Routine Extubation in the Operating Room after Isolated Coronary Artery Bypass
BACKGROUND:The benefits of fast track extubation in the intensive care unit (ICU) after cardiac surgery are well-established. While extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR versus ICU extubation in patients undergoing non-emergent isolated coronary artery bypass grafting (CABG). METHODS:Single-center Society of Thoracic Surgeons (STS) data for all patients who underwent non-emergent isolated CABG over a six-year interval were analyzed. Perioperative morbidity and mortality with ICU versus OR extubation were compared. RESULTS:Between January 1, 2017 and December 31, 2022, 1397 patients underwent non-emergent, isolated CABG; 891 (63.8%) extubated in the ICU and 506 (36.2%) extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the two groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR extubated patients had shorter ICU hours (14 vs. 20 hours, p<0.0001), shorter postoperative hospital length of stay (LOS) (3 vs. 5 days, p<0.0001), were more likely to be discharged direct-to-home (97.3% vs. 89.9%, p<0.0001), and had a lower 30-day readmission rate (1.7% vs. 4.1%, p=0.04). CONCLUSIONS:Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after non-emergent CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for non-emergent CABG is indicated.
Commentary: Direct cardiac compression device for biventricular support: If we put lipstick on a pig, is it still a pig? [Editorial]
Thoracoabdominal normothermic regional perfusion in donation after circulatory death does not restore brain blood flow
Use of thoracoabdominal normothermic regional perfusion (TA-NRP) during donation after circulatory death (DCD) is an important advance in organ donation. Prior to establishing TA-NRP, the brachiocephalic, left carotid, and left subclavian arteries are ligated, thereby eliminating anterograde brain blood flow via the carotid and vertebral arteries. While theoretical concerns have been voiced that TA-NRP after DCD may restore brain blood flow via collaterals, there have been no studies to confirm or refute this possibility. We evaluated brain blood flow using intraoperative transcranial Doppler (TCD) in two DCD TA-NRP cases. Pre-extubation, anterior and posterior circulation brain blood flow waveforms were present in both cases, similar to the waveforms detected in a control patient on mechanical circulatory support undergoing cardiothoracic surgery. Following declaration of death and initiation of TA-NRP, no brain blood flow was detected in either case. Additionally, there was absence of brainstem reflexes, no response to noxious stimuli and no respiratory effort. These TCD results demonstrate that DCD with TA-NRP did not restore brain blood flow.
Pig-to-human heart xenotransplantation in two recently deceased human recipients
Genetically modified xenografts are one of the most promising solutions to the discrepancy between the numbers of available human organs for transplantation and potential recipients. To date, a porcine heart has been implanted into only one human recipient. Here, using 10-gene-edited pigs, we transplanted porcine hearts into two brain-dead human recipients and monitored xenograft function, hemodynamics and systemic responses over the course of 66 hours. Although both xenografts demonstrated excellent cardiac function immediately after transplantation and continued to function for the duration of the study, cardiac function declined postoperatively in one case, attributed to a size mismatch between the donor pig and the recipient. For both hearts, we confirmed transgene expression and found no evidence of cellular or antibody-mediated rejection, as assessed using histology, flow cytometry and a cytotoxic crossmatch assay. Moreover, we found no evidence of zoonotic transmission from the donor pigs to the human recipients. While substantial additional work will be needed to advance this technology to human trials, these results indicate that pig-to-human heart xenotransplantation can be performed successfully without hyperacute rejection or zoonosis.
Commentary: United Network for Organ Sharing policies work, but progress only occurs at the speed of a snail: A need for expeditious adjustments [Editorial]
Extracorporeal hemoadsorption in critically ill COVID-19 patients on VV ECMO: the CytoSorb therapy in COVID-19 (CTC) registry
OBJECTIVES:The CytoSorb therapy in COVID-19 (CTC) registry evaluated the clinical performance and treatment parameters of extracorporeal hemoadsorption integrated with veno-venous extracorporeal membrane oxygenation (VV ECMO) in critically ill COVID-19 patients with acute respiratory distress syndrome (ARDS) and respiratory failure under US FDA Emergency Use Authorization. DESIGN:Multicenter, observational, registry (NCT04391920). SETTING:Intensive care units (ICUs) in five major US academic centers between April 2020 and January 2022. PATIENTS:A total of 100 critically ill adults with COVID-19-related ARDS requiring VV ECMO support, who were treated with extracorporeal hemoadsorption. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:(p = 0.14). No device-related adverse events were reported. CONCLUSIONS:In critically ill patients with severe COVID-19-related ARDS treated with the combination of VV-ECMO and hemoadsorption, 90-day survival was 74% and earlier intervention was associated with shorter need for organ support and ICU stay. These results lend support to the concept of "enhanced lung rest" with the combined use of VV-ECMO plus hemoadsorption in patients with ARDS.
Extracorporeal Membrane Oxygenation Impact on Host Transcriptomic Response in Severe Coronavirus
BACKGROUND/UNASSIGNED:Evidence suggests that patients critically ill with COVID-19 have a dysregulated host immune response that contributes to end-organ damage. Extracorporeal membrane oxygenation (ECMO) has been used in this population with varying degrees of success. This study was performed to evaluate the impact of ECMO on the host immunotranscriptomic response in these patients. METHODS/UNASSIGNED:Eleven patients critically ill with COVID-19 requiring ECMO underwent an analysis of cytokines and immunotranscriptomic pathways before ECMO (T1), after ECMO for 24 hours (T2), and 2 hours after ECMO decannulation (T3). A Multiplex Human Cytokine panel was used to identify cytokine changes, and immunotranscriptomic changes in peripheral leukocytes were evaluated by PAXgene and NanoString nCounter. RESULTS/UNASSIGNED:, which code for binding ligands for the activation of toll-like receptors 2 and 4. Reactome analyses of differential gene expression demonstrated an impact on many of the body's most important immune inflammatory pathways. CONCLUSIONS/UNASSIGNED:These findings suggest a temporal impact of ECMO on the host immunotranscriptomic response in patients critically ill with COVID-19.
Donation after circulatory death heart transplantation using normothermic regional perfusion:The NYU Protocol
OBJECTIVE/UNASSIGNED:This study aimed to evaluate the impact of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion on the metabolic milieu of donation after cardiac death organ donors before transplantation. METHODS/UNASSIGNED:Local donation after cardiac death donor offers are assessed for suitability and willingness to participate. Withdrawal of life-sustaining therapy is performed in the operating room. After declaration of circulatory death and a 5-minute observation period, the cardiac team performs a median sternotomy, ligation of the aortic arch vessels, and initiation of thoraco-abdominal normothermic regional perfusion via central cardiopulmonary bypass at 37 °C. Three sodium chloride zero balance ultrafiltration bags containing 50 mEq sodium bicarbonate and 0.5 g calcium carbonate are infused. Arterial blood gas measurements are obtained every 15 minutes after every zero balance ultrafiltration bag is infused, and blood is transfused as needed to maintain hemoglobin greater than 8 mg/dL. Cardiopulmonary bypass is weaned with concurrent hemodynamic and transesophageal echocardiogram evaluation of the donor heart. The remainder of the procurement, including the abdominal organs, proceeds in a similar controlled fashion as is performed for a standard donation after brain death donor. RESULTS/UNASSIGNED:.001) . On average, donation after cardiac death donors received transfusions of 2.3 ± 1.5 units of packed red blood cells. Of the 18 donors who underwent normothermic regional perfusion, all hearts were deemed suitable for recovery and successfully transplanted, a yield of 100%. Other organs successfully recovered and transplanted include kidneys (80.6% yield), livers (66.7% yield), and bilateral lungs (27.8% yield). CONCLUSIONS/UNASSIGNED:The use of cardiopulmonary bypass for thoraco-abdominal normothermic regional perfusion is a burgeoning option for improving the quality of organs from donation after cardiac death donors. Meticulous intraoperative management of donation after cardiac death donors with a specific focus on improving their metabolic milieu may lead to improved graft function in transplant recipients.
Supporting the "forgotten" ventricle: The evolution of percutaneous RVADs
Right heart failure (RHF) can occur as the result of an acute or chronic disease process and is a challenging clinical condition for surgeons and interventionalists to treat. RHF occurs in approximately 0.1% of patients after cardiac surgery, in 2"“3% of patients following heart transplantation, and in up to 42% of patients after LVAD implantation. Regardless of the cause, RHF portends high morbidity and mortality and is associated with longer hospital stays and higher healthcare costs. The mainstays of traditional therapy for severe RHF have included pharmacological support, such as inotropes and vasopressors, and surgical right ventricular (RV) assist devices. However, in recent years catheter-based mechanical circulatory support (MCS) strategies have offered novel solutions for addressing RHF without the morbidity of open surgery. This manuscript will review the pathophysiology of RHF, including the molecular underpinnings, gross structural mechanisms, and hemodynamic consequences. The evolution of techniques for supporting the right ventricle will be explored, with a focus on various institutional experiences with percutaneous ventricular assist devices.
Reduced CT iodine perfusion score is associated with adverse clinical outcomes in acute pulmonary embolism [Letter]