms to examine effect modification of risk and volume on mortality.ResultsIn all, 18,226 patients underwent transplant at 141 centers: 1173 (6.4%) recipients at low-volume centers (15 procedures/y). Low center volume was associated with worse 1-year mortality (odds ratio, 1.58; 95% confidence interval, 1.30-1.92; P