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J Trent Magruder,1 Todd C Crawford,1 Joshua C Grimm,1 Joseph L Fredi,2 Ashish S Shah3 1Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, 2Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 3Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA Abstract: Based on the principle of surgical edge-to-edge mitral valve repair (MVR), the MitraClip percutaneous MVR technique has emerged as a minimally invasive option for MVR. This catheter-based system has been widely demonstrated to be safe, although inferior to surgical MVR. Studies examining patients with ≥3+ mitral regurgitation (MR) show that, for all patients treated, freedom from death, surgery, or MR ≥3+ is in the 75%–80% range 1 year following MitraClip implantation. Despite its inferiority to surgical therapy, in high-risk surgical patients, data suggest that the MitraClip system can be employed safely and that it can result in symptomatic improvement in the majority of patients, while not precluding future surgical options. MitraClip therapy also appears to reduce heart failure readmissions in the high-risk cohort, which may lead to an economic benefit. Ongoing study is needed to clarify the impact of percutaneous mitral valve clipping on long-term survival in high-risk populations, as well as its role in other patient populations, such as those with functional MR. Keywords: mitral clips, mitral regurgitation, cardiac surgery, percutaneous, transcatheter

Background: Coronary artery occlusion (CO) during transcatheter aortic valve replacement (TAVR) is a devastating complication. The objective of this study was to assess the clinical impact of a computational predictive modeling algorithm for CO during TAVR planning., Methods: From January 2020 to December 2022, 116 patients (7.6%) who underwent TAVR evaluation were deemed to be at increased risk of CO on the basis of traditional criteria. Patients underwent prospective computational modeling (DASI Simulations) to assess their risk of CO during TAVR; procedural modifications and clinical results were reviewed retrospectively., Results: Of the 116 patients at risk for CO by traditional methodology, 53 had native aortic valve stenosis (45.7%), 47 had undergone previous surgical AVR (40.5%), and 16 had undergone previous TAVR (13.8%). Transcatheter valve choice, size, or implantation depth was modeled for all patients. Computational modeling predicted an increased risk of CO in 39 of 116 (31.9%) patients. Within this subcohort, 29 patients proceeded with TAVR. Procedural modifications to augment the risk of CO included bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (n = 10), chimney coronary stents (n = 8), and coronary access without stents (n = 3). There were no episodes of coronary artery compromise among patients after TAVR, either for those predicted to be at high risk of CO (with procedural modifications) or those predicted to be at low risk (standard TAVR)., Conclusions: The use of preoperative simulations for TAVR in patient-specific geometry through computational predictive modeling of CO is an effective enhancement to procedure planning., Competing Interests: Disclosures Taylor Becker reports a relationship with DASI Simulations that includes: consulting or advisory. Pradeep Yadav reports a relationship with Edwards Lifesciences that includes: consulting or advisory and speaking and lecture fees; with Abbott Vascular that includes: consulting or advisory and speaking and lecture fees; with Boston Scientific that includes: consulting or advisory; with DASI Simulations that includes: equity or stocks; with Edwards Lifesciences that includes: funding grants; with Abbott Vascular that includes: funding grants; with Boston Scientific that includes: funding grants; with Medtronic that includes: funding grants; with JenaValve Technology that includes: funding grants; with Trisol Medical that includes: funding grants; with HighLife that includes: funding grants; with Innovalve that includes: funding grants; and with CroiValve that includes: funding grants. Vivek Rajagopal reports a relationship with Opus Medical Therapies that includes: equity or stocks. Venkateshwar Polsani reports a relationship with DASI Simulations that includes: board membership. Lakshmi Prasad Dasi reports a relationship with DASI Simulations that includes: board membership and equity or stocks; and reports holding patent PCT/US2022/072784. Vinod H. Thourani reports a relationship with Abbott Vascular that includes: consulting or advisory and speaking and lecture fees; with Artivion that includes: consulting or advisory and speaking and lecture fees; with AtriCure that includes: consulting or advisory; with Boston Scientific that includes: consulting or advisory; with CroiValve that includes: consulting or advisory; with Edwards Lifesciences that includes: funding grants; with JenaValve Technology that includes: consulting or advisory and speaking and lecture fees; with DASI Simulations that includes: equity or stocks; with Abbott Vascular that includes: funding grants; with Artivion that includes: funding grants; with AtriCure that includes: funding grants; with Boston Scientific that includes: funding grants; with CroiValve that includes: funding grants; with Edwards Lifesciences that includes: funding grants; with Medtronic that includes: funding grants; and with Trisol that includes: funding grants. All other authors declare that they have no conflicts of interest to disclose., (Copyright © 2024 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Aortic stenosis (AS) contributes to significant cardiovascular morbidity and mortality worldwide, and the natural history from symptoms to ventricular decompensation, heart failure, and death has been well documented. For more than 2 decades, technologies including imaging and biomarkers have shown a promising ability to detect myocardial damage associated with AS before symptoms arise. Current treatment guidelines rely heavily on symptoms or ventricular decompensation as triggers for aortic valve intervention. There is increasing appreciation of the relationship between myocardial damage due to AS before the emergence of symptoms, and a number of published randomised trials suggest a benefit to early intervention in asymptomatic AS, with additional trials actively enrolling. Future treatment paradigms may incorporate early detection of ventricular damage by noninvasive new technologies as triggers for asymptomatic intervention. Enthusiasm for early aortic valve replacement should be tempered by consideration of the competing risks of early valve intervention, but an increasing preponderance of evidence continues to suggest that earlier intervention in AS is warranted., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosures Dr Thourani reports the following relationships: Abbott Vascular (consulting or advisory); Artivion, Inc. (consulting or advisory); Boston Scientific Corp (consulting or advisory); Dasi Simulations (consulting or advisory); Edwards Lifesciences Corporation (consulting or advisory); JenaValve Technology Inc (consulting or advisory); and Medtronic (consulting or advisory).

Background: The relationship between low oxygen delivery (DO 2 ) on cardiopulmonary bypass and morbidity and mortality following cardiac surgery remains unexamined., Methods: We reviewed patients undergoing Society of Thoracic Surgeons index procedures from March 2019 to July 2020, coincident with implementation of a new electronic perfusion record that provides for continuous recording of DO 2 and flow parameters. Continuous perfusion variables were analyzed using area-over-the-curve (AOC) calculations below predefined thresholds (DO 2 <280 mL O 2 /min/m 2 , cardiac index <2.2 L/min, hemoglobin < baseline, and mean arterial pressure <65 mm Hg) to quantify depth and duration of potentially harmful exposures. Multivariable logistic regression adjusted by Society of Thoracic Surgeons predicted-risk scores were used to assess for relationship of perfusion variables with the primary composite outcome of any Society of Thoracic Surgeons index procedure, as well as individual Society of Thoracic Surgeons secondary outcomes (eg, mortality, renal failure, prolonged ventilation >24 hours, stroke, sternal wound infection, and reoperation)., Results: Eight hundred thirty-four patients were included; 42.7% (356) underwent isolated coronary artery bypass grafting (CABG), whereas 57.3% underwent nonisolated CABG (eg, valvular or combined CABG/valvular operations). DO 2 <280-AOC trended toward association with the primary outcome across all cases (P = .07), and was significantly associated for all nonisolated CABG cases (P = .02)-more strongly than for cardiac index <2.2-AOC (P = .04), hemoglobin <7-AOC (P = .51), or mean arterial pressure <65-AOC (P = .11). Considering all procedures, DO 2 <280-AOC was independently associated prolonged ventilation >24 hours (P = .04), an effect again most pronounced in nonisolated-CABG cases (P = .002), as well as acute kidney injury <72 hours (P = .04). Patients with glomerular filtration rate <65 mL/min and baseline hemoglobin <12.5 g/dL appeared especially vulnerable., Conclusions: Low DO 2 on bypass may be associated with morbidity/mortality following cardiac surgery, particularly in patients undergoing nonisolated CABG. These results underscore the importance of goal-directed perfusion strategies., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: We sought to assess the relationship of intraoperative perfusion parameters while on cardiopulmonary bypass, including oxygen delivery (DO 2 ), to the need for ECMO following orthotopic heart transplantation (OHT)., Methods: We included all adult (>18 years old) OHTs performed at our institution since implementation of an electronic perfusion record (March 2019-February 2020). Multi-organ transplants were excluded. The primary outcome was the need for immediate venoarterial ECMO in the OR following OHT. Univariable statistics were computed across demographic, clinical, operative, and perfusion variables, including oxygen delivery (DO 2 ) measured each minute., Results: Fifty-three OHT were included with a median age of 54 years (interquartile range, 45-61). The primary outcome occurred in eight patients (15.1%). A significantly greater proportion of patients requiring ECMO had ischemic cardiomyopathy (50.0% (4/8) vs. 15.6% (7/45), p = 0.02) and had preoperative ventricular assist devices (37.5% (3/8) vs. 8.9% (4/45), p = 0.03). Median bypass times were longer in the ECMO group (217 vs. 147 minutes, p = 0.001). Phenylephrine doses were nonsignificantly higher in ECMO patients (4.1 vs. 1.9 mg, p = 0.10). No significant differences were observed in single-point median DO 2 (275 vs. 294 mL O 2 /min/m 2 BSA, p = 0.17) and nadir DO 2 (226 vs. 222, p = 0.94), but increasing time and depth of DO2 below a threshold of 300 mL O 2 /min/m 2 BSA (i.e. area over the DO 2 curve (AOC) but below threshold) was significantly associated with the need for postoperative ECMO (p = 0.04)., Conclusion: This is the first study to examine the relationship of perfusion parameters, including oxygen delivery, to outcomes following heart transplantation. We note that DO 2  < 300-AOC was significantly associated with the need for postoperative ECMO following heart transplant. Further study will clarify whether potential DO 2 differences in patients who require post-OHT ECMO reflect vasoplegia, or a more causative relationship which might be leveraged to improve outcomes.

Objectives: We sought to develop strategies for management of the aortic arch in patients with Loeys-Dietz syndrome (LDS) through a review of our clinical experience with these patients and a comparison with our experience in patients with Marfan syndrome (MFS)., Methods: We reviewed hospital and follow-up records of 79 patients with LDS and compared them with 256 patients with MFS who served as reference controls., Results: In the LDS group, 16% of patients presented initially with acute aortic dissection (AAD) (67% type A, 33% type B) or developed AAD during follow-up, compared with 10% of patients with MFS (95% type A, 5% type B). There was no difference between patients with LDS or MFS in need for subsequent arch interventions after aortic root surgery (46% vs 50%, P = 1.0). Among the patients who never had AAD, the need for arch repair at initial root surgery was greater in patients with LDS (5% vs 0.4%, P = .04), as was the need for any subsequent aortic surgery (12% vs 1.3%, P = .0004). Late mortality in patients with LDS after arch repair was greater than in those patients who had no arch intervention (33% vs 6%, P = .007)., Conclusions: In the absence of dissection, patients with LDS have a greater rate of arch intervention after root surgery than patients with MFS. After a dissection, arch reintervention rates are similar in the 2 groups. Arch intervention portends greater late mortality in LDS., (Copyright © 2019. Published by Elsevier Inc.)

We assessed the impact of donor multiorgan procurement on survival following orthotopic heart transplantation (OHT). From the UNOS STAR database, we included all adult (≥18 Y) heart transplants (OHT) performed since 2000 and used donor IDs to determine how many other organs were procured from the same donor as the recipient's heart allograft (regardless of recipient). The Kaplan-Meier survival functions and risk-adjusted Cox proportional hazards regression models were computed to assess the association of multiorgan procurement with post-heart transplantation mortality. We included 40 336 OHT patients. Including the heart, the median number of donor organs procured was 3 (IQR, 3-4). Heart donors underwent liver procurement in 89.7%; kidney(s) in 98.1% (single 95%, bilateral 5%); lung(s) in 38.0% (single 28%, bilateral 72%); pancreas in 10.4%; and intestine in 1.6%. Following risk adjustment across 16 recipient- and donor-specific variables, an increasing number of organs procured were independently associated with reduced post-OHT mortality (HR 0.98, 95% CI 0.96-0.99, P = .025). Though no significant associations were found examining specific organ types, double lung procurement trended toward a protective effect (HR 0.96, 0.92-1.01, P = .086), with counts of non-lung organs procured still bordering on significance (HR 0.97, 95% CI 0.95-1.00, P = .067). These results likely reflect improved multiorgan donor quality., (© 2020 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: At the recent 6th World Symposium on Pulmonary Hypertension (PH), the definition of PH was redefined to include lower pulmonary artery pressures in the setting of elevated pulmonary vascular resistance (PVR). However, the relevance of this change to subjects with PH due to left-heart disease as well as the preoperative assessment of heart transplant (HT) recipients is unknown., Methods: The United Network for Organ Sharing database was queried to identify adult recipients who underwent primary HT from 1996 to 2015. Recipients were subdivided into those with mean pulmonary artery pressure (mPAP) < 25 mm Hg and ≥ 25 mm Hg. Exploratory univariable analysis was undertaken to identify candidate risk factors associated with 30-day and 1-year survival (conditional on 30-day survival) in recipients with mPAP < 25 mm Hg, and subsequently, parsimonious multivariable Cox proportional hazards models were constructed to assess the independent association with PVR., Results: Over the study period, 32,465 patients underwent HT, including 12,257 (38%) with mPAP < 25 mm Hg. The median age was 55 years (interquartile range, 47-62) and the median PVR was 1.5 Wood units (WU) (interquartile range, 1-2.2) in recipients with mPAP < 25 mm Hg. After controlling for confounders, PVR was independently associated with increased risk for 30-day mortality (hazard ratio, 1.16; 95% CI, 1.05-1.27; P < .01), but not conditional 1-year mortality (hazard ratio, 1.03; 95% CI, 0.94-1.12; P = .55). PVR ≥ 3 WU was associated with an absolute 1.9% increase in 30-day mortality in those with mPAP < 25 mm Hg, a similar risk to recipients with PVR ≥ 3 WU and mPAP ≥ 25 mm Hg., Conclusions: Elevated PVR remains associated with a significant increase in the hazard for 30-day mortality after cardiac transplantation, even in the setting of lower pulmonary artery pressures. These data support the validity of the new definition of pulmonary hypertension., (Copyright © 2019 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Sensitization has been associated with worse outcomes following heart transplantation (HTx). The use of ventricular assist devices (VAD) is a risk factor for the development of sensitization. We investigated the impact of left ventricular assist devices (LVAD) and sensitization in HTx recipients., Methods: We queried the UNOS database for all heart transplants performed from January 2000 through December 2016. Patients were considered highly sensitized and included if panel-reactive antibody (PRA) activity was 25% or higher. Patients were separated by pretransplant LVAD utilization and subgroup analysis was performed by device type (HeartMate II or HeartWare). Outcomes included Kaplan-Meier survival and episodes of rejection within 1 year of HTx., Results: Of 18 009 recipients, 2434 (14%) were highly sensitized. 1055 (43.3%) were bridged with a VAD. In multivariate analysis, LVAD use did not impact 1-year (hazards ratio [HR], 1.30; P = 0.052) or 5-year survival (HR, 1.18; P = 0.112) in highly sensitized recipients. Furthermore, episodes of rejection were not affected by LVAD status (P = 0.765). Of the 1055 sensitized LVAD-bridged transplant recipients, 624 (59%) were implanted with a HeartMate II and 99 (9.4%) were bridged with a HeartWare device. In multivariate analysis, no differences were observed in 1-year survival (HR, 0.86; P = 0.664), 5-year survival (HR, 1.35; P = 0.209), or episodes of rejection (P = 0.497)., Conclusions: The use of ventricular assist devices did not impact survival or rejection within 1 year of HTx in highly sensitized patients. Highly sensitized recipients have similar outcomes regardless of prior LVAD support or type of LVAD used as a bridge to transplantation., (© 2019 Wiley Periodicals, Inc.)

Background: Given the shortage of donor organs in pediatric heart transplantation (HTx), pretransplant risk stratification may assist in organ allocation and recipient optimization. We sought to construct a scoring system to preoperatively stratify a patient's risk of one-year mortality after HTx., Methods: The United Network for Organ Sharing database was queried for pediatric (<18 years) patients undergoing HTx between 2000 and 2016. The population was randomly divided in a 4:1 fashion into derivation and validation cohorts. A multivariable logistic regression model for one-year mortality was constructed within the derivation cohort. Points were then assigned to independent predictors ( P < .05) based on relative odds ratios (ORs). Risk groups were established based on easily applicable, whole-integer score cutoffs., Results: A total of 5,700 patients underwent HTx; one-year mortality was 10.7%. There was a similar distribution of variables between derivation (n = 4,560) and validation (n = 1,140) cohorts. Of the 12 covariates included in the final model, nine were allotted point values. The low-risk (score 0-9), intermediate-risk (10-20), and high-risk (>20) groups had a 5.18%, 10%, and 28% risk of one-year mortality ( P < .001), respectively. Both intermediate-risk (OR = 2.46, 95% confidence interval [95% CI]: 1.93-3.15; P < .001) and high-risk (OR = 9.24, 95% CI: 6.92-12.35; P < .001) scores were associated with an increased risk of one-year mortality when compared to the low-risk group., Conclusions: The Children's Heart Assessment Tool for Transplantation score represents a pediatric-specific, recipient-based system to predict one-year mortality after HTx. Its use could assist providers in identification of patients at highest risk of poor outcomes and may aid in pretransplant optimization of these children.

Background: Previous studies suggest double-lung transplant (DLT) may be associated with superior survival compared to single-lung transplantation (SLT) in chronic obstructive pulmonary disease (COPD) recipients. The purpose of this study was to compare survival in patients with COPD undergoing DLT versus SLT since the inception of the lung allocation score., Methods: We used the United Network for Organ Sharing database to retrospectively identify adult patients with COPD who underwent isolated lung transplantation from 5/4/2005-12/31/2014. We then separated patients into DLT versus SLT. Short-term (1 y) and long-term survival (5 y) were compared between DLT and SLT cohorts by the method of Kaplan-Meier, and Cox proportional hazards modeling was used to adjust for case mix., Results: Four thousand eight hundred thirty-two COPD patients were listed, and 3554 underwent lung transplantation over the study period, including 1358 SLTs (38%) and 2196 DLTs (62%). Survival 1 y after listing was 93% for those remaining wait listed (n = 1892) versus 91% for SLT (n = 1093) versus 89% for DLT (n = 1847) (log-rank P < 0.01). Survival at 1 y after transplant was 88% for both SLT and DLT groups (log-rank P = 0.93); however, 5-y survival was significantly lower after SLT (51% versus 59%, log-rank P < 0.01). After risk adjustment, hazard for 1-y mortality after DLT was not significantly reduced compared to SLT (hazard ratio 0.89 [0.69-1.14], P = 0.36) but was significantly reduced 5 y after DLT (hazard ratio 0.88 [0.78-0.99], P = 0.04)., Conclusions: In the largest survival analysis of COPD recipients since the inception of the lung allocation score, the hazard for 5-y mortality was significantly reduced in recipients who underwent DLT as compared to SLT., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) is common after cardiac surgery and contributes to increased morbidity and mortality. Our objective was to derive and validate a predictive model for AF after CABG in patients, incorporating novel echocardiographic and laboratory values., Methods: We retrospectively reviewed patients at our institution without preexisting dysrhythmia who underwent on-pump, isolated CABG from 2011-2015. The primary outcome was new onset AF lasting >1 hour on continuous telemetry or requiring medical treatment. Patients with a preoperative echocardiographic measurement of left atrial diameter were included in a risk model, and were randomly divided into derivation (80%) and validation (20%) cohorts. The predictors of AF after CABG (PAFAC) score was derived from a multivariable logistic regression model by multiplying the adjusted odds ratios of significant risk factors (P < .05) by a factor of 4 to derive an integer point system., Results: 1307 patients underwent isolated CABG, including 762/1307 patients with a preoperative left atrial diameter measurement. 209/762 patients (27%) developed new onset AF including 165/611 (27%) in the derivation cohort. We identified four risk factors independently associated with postoperative AF which comprised the PAFAC score: age > 60 years (5 points), White race (5 points), baseline GFR < 90 mL/min (4 points) and left atrial diameter > 4.5 cm (4 points). Scores ranged from 0-18. The PAFAC score was then applied to the validation cohort and predicted incidence of AF strongly correlated with observed incidence (r = 0.92)., Conclusion: The PAFAC score is easy to calculate and can be used upon ICU admission to reliably identify patients at high risk of developing AF after isolated CABG.

Objective: The authors sought to assess the relationship between low oxygen delivery (DO 2 ) during cardiopulmonary bypass (CPB) and a neuron-specific biomarker of neurologic injury, ubiquitin C-terminal hydrolase L1 (UCH-L1)., Design: Retrospective analysis of patient charts and prospectively collected blood samples., Setting: University-affiliated tertiary care hospital., Participants: Adult patients undergoing cardiac surgery on CPB., Interventions: Serum UCH-L1 levels were drawn at baseline and 6 and 24 hours after CPB cessation. DO 2 was computed from perfusion records, with area-under-the-curve (AUC) computations performed to account for distance of DO 2 excursions below predefined DO 2 thresholds and the amount of time spent below them. Strokes were defined radiographically using computed tomography and magnetic resonance imaging., Measurements and Main Results: Forty-three adults were included (median age 65 y, interquartile range 59-72). Three patients experienced strokes (imaged at 2, 7, and 8 d postoperatively). Most patients underwent isolated coronary artery bypass grafting (41%, 18 patients) or isolated aortic valve replacement (30%, 13). Median UCH-L1 levels differed from baseline to 6 and 24 hours after CPB (40, 232, and 166 pg/mL, respectively; p < 0.001). On multivariable linear regression analysis controlling for baseline and surgical variables, only DO 2 AUC <225 was significantly associated with 6-hour UCH-L1 levels (p = 0.001), whereas only DO 2 AUC <300 was significantly associated with 24- hour levels (p < 0.001). The 3 patients who experienced radiographic strokes had nonsignificantly elevated 24-hour UCH-L1 levels compared with control patients (585 v 151 pg/mL, p = 0.11)., Conclusions: This is the first study to demonstrate an independent association between DO 2 during CPB and elevations of a brain injury biomarker; additional study is needed to clarify the clinical significance of these results., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Pediatric stroke is relatively rare, with approximately 1000 childhood strokes in the United States per year. However, the occurrence of stroke in children leads to significant morbidity and mortality, warranting the development proven screening tools, protocols, and treatment options. Because significant delays in seeking medical attention can occur, time to recognition of pediatric stroke in the emergency department is uniquely challenging and critical. Once recognized, a trained multidisciplinary team with a multifaceted approach is needed to provide the best possible outcome for the patient. Key elements of the pediatric stroke protocol should include recognition tools, stroke alert mechanism, stroke order sets, timely imaging, laboratory evaluation, and treatment options. Substantial advancements have been made in the field of pediatric stroke protocols mainly due to formation of international consortiums and clinical trial. Despite significant progress, treatment options remain controversial.

Background: Bilateral internal mammary artery (BIMA) grafting in diabetic patients undergoing coronary artery bypass grafting remains controversial. Our study compared morbidity and mortality between (1) diabetic and nondiabetic BIMA patients and (2) diabetic BIMA versus diabetic patients who underwent left internal mammary artery (LIMA) grafting only., Methods: Patients who underwent isolated coronary artery bypass grafting from July 2011 to June 2016 at any of the 10 Maryland Cardiac Surgery Quality Initiative centers were propensity scored across 16 variables. Diabetic BIMA patients were matched 1:1 by nearest neighbor matching to nondiabetic BIMA patients and were separately matched 1:1 to diabetic LIMA patients. We calculated observed-to-expected (O/E) ratios for composite morbidity/mortality, operative mortality, unplanned reoperation, stroke, renal failure, prolonged ventilation, and deep sternal wound infection and compared ratios among matched populations., Results: During the study period, 812 coronary artery bypass grafting patients received BIMA grafts, including 302 patients (37%) with diabetes. We matched 259 diabetic and nondiabetic BIMA patients. O/E ratios were higher in matched diabetic (versus nondiabetic) BIMA patients when comparing composite morbidity/mortality, reoperation, stroke, renal failure, and prolonged ventilation (all O/E ratios >1.0); however, the O/E ratio for operative mortality was higher in nondiabetic BIMA patients. We additionally matched 292 diabetic BIMA to diabetic LIMA patients. Diabetic BIMA patients had a higher O/E ratio for composite morbidity/mortality, operative mortality, stroke, renal failure, and prolonged ventilation., Conclusions: In this statewide analysis, diabetic patients who received BIMA grafts (compared with diabetic patients with LIMA grafts or nondiabetic patients with BIMA grafts) had higher O/E ratios for composite morbidity/mortality as a result of higher O/E ratios for major complications., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Concern has been raised over inferior lung transplantation survival associated with traumatic brain injury (TBI) organ donors. Our purpose was to explore the relationship between TBI donors and lung transplantation survival in the lung allocation score (LAS) era., Methods: We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients and identified all adult (≥18 years) lung transplantations performed from May 4, 2005, to December 31, 2015. Recipients were dichotomized based on donor cause of death, TBI versus non-TBI, propensity score across eight variables (final LAS, intensive care unit admission before transplantation, extracorporeal membrane oxygenation before transplantation, donor age 50 years or older, cytomegalovirus antibody recipient - /donor + , ischemia time, annual center transplantation volume, single versus double lung transplantation), and matched 1:1 without replacement. Our primary outcomes were survival at 1, 3, and 5 years by Kaplan-Meier method., Results: A total of 17,610 patients underwent isolated lung transplantation over the study period at 75 different transplantation centers. TBI was the leading cause of death in the donor population: 47% of all donors. Propensity score matching generated 6,782 well-matched donor TBI versus non-TBI pairs (all covariate p > 0.2). Risk-adjusted survival was similar between recipients of TBI donors versus non-TBI donors at 1 year (86% versus 86%, log-rank p = 0.27), 3 years (68% versus 68%, log-rank p = 0.47), and 5 years (55% versus 54%, log-rank p = 0.40)., Conclusions: In the largest analysis of TBI donors and the impact on lung transplantation survival to date, we found similar survival out to 5 years in lung transplant recipients of TBI versus non-TBI donors, alleviating concerns over continued transplantation with this unique donor population., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The safety of surgical closure of patent ductus arteriosus (PDA) in very low birth weight premature neonates has been questioned because of associated morbidities. However, these studies are vulnerable to significant bias as surgical ligation has historically been utilized as "rescue" therapy. The objective of this study was to review our institutions' outcomes of surgical PDA ligation., Methods: All neonates with operative weight of ≤1.00 kg undergoing surgical PDA ligation from 2003 to 2015 were analyzed. Records were queried to identify surgical complications, perioperative morbidity, and mortality. Outcomes included pre- and postoperative ventilator requirements, pre- and postoperative inotropic support, acute kidney injury, surgical complications, and 30-day mortality., Results: One hundred sixty-six preterm neonates underwent surgical ligation. One hundred twenty-one (70.3%) had failed indomethacin closure. One hundred sixty-four (98.8%) patients required mechanical ventilation prior to surgery. At 17 postoperative days, freedom from the ventilator reached 50%. Of 109 (66.4%) patients requiring prolonged preoperative inotropic support, 59 (54.1%) were liberated from inotropes by postoperative day 1. Surgical morbidity was encountered in four neonates (2.4%): two (1.2%) patients had a postoperative pneumothorax requiring tube thoracostomy, one (0.6%) patient had a recurrent laryngeal nerve injury, and one (0.6%) patient had significant intraoperative bleeding. The 30-day all-cause mortality was 1.8% (n = 3); no deaths occurred intraoperatively., Conclusion: In this retrospective investigation, surgical PDA closure was associated with low 30-day mortality and minimal morbidity and resulted in rapid discontinuation of inotropic support and weaning from mechanical ventilation. Given the safety of this intervention, surgical PDA ligation merits consideration in the management strategy of the preterm neonate with a PDA.

Background: Although tricuspid valve detachment (TVD) facilitates improved exposure during transatrial ventricular septal defect (VSD) closure, few have analyzed the impact of TVD on long-term valve durability., Methods: Pediatric patients undergoing VSD closure at our institution from 1997 to 2013 were identified, and charts were retrospectively reviewed. Patients were separated into groups based on utilization of TVD. Propensity score matching was then performed using a nonparsimonious logistic regression model involving 7 variables. Primary outcome was residual TV dysfunction at long-term follow-up, defined as mild (2+) and moderate (3+) TV regurgitation (TR) on follow-up echocardiography. Secondary outcomes included postoperative atrioventricular dissociation, residual VSD, and reinterventions., Results: A total of 247 patients underwent VSD closure; 164 (66.4%) without TVD and 83 (33.6%) with TVD. Median follow-up time was 2,343 days (interquartile range, 1,237 to 3,963.5 days) in the group without TVD versus 1,606 days (interquartile range, 826 to 3,017 days) in those with TVD. After successfully matching 83 patients, 29 of 83 (34.9%) patients in the non-TVD group had mild TR versus 28 of 83 (33.7%) patients in the TVD group (p = 0.87). 2 patients in the non-TVD group had moderate TR versus 1 patient in the TVD group at long-term follow-up. One patient in each group suffered transient atrioventricular block, but neither required pacemaker insertion., Conclusions: TVD did not compromise long-term valve durability and did not impose increased morbidity. Patients who underwent TVD had a similar prevalence of mild TR to patients without TVD. Moderate TR was exceptionally rare in both groups. When exposure is difficult, TVD is a safe and effective technical adjunct., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Patients with end-stage cardiomyopathy due to cardiac sarcoidosis (CS) may be referred for mechanical circulatory support (MCS) and heart transplantation (HT). We describe outcomes of patients with CS undergoing HT, focusing on the use of MCS as a bridge to transplant (BTT)., Methods: Using the United Network for Organ Sharing Scientific Registry of Transplant Recipients, we identified all adult waitlisted patients and isolated HT recipients from 2006 to 2015. These were divided into those with and without CS and further divided into those who did or did not receive MCS as BTT. Outcomes included 1- and 5-year post-transplantation freedom from mortality and 5-year freedom from primary graft failure., Results: Over the study period, 31,528 patients were listed for HT, 148 (0.4%) of whom had CS. Among the CS patients, 34 (23%) received MCS as BTT. 18,348 patients (58%) eventually underwent HT, including 67 (0.4%) with CS, 20 (30%) of whom had received BTT MCS. Compared with non-CS diagnoses, CS patients had similar 1-year (91% vs 90%; log rank P = .88) and 5-year (83% vs 77%; log rank P = .46) freedom from mortality. Survival was also similar between CS BTT and non-CS BTT groups at 1 year (89% vs 89%; log-rank P = .92) and 5 years (72% vs 75%; log-rank P = .77)., Conclusions: Survivals after HT were similar between CS and non-CS patients out to 5 years, and were also similar between CS and non-CS BTT cohorts. Both HT and BTT MCS should be considered in patients with CS., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The incidence of squamous cell carcinoma (SCC) of the anal canal has been rising over the past decades, especially in patients infected with human immunodeficiency virus (HIV). Despite the advent of potent multidrug regimens to treat HIV-termed highly active antiretroviral therapy (HAART), anal SCC rates have not declined, and the impact of HAART on anal SCC remains controversial., Aim: The purpose of this study was to define outcomes of anal SCC treatment in HIV-positive and HIV-negative patients., Methods and Materials: A retrospective single-institution analysis was performed on all patients with anal SCC treated at the Johns Hopkins Hospital between 1991 and 2010. The primary outcomes measured were 5-year overall survival (5-year OS), median survival, and relapse rates., Results: Our search identified 93 patients with anal SCC. Patients had a mean age of 54 years; 37.6% were male, and 21.5% were HIV-positive. Median follow-up was 28 months. Relapse occurred in 16.1% of patients. Median time to relapse was 20 months. Relapse rates were slightly higher with HIV-positive versus negative patients (30.0 vs. 12.3%) but did not reach statistical significance (p = 0.06). Among HIV-positive patients, those who relapsed were more likely to be on HAART than those who did not relapse (83.3 vs. 14.3%, p = 0.007). 5-year OS was 58.9% for the total group of patients with no significant difference between those who relapsed versus those who did not (76.2 vs. 54.5%, p = 0.20). No survival difference was seen between HIV-positive and negative patients. Survival was associated with AJCC stage in all patients., Conclusion: In our small series, HIV infection was not associated with a significantly higher relapse rate or worse 5-year OS among patients with anal SCC. HAART was associated with a higher rate of relapse in HIV-positive patients. AJCC staging predicted survival in both relapsed and non-relapsed patients regardless of HIV status.

Background: Ischemia-reperfusion injury is characterized by an increase in oxidative stress and leads to significant morbidity and death. The tyrosine kinase c-Abl is activated by oxidative stress and mediates processes that affect endothelial barrier function. We hypothesized treatment with the c-Abl inhibitor imatinib would be protective against ischemia-reperfusion injury in our ex vivo rabbit model., Methods: Heart-lung blocs were harvested from rabbits and stored in cold in Perfadex (Vitrolife, Englewood, CO) for 18 hours. Blocs were reperfused for 2 hours in an ex vivo circuit with donor rabbit blood alone (untreated group, n = 7) or donor rabbit blood and 4 mg imatinib (treatment group, n = 10). Serial clinical variables measured every 15 minutes (arterial oxygen and carbon dioxide tension and mean pulmonary artery pressures) and biochemistry of tissue samples before and after reperfusion were assessed., Results: Compared with untreated lungs, imatinib treatment improved physiologic parameters, including oxygen, carbon dioxide, and pulmonary artery pressures. Imatinib-treated lungs had less vascular barrier dysfunction as quantified by wet-to-dry weight ratios and bronchoalveolar lavage protein concentrations. Treated lungs showed less inflammation as measured by bronchoalveolar lavage myeloperoxidase assay, less mitochondrial reactive oxygen species production, and increased antioxidant catalase levels. Finally, imatinib protected lungs from DNA damage and p53 upregulation., Conclusions: Imatinib treatment significantly improved the physiologic performance of reperfused lungs and biochemical indicators associated with reperfusion injury in this ex vivo model. Further study is necessary to elucidate the mechanism of tyrosine kinase inhibition in lungs exposed to ischemia and reperfusion., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Prolonged hospital length of stay (PLOS) after heart transplantation increases cost and morbidity. To better inform care, we developed a risk score to identify patients at risk for PLOS after heart transplantation., Methods: We queried the United Network for Organ Sharing Scientific Registry of Transplant Recipients database for adult patients who underwent isolated heart transplantation from 2003 to 2012. The population was randomly divided into a derivation cohort (80%) and a validation cohort (20%). The outcome of interest was PLOS, defined as a posttransplant hospital length of stay of more than 30 days. Associated univariables (p < 0.20) in the derivation cohort were included in a multivariable model, and a risk index was derived from the adjusted odds ratios of significant covariates., Results: During the study period, 16,723 patients underwent heart transplantation with an average PLOS of 19 ± 21 days, and 2,020 orthotopic heart transplant recipients (12%) had PLOS. Baseline characteristics were similar between the derivation and validation cohorts. Twenty-four recipient and nine donor variables, cold ischemic time, and center volume were tested as univariables. Seventeen covariates significantly affected PLOS and comprised the prolonged hospitalization after heart transplant risk score, which was stratified into three risk groups. The risk model was subsequently validated, and predicted rates of PLOS correlated well with observed rates (R = 0.79). Rates of PLOS in the validation cohort were 8.3%, 11%, and 22% for low, moderate, and high risk groups, respectively., Conclusions: The risk of PLOS after heart transplantation can be determined at the time of transplant. The prolonged hospitalization after heart transplant score may lead to individualized postoperative management strategies to reduce duration of hospitalization for patients at high risk., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Debate persists over the association between blood transfusions, especially those considered discretionary, and outcomes after cardiac operations. Using data from the Maryland Cardiac Surgery Quality Initiative, we sought to determine whether outcomes differed among coronary artery bypass grafting (CABG) patients receiving 1 U of red blood cells (RBCs) vs none., Methods: We used a statewide database to review patients who underwent isolated CABG from July 1, 2011, to June 30, 2016, across 10 Maryland cardiac surgery centers. We included patients who received 1 U or fewer of RBCs from the time of the operation through discharge. Propensity scoring, using 20 variables to control for treatment effect, was performed among patients who did and did not receive a transfusion. These two groups were matched 1:1 to assess for differences in our primary outcomes: operative death, prolonged postoperative length of stay (>14 days), and a composite postoperative respiratory complication of pneumonia or reintubation, or both., Results: Of 10,877 patients who underwent CABG, 6,124 (56%) received no RBCs (group 1) during their operative hospitalization, and 981 (9.0%) received 1 U of RBCs (group 2), including 345 of 981 patients (35%) who received a transfusion intraoperatively. Propensity score matching generated 937 well-matched pairs. Compared with group 2, propensity-matched analysis revealed significantly greater 30-day survival in group 1 (99% vs 98%, p = 0.02) and reduced incidence of prolonged length of stay (3.7% vs 4.0%, p < 0.01)., Conclusions: Our collaborative statewide analysis demonstrated that even 1 unit of blood was associated with significantly worse survival and longer length of stay after CABG. Multiinstitutional quality initiatives may seek to address discretionary transfusions and possess the potential to improve patient outcomes., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac surgery patients colonized with Staphylococcus aureus have a greater risk of surgical site infection (SSI). The purpose of this study was to evaluate the cost-effectiveness of decolonization strategies to prevent SSIs., Methods: We compared three decolonization strategies: universal decolonization (UD), all subjects treated; targeted decolonization (TD), only S aureus carriers treated; and no decolonization (ND). Decolonization included mupirocin, chlorhexidine, and vancomycin. We implemented a decision tree comparing the costs and quality-adjusted life-years (QALYs) of these strategies on SSI over a 1-year period for subjects undergoing coronary artery bypass graft surgery from a US health sector perspective. Deterministic and probabilistic sensitivity analyses were conducted to address the uncertainty in the variables., Results: Universal decolonization was the dominant strategy because it resulted in reduced costs at near-equal QALYs compared with TD and ND. Compared with ND, UD decreased costs by $462 and increased QALYs by 0.002 per subject, whereas TD decreased costs by $205 and increased QALYs by 0.001 per subject. For 1,000 subjects, UD prevented 19 SSI and TD prevented 10 SSI compared with ND. Sensitivity analysis showed UD to be the most cost-effective strategy in more than 91% of simulations. For the 220,000 coronary artery bypass graft procedures performed yearly in the United States, UD would save $102 million whereas TD would save $45 million compared with ND., Conclusions: Universal decolonization outperforms other strategies. However, the potential costs savings of $57 million per 220,000 coronary artery bypass graft procedures comparing UD versus TD must be weighed against the potential risk of developing resistance associated with universal decolonization., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Sellar pathology is increasingly addressed using the expanded endonasal approach (EEA). Although avascular graft reconstruction is an acceptable means to prevent cerebrospinal fluid leak, there are few data regarding sinonasal morbidity in these patients. In this study we compare rates of persistent postoperative crusting (PPC) and rhinosinusitis in patients undergoing sellar reconstruction with mucosal autografting and acellular dermal allografting (ADA)., Methods: Patients undergoing the EEA between 2008 and 2014 were categorized into 2 subgroups: mucosal reconstruction and ADA reconstruction. Univariate analyses were performed to compare differences in PPC and rhinosinusitis in these groups and to identify risk factors for sinonasal morbidity. Multivariate propensity matching analysis was performed to match ADA and mucosa reconstruction groups with respect to age, race, gender, smoking status, diabetes status, tumor type, tumor size, and revision vs primary surgery., Results: A total of 149 patients were identified. There were 105 patients reconstructed with autologous mucosa (70.5%) and 44 reconstructed with ADA (29.5%). Overall, PPC was seen in 20 patients (13.4%) and rhinosinusitis in 10 patients (6.7%). Propensity matching generated 39 patients reconstructed with ADA and 39 reconstructed with mucosa. There was a significant increase in PPC in patients reconstructed with ADA compared to those reconstructed with mucosa (8 of 39 [20.5%] vs 2 of 39 [5.1%], p = 0.04). There was no association between reconstruction with ADA and increased rhinosinusitis (3 of 39 [7.7%] vs 4 of 39 [10.3%], p = 0.64)., Conclusion: Sinonasal morbidity is not uncommon after sellar reconstruction. Patients undergoing sellar reconstruction with ADA may be at increased risk of postoperative crusting compared with those undergoing reconstruction with mucosa., (© 2017 ARS-AAOA, LLC.)

Acute kidney injury after cardiac surgery is associated with increased morbidity and mortality. Methods for measuring urine output in real time may better ensure renal perfusion perioperatively in contrast to the current standard of care where urine output is visually estimated after empiric epochs of time. In this study, we describe an accurate method for monitoring urine output continuously during cardiopulmonary bypass. This may provide a means for setting patient-specific targets for blood pressure and cardiopulmonary bypass flow as a potential strategy to reduce the risk for acute kidney injury.

Over the past few decades, the use of endoscopic harvest of the saphenous vein has gained popularity due to a significant reduction in rates of wound infection and improved cosmesis. The widespread adoption of this technique has introduced a set of complications associated with the use CO 2 insufflation which facilitates exposure during the vein harvest. We describe a case of pneumoperitoneum with systemic acidosis and subcutaneous air following endoscopic vein harvest for coronary artery bypass grafting and review the complications that may arise from CO 2 insufflation during endoscopic vein harvesting., (© 2017 Wiley Periodicals, Inc.)

Background: In specific patients, early postoperative nutrition mitigates malnutrition-related morbidity and mortality. The goal of this study was to develop and validate a prediction score designed to stratify patients immediately after cardiac surgery according to risk for nutrition support (NS)., Methods: We identified adult cardiac surgery patients at our institution in 2012 requiring postoperative NS, enteral or parenteral. Using multivariable logistic regression modeling, we developed a Johns Hopkins Hospital Nutrition Support (JHH NS) score from relative odds ratios generated by variables that independently predicted the need for NS. The JHH NS score was then prospectively validated using all patients undergoing cardiac surgery in 2015., Results: Among 1,056 patients in the derivation cohort, 87 (8%) required postoperative NS. Seven variables were identified on multivariable analysis as independent predictors of NS need and were used to create the JHH NS score. Scores ranged from 0 to 36. Each 1-point increase in the JHH NS score was associated with a 20% increase in the risk of requiring NS (odds ratio 1.20, p < 0.001). The c-statistic of the regression model for NS was 0.85. In all, 115 of 1,336 patients (8.6%) in the validation cohort required NS. Observed rates of NS in the validation group correlated positively with predicted rates (r = 0.89)., Conclusions: The JHH NS score reliably stratified patients at risk for the need for postoperative NS. This easily calculable and highly predictive screening tool may expedite timing of initiation of NS in patients at high risk for not being able to physically take in adequate nutrition., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: We assessed the impact of preoperative Staphylococcus aureus screening and targeted decolonization on the incidence of postoperative methicillin-resistant S aureus (MRSA) colonization, intensive care unit MRSA transmission, and surgical site infections in cardiac surgery patients., Methods: We reviewed medical records for all adult patients during two periods: preintervention (January 2007 to April 2010) and intervention (January 2011 to December 2014). In the intervention period, we performed nasal screening for methicillin-sensitive S aureus and MRSA using polymerase chain reaction within 30 days of the operation. Colonized patients received intranasal mupirocin twice daily and chlorhexidine baths daily for 5 days; patients colonized with MRSA also received prophylactic vancomycin plus cefazolin with contact isolation precautions. Nasal surveillance for MRSA was performed on intensive care unit admission and weekly thereafter. Multivariable logistic regression models were constructed to determine risk factors for postoperative MRSA colonization, and surgical site infections and the impact of our screening program was assessed in these models. Poisson regression was used to assess MRSA transmission., Results: Comparing 2,826 preintervention and 4,038 intervention patients, cases differed in age, diabetes mellitus, preoperative infection, preoperative length of stay, and bypass time (all p ≤ 0.03). Intervention patients had risk-adjusted reductions in MRSA colonization (odds ratio 0.53, 95% confidence interval [CI]: 0.37 to 0.76, p < 0.001), transmission (incidence rate ratio 0.29, 95% CI: 0.13 to 0.65, p = 0.002), and surgical site infections (odds ratio 0.58, 95% CI: 0.40 to 0.86, p = 0.007). Increased duration of preoperative decolonization therapy was associated with decreased postoperative MRSA colonization (odds ratio 0.73, 95% CI: 0.53 to 1.00, p = 0.05)., Conclusions: Preoperative S aureus screening with targeted decolonization was associated with reduced MRSA colonization, transmission, and surgical site infections. Duration of preoperative therapy correlated with decreased frequency of postoperative MRSA colonization., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies have demonstrated an association between pretransplantation renal dysfunction (PRD) and increased mortality after lung transplantation (LT). The purpose of this study was to determine whether PRD impacts survival after LT in patients with cystic fibrosis (CF)., Methods: We queried the United Network for Organ Sharing (UNOS) database to identify all adult (≥18 years) recipients with CF who underwent isolated LT from May 4, 2005 to December 31, 2014. We separated recipients into those with and those without PRD (glomerular filtration rate [GFR] ≤60 mL/min). We excluded patients who required dialysis before transplantation. Kaplan-Meier analysis was used to assess unadjusted survival differences. Cox proportional hazards modeling was then performed across 26 variables to assess the risk-adjusted impact of PRD on 1-, 3-, and 5-year mortality., Results: Isolated LT was performed on 1,830 patients with CF; 17 patients were excluded because of pretransplantation dialysis. Eighty-two of 1,813 patients (4.5%) had PRD (GFR ≤60 mL/min). Kaplan-Meier analysis revealed no survival differences between PRD and non-PRD groups at 1 year (85.3% versus 89.5%; log-rank p = 0.23), 3 years (71.0% versus 72.5%; p = 0.57), or 5 years (63.3% versus 59.8%; p = 0.95). After risk adjustment, PRD was not independently associated with an increased hazard for mortality at 1 year (hazard ratio [HR], 1.38 [95% confidence interval [CI], 0.74-2.58]; p = 0.31), 3 years (HR, 1.44 [95% CI, 0.92-2.24]; p = 0.11), or 5 years (HR, 1.30 [95% CI, 0.86-1.94]; p = 0.29)., Conclusions: Although PRD has historically served as a relative contraindication to LT, our study is the first to suggest that among CF recipients, PRD was not associated with increased hazard for mortality out to 5 years after LT., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Dendrimer nanoparticle therapies represent promising new approaches to drug delivery, particularly in diseases associated with inflammatory injury. However, their application has not been fully explored in models of acute myocardial ischemia (MI) and reperfusion injury., Methods: White male New Zealand rabbits underwent left thoracotomy with 30-minute temporary left anterior descending artery occlusion and MI confirmed by electrocardiography and histology (MI rabbits, n = 9), or left thoracotomy and pericardial opening for 30 minutes but no left anterior descending artery occlusion (control [C] rabbits, n = 9) rabbits. Following the 30-minute period, a dendrimer (generation 6 dendrimer conjugated to cyanine-5 fluorescent dye [G6-Cy5], 6.7 nm diameter) was administered intravenously and the chest closed in layers. Animals were sacrificed at 3 hours (3 MI, 3 C), 24 hours (3 MI, 3 C), or 48 hours (3 MI, 3 C) postsurgery., Results: As compared to controls, MI rabbits had twofold G6-Cy5 uptake in the myocardial anterior wall as compared to the same region in nonischemic control rabbits at 24 hours postsurgery (6.01 ± 0.57 μg/g versus 2.85 ± 0.85 μg/g; p = 0.04). This trend was also present at 48 hours (6.38 ± 1.53 μg/g versus 3.95 ± 0.60 μg/g, p = 0.21) and was qualitatively evident on confocal microscopy. G6-Cy5 half-life in serum was approximately 12 hours, with 22% of the injected G6-Cy5 dose remaining at 48 hours., Conclusions: This study demonstrates for the first time that dendrimer nanodevices selectively localize in ischemic as compared to healthy myocardium. This indicates that dendrimer nanodevices are promising agents to deliver drugs specifically to the ischemic myocardium to attenuate the injury. Subsequent studies will assess the efficacy of a dendrimer-drug conjugate in ameliorating reperfusion injury following MI., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Society of Thoracic Surgeons (STS) database does not distinguish between a decline in creatinine clearance vs new hemodialysis (HD) when qualifying acute renal failure (ARF) after a cardiac operation. We hypothesized that patients requiring HD experience significantly greater postoperative morbidity and death., Methods: We included all patients who underwent STS index cardiac operations at our institution from 2008 to March 2015 and did not have preexisting renal failure (creatinine >4.0 mg/dL or preoperative HD). We identified patients meeting STS criteria for ARF: threefold rise in serum creatinine, creatinine exceeding 4.0 mg/dL (non-HD ARF) with minimum rise of 0.5 mg/dL, or HD (ARF-HD). After propensity matching non-HD ARF and ARF-HD groups across 14 variables (including baseline glomerular filtration rate), we compared incidences of our primary outcome, death, and secondary outcomes, intensive care unit (ICU) and hospital length of stay (LOS), and discharge to a location other than home., Results: Among 4,154 study patients, we identified 113 (2.7%) that experienced new-onset non-HD ARF (n = 57) or ARF-HD (n = 56) postoperatively. Propensity matching resulted in 51 well-matched pairs who experienced non-HD ARF or ARF-HD (all p > 0.10). Patients requiring HD suffered significantly greater operative mortality (67% vs 22%, p < 0.01), longer ICU LOS (326 vs 176 hours, p < 0.01), and greater postoperative hospital LOS (34 vs 17 days, p < 0.01). ARF-HD patients also demonstrated a trend toward higher rates of discharge to a location other than home (71% vs 45%, p = 0.08)., Conclusions: After cardiac operations, patients who experienced ARF-HD experienced triple the mortality and double the ICU and postoperative hospital LOS compared with patients who experienced non-HD ARF., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Concerns over prolonged allograft ischemia have limited the widespread adoption of long-distance organ procurement in heart transplantation (HT). We sought to assess whether donor distance from the center of transplantation independently affects mortality., Methods: We queried the United Network for Organ Sharing (UNOS) database for adults undergoing isolated HT from 2005 to 2012. Risk-adjusted Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality, and the independent impact of donor distance from transplantation center at the time of procurement was assessed., Results: We included 14,588 heart transplant recipients. The mean distance from location of the donor heart to transplantation center was 184.4 ± 214.6 miles; 1,214 HTs (8.3%) occurred at the same location as the donor heart. Ischemic times were inversely related to the distance from the site of donor procurement to recipient transplantation. After risk adjustment, longer donor distances (in miles) were associated with a significantly lower risk of mortality at both 30 days (hazard ratio [HR] 0.9993, 95% confidence interval [CI]: 0.9988 to 0.9998, p < 0.01) and 1 year (HR 0.9994, 95% CI: 0.9989 to 0.9999, p = 0.015). Risk-adjusted hazards for mortality were significantly reduced in recipients receiving hearts from more than 25 miles away. The hazard reduction was greatest in recipients receiving donor hearts from more than 500 miles away (1-year HR 0.64, p < 0.01; 30-day HR 0.47, p < 0.01)., Conclusions: Longer distances between donor location and center of heart transplantation are associated with a reduced hazard for survival at 30 days and 1 year, despite greater ischemic times. Future studies are necessary to elucidate the protective factors surrounding long-distance heart donation., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Since the introduction of the Lung Allocation Score (LAS), the mean LAS has risen. Still, it remains uncertain whether mortality has improved in the most severely ill lung transplant recipients over this time period., Methods: Using the United Network for Organ Sharing database, we identified 3,548 adult lung transplant recipients from May 4, 2005, to March 31, 2014, with a match-time LAS in the upper quartile (>75th%ile). We divided this population across three eras: 1 = May 4, 2005, to December 31, 2008 (n = 1,280); 2 = January 1, 2009, to December 31, 2011 (n = 1,266); and 3 = January 1, 2012, to March 31, 2014 (n = 1,002). Cox proportional hazards models were constructed for the primary outcomes of 30-day and 1-year mortality to assess the independent impact of the era of transplantation., Results: The mean LAS at time of transplant for patients in the upper quartile in eras 1, 2, and 3 was 63, 73, and 79, respectively (p < 0.001). Later eras of transplantation benefited from a significant improvement in survival at 1 year (log-rank p = 0.001) but not at 30 days (log-rank p = 0.152). After risk adjustment, lung transplantation in more recent eras was associated with improved mortality at both 30 days (era 3 hazard ratio [HR] = 0.50, 95% confidence interval [CI] 0.32% to 0.78%, p = 0.002) and 1 year (era 2 HR = 0.77, 95% CI 0.64% to 0.94%, p = 0.008; era 3 HR = 0.54, 95% CI 0.43% to 0.68%, p < 0.001)., Conclusions: Despite a progressively rising LAS, survival is improving among recipients with the highest LAS at the time of lung transplantation. This calls into question the notion of a maximum LAS beyond which lung transplantation becomes futile, a so-called LAS ceiling., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Our objective was to determine whether the choice of a HeartWare HVAD as opposed to a Heartmate II left ventricular assist device (HMII LVAD), impacts survival after heart transplantation after controlling for patient, donor, and center characteristics., Methods: We queried the United Network for Organ Sharing (UNOS) database, which has recently made pretransplantation device duration available, for all adult patients undergoing bridge to transplantation (BTT) between January 2011 and March 2016. Recipient, donor, and transplant-specific characteristics were compared between patients receiving either device. Unadjusted survival was estimated with the Kaplan-Meier method. Risk-adjusted Cox proportional hazard models were constructed to determine the independent impact of device selection on mortality., Results: Three thousand three hundred fifty-six patients who received the HMII and 1,051 patients who received the HVAD met inclusion criteria. Patients who received the HMII had a longer mean duration of VAD support (HMII, 429 days versus HVAD, 314 days; p < 0.001) but spent shorter periods on the waiting list (median, 190 days versus 232 days; p < 0.001). Patients who received the HMII had worse pre-LVAD renal function than did those who received the HVAD (glomerular filtration rate [GFR], 57 mL/min versus 62 mL/min, respectively; p = 0.001), but there was no difference in postoperative new-onset dialysis after transplantation (11.6% versus 10.5%, respectively; p = 0.14). There was no difference in unadjusted posttransplantation 30-day (95.5% versus 96.7%, respectively; log-rank p = 0.09), 6-month (91.8% versus 92.6%, respectively; p = 0.35), or 1-year (89.7% versus 90.9%, respectively; p = 0.22) survival between the 2 groups. After risk adjustment with Cox modeling, device selection did not predict mortality at any time point., Conclusions: Among patients who received a BTT LVAD and then received a heart transplant, no survival differences were seen between patients initially implanted with an HVAD versus an HMII., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The benefit of nanomedicine in mitigating acute lung injury (ALI) is currently unknown. Therefore, we introduced the generation IV polyamidoamine dendrimers with neutral surface property (dendrimer) into our established ex vivo animal model and sought to determine their biodistribution to define their cellular uptake profile and to evaluate their potential as a drug delivery candidate for the treatment of ischemia-reperfusion-induced ALI., Methods: Eight rabbit heart-lung blocks were harvested and exposed to 18 h of cold ischemia. The heart-lung blocks were then reperfused with rabbit donor blood. Dendrimer was conjugated to fluorescein isothiocyanate (D-FITC) for localization and quantification studies. D-FITC (30 mg or 150 mg) was injected into the bypass circuit and baseline, 1- and 2-h tissue samples were obtained to determine percent uptake. Low (10×) and high (40×) magnification images were obtained using confocal microscopy to confirm the accumulation and to determine the cellular targets of the dendrimer., Results: Four heart-lung blocks were exposed to 30 mg and four to 150 mg of D-FITC. After adjusting for dry weight, the mean uptake in the 30 and 150 mg samples after 2 h of reperfusion were 0.79 ± 0.16% and 0.39 ± 0.22% of perfused doses, respectively. Confocal imaging demonstrated dendrimer uptake in epithelial cells and macrophages., Conclusions: Fluorescently tagged dendrimers demonstrated injury-dependent tissue accumulation in a variety of different cell types. This unique approach will allow conjugation to and delivery of multiple agents with the potential of mitigating ALI injury while avoiding systemic toxicity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Mediastinal reexplorations for bleeding are associated with significant morbidity and mortality. This study hypothesized that bleeding patients who undergo delayed chest closure after an initial operation experience similar outcomes in comparison with patients who have initial chest closure and later require an unplanned reexploration., Methods: This study included all patients in the Johns Hopkins University School of Medicine (Baltimore, MD) institutional Society of Thoracic Surgeons (STS) database who underwent cardiac surgical procedures or thoracic transplantation from 2011 to June 2014, had an intraoperative red blood cell transfusion requirement of 2 units or more, and required mediastinal reexploration for bleeding. Reexplorations were classified as planned (temporary chest closure for a planned "second look") or unplanned (initial sternal closure and subsequent reexploration). The two groups were then propensity matched. The primary outcome was 30-day mortality. Secondary outcomes were major complication rates, hospital length of stay, duration of mechanical ventilation, and incidence of postoperative pneumonia and cardiac arrest., Results: Among 3,293 patients, 110 (3.3%) met inclusion criteria and required mediastinal reexploration for bleeding. This group included 62 planned (56%) and 48 unplanned (44%) reexplorations. After propensity matching 30 pairs of patients across 16 variables, operative mortality rates were comparable (37% vs 37%; p = 1.00) between unplanned and planned reexploration cohorts. There were no differences in rates of deep sternal wound infection, renal failure, postoperative hospital length of stay, pneumonia, or cardiac arrest, with the exception of a higher rate of prolonged intubation (93% vs 53%; p < 0.01) in the planned reexploration group., Conclusions: Delayed sternal closure is a safe alternative to initial definitive chest closure when concern exists for postoperative bleeding., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Endovenous heat-induced thrombosis (EHIT) is a well-documented phenomenon that follows endovenous ablation, but the treatment, surveillance, and risk factors for EHIT have yet to be comprehensively elucidated. We sought to identify characteristics that may put patients at higher risk for development of EHIT after radiofrequency ablation (RFA) for the treatment of symptomatic superficial venous insufficiency., Methods: A retrospective review was performed of all consecutive patients undergoing treatment with RFA to the great saphenous vein by a single surgeon from July 2013 through October 2015. On postprocedural day 2, a surveillance venous duplex ultrasound examination was obtained and the presence of EHIT was recorded. Demographics of the patients, venous thromboembolism (VTE) risk factors, and procedural details were compared between patients with EHIT and those with no EHIT using multivariable logistic regression for risk adjustment. As a sensitivity analysis, propensity score matching on the basis of 18 demographic and perioperative variables was then used to confirm significant findings., Results: There were 299 patients who underwent RFA for symptomatic chronic venous insufficiency (median age, 55 years; 65% female; 46% right lower extremity). Concomitant stab phlebectomy was performed in 71%. EHIT occurred in 12% (n = 35) of patients (class 1, 5%; class 2, 4%; class 3, 1%; class 4, 2%). The incidence of EHIT was significantly higher after RFA with concomitant stab phlebectomy vs RFA alone (14% vs 6%; P = .04). There were also nonsignificant trends toward a higher incidence of EHIT in patients with a history of VTE (20% vs 10%; P = .06), worsening venous disease (Clinical, Etiology, Anatomy, Pathophysiology [CEAP] class >2, 37% vs 26%; P = .13), and history of tobacco use (43% vs 31%; P = .18). On multivariable analysis, RFA with concomitant stab phlebectomy (odds ratio, 3.46; 95% confidence interval, 1.36-10.8) and history of VTE (odds ratio, 3.48; 95% confidence interval, 1.22-9.25) were independently associated with EHIT (P ≤ .02). After propensity matching of 60 pairs of similar patients, RFA with concomitant stab phlebectomy had a persistently higher incidence of EHIT compared with RFA alone (23% vs 7%; relative risk, 3.48; P = .01)., Conclusions: Concomitant stab phlebectomy and the patient's history of VTE are independent risk factors for EHIT after endovenous ablation with RFA. History of tobacco use and advanced stages of venous disease may also play a role. For patients with these high-risk features, care should be taken to prevent, identify, and treat EHIT early., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)