Faculty Bibliography

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/:

BACKGROUND:The Lung Allocation Score (LAS) significantly improved outcomes and waitlist mortality in lung transplantation. However, mortality remains high for the sickest waitlist candidates despite additional changes to allocation distance. Regulatory considerations of overhauling the current lung allocation system has met significant resistance, and would require years to implement. This study evaluates if a modest change to the current system by prioritization of only high-LAS lung transplant candidates would result in lowered waitlist mortality. METHODS:The Thoracic Simulated Allocation Model was used to evaluate all lung transplant candidates and donor lungs recovered between July 1, 2009 and June 30, 2011. Current lung allocation rules (initial offer within 250 nautical-mile radius for ABO-identical then compatible offers) were run. Allocation was then changed for only patients with an LAS≥50 (high-LAS) to be prioritized within a 500 nautical-mile radius with no stratification between ABO-identical and compatible offers. Ten iterations of each model were run. Primary endpoints were waitlist mortality and post-transplant 1-year survival. RESULTS:6,538 waitlist candidates and transplant recipients were evaluated per iteration, for a total of 130,760 simulated patients. Compared with current allocation, the adjusted model had a 23.3% decrease in waitlist mortality. Post-transplant 1-year survival was minimally affected. CONCLUSIONS:Without overhauling the entire system, simple prioritization changes to the allocation system for high-LAS candidates may lead to decreased waitlist mortality and increased organ utilization. Importantly, these changes do not appear to lead to clinically significant changes in post-transplant 1-year survival.

BACKGROUND:Coronavirus disease 2019 (Covid-19) remains a worldwide pandemic with a high mortality rate among patients requiring mechanical ventilation. The limited data that exists regarding the utility of extracorporeal membrane oxygenation (ECMO) in these critically ill patients shows poor overall outcomes. This paper describes our institutional practice regarding the application and management of ECMO support for patients with Covid-19 and reports promising early outcomes. METHODS:>60 mmHg with no life-limiting comorbidities. Patients were cannulated at bedside and were managed with protective lung ventilation, early tracheostomy, bronchoscopies and proning as clinically indicated. RESULTS:Of 321 patients intubated for Covid-19, 77 (24%) patients were evaluated for ECMO support with 27 (8.4%) patients placed on ECMO. All patients were placed on veno-venous ECMO. Current survival is 96.3%, with only one mortality to date in over 350 days of total ECMO support. Thirteen patients (48.1%) remain on ECMO support, while 13 patients (48.1%) have been successfully decannulated. Seven patients (25.9%) have been discharged from the hospital. Six patients (22.2%) remain in the hospital of which four are on room-air. No healthcare workers that participated in ECMO cannulation developed symptoms of or tested positive for Covid-19. CONCLUSIONS:The early outcomes presented here suggest that the judicious use of ECMO support in severe Covid-19 may be clinically beneficial.

Screening for lung cancer has changed substantially in the past decade since The National Lung Screening Trial. The resultant increased discovery of incidental pulmonary nodules has led to a growth in the number of lesions requiring tissue diagnosis. Bronchoscopy is one main modality used to sample lesions, but peripheral lesions remain challenging for bronchoscopic biopsy. Alternatives have included transthoracic biopsy or operative biopsy, which are more invasive and have a higher morbidity than bronchoscopy. In hopes of developing less invasive diagnostic techniques, technologies have come to assist the bronchoscopist in reaching the outer edges of the lung. Navigational bronchoscopy is able to virtually map the lung and direct the biopsy needle where the scope cannot reach. Robotic bronchoscopy platforms have been developed to provide stability and smaller optics to drive deeper into the bronchial tree. While these new systems have not yet proven better outcomes, they may reduce the need for invasive procedures and be valuable armamentarium in diagnosing and treating lung nodules, especially in the periphery.

The use of telemedicine and telehealth services has grown exponentially over the past decade and has become increasingly relevant and necessary during the coronavirus 2019 (COVID-19) pandemic. There remains ample opportunity to electronically connect cardiothoracic surgeons with their patients during both preoperative and postoperative visits. In this review, we examine the various implementations of telemedicine within thoracic surgery and explore future applications in this quickly developing field.

In the last decade, healthcare systems have shifted their focus from increased volume of patients and procedures to improving patient outcomes and quality. While there are many societies and companies that have surrogate measures of excellence, these metrics are determined by those who do not directly participate and fully understand the best measurements of quality. In order to better assess quality and value, the Efficiency Quality Index (EQI) was created. The novel aspect of the EQI is the determination of metrics by the physicians who actually perform the procedures, in order to create an accurate and fair measurement of performance and outcomes. In this article, we describe how to create and implement the EQI, as well as outline its benefits.

OBJECTIVES/OBJECTIVE:The coronavirus disease 2019 (COVID-19) pandemic has resulted in patient reluctance to seek care due to fear of contracting the virus, especially in New York City which was the epicentre during the surge. The primary objectives of this study are to evaluate the safety of patients who have undergone pulmonary resection for lung cancer as well as provider safety, using COVID-19 testing, symptoms and early patient outcomes. METHODS:Patients with confirmed or suspected pulmonary malignancy who underwent resection from 13 March to 4 May 2020 were retrospectively reviewed. RESULTS:Between 13 March and 4 May 2020, 2087 COVID-19 patients were admitted, with a median daily census of 299, to one of our Manhattan campuses (80% of hospital capacity). During this time, 21 patients (median age 72 years) out of 45 eligible surgical candidates underwent pulmonary resection-13 lobectomies, 6 segmentectomies and 2 pneumonectomies were performed by the same providers who were caring for COVID-19 patients. None of the patients developed major complications, 5 had minor complications, and the median length of hospital stay was 2 days. No previously COVID-19-negative patient (n = 20/21) or healthcare provider (n = 9: 3 surgeons, 3 surgical assistants, 3 anaesthesiologists) developed symptoms of or tested positive for COVID-19. CONCLUSIONS:Pulmonary resection for lung cancer is safe in selected patients, even when performed by providers who care for COVID-19 patients in a hospital with a large COVID-19 census. None of our patients or providers developed symptoms of COVID-19 and no patient experienced major morbidity or mortality.

Increased detection of lung nodules has led to trying to improve technologies for localization and/or tissue acquisition. Previous bronchoscopic techniques have limitations that have led to further advancements in technology. Robotic bronchoscopy has emerged as new technology for the localization, diagnosis, and potential treatment of lung nodules. The robotic bronchoscopic platform was developed to improve peripheral reach of lung nodules, provide direct continuous visualization of the periphery, and offer more precise control of the instrumentation. We review the progression of bronchoscopy, evolution to the robotic platform and its early outcomes, with considerations for future advancements.

Over the past several decades, the operation of choice for end-stage lung disease secondary to severe pulmonary hypertension (PH) has shifted from heart-lung transplantation (HLT) to bilateral lung transplantation (BLT). This change has maintained excellent long-term outcomes and is appropriate for the majority of patients presenting with end-stage disease in need of transplantation. However, a distinct subset of patients with severe PH have an excessive early mortality within 90 days of transplantation. Based on the different causes of this early mortality compared to BLT recipients with other indications, right heart failure and refractory primary graft dysfunction (PGD) appear to play a significant role. It is therefore critical to identify this subset of patient during their evaluation for transplant. This distinction would allow specific patient referral for HLT, which may mitigate those causes of early mortality. Similarly, there is a subgroup of BLT recipients for severe PH that fail to recover right ventricular function, with suboptimal long-term functional status that is independent of early survival. Identification and referral for HLT of these patients may also be important. In this manuscript, we describe our institutional approach and consideration for the risks of early mortality from right heart failure and PGD, as well failure of right ventricular recovery long-term. The described evaluation is used to ascertain those patients with severe PH who may benefit from a HLT over BLT.