Faculty Bibliography

INTRODUCTION: An extracorporeal membrane oxygenation (ECMO) circuit exchange is a commonly encountered procedure with potential for significant hemodynamic risks in patients with already compromised physiology. We aim to examine potential predictors and safety of circuit exchanges (CE) in COVID-19 patients receiving veno-venous (VV) ECMO support.
METHOD(S): This is a single-center, retrospective study of 29 patients with COVID-19 infection requiring VV ECMO support between March 2020 and April 2020. Pre- ECMO characteristics, complications, and blood product requirements were compared between patients with and without CE using independent two-sample Student's t-tests for continuous variables and chi-squared test for categorical variables.
RESULT(S): Overall survival to discharge was 97% (28/29). 13 patients did not require any CE and 16 patients required a total of 42 CEs. There was no difference in baseline characteristics, pre-ECMO ventilator settings, SOFA, or VIS scores between patients who required a circuit exchange versus those who did not. However, patients who required circuit exchanges had a higher lactate at time of cannulation (1.83 vs 1.32, p=0.011). The CE group had a longer duration of ECMO support (53.31 vs 13.31 days, p=0.004), higher pulmonary complications defined as hemothorax or pneumothorax (8/16 vs 0/13, p=0.003), and higher blood product transfusions including packed red blood cell (5,525 mL vs 1,261 mL, p=0.0001), cryoprecipitate (1,735 mL vs 501 mL, p=0.004), and platelet (486 mL vs 111 mL, p=0.019). In the 42 CEs, no major complications, including hemodynamic instability or cardiac arrest, occurred during the exchange.
CONCLUSION(S): Severity of underlying lung injury, ECMO duration, and pre-cannulation lactate may be markers for potential CE in COVID-19 patients requiring ECMO. They may be associated with higher blood product transfusion requirements and while CEs are procedures performed in hemodynamically tenuous patients, they are able to be performed safely

BACKGROUND AND AIM/OBJECTIVE:Patients with severe coronavirus disease 2019 (COVID-19) develop a profound cytokine-mediated pro-inflammatory response. This study reports outcomes in 10 patients with COVID-19 supported on veno-venous extracorporeal membrane oxygenation (VV-ECMO) who were selected for the emergency use of a hemoadsorption column integrated in the ECMO circuit. MATERIALS AND METHODS/METHODS:Pre and posttreatment, clinical data, and inflammatory markers were assessed to determine the safety and feasibility of using this system and to evaluate the clinical effect. RESULTS:During hemoadsorption, median levels of interleukin (IL)-2R, IL-6, and IL-10 decreased by 54%, 86%, and 64%, respectively. Reductions in other markers were observed for lactate dehydrogenase (-49%), ferritin (-46%), d-dimer (-7%), C-reactive protein (-55%), procalcitonin (-76%), and lactate (-44%). Vasoactive-inotrope scores decreased significantly over the treatment interval (-80%). The median hospital length of stay was 53 days (36-85) and at 90-days post cannulation, survival was 90% which was similar to a group of patients without the use of hemoadsorption. CONCLUSIONS:Addition of hemoadsorption to VV-ECMO in patients with severe COVID-19 is feasible and reduces measured cytokine levels. However, in this small series, the precise impact on the overall clinical course and survival benefit still remains unknown.

BACKGROUND:The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic non-full sternotomy approaches using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, a lack of consensus remains regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation. METHODS:A worldwide group of LT-VAD experts was convened to discuss these key topics openly. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed. RESULTS:This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula, and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts' opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This review also emphasizes the critical need for multidisciplinary teams and specific training. CONCLUSIONS:This expert consensus review provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.

Opioid analgesics are commonly used post-lung transplant, but have many side effects and are associated with worse outcomes. We conducted a retrospective review of all lung transplant recipients who were treated with a multimodal opioid-sparing pain protocol. The use of liposomal bupivacaine intercostal nerve block was variable due to hospital restrictions. The primary objective was to describe opioid requirements and patient-reported pain scores early post-lung transplant and to assess the impact of intraoperative liposomal bupivacaine intercostal nerve block. We treated 64 lung transplant recipients with our protocol. Opioid utilization decreased to a mean of 43 milligram oral morphine equivalents by postoperative day 4. Median pain scores peaked at 4 on postoperative day 1 and decreased thereafter. Only three patients were discharged home with opioids, all of whom were taking opioid agonist therapy pre-transplant for opioid use disorder. Patients who received liposomal bupivacaine intercostal nerve block in the operating room had a significant reduction in opioid consumption over postoperative day 1 through 4 (228 mg vs. 517 mg, P= .032). A multimodal opioid-sparing pain management protocol is feasible and resulted in weaning of opioids prior to hospital discharge.

Transplanting hepatitis C viremic donor organs into hepatitis C virus (HCV)-negative recipients is becoming increasingly common; however, practices for posttransplant direct-acting antiviral (DAA) treatment vary widely. Protracted insurance authorization processes for DAA therapy often lead to treatment delays.

BACKGROUND:There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences. METHODS:An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive. RESULTS:Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway. CONCLUSIONS:This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.

OBJECTIVES/OBJECTIVE:To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. DESIGN/METHODS:Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. SETTING/METHODS:Critical care units at two large metropolitan hospitals in New York City. PATIENTS/METHODS:Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. INTERVENTIONS/METHODS:Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. MEASUREMENTS AND MAIN RESULTS/RESULTS:Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. CONCLUSIONS:In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.

Thoracic organs from Hepatitis C virus (HCV) positive donors are not commonly used for transplantation. The development of direct-acting antivirals (DAA) for HCV treatment has led to renewed interest in using HCV-positive organs. We evaluated HCV transmission rates, viremia clearance, and short-term outcomes in HCV-negative patients who received HCV-positive thoracic organs at our institution. From January 1, 2018 to May 31, 2019, 38 patients underwent HCV-positive thoracic organ transplantation (16 lungs and 22 hearts). Heart recipients were started on glecaprevir/pibrentasvir, a pangenotypic DAA, when they developed HCV viremia. Lung recipients were empirically started on glecaprevir/pibrentasvir within the first three post-transplant days. The primary outcome was cure of HCV defined as sustained virologic response at 12 weeks (SVR12). All heart recipients developed HCV viremia with median initial viral load of 64,565 IU/mL (interquartile range: 1660 to 473,151). The median time from DAA initiation to viremia clearance was 19 days (confidence interval: 15-27 days). 11 out of 16 (68.8%) lung recipients developed HCV viremia with median initial viral load of 26 IU/mL (interquartile range: 15 to 143). The median time from DAA initiation to viremia clearance was 10 days (confidence interval: 6-17 days). 5 out of 16 (31.3%) lung recipients never became viremic. All patients demonstrated SVR12. Thoracic organ transplantation from HCV viremic donors is safe with excellent short-term survival. Early initiation of HCV treatment results in rapid viremia clearance and SVR12. Long-term outcomes and optimal timing of DAA initiation remains to be determined.

BACKGROUND:The lung allocation score (LAS) was designed to optimize the utilization of pulmonary allografts based on anticipated pre-transplant survival and post-transplant outcome. Hospital admission status, not included in the LAS, has not been comprehensively investigated with regards to organ allocation. The objective of this study was to determine if pre-transplant hospital admission status is independently associated with post-transplant mortality and to determine if high center volume is associated with improved survival in that cohort.background METHODS: All consecutive adult lung transplants provided by the Scientific Registry of Transplant Recipients were retrospectively reviewed (2007-2017). Group stratification was performed based on admission status at the time of transplantation. A Cox proportional hazard regression was used to determine independent associations with post-transplant mortality. RESULTS:During the study period, 20% (3,747/18,416) of recipients were admitted to the hospital at the time of transplantation. Compared to non-admitted recipients, LAS were significantly higher and waitlist times significantly shorter. Admitted recipients had higher rates of prolonged mechanical ventilation, higher rates of post-transplant dialysis, and longer post-transplant lengths of stay. Pre-transplant admission to a low volume center conferred significantly worse survival compared to non-admitted patients, and high volume centers were independently associated with improved survival compared to low volume centers.results CONCLUSIONS: Hospital admission status is associated with increased post-transplant mortality independent from the LAS and the factors from which it is calculated. However, adjusted survival analysis demonstrates that admission to a high volume center appears to be independently associated with improved survival compared to low volume centers. CONCLUSION/CONCLUSIONS/: