Significant Difference In 1-year Survival Research Articles

The Risk of Pretransplant Blood Transfusion for Primary Graft Dysfunction After Lung Transplant

BackgroundPrimary graft dysfunction (PGD) is the leading cause of short- and long-term mortality associated with lung transplantation. The impact of pretransplantation blood transfusions for recipients is not fully elucidated. MethodsThis is a retrospective review of 206 consecutive lung transplantations performed at a single academic center (Northwestern University Feinberg School of Medicine, Chicago, IL) from January 2018 to July 2022. Data on patient characteristics, pretransplantation laboratory values, transfusion requirements, and intraoperative and postoperative outcomes were collected. ResultsPGD grade 3 (PGD 3) occurred in 13.2% of the cohort (n = 28). A total of 33 patients received a blood transfusion within 4 weeks, whereas 21 patients received a blood transfusion a week before their lung transplant. Pretransplantation transfusions were strongly associated with a higher incidence of PGD 3 (48.5% vs 6.9%; P < .001). There was no significant difference in 1-year survival between the pretransplantation transfused group and the nontransfused group (77.7% vs 88.0%; P = .478). The 1year survival was reduced in recipients with PGD 3 compared with recipients without PGD 3 (63.5% vs 89.9%; P = .0012). In univariate analysis, pretransplant and intratransplant predictors of PGD 3 included younger age (P < .01), pretransplant extracorporeal membrane oxygenation (ECMO) use (P < .001), higher lung allocation score (P < .001), coronavirus disease 2019 (COVID-19)–related acute respiratory distress syndrome (P < .01), blood transfusion within 4 weeks (P < .001), longer operative time (P < .001), intratransplant blood transfusion (P < .001), and intratransplant venoarterial ECMO use (P < .001). ConclusionsPretransplantation blood transfusions could be associated with a higher rate of PGD. The findings indicated the potential risks of pretransplantation blood transfusions in lung transplant recipients.

Efficacy and safety of the vein of Marshall ethanol infusion with radiofrequency catheter ablation for the treatment of persistent atrial fibrillation in elderly patients.

Increasing age is a significant risk factor for atrial fibrillation (AF) recurrence after catheter ablation (CA). We accomplished this study to evaluate the efficacy and safety of the vein of Marshall (VOM) ethanol infusion (VOM-EI) with CA in elderly patients with persistent AF (PsAF). This retrospective observational study included 360 consecutive adult patients with PsAF, of which 141 were in the Elder group (age ≥65 years) and 219 were in the Younger group (age <65 years), who underwent the VOM-EI and radiofrequency CA (RFCA) between May 2020 and April 2022. The efficacy endpoint was no recurrence of AF within one year after CA. The VOM-EI was successfully performed in 90.8% of patients from the Elder and 88.6% from the Younger group. All patients achieved PVI; 97.9% of patients from the Elder and 98.6% from the Younger group reached LA roof block, and 93.6% of patients from the Elder and 95.9% from the Younger group achieved MI block. There was no significant difference in 1-year survival without recurrence of AF between the two groups (83.0% and 84.5%, respectively). The incidence of complications within 30 days after the procedure from the two groups was low and did not differ significantly. The VOM-EI combined with RFCA proved to be an effective and safe strategy for treating PsAF in elderly and younger patients.

Impact of sex on Transcatheter aortic valve replacement outcomes: Results of a single-center study

BackgroundEarly studies on transcatheter aortic valve replacement (TAVR) outcomes showed that female sex was associated with better survival. With increased use of new-generation valves, the impact of sex on contemporary TAVR outcomes is less well known. MethodsRetrospective analysis using institutional National Cardiovascular Data Registry STS/ACC TVT data was performed on all patients undergoing TAVR at Yale New Haven Hospital from July 2012 to August 2019. New-generation valves were Evolut PRO, Evolut R, and SAPIEN 3. Old-generation valves were CoreValve, SAPIEN, and SAPIEN XT. Log-rank test and Kaplan-Meier curves were used to compare sex differences in survival up to 1 year after TAVR. Cox modeling was used to adjust for baseline and procedural characteristic differences. Results927 consecutive patients (41.4% women) underwent TAVR. Women were older (82.8 vs 80.6 years old; p < 0.001) with higher STS mortality scores compared with men (7.6% vs 6.4%; p < 0.001) despite lower prevalence of cardiovascular comorbidities including coronary artery disease, peripheral artery disease, and smoking. Most cases used transfemoral access (90.5%) and new-generation devices (72.3%). Women received smaller valves compared with men (20–26 mm: 78.0% vs 32.9%; 29–34 mm: 22.1% vs 67.1%; overall p < 0.0001). There were no statistically significant differences between sexes in both unadjusted and adjusted 1-year mortality. ConclusionOur data show no significant difference in 1-year survival between sexes using primarily new generation valves. Further studies should reassess the impact of sex on TAVR outcomes and whether newer technologies like new valve design and sizes, and CT imaging may have eliminated sex-based disparities.

Systematic Review on Early and Follow-up Mortality Rate in Octogenarians Treated With a Fenestrated and/or Branched Endovascular Aortic Repair.

Advanced age has been related to conflicting outcomes after fenestrated/branched endovascular aortic aneurysm repair (F/BEVAR). The aim of this meta-analysis is to compare 30-day mortality, technical success, and 1-year and 5-year survival in octogenarians and non-octogenarians who underwent F/BEVAR for complex aortic aneurysms. This meta-analysis was pre-registered to PROSPERO (CRD42022348659). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 statement was followed. A search of the English literature, via Ovid, using MEDLINE, Embase, and CENTRAL databases, until August 30, 2022, was executed. Randomized Control Trials and observational studies (2000-2022), with ≥5 patients, reporting on 30-day mortality and 1-year and 5-year survival rates among octogenarians and non-octogenarians after F/BEVAR were eligible. The Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool was applied to assess the risk of bias. The primary outcome was 30-day mortality and secondary was 1-year and 5-year survival in octogenarians and non-octogenarians. The outcomes were summarized as odds ratio (OR) with 95% confidence intervals (CIs). A narrative presentation was selected in case of missing outcomes. The initial research isolated 3263 articles; 6 retrospective studies were finally included. A total of 7410 patients were managed with F/BEVAR; 1499 patients (20.2%) were ≥80 years old (75.5% males, 259/343). The estimated 30-day mortality was 6% among octogenarians vs 2% in younger patients, with a significantly higher 30-day mortality for patients ≥80 years old (OR 1.21, 95% CI 0.61-1.81; p=0.0.11; Ι2=36.01%). Technical success was similar between the groups (OR -0.83; 95% CI -1.74-0.07, p<0.0.001; Ι2=95.8%). Regarding survival, a narrative approach was decided due to missing data. Two studies reported a statistically significant difference in 1-year survival between groups, with higher mortality in octogenarians (82.5%-90% vs 89.5%-93%), while 3 reported a similar 1-year survival rate in both groups (87.1%-95% vs 88%-89.5%). At 5 years, 3 studies reported a statistically significant lower survival for octogenarians (26.9%-42% vs 61%-71%). Octogenarians treated with F/BEVAR presented higher 30-day mortality while a lower survival rate at 1 and 5 years was reported in the literature. Patient selection is thus mandatory among older patients. Further studies, especially on patient risk stratification, are needed to estimate the F/BEVAR outcomes on elder patients. Age may be a factor of increased early and long-term mortality within patients managed for aortic aneurysms. In this analysis, patients over 80 years old were compared to their younger counterparts when managed with fenestrated or branched endovascular aortic repair (F/BEVAR) . The analysis showed that early mortality was acceptable for octogenrains but significantly higher when compared to patients younger than 80 years. One-year survival rates are controversial. At 5-year follow-up, octogenarians present lower survival but data to provide metanalysis are lacking. Patient selection and risk stratification are mandatory in older candidates for F/BEVAR.

Outcomes of heart transplant recipients bridged with percutaneous versus durable left ventricular assist devices.

The new United Network for Organ Sharing (UNOS) heart allocation policy prioritizes temporary percutaneous over durable left ventricular assist devices (LVAD) as bridge to transplant. We sought to examine 1-year outcomes of heart transplant recipients bridged with Impella versus durable LVADs. All primary adult orthotopic heart transplant recipients registered in UNOS between January 2016 and June 2021 were analyzed. Recipients were identified as being bridged with isolated durable or percutaneous LVAD at the time of transplant. Baseline characteristics were compared and 1-year survival was examined using the Kaplan Meier method and multivariable Cox proportional hazards regression. During our study period, heart transplant recipients bridged with LVADs were divided between 5422(94%) durable and 324(6%) percutaneous options. Impella-bridged recipients were more likely to be status 1A under the old allocation system (98% vs. 70%, p<.01) and status 2 or higher under the new allocation system (99% vs. 24%, p<.01). Impella-bridged recipients were less likely to be obese (27% vs. 42%, p<.01), have ischemic cardiomyopathy (27% vs. 34%, p<.01), and were more likely to be on inotropic agents at the time of transplant (68% vs. 6%, p<.01). One-year post-transplant survival was not significantly different between the two groups on univariable (HR .87, 95% CI .56-1.37) or multivariable analysis (aHR .63, 95% CI .37-1.07). Following the UNOS allocation policy change, Impella utilization has increased with no significant difference in 1-year survival compared to bridge with durable LVADs. Impella may be a reasonable alternative to durable LVADs in select patients.

Prediction of Coronary Artery Calcium Using Deep Learning of Echocardiograms

Coronary artery calcification (CAC), often assessed by computed tomography (CT), is a powerful marker of coronary artery disease that can guide preventive therapies. Computed tomographies, however, are not always accessible or serially obtainable. It remains unclear whether other widespread tests such as transthoracic echocardiograms (TTEs) can be used to predict CAC. Using a data set of 2,881 TTE videos paired with coronary calcium CTs, we trained a video-based artificial intelligence convolutional neural network to predict CAC scores from parasternal long-axis views. We evaluated the model's ability to classify patients from a held-out sample as well as an external site sample into zero CAC and high CAC (CAC ≥ 400 Agatston units) groups by receiver operating characteristic and precision-recall curves. We also investigated whether such classifications prognosticated significant differences in 1-year mortality rates by the log-rank test of Kaplan-Meier curves. Transthoracic echocardiogram artificial intelligence models had high discriminatory abilities in predicting zero CAC (receiver operating characteristic area under the curve [AUC]=0.81 [95% CI, 0.74-0.88], F1 score=0.95) and high CAC (AUC=0.74 [0.68-0.8], F1 score=0.74). This performance was confirmed in an external test data set of 92 TTEs (AUC=0.75 [0.65-0.85], F1 score=0.77; and AUC=0.85 [0.76-0.93], F1 score=0.59, respectively). Risk stratification by TTE-predicted CAC performed similarly to CT CAC scores in prognosticating significant differences in 1-year survival in high-CAC patients (CT CAC ≥400 vs CT CAC < 400, P=.03; TTE-predicted CAC ≥ 400 vs TTE-predicted CAC < 400, P=.02). A video-based deep learning model successfully used TTE videos to predict zero CAC and high CAC with high accuracy. Transthoracic echocardiography-predicted CAC prognosticated differences in 1-year survival similar to CT CAC. Deep learning of TTEs holds promise for future adjunctive coronary artery disease risk stratification to guide preventive therapies.

Impact of Vasoplegic Syndrome on Early Clinical Outcome After Orthotopic Heart Transplantation

<h3>Purpose</h3> Vasoplegic syndrome (VS) is a possible complication after cardiac surgery using cardiopulmonary bypass (CPB) and is mainly characterized by a loss of systemic resistance leading to refractory hypotension and inadequate peripheral tissue perfusion. The objective of this retrospective study is to determine the impact of VS on short- and long-term morbidity and mortality after heart transplantation (OHT). <h3>Methods</h3> We retrospectively reviewed data of 156 consecutive adult patients who underwent OHT at our center between 2010 and 2021. VS was defined as persistent low systemic vascular resistance (<800 dynes/s/cm⁵) with preserved cardiac index (>2.5 L/min/m²) and catecholamine resistant hypotension despite intravenous vasopressors at a high dose (>0.2μg/kg/min norepinephrine) within the first 6-24 hours after surgery. Patients were divided into two groups classified by the presence or absence of vasoplegia. <h3>Results</h3> The incidence of VS was 11.5% (18 patients) with comparable donor and recipient characteristics in both groups. The mean age of vasoplegic patients was 51±10 (vs. 50±12) years and 88.9 % (vs.71.0%) were male. 61.6% (vs. 48.1%) had a history of prior cardiac surgery of which 44.4 % (vs. 28.1%) were implantations of left ventricular assist devices. Vasoplegic patients showed increased lactate levels at the end of CPB (9.0±5.3 vs. 4.9±3.1 mmol/L, p<.001) and higher rate of reoperation for bleeding (55,6% vs. 15.2% p<.001). Of the 18 vasoplegic patients, five patients (27.8%) received immediate mechanical circulatory support (MCS) at the end of CPB for a mean of 5±2.7 days, six patients (33.3%) received delayed MCS after a mean of 7.8±5.7 hours postoperatively for 6.1±4.6 days and seven patients (38.9%) were treated without MCS. 30-day survival rates were 100 % in patients receiving immediate MCS, 50% in patients with delayed MCS and 71.4% in patients without MCS, respectively. Overall 30-day survival rate was lower in vasoplegic patients (72.2% vs 94.9%, p<.001). If patients survived the first 30 days there was no significant difference in 1-year survival (92.3 % vs 90.2%). <h3>Conclusion</h3> Vasoplegic syndrome following heart transplantation was associated with increased perioperative 30-day mortality. Early MCS implantation seemed to be beneficial for short-term survival. Vasoplegic patients surviving the first 30 days had a comparable and good long-term outcome.

Simultaneous Heart-Kidney Transplant Outcomes Pre- and Post-Heart Allocation System Change: Impact of Temporary Mechanical Circulatory Support

<h3>Purpose</h3> The United Network for Organ Sharing (UNOS) changed the donor heart allocation system in October 2018 aiming to prioritize organ availability to candidates with the highest mortality risk. Following this change, the use of temporary mechanical circulatory support devices (tMCS) increased dramatically in transplant centers across the United States. However, the potential effect of this change remains unknown in patients undergoing simultaneous heart-kidney (SHK) transplantation. The aim of this study was to compare outcomes in SHK recipients before and after the allocation change. <h3>Methods</h3> We identified all SHK recipients from the Scientific Registry of Transplant Recipients who underwent transplantation between January 2016 and November 2019. Patients were stratified into pre- and post-heart allocation change groups based on the date of surgery. Kaplan-Meier curves were generated to compare 1-year outcomes by era. Subsequently, patients with the following tMCS devices were identified within each group: Intra-aortic balloon pump (IABP); Impella 2.5, CP, 5.0; Centrimag and VA-ECMO. Separate 1-year survival analyses were performed and compared between pre- and post-heart allocation change. <h3>Results</h3> We identified 400 and 138 patients who underwent SHK transplant pre- and post-heart allocation change, respectively. The overall 1-year survival rate of SHK recipients was lower after October 2018 (p=0.002; Figure 1A). 56 patients (14.1%) were transplanted with a tMCS device before and 65 (47.1%) after the allocation change. There was no significant difference in 1-year survival between the two groups (p=0.319; Figure 1B). <h3>Conclusion</h3> tMCS device use increased following the heart allocation change. Our results indicate that the one-year survival of SHK recipients has declined after the change, but it was independent of the increased tMCS device use. Further studies are needed to evaluate long-term outcomes.

Outcome of urgent desensitization in sensitized heart transplant recipients

Sensitization, the presence of preformed anti-human antibody in recipients, restricts access to ABO-compatible donors in heart transplant. Desensitization therapy works by reducing preformed antibodies to increase the chances of a negative crossmatch or permit safe transplantation across positive crossmatch. There is no consensus regarding the desensitization protocol in cardiac patients, and the outcome of desensitization remains under debate. Twenty-five consecutive sensitized heart transplant recipients received perioperative desensitization in our institution from 2012 to 2019. One-year patient survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients. Within the first year after transplant, patient survival in sensitized recipients was 76%. Infection was the major cause of death. The cumulative incidence of rejection was 8% for antibody-mediated rejection and 16% for acute cellular rejection. No significant difference in 1-year survival or rejection rate could be demonstrated between sensitized and nonsensitized recipients. Acceptable early outcomes in patient survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity crossmatch- or panel-reactive antibody-directed urgent immunomodulation strategies, while infection remains the major concern.

Evaluating an ‘incident control’ approach to non-communicable disease

ObjectivesThis article evaluates the application of ‘incident control’ methodology usually applied in communicable disease control to an ‘incident’ of unexplained deaths, specifically to resolve a significant difference in 1-year survival after a lung cancer diagnosis observed between two Clinical Commissioning Groups and the England national average, 2011–14. The purpose of the evaluation was to assess whether a formalised incident control approach is feasible and effective in improving outcomes for non-communicable diseases. Study designDescriptive, qualitative, process evaluation. MethodsThere were two components to the evaluation: a document review against identified phases of a non-communicable disease incident control framework and a qualitative analysis of semi-structured interviews with stakeholders who had been involved in implementation. ResultsThe findings indicate feasibility of the incident control model, with some limitations. Identified strengths of the model included the articulation of a clear case and incident definition. The structure and stepped phased approach facilitated partner engagement, robust data analysis, action planning and communication strategies. Delays in data publication and the lack of comparable data across different non-communicable diseases present challenges in timely response and prioritisation of ‘incidents’. ConclusionsThe evaluation indicates value in applying defined incident control methodology to management of non-communicable diseases, especially where there is identification of a potential outlier or a measurable variation, i.e. there is a definable ‘incident’ and ‘case’.

The Impact of Renal Dysfunction in Mechanical Circulatory Support Device Patients on Post-Heart Transplant Outcomes

<h3>Purpose</h3> Patients with severe heart failure who have undergone placement of a mechanical circulatory support (MCS) device do develop renal dysfunction. This renal dysfunction is not severe enough to necessitate the use of combined heart transplantation (HTx) and kidney transplantation. However, it has not been firmly established whether kidney dysfunction does add to increased morbidity or mortality after HTx in these device patients. <h3>Methods</h3> Between 2012 and 2019, we assessed 79 patients who have undergone MCS, either with total artificial heart (n=22) or left ventricular assist device (n=53). Baseline creatinine/glomerular filtration rate (GFR) was measured and patients were divided into GFR categories which include 30-39 mL/min, 40-49 mL/min, 50-59 mL/min, and greater than or equal to 60 mL/min. All patients underwent HTx alone. The need for temporary dialysis was recorded, as well as peak creatinine in the first 3 months after HTx and serum creatinine at 1 year compared to baseline. Further outcomes include subsequent 1-year survival, freedom from cardiac allograft vasculopathy (CAV, stenosis ≥30%), and freedom from non-fatal major adverse cardiac event (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke). <h3>Results</h3> There was no significant difference in 1-year survival, CAV, and NF-MACE or the need for temporary dialysis amongst all groups. Furthermore, no patient in any group needed chronic dialysis. In the GFR 40-49 group compared to the other groups, there was a trend for higher creatinine at 1 year but the baseline was high. <h3>Conclusion</h3> Baseline lower GFRs between 30-39 and 40-49 mL/min in MCS patients do not appear to be a predictor of poorer outcomes after HTx in patients. These patients do not appear to require combined heart and kidney transplantation.

Does Crossing Historical DSA in Patients Undergoing Heart Transplantation Have Any Impact on Post-Transplant Outcomes?

<h3>Purpose</h3> Patients who are awaiting heart transplantation (HTx) have blood screened for circulating antibodies. Antibodies can sometimes come and go and not be detected at the time of HTx. However, there are instances when the patient has demonstrated donor specific antibodies (DSA) in the past but yet are not present at the time of HTx. It is not known whether these historical DSA have an impact on post-HTx outcomes. <h3>Methods</h3> Between 2010 and 2019, we assessed 11 patients awaiting HTx who had historical DSA but none detected at the time of HTx. These patients were compared to patients with DSA at the time of HTx and also compared to a non-sensitized group of patients undergoing HTx in a contemporaneous era. Post-HTx detection of DSA was performed and assessed if there was an amnestic response to the historical DSA. DSA are routinely checked post-HTx at 1, 3, 6, 12 months post-operatively. Other endpoints included 1-year freedom from any treated rejection, acute cellular rejection, and antibody-mediated rejection. 1-year survival, 1-year freedom from non-fatal major adverse cardiac event (NF-MACE, defined as MI, new CHF, PCI, ICD/pacemaker placement, stroke) and 1-year freedom from cardiac allograft vasculopathy were also recorded. <h3>Results</h3> Patients with historical DSA did not have an amnestic response with an increase of that specific DSA post-HTx. The historical DSA group compared to the non-sensitized group had no significant differences in 1-year survival, freedom from DSA, CAV, NF-MACE or rejections. Specifically, the historical DSA group did not appear to have an increase in any type of rejection in the first year post-HTx compared to (crossing) DSA at transplant group or the non-sensitized group. (See table) <h3>Conclusion</h3> Historical DSA does not appear to be a factor in terms of an amnestic response possibly due to the immunosuppression that is being administered. Therefore, crossing historical DSA at heart transplant does not appear to have adverse sequelae.

Outcome of Urgent Desensitization in Sensitized Heart Transplant Recipients

<h3>Purpose</h3> Desensitization therapy through reducing preformed antibody to increase the chances of a negative cross-match or permit safe transplantation across positive crossmatch. There was no consensus regarding desensitization protocol in cardiac patients, and the outcome of desensitization in sensitized recipient was still under debate. <h3>Methods</h3> Consecutive 25 sensitized heart transplant recipients received peri-operative desensitization in our institution from 2012 to 2019. One-year survival and graft rejection rate were analyzed and compared between sensitized recipients and non-sensitized recipients in our institution. <h3>Results</h3> One-year survival after transplant was 76% in sensitized recipients. Infection was the major cause of death. Incidence of rejection in the first year after transplant was 8% for antibody-mediated rejection and 16% for acute cellular rejection. Compared with the outcome in non-sensitized recipients, no significant difference in 1-year survival or rejection rate (sensitized vs. non-sensitized, survival 76 vs. 84.6%, P = 0.32; antibody-mediated rejection rate 8 vs. 3.1%, P = 0.41; acute cellular rejection rate 16 vs. 6.2% P = 0.20) could be demonstrated. <h3>Conclusion</h3> Acceptable early outcomes in patient's survival and graft rejection could be anticipated in sensitized heart transplant recipients under a perioperative algorithm using complement-dependent cytotoxicity (CDC) crossmatch - or panel reactive antibody (PRA) - directed urgent immunomodulation strategies, while infection remains the major concern.

Transplant Outcomes in Destination Therapy Left Ventricular Assist Device Patients.

Left ventricular assist devices (LVAD) can be implanted as either a bridge to transplantation (BTT) or destination therapy (DT). This definition is fluid, as some DT patients undergo transplantation. This study compared posttransplant outcomes between BTT and DT LVAD patients. We performed a retrospective analysis of LVAD patients who underwent cardiac transplantation from 2010 to 2016. Outcomes including mortality, rejection, infection, and overall readmission were assessed with univariable Cox analyses. This cohort included 92 LVAD patients underwent transplantation: 57 BTT, mean age 52 years, and 79% male. The DT group had a longer LVAD support time (median support 406 versus 161 days, p < 0.001) with no significant difference in 1-year survival (BTT 86% and DT 92%, p = 0.52) or survival time (HR 0.89, 95% confidence interval [CI] 0.33-2.41, p = 0.82). Rates of nonfatal adverse events were also similar between BTT and DT patients. In our cohort, DT patients had similar long-term survival and rates of adverse events as compared with BTT, despite a longer time to transplant. This study suggests that transplant outcomes are acceptable for patients initially labeled DT and that a longer duration of LVAD support may not adversely affect posttransplant outcomes.

EP1.17-08 Good Survival in Females Undergoing Surgery Without Adjuvant Chemotherapy for Stage Three Lung Cancer: A Review of Our 12-Year Experience

Lung cancer is a major disease in Singapore. Anatomical surgical resection is the treatment of choice for early lung cancer. No study on outcome of surgery on early lung cancer has been reported in a mixed Asian population. We aim to review the outcome of patients with early lung cancer who underwent surgery in our tertiary centre. We performed a retrospective cross-sectional study on all patients who underwent lung resection between 1st January 2006 and 31st December 2017. Information collected included patient”s age, gender, race, stage of disease and outcome data. Those with a diagnosis of primary lung cancer were included whilst those whose surgery was not for curative intent were excluded. 404 patients are included in our study. The mean age is 62.9 years with the modal age group between 60 and 69 years old. Females are significantly younger than males (mean 61.6 years vs 64.0 years, p = 0.019). 76.6% (n = 310) are early disease (Stage 1 or Stage 2) and 20.0% (n = 81) are late disease (Stage 3). Overall survival is significantly higher in early than late disease and in females than males. In female patients with Stage 3 disease, there is no significant difference in 1-year survival between early (97.3%) and late (89.7%) (p = 0.177) disease. Those aged between 70 and 79 years has a significantly higher mortality at 3 years (27.3%, odds ratio 3.73 (1.0 – 13.5, CI 95%)). There is no significant difference in 3 year mortality between early and late disease in females younger than 60 years old (87.5% vs 77.8%, p = 0.303). T3/T4 disease patients have better survival rates than N2 disease patients. All female patients with T3/T4 disease are still alive at 5 years even in those without adjuvant chemotherapy. In females with N2 disease, 3 and 5-year survival is also higher in patients with partial or no adjuvant chemotherapy but this is not statistically significant. The use of adjuvant chemotherapy is also associated with a significant higher rate of recurrence (53.5% vs 16.1%, p = 0.001) in all patients with Stage 3 disease, especially in female patients (68.2% vs 18.2%, p = 0.009). In females with N2 disease, the recurrence rate is significantly higher in those who had adjuvant chemotherapy (68.4% vs 25.0%, p = 0.049). For those with T3/T4 disease, there is no recurrence in patients who did not have any adjuvant chemotherapy but this is not statistically significant. Our study demonstrate that female patients with early lung cancer present earlier and have significant higher survival rates than males. Even in patients with stage 3 disease, there is good survival benefit up to 3 years post-surgery for patients aged 60 years old and below. Three and five year survival are better in female patients with N2 disease who did not have or did not complete their adjuvant chemotherapy than those who did. The use of adjuvant chemotherapy is also associated with a higher rate of recurrence, especially in females with N2 disease.

Increasing heart transplant donor pool by liberalization of size matching.

The heart transplant (HT) guidelines recommendation to match recipient and donors within 30% of body weight lacks a strong evidence base and is not well established in patients bridged to transplant with left ventricular assist devices (LVAD). In light of the scarcity of donor hearts, we investigated the effect of size mismatch on hemodynamics, one-year survival and length of stay (LOS) following HT. Single-center retrospective analysis of consecutive HT patients from April 2007 to September 2017. Recipients were divided into 3 cohorts based on donor-to-recipient weight ratio (DRWR): (1) undersized (<0.7), (2) size-matched, (0.7-1.3); (3) oversized (>1.3). 288 consecutive patients were identified (mean age 53 ± 11 years; 76% male), 46 were undersized (0.61 ± 0.05), 210 size-matched (0.94 ± 0.16), and 32 oversized (1.65 ± 0.38). There was no significant difference in donor left ventricular end diastolic diameter (LVEDD) between the 3 groups (p = 0.11). The donor/recipient (D/R) predicted heart mass (PHM) was lowest in the undersized group (0.92 ± 0.13). There were no significant differences in 1-year survival in the overall and LVAD cohort (p = 0.65 and 0.59, respectively). Neither donor LVEDD nor D/R PHM differed among survivors or non-survivors. LOS was longer in the undersized group than the size-matched cohort (p = 0.004). The undersized group had hearts with the highest filling pressures and lowest cardiac index at 1 week among the remaining groups (p = 0.009, 0.017, and p = 0.05, respectively). There were no clinically significant differences in hemodynamics at 1 or 6 months. HT undersizing affects hemodynamics early but not later in the course and does not impact 1-year survival. The liberalization of size matching may increase the HT donor pool significantly.

Left Ventricular Assist Devices vs. Cardiac Transplantation: The Age Factor

Background Outcomes of patients bridged with a left ventricular assist device (LVAD) when compared to primary cardiac transplantation may vary by age group. Methods Single-center study of patients who underwent cardiac transplantation or LVAD implantation. The study population was categorized by age groups. Group 1 included patients under 50 years of age, while Group 2 included patients over 50 years of age. For each age group, separate analyses of baseline demographics and outcomes were compared between 3 subgroups: patients bridged with an LVAD (BTT-LVAD group), primary cardiac transplantation patients (TXP group), and destination therapy (DT-LVAD group). For the BTT-LVAD group, survival was assessed from time of LVAD implantation and included days alive after cardiac transplantation. For the TXP group, survival was defined as days alive since transplantation. Kaplan-Meier curves were used to analyze survival between groups. Results A total of 380 patients were analyzed in the study. 136 patients were included in Group 1 (35.8%). At baseline, no significant differences with regards to age, gender, ethnicity and BMI were noted among subgroups. During the study period, 76% of Group 1 BTT-LVAD patients underwent transplantation. A high survival rate was observed with no significant differences in 1-year survival noted between subgroups (Group 1 BTT-LVAD: 96%; Group 1 TXP: 97.3%; Group 1 DT-LVAD:91.8%, p=0.472). 3-year survival remained high in Group 1 BTT-LVAD patients, but a significant decrease in survival of both Group 1 TXP and DT-LVAD was noted (Fig. A). Group 2 patients comprised 244 patients (64.2% of total population; Group 2 BTT-LVAD: 36.1.%; Group 2 TXP: 25.4%; Group 2 DT-LVAD: 38.5%). At baseline, no significant differences with regards to age, gender, BMI were noted among subgroups. Group 2 DT-LVAD had a higher proportion of black patients. During the study period, 76% of Group 2 BTT-LVAD patients underwent transplantation. A high survival rate was observed in Group 2 with no significant differences in 1-year survival noted between subgroups (Group 2 BTT-LVAD: 95.5%; Group 2 TXP: 87.1%; Group 2 DT-LVAD: 88.3%, p=0.14). 3-year survival remained high in Group 2 BTT-LVAD and TXP, but a significant decrease in survival of Group 2 DT-LVAD was noted (Fig. B). Conclusions Our study showed exceptionally high mid- and long-term survival rates in patients bridged with a LVAD in both age groups. While a TXP strategy may be reasonable in older patients, younger patients who underwent TXP had a significant decline in survival at 3 and 5 years. Conversely, outcomes of DT-LVAD therapy in younger patients continues to improve.

LVAD as Bridge to Transplant Leads to Better Outcomes When Compared to Transplant-Only Strategy

Background Patient who are bridged to transplantation with a left ventricular assist device (LVAD) when compared to primary heart transplantation have had mixed outcomes. Methods Single-center study of patients who underwent cardiac transplantation or LVAD implantation. Baseline demographics and outcomes were compared between 3 groups: patients bridged with a LVAD (BTT-LVAD group), patients who underwent primary cardiac transplantation (TXP group), and patients who underwent LVAD as destination therapy (DT-LVAD group). For the TXP group, survival was defined as days alive since cardiac transplantation. For the BTT-LVAD group, survival was defined from time of LVAD implantation and included days alive after cardiac transplantation. In the DT-LVAD group, survival was defined as days alive since LVAD implantation. Kaplan-Meier curves were used to analyze survival between the groups. Results A total of 380 patients were included (BTT-LVAD group: 36.3.%; TXP group: 26%; DT-LVAD group: 37.6%). At baseline, no significant differences with regards to age and BMI were noted. Male gender and blood type O were more common in the BTT-LVAD group. The DT-LVAD group had a higher proportion of black patients. During the study period, 76% of LVAD-BTT group underwent cardiac transplantation. A high survival rate was observed is the study population at 1-year (92.1%). Non-statistically significant differences in 1-year survival were noted between groups with higher trends of survival observed in the BTT-LVAD group (BTT-LVAD group: 95.7%; TXP group: 90.9%; DT-LVAD group: 89.5%, p=0.14). By 2 years, survival rates remained high in all groups with statistically significant differences noted among the groups (BTT-LVAD group: 94.6%; TXP group: 85.9%; DT-LVAD group: 81.4%, p=0.01). 3-year survival remained high for both the BTT-LVAD and TXP groups however, a decline in survival was noted in the DT-LVAD group (BTT-LVAD group: 93.5%; TXP group: 81.6%; DT-LVAD group: 60.8%, p=0.00). While 5-year survival remained high for the LVAD-BTT group (figure), a further survival decrease was observed in both the TXP and DT-LVAD groups (BTT-LVAD group:8 4.2%; TXP group: 63%; DT-LVAD group: 29.8%, p=0.00). Conclusions Our study showed an exceptionally high survival rate in patients bridged to cardiac transplantation with LVAD implantation. These findings also suggest that the use of a LVAD as a BTT may be a better strategy than primary cardiac transplantation as it may add an additional survival benefit (total support time).

Single versus multi-drug antimicrobial surgical infection prophylaxis for left ventricular assist devices: A systematic review and meta-analysis.

Infection remains the Achilles heel of left ventricular assist device (LVAD) therapy. However, an optimal antimicrobial surgical infection prophylaxis (SIP) regimen has not been established. This study evaluated the efficacy of a single-drug SIP compared to a multi-drug SIP on clinical outcomes in patients undergoing continuous-flow LVAD (CF-LVAD) and pulsatile LVAD (P-LVAD) implantation. An electronic search was performed to identify studies in the English literature on SIP regimens in patients undergoing LVAD implantation. Identified articles were assessed for inclusion and exclusion criteria. Fourteen articles with 1,311 (CF-LVAD: 888; P-LVAD: 423) patients were analyzed. Overall, 501 (38.0%) patients received single-drug SIP, whereas 810 (62.0%) received multi-drug SIP. Time to infection was comparable between groups. There was no significant difference in overall incidence of LVAD-specific infections [single-drug: 18.7% vs. multi-drug: 24.8%, P = 0.49] including driveline infections [single-drug: 14.1% vs. multi-drug: 20.8%, P = 0.37]. Compared to single-drug SIP, patients who received multi-drug SIP had a significantly lower survival rate [single-drug: 90.0% vs. multi-drug: 76.0%, P = 0.01] and infection-free survival rate [single-drug: 88.4% vs. multi-drug: 77.3%, P = 0.04] at 90 days. However, there were no significant differences in 1-year survival and 1-year infection-free survival between groups. No survival differences were observed in the CF-LVAD subset as well. This study demonstrated no additional advantage of a multi-drug compared to a single-drug regimen for SIP. Although there was a modest advantage in early survival among CF-LVAD and P-LVAD patients who received single-drug SIP, there were no significant differences in the 1-year survival and 1-year infection-free survival.

Heart Transplant Under Sizing is Associated with Adverse Early Hemodynamics but Does Not Affect Survival

Purpose Guidelines recommend against significant > 30% size mismatch in heart transplantation (HT). However this approach is controversial in general and not well established in patients with left ventricular assist devices (LVAD). We investigated the effect of size mismatch on hemodynamics (HD) post HT and one year survival. Methods Retrospective analysis of HT patients from 04/07 to 09/17. Donor information was retrieved from UNOS Donor Net database. Recipients were divided in three groups based on Recipient to Donor Weight Ratio (RDWR): (1) in range (0.7-1.3); (2) undersized donor heart (>1.3); and oversized donor heart (<0.7). Post-HT outcomes were analyzed including HD at 1 week, 1 month and 6 months. Subgroup analysis for LVAD patients was done. Results 288 consecutive patients were identified (mean age 53±11 years, 76% male) and grouped based on RDWR: 18 oversized (0.55 ± 0.10), 191 in range (1.01 ± 0.16) and 79 undersized (1.53 ± 0.19) p<0.001. Importantly the recipient-to-donor left ventricular end diastolic diameters ratios were similar between the groups (Table). Despite under sizing there were was no significant difference in 1-year survival between the groups (Figure). The percentage of undersized HT was almost identical between the overall cohort and LVAD subgroup (27.4 and 27.5%). Notably patients with under sizing had significantly higher filling pressures and lower cardiac index 1 week post HT (Table). The same results were applicable to patients bridged with LVAD. Conclusion HT under sizing negatively affects early hemodynamics post HT but does not affect 1-year survival in the overall cohort and LVAD patients. Guidelines recommend against significant > 30% size mismatch in heart transplantation (HT). However this approach is controversial in general and not well established in patients with left ventricular assist devices (LVAD). We investigated the effect of size mismatch on hemodynamics (HD) post HT and one year survival. Retrospective analysis of HT patients from 04/07 to 09/17. Donor information was retrieved from UNOS Donor Net database. Recipients were divided in three groups based on Recipient to Donor Weight Ratio (RDWR): (1) in range (0.7-1.3); (2) undersized donor heart (>1.3); and oversized donor heart (<0.7). Post-HT outcomes were analyzed including HD at 1 week, 1 month and 6 months. Subgroup analysis for LVAD patients was done. 288 consecutive patients were identified (mean age 53±11 years, 76% male) and grouped based on RDWR: 18 oversized (0.55 ± 0.10), 191 in range (1.01 ± 0.16) and 79 undersized (1.53 ± 0.19) p<0.001. Importantly the recipient-to-donor left ventricular end diastolic diameters ratios were similar between the groups (Table). Despite under sizing there were was no significant difference in 1-year survival between the groups (Figure). The percentage of undersized HT was almost identical between the overall cohort and LVAD subgroup (27.4 and 27.5%). Notably patients with under sizing had significantly higher filling pressures and lower cardiac index 1 week post HT (Table). The same results were applicable to patients bridged with LVAD. HT under sizing negatively affects early hemodynamics post HT but does not affect 1-year survival in the overall cohort and LVAD patients.