Faculty Bibliography

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.

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.

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.

BACKGROUND:Lung procurement for transplantation occurs in approximately 20% of brain dead donors and is a major impediment to wider application of lung transplantation. We investigated the effect of lung protective management at a specialized donor care facility on lung procurement rates from brain dead donors. METHODS:Our local organ procurement organization instituted a protocol of lung protective management at a freestanding specialized donor care facility in 2008. Brain dead donors from 2001 to 2007 (early period) were compared with those from 2009 to 2016 (current period) for lung procurement rates and other solid-organ procurement rates using a prospectively maintained database. RESULTS:An overall increase occurred in the number of brain dead donors during the study period (early group, 791; late group, 1,333; p < 0.0001). The lung procurement rate (lung donors/all brain dead donors) improved markedly after the introduction of lung protective management (early group, 157 of 791 [19.8%]; current group, 452 of 1,333 [33.9%]; p < 0.0001). The overall organ procurement rate (total number of organs procured/donor) also increased during the study period (early group, 3.5 organs/donor; current group, 3.8 organs/donor; p = 0.006). CONCLUSIONS:Lung protective management in brain dead donors at a specialized donor care facility is associated with higher lung utilization rates compared with conventional management. This strategy does not adversely affect the utilization of other organs in a multiorgan donor.

Individuals with robust natural killer (NK) cell function incur lower rates of malignancies. To expand our understanding of genetic factors contributing to this phenomenon, we analyzed NK cells from cancer resistant and susceptible strains of mice. We identified a correlation between NK levels of the X-chromosome-located adaptor protein SLy1 and immunologic susceptibility to cancer. Unlike the case for T or B lymphocytes, where SLy1 shuttles between the cytoplasm and nucleus to facilitate signal transduction, in NK cells SLy1 functions as a ribosomal protein and is located solely in the cytoplasm. In its absence, ribosomal instability results in p53-mediated NK cell senescence and decreased clearance of malignancies. NK defects are reversible under inflammatory conditions and viral clearance is not impacted by SLy1 deficiency. Our work defines a previously unappreciated X-linked ribosomopathy that results in a specific and subtle NK cell dysfunction leading to immunologic susceptibility to cancer.