Faculty Bibliography

BACKGROUND: The short-term and long-term effect of using ABO compatible donors in the era of lung allocation score is unknown. This study determined if carefully selected ABO compatible donors could be used in double lung transplantation (DLT) with good outcomes. METHODS: The United Network for Organ Sharing database was retrospectively reviewed for adult DLT from May 2005 to December 2011. RESULTS: Of 6,655 double lung transplants, 493 (7.4%) were with ABO compatible donors and 6,162 (92.6%) were with ABO identical donors. In multivariate analysis, use of ABO compatible donors was not associated with mortality at 30 days (HR, 1.16; 95% CI, 0.76 to 1.79, p = 0.49), 1 year (HR, 1.10; 95% CI, 0.86 to 1.42, p = 0.46), and 5 years (HR, 1.06; 95% CI, 0.83 to 1.34, p = 0.65). Variables associated with mortality at 5 years were donor female sex, donor age 60 years or greater, prolonged ischemic time, increasing recipient creatinine, recipient age, race mismatch, and mechanical ventilation or extracorporeal membrane oxygenation as a bridge to transplantation. Length of stay was longer in the ABO compatible group (30.9 vs 25.9 days, p = 0.001). Acute rejection episodes on index hospitalization (8.8 vs. 8.9%, p = 1.00), peak posttransplant forced expiratory volume in 1 second (FEV1) (82.7 vs 79.7%, p = 0.053), and decrement in FEV1 over time were not different (p = 0.13). Freedom from bronchiolitis obliterans syndrome was similar (1,475 vs 1,454 days, p = 0.17). CONCLUSIONS: The use of ABO compatible donors in the era of lung allocation score was not associated with short-term or long-term mortality and resulted in equivalent posttransplant lung function. A DLT with carefully selected ABO compatible donors can result in excellent outcomes.

BACKGROUND: The goal of this study was to determine if carefully selected ABO-compatible donors in single-lung transplantation results in acceptable outcomes. METHODS: The United Network for Organ Sharing database was reviewed for adult single-lung transplant recipients from May 2005 to December 2011. Recipients of lungs from ABO-compatible donors were compared with those of ABO-identical donors. Mortality was examined with risk-adjusted multivariable Cox proportional hazards regression using significant univariate predictors. RESULTS: Of 3,572 single-lung transplants, 342 (9.6%) were from ABO-compatible donors. The two groups were evenly matched in recipient age (60.8 vs 60.2 years, p = 0.28), male gender (61.8% vs 58.2%, p = 0.10), lung allocation score (43.4 vs 42.6, p = 0.32), forced expiratory volume in 1 second (FEV1; 41.2% vs 40.8%, p = 0.32), and ischemic time (4.2 vs 4.0 hours, p = 0.09), and donor age (34.4 vs 32.9, p = 0.07) and male gender (61.5 vs 65.5, p = 0.14). ABO-compatible donors were less likely to be race mismatched (58.3% vs 50.9%, p = 0.01). Median survival was not different (1,284.0 vs 1,540 days, p = 0.39). On multivariate analysis, lungs from ABO-compatible donors were not associated with mortality (hazard ratio, 1.02; 95% confidence interval, 0.85-1.22; p = 0.86). Prolonged ischemic time, increasing recipient creatinine, increasing recipient age, race mismatch, class I plasma reactive antigen panel > 10%, and the use of mechanical ventilation or extracorporeal membrane oxygenation were associated with mortality. Peak post-transplant FEV1 (64.5% vs 64.0%, p = 0.69) and decrement in FEV1 over time were similar (p = 0.82). CONCLUSIONS: This large multi-institutional analysis of ABO-compatible donors in single-lung transplantation demonstrates that careful selection of ABO-compatible donors results in excellent outcomes.

Open heart surgery in patients with liver cirrhosis is considered to be very risky, but the predictors of poor outcomes in such cases have not been established. We report the perioperative results of open heart surgery in patients with liver cirrhosis in our hospital. We reviewed the results of 13 cases in 12 patients with liver cirrhosis who underwent open heart surgery between January 2001 and December 2010. The Child-Turcotte-Pugh classification, the model for end-stage liver disease score, EuroSCORE, and perioperative data were used to identify risk factors for morbidity and mortality retrospectively. Ten patients had postoperative complications. Significant differences in morbidity were evident for Child-Turcotte-Pugh class, cardiopulmonary bypass time, and crossclamp time. Two patients died of liver failure, one at 40 days and the other at 2 years after surgery. Statistically significant differences in liver-related mortality were evident in the model for end-stage liver disease scores and serum cholinesterase levels. We concluded that a high Child-Turcotte-Pugh class was associated with increased morbidity. Cardiopulmonary bypass and crossclamp times were also related to high morbidity, while high model for end-stage liver disease scores and low serum cholinesterase levels predicted liver-related mortality.

A 68-year-old man presented at the outpatient clinic with epigastric discomfort. He had suffered a myocardial infarction 10 years previously. Chest radiography and computed tomography showed a giant calcified aneurysm in the left ventricle. Electrocardiography indicated atrial fibrillation. Echocardiography showed moderate mitral regurgitation and enlarged left atrium. End-diastolic volume and ejection fraction were 164 ml and 31%, respectively. Coronary angiography revealed total occlusion of the left anterior descending artery and diffuse stenosis of the right coronary artery. Aneurysmectomy, mitral annuloplasty, maze procedure, and coronary artery bypass were performed. The patient was discharged 16 days postoperatively in a satisfactory condition without complications.

The efficacy of using composite arterial Y-grafts in off-pump coronary artery bypass has not been established. We assessed graft patency, long-term clinical outcomes, and the indications for composite arterial Y-grafting by reviewing 53 patients who underwent primary isolated elective off-pump coronary artery bypass with composite arterial Y-grafts between January 2002 and December 2008. Coronary angiography or 64-slice multidetector computed tomographic coronary angiography was used to assess graft patency. Follow-up ranged from 18 to 97 months. The rates of mortality, graft failure, and recurrence of ischemic heart disease were 0%, 22.6%, and 13.2%, respectively. Only 4 (7.5%) patients required additional procedures (percutaneous coronary interventions or repeat surgery) because of graft failure. A significantly higher rate of graft failure was evident when one end of the composite graft was anastomosed to a 75% stenosed branch of a native coronary artery and the other end to a branch with >90% stenosis. The long-term patency of composite arterial Y-grafts in off-pump coronary artery bypass requires proper judgment of the indications.