Publications by authors named "Cecillia Lui"

44 Publications

NMDA Receptor Antagonism for Neuroprotection in a Canine Model of Hypothermic Circulatory Arrest.

J Surg Res 2020 Dec 18;260:177-189. Epub 2020 Dec 18.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: Hypothermic circulatory arrest (HCA) is associated with neurologic morbidity, in part mediated by activation of the N-methyl-D-aspartate glutamate receptor causing excitotoxicity and neuronal apoptosis. Using a canine model, we hypothesized that the N-methyl-D-aspartate receptor antagonist MK801 would provide neuroprotection and that MK801 conjugation to dendrimer nanoparticles would improve efficacy.

Materials And Methods: Male hound dogs were placed on cardiopulmonary bypass, cooled to 18°C, and underwent 90 min of HCA. Dendrimer conjugates (d-MK801) were prepared by covalently linking dendrimer surface OH groups to MK801. Six experimental groups received either saline (control), medium- (0.15 mg/kg) or high-dose (1.56 mg/kg) MK801, or low- (0.05 mg/kg), medium-, or high-dose d-MK801. At 24, 48, and 72 h after HCA, animals were scored by a standardized neurobehavioral paradigm (higher scores indicate increasing deficits). Cerebrospinal fluid was obtained at baseline, eight, 24, 48, and 72 h after HCA. At 72 h, brains were examined for histopathologic injury in a blinded manner (higher scores indicate more injury).

Results: Neurobehavioral deficit scores were reduced by low-dose d-MK801 on postoperative day two (P < 0.05) and by medium-dose d-MK801 on postoperative day 3 (P = 0.05) compared with saline controls, but free drug had no effect. In contrast, high-dose free MK801 significantly improved histopathology scores compared with saline (P < 0.05) and altered biomarkers of injury in cerebrospinal fluid, with a significant reduction in phosphorylated neurofilament-H for high-dose MK801 versus saline (P < 0.05).

Conclusions: Treatment with MK-801 demonstrated significant improvement in neurobehavioral and histopathology scores after HCA, although not consistently across doses and conjugates.
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http://dx.doi.org/10.1016/j.jss.2020.11.075DOI Listing
December 2020

Evaluation of Extracorporeal Membrane Oxygenation Therapy as a Bridging Method.

Ann Thorac Surg 2020 Oct 21. Epub 2020 Oct 21.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address:

Background: With the implementation of the new heart allocation system, heart transplantation teams are prompted to reevaluate management of patients requiring mechanical circulatory support. The purpose of our study is to compare the outcomes of patients supported with extracorporeal membrane oxygenation (ECMO) prior to transplantation.

Methods: The UNOS database was queried for all adult patients (age >=18) who required support with ECMO prior to heart transplantation from 2001-2018. Patients were stratified into patients who did not require ECMO prior to transplantation, who were weaned off ECMO prior to transplantation, who were bridged immediately to transplantation from ECMO, and who were bridged to an LVAD prior to transplantation. Demographics and outcomes including one-year survival, postoperative stroke, postoperative renal failure requiring dialysis, episodes of rejection, and graft failure were compared.

Results: 29370 patients did not require ECMO prior to transplantation, 101 patients were weaned off of ECMO prior to transplantation, 118 bridged from ECMO directly to transplantation, and 55 patients successfully bridged from ECMO to an LVAD prior to transplantation. Kaplan-Meier survival estimates found a statistically significant decrease in one-year survival for patients who were bridged from ECMO to transplantation compared to those who were bridged to an LVAD prior to subsequent transplantation (p=0.0004, Figure 2).

Conclusions: Our study suggests bridging ECMO patients to an LVAD prior to transplantation will result in improved one year survival compared to patients bridged to immediate transplantation. With the new heart allocation system, continued evaluation of outcomes is required to inform management strategies.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.041DOI Listing
October 2020

Diazoxide preserves myocardial function in a swine model of hypothermic cardioplegic arrest and prolonged global ischemia.

J Thorac Cardiovasc Surg 2020 Aug 26. Epub 2020 Aug 26.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md. Electronic address:

Objective: Adenosine triphosphate potassium sensitive channels provide endogenous myocardial protection via coupling of cell membrane potential to myocardial metabolism. Adenosine triphosphate potassium sensitive channel openers, such as diazoxide, mimic ischemic preconditioning, prevent cardiomyocyte swelling, preserve myocyte contractility after stress, and provide diastolic protection. We hypothesize that diazoxide combined with hyperkalemic cardioplegia provides superior myocardial protection compared with cardioplegia alone during prolonged global ischemia in a large animal model.

Methods: Twelve pigs were randomized to global ischemia for 2 hours with a single dose of cold blood (4:1) hyperkalemic cardioplegia alone (n = 6) or with diazoxide (100 μmol/L) (n = 6) and reperfused for 1 hour. Cardiac output, myocardial oxygen consumption, left ventricular developed pressure, left ventricular ejection fraction, diastolic function, myocardial troponin, myoglobin, markers of apoptosis, and left ventricular infarct size were compared.

Results: Four pigs in the cardioplegia alone group could not be weaned from cardiopulmonary bypass. There were no differences in myoglobin, troponin, or apoptosis between groups. Diazoxide preserved cardiac output versus control (74.5 vs 18.4 mL/kg/min, P = .01). Linear mixed regression modeling demonstrated that the addition of diazoxide to cardioplegia preserved left ventricular developed pressure by 36% (95% confidence interval, 9.9-61.5; P < .01), dP/dt max by 41% (95% confidence interval, 14.5-67.5; P < .01), and dP/dt min by 33% (95% confidence interval, 8.9-57.5; P = .01). It was also associated with higher (but not significant) myocardial oxygen consumption (3.7 vs 1.4 mL O/min, P = .12).

Conclusions: Diazoxide preserves systolic and diastolic ventricular function in a large animal model of prolonged global myocardial ischemia. Diazoxide as an adjunct to hyperkalemic cardioplegia may allow safer prolonged ischemic times during increasingly complicated cardiac procedures.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.069DOI Listing
August 2020

Time-Resolved Echo-PIV/PTV Measurement of Interactions Between Native Cardiac Output and Veno-Arterial ECMO Flows.

J Biomech Eng 2020 Sep 11. Epub 2020 Sep 11.

Department of Mechanical Engineering, Johns Hopkins University, 3400 North Charles Street, Latrobe 122, Baltimore, MD 21218.

Determination of optimal hemodynamic and pressure-volume loading conditions for patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) would benefit from understanding the impact of ECMO flowrates (QE) on the native cardiac output in the admixing zone, i.e. aortic root. This study characterizes the flow in the aortic root of a pig with severe myocardial ischemia noninvasively using contrast-enhanced ultrasound particle image/tracking velocimetry (echo-PIV/PTV). New methods for data pre-processing are introduced, including auto contouring to remove surrounding tissues, followed by blind deconvolution to identify the centers of elongated bubble traces in images with low signal to noise ratio. Calibrations based on synthetic images show that this procedure increases the number of detected bubbles and reduces the error in their locations by 50 percent. Then, an optimized echo-PIV/PTV procedure, which integrates image enhancement with velocity measurements, is used for characterizing the time-resolved 2D velocity distributions. Phase-averaged and instantaneous flow fields show that the ECMO flowrate influences the velocity and acceleration of the cardiac output during systole, and secondary flows during diastole. When QE is 3.0L/min or higher, the cardiac ejection velocity, phase interval with open aortic valve, velocity-time integral (VTI), and mean arterial pressure (MAP) increase with decreasing QE, all indicating sufficient support. For lower QE, the MAP and VTI decrease as QE is reduced, and the deceleration during transition to diastole becomes milder. Hence, for this specific case, the optimal ECMO flowrate is 3.0L/min.
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http://dx.doi.org/10.1115/1.4048424DOI Listing
September 2020

Long-term Survival After Heart Transplantation: A Population-based Nested Case-Control Study.

Ann Thorac Surg 2021 03 31;111(3):889-898. Epub 2020 Jul 31.

Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Heart transplantation is the mainstay of treatment for patients in end-stage heart failure. This study sought to contrast survival after transplantation with that of the general population to quantify standardized mortality rates using a nested case-control study design.

Methods: Control subjects were noninstitutionalized inhabitants of the United States identified through the National Longitudinal Mortality study. Case subjects were adults who underwent heart transplantation between 1990 and 2007 and identified through the Organ Procurement and Transplantation Network. Propensity-matching (5:1, nearest neighbor, caliper = 0.1) was utilized to identify suitable control subjects based on age, sex, race, and state of permanent residency. The primary study endpoint was 10-year survival.

Results: In all, 31,883 heart transplant recipients were matched to 159,415 noninstitutionalized residents of the United States. The 10-year survival of heart transplant recipients was 53%. The population expected mortality rate was 15.9 deaths per 100 person-years with an observed rate of 45.1 deaths per 100 person-years (standardized mortality rate [SMR] 2.84; 95% confidence interval, 2.82 to 2.87). The broadest gaps between observed and expected survival were evident in female (SMR 3.63), black (SMR 3.67), and Hispanic (SMR 4.12) recipients. Standardized mortality ratios declined over time (1990 to 1995, 3.09; 1996 to 2000, 2.90; 2001 to 2007, 2.58). The long-term standardized survival of older recipients was closest to that expected for their age.

Conclusions: Heart transplant recipients have considerable long-term survival and have a threefold higher standardized long-term mortality rate than that of the noninstitutionalized population. Long-term mortality rates have consistently declined over time and will likely continue to decrease.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.163DOI Listing
March 2021

Left Ventricular Assist Device Exchange Increases Heart Transplant Wait-List Mortality.

J Surg Res 2020 11 20;255:277-284. Epub 2020 Jun 20.

Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The new heart transplant allocation criteria prioritize inpatients who require temporary mechanical circulatory support and give lower urgency to candidates on a durable left ventricular assist device (LVAD) who require a device exchange. This study explores whether the latter group should warrant higher priority to reduce wait-list mortality.

Methods: This is a retrospective observational study of 13,113 adult heart transplant candidates in the Organ Procurement and Transplantation Network database who underwent LVAD implantation between 2007 and 2017. It evaluates the impact of LVAD exchange on the composite endpoint of death or removal from the wait list owing to worsening medical condition 1 y after device implantation.

Results: There were 1085 pump exchanges in 954 patients (7% of candidates), of which 22% were women. The pump exchange rate was 5.92 events per 100 patient-years. One-year survival was lower for those who required a pump exchange (76.3% versus 88.5%, logrank P < 0.001). This was congruent with the risk-adjusted mortality 1-y after implantation (hazards ratio: 2.56, 95% confidence interval: 2.18-3.00, P < 0.001).

Conclusions: These findings indicate that among candidates awaiting heart transplantation with a durable LVAD, undergoing pump exchange doubles the risk of 1-y mortality. Giving priority to these candidates may reduce wait-list mortality.
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http://dx.doi.org/10.1016/j.jss.2020.05.062DOI Listing
November 2020

Impact of cytomegalovirus serologic status on heart transplantation.

J Card Surg 2020 Jul 3;35(7):1431-1438. Epub 2020 May 3.

Department of Surgery, Johns Hopkins University, Baltimore, Maryland.

Background: Cytomegalovirus (CMV) infection has been associated with increased risk of mortality, cardiac allograft vasculopathy, and de novo malignancy following heart transplantation in prior institutional reports. This study examines the impact of the recipient and donor CMV status on heart recipients in the United States.

Methods: Adult heart transplant recipients were identified in the OPTN registry between 2005-2016. Recipients were stratified based on the recipient (R) and donor (D) CMV serologic status (+/-). The primary endpoint was survival 5-years after transplantation. The secondary endpoint was cardiac allograft vasculopathy 5-years after transplantation. Separate Cox proportional hazards regression models were developed to evaluate independent associations between CMV status and each of the study endpoints.

Results: A total of 21 878 recipients met the inclusion criteria. The breakdown of study arms by CMV serologic status was R-/D- = 3412, R+/D- = 4939; R-/D+ = 5230, and R+/D+ = 8,297. Five-year survival estimates were similar across groups (77-79%). CMV status was associated with increased mortality at 5-years (23%-41% increased risk) which was most evident in the first 3 months. The use of valganciclovir was associated with decreased risk of mortality (HR 0.56; 95% CI, 0.52-0.60). The cumulative incidence of cardiac allograft vasculopathy (R-/D- = 31%, R+/D- = 30%, R-/D+ = 31%, and R+/D+ = 30%) was similar across groups.

Conclusions: CMV seropositivity at the time of transplantation is associated with increased long-term risk of mortality. Chemoprophylaxis with antivirals seems to mitigate this risk. There was no association with an increased risk of allograft vasculopathy.
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http://dx.doi.org/10.1111/jocs.14588DOI Listing
July 2020

Conditional Survival in Heart Transplantation: An Organ Procurement and Transplantation Network Database Analysis.

Ann Thorac Surg 2020 10 12;110(4):1339-1347. Epub 2020 Mar 12.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Survival after heart transplantation is typically reported only in terms of overall survival. Conditional survival may provide prognostic information for patients after surviving a given period. This study sought to provide an analysis of conditional survival in heart transplantation.

Methods: Data from 29,000 patients who underwent heart transplantation between 2002 and 2016 were analyzed from the Organ Procurement and Transplantation Network database, and 5-year conditional survival rates were calculated according to age, sex, race, renal function, and hepatic function at transplantation.

Results: As time from transplantation increased from 0 to 5 years, the 5-year observed conditional survival changed from 74% to 82% for ages younger than 40 years, 79% to 82% for ages 40 to 49, 79% to 78% for ages 50 to 60, and 75% to 70% for ages older than 60 at transplantation. Conditional survival peaked at 1 and 2 years after transplantation for most subgroups. In recipients younger than 40 years, men had slightly higher conditional survival than women (absolute difference, 3%-4%). In recipients older than 60 years, women had slightly higher conditional survival (absolute difference, 1%-4%). Black recipients had lower survival than white and Hispanic recipients for nearly all time points. Recipients younger than 40 years with the worst renal (65% to 88%) and hepatic function (66% to 83%) at transplantation experienced the largest increase in conditional survival.

Conclusions: The conditional survival of patients who undergo heart transplantation changes substantially over time. The largest increases in conditional survival are in young patients with impaired renal and hepatic function. Conditional survival can provide more accurate prognostic information for heart recipients who survive a given period after transplantation.
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http://dx.doi.org/10.1016/j.athoracsur.2020.02.014DOI Listing
October 2020

Increased Use of Multiorgan Transplantation in Heart Transplantation: Only Time Will Tell.

Ann Thorac Surg 2020 10 20;110(4):1308-1315. Epub 2020 Feb 20.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The utilization of multiorgan transplantation in cardiac transplantation has steadily increased over the past several years. We sought to characterize the trends and outcomes in simultaneous heart and other organ transplantation compared with heart transplantation alone.

Methods: The United Network for Organ Sharing database was queried for all adult patients (age ≥ 18 y) who underwent isolated heart transplantation or simultaneous heart-lung or heart-kidney transplantation from 1987-2016. Patients were stratified into 3 equal time intervals. Demographics and postoperative outcomes were compared.

Results: A total of 58,060 patients were identified with a distribution based on era. Dual organ recipients had more factors associated with increased operative risk including higher rates of diabetes, pulmonary hypertension, intensive care unit admissions, and dialysis prior to transplantation. Heart-lung and heart-kidney recipients had decreased 1-year survival compared with isolated heart recipients from 2007-2016. However, heart-kidney recipients had significantly increased 5-year post-transplantation survival compared with isolated heart recipients with impaired renal function. For isolated heart transplants and heart-lung transplants, 5-year survival rates improved over time, whereas 5-year survival for heart-kidney recipients did not improve with time.

Conclusions: We found a significantly increased 5-year survival rate for heart-kidney transplant recipients compared with isolated heart transplant recipients with renal impairment. Lack of improvement in 5-year postoperative outcomes for heart-kidney recipients in the setting of higher-risk pretransplant clinical characteristics suggests decreased selectivity regarding heart-kidney recipients. Continued scrutiny and evaluation of postoperative outcomes are required to ensure just and appropriate utilization of organs.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.081DOI Listing
October 2020

Early Vascular Cells Improve Microvascularization Within 3D Cardiac Spheroids.

Tissue Eng Part C Methods 2020 02;26(2):80-90

Department of Cardiac Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland.

A key obstacle in the creation of engineered cardiac tissues of clinically relevant sizes is limited diffusion of oxygen and nutrients. Thus, there is a need for organized vascularization within a three-dimensional (3D) tissue environment. Human induced pluripotent stem cell (hiPSC)-derived early vascular cells (EVCs) have shown to improve organization of vascular networks within hydrogels. We hypothesize that introduction of EVCs into 3D microtissue spheroids will lead to increased microvascular formation and improve spheroid formation. HiPSC-derived cardiomyocytes (CMs) were cocultured with human adult ventricular cardiac fibroblasts (FB) and either human umbilical vein endothelial cells (HUVECs) or hiPSC-derived EVCs for 72 h to form mixed cell spheroids. Three different groups of cell ratios were tested: Group 1 (control) consisted of CM:FB:HUVEC 70:15:15, Group 2 consisted of CM:FB:EVC 70:15:15, and Group 3 consisted of CM:FB:EVC 40:15:45. Vascularization, cell distribution, and cardiac function were investigated. Improved microvasculature was found in EVC spheroids with new morphologies of endothelial organization not found in Group 1 spheroids. CMs were found in a core-shell type distribution in Group 1 spheroids, but more uniformly distributed in EVC spheroids. Contraction rate increased into Group 2 spheroids compared to Group 1 spheroids. The triculture of CM, FB, and EVC within a multicellular cardiac spheroid promotes microvascular formation and cardiac spheroid contraction.
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http://dx.doi.org/10.1089/ten.TEC.2019.0228DOI Listing
February 2020

Effects of Systemic and Device-Related Complications in Patients Bridged to Transplantation With Left Ventricular Assist Devices.

J Surg Res 2020 02 9;246:207-212. Epub 2019 Oct 9.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The use of left ventricular assist devices (LVADs) as a bridge to heart transplantation has increased rapidly over the last 2 decades. We aim to explore the effect of pretransplant systemic and device-related complications on posttransplant survival for patients bridged with LVADs.

Materials And Methods: The United Network of Organ Sharing (Organ Procurement and Transplantation Network) database was queried for all adult heart transplant recipients (aged ≥ 18 y) transplanted from April 1, 2015, to June 31, 2018. Device-related complications included thrombosis, device infection, device malfunction, life-threatening arrhythmia, and other device complications. Systemic complications included a new dialysis need or ventilator dependence between the time of listing and transplantation, transfusion, or systemic infection requiring treatment with intravenous antibiotics within 2 wk of transplantation.

Results: A total of 2131 patients were identified as requiring LVAD support before transplantation. LVAD patients had high rates of preoperative systemic complications (53%) and high rates of device-related complications (42.7% experienced at least one device-related complication). Kaplan-Meier analysis revealed a significantly decreased 1-y survival for LVAD patients bridged to transplantation who experienced a pretransplant systemic complication (P = 0.041). Interestingly, preoperative device-related complications had no effect on 1-y posttransplantation survival (P = 0.93). Multivariate Cox modeling revealed that systemic complications were associated with a significantly increased risk of posttransplant mortality for LVAD patients (hazard ratio 1.45; P = 0.033).

Conclusions: Recipients who suffered a systemic complication while awaiting heart transplantation experienced higher short-term mortality rates. Device-related complications do not appear to impact posttransplantation outcomes.
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http://dx.doi.org/10.1016/j.jss.2019.08.016DOI Listing
February 2020

Cardiac regeneration using human-induced pluripotent stem cell-derived biomaterial-free 3D-bioprinted cardiac patch in vivo.

J Tissue Eng Regen Med 2019 11 3;13(11):2031-2039. Epub 2019 Sep 3.

Department of Surgery, Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD.

One of the leading causes of death worldwide is heart failure. Despite advances in the treatment and prevention of heart failure, the number of affected patients continues to increase. We have recently developed 3D-bioprinted biomaterial-free cardiac tissue that has the potential to improve cardiac function. This study aims to evaluate the in vivo regenerative potential of these 3D-bioprinted cardiac patches. The cardiac patches were generated using 3D-bioprinting technology in conjunction with cellular spheroids created from a coculture of human-induced pluripotent stem cell-derived cardiomyocytes, fibroblasts, and endothelial cells. Once printed and cultured, the cardiac patches were implanted into a rat myocardial infarction model (n = 6). A control group (n = 6) without the implantation of cardiac tissue patches was used for comparison. The potential for regeneration was measured 4 weeks after the surgery with histology and echocardiography. 4 weeks after surgery, the survival rates were 100% and 83% in the experimental and the control group, respectively. In the cardiac patch group, the average vessel counts within the infarcted area were higher than those within the control group. The scar area in the cardiac patch group was significantly smaller than that in the control group. (Figure S1) Echocardiography showed a trend of improvement of cardiac function for the experimental group, and this trend correlated with increased patch production of extracellular vesicles. 3D-bioprinted cardiac patches have the potential to improve the regeneration of cardiac tissue and promote angiogenesis in the infarcted tissues and reduce the scar tissue formation.
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http://dx.doi.org/10.1002/term.2954DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254497PMC
November 2019

Discrepancies in access and institutional risk tolerance in heart transplantation: A national open cohort study.

J Card Surg 2019 Oct 2;34(10):994-1003. Epub 2019 Aug 2.

Department of Surgery, Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: The impact of center volume on heart transplantation is widely recognized and serves as a benchmark for certification and reimbursement.

Study Aims: Study sociodemographic variables associated with access to high-volume centers and substantiate the importance of extending access to underserved populations.

Methods: This study focused on adults undergoing heart transplantation between 2006 and 2015. Centers were clustered into terciles (>25, 14-25, or <14 transplants per year) and factors associated with receiving care in different terciles were identified through multinomial regression.

Results: During the study period, 18 725 patients were transplanted at 145 centers. Younger age (<30 years) (P = .005), lower educational level (P < .001), and government-based insurance (P < .001) were associated to lower odds of receiving care at a high-volume center. These centers had higher risk recipients and accepted organs from higher risk donors, when compared to intermediate- and low-volume centers. Receiving care at high (odds ratio [OR], 1.212; P = .017) and intermediate-volume centers (OR, 1.304; P = .001) was associated with greater odds of 1-year survival when compared with low-volume centers.

Conclusion: Social, demographic, and geographic factors affect access to high- and intermediate-volume centers. High-volume centers tolerate more risk while providing excellent survival. Awareness of this impact should prompt an extension of access to care for underserved patient populations.
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http://dx.doi.org/10.1111/jocs.14179DOI Listing
October 2019

Nutritional Support in Postcardiotomy Shock Extracorporeal Membrane Oxygenation Patients: A Prospective, Observational Study.

J Surg Res 2019 12 11;244:257-264. Epub 2019 Jul 11.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Despite the 6000 patients treated with extracorporeal membrane oxygenation (ECMO) annually, there is a paucity of data regarding the nutritional management of these patients.

Materials And Methods: We performed a prospective, observational study of nutrition in postcardiotomy shock patients at our institution. Over a 3.5-year study period, we identified 50 ECMO patients and 225 non-ECMO patients. We identified type, amount, duration, and disruption of nutritional delivery by cohort. The primary outcome was percent of caloric goal met, and secondary outcome was gastrointestinal complications.

Results: ECMO patients met less of their caloric (29% versus 40%, P = 0.017) and protein goals (34% versus 55%, P < 0.001) compared with non-ECMO patients. Tube feeds were administered more slowly (26 versus 37 mL/h, P < 0.001) and held for longer (8.3 versus 4.5 h/d, P < 0.001) in ECMO patients because of procedures (60%) and high-dose pressors (20% versus 7%, P < 0.001). Multivariate analysis demonstrated that ECMO decreased caloric intake by 14%, with no detected increased risk of gastrointestinal complications.

Conclusions: -ECMO patients received significantly less nutrition support compared with a non-ECMO population. Tube feed hold deficits could potentially be avoided by utilizing postpyloric tubes to feed through procedures, by eliminating holds for vasopressors/inotropes in hemodynamically stable patients, or by establishing volume-based feeding protocols. Further clinical studies are needed to establish efficacy of these interventions and to understand the impact of nutrition on outcomes in ECMO patients.
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http://dx.doi.org/10.1016/j.jss.2019.06.054DOI Listing
December 2019

Impact of Left Ventricular Assist Device Exchange on Outcomes After Heart Transplantation.

Ann Thorac Surg 2020 01 4;109(1):78-84. Epub 2019 Jul 4.

Division of Cardiac Surgery, The Johns Hopkins University, Baltimore, Maryland.

Background: Left ventricular assist devices (LVADs) are the most common mode of circulatory support for patients awaiting heart transplantation. Unfortunately, a fraction of these patients require pump exchange during their course for pump-related adverse events. This study examined whether LVAD exchanges affect posttransplantation outcomes.

Methods: This study focused on adult patients in the Organ Procurement and Transplantation Network database who were bridged to transplant with a LVAD implanted between 2007 and 2017. Patients who underwent LVAD exchange were compared with those supported with a single device. The primary end point was all-cause mortality at 1, 2, and 5 years after transplantation. The impact of device exchange on risk-adjusted outcomes was examined using Cox proportional hazards models.

Results: Among 8239 patients who met the inclusion criteria, there were 611 pump exchanges in 560 patients (7% of recipients). The pump exchange rate was 6.24 events per 100 patient-years. Survival at 5 years was lower for those who underwent LVAD exchange (69.4% vs 77.5%, log-rank P = .027). This finding was similar for risk-adjusted 5-year mortality (hazard ratio, 1.36; 95% confidence interval, 1.11 to 1.67; P = .003). Subgroup analysis revealed lower 5-year survival for female recipients who underwent LVAD exchange (55.4% vs 79.7%, log-rank P < .001). The interaction between female sex and LVAD exchange was associated with increased risk-adjusted 5-year mortality (hazard ratio, 1.65; 95% confidence interval, 1.05 to 2.59; P = .030).

Conclusions: Recipients who underwent pump exchange while awaiting heart transplantation had a higher mortality compared with those on a primary device. Subgroup analysis revealed a marked increase in mortality of female recipients who experienced LVAD exchange.
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http://dx.doi.org/10.1016/j.athoracsur.2019.05.038DOI Listing
January 2020

Predictors of operative mortality among cardiac surgery patients with prolonged ventilation.

J Card Surg 2019 Sep 3;34(9):759-766. Epub 2019 Jul 3.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Prolonged ventilation after cardiac surgery affects survival and increases morbidity. Previous studies have focused on predicting this complication preoperatively; however, indicators of poor outcome in those requiring prolonged ventilation remain ill-defined. We sought to identify predictors of operative mortality in cardiac surgery patients who experience prolonged mechanical ventilation.

Methods: 1698 patients who underwent cardiac surgery (CAB, aortic valve replacement ± CAB, or mitral valve repair/replacement ± CAB) required prolonged postoperative mechanical ventilation (>24 hours) between 2012 to 2016 in a statewide consortium. Perioperative factors were evaluated to identify the association with operative mortality. Covariates were selected through bootstrap aggregation to fit multivariable logistic regression models. The relative strength of association was determined by the Wald chi-square statistic.

Results: Median patient age was 68 years [IQR 61 to 76], 38% (644/1,698) were female, median duration of mechanical ventilation was 65 hours [IQR 38 to 143], median STS predicted risk of mortality was 3.1% [IQR 1.4 to 6.9%], and 15.7% (266/1698) suffered operative mortality. Among preoperative and operative characteristics, patient age and intraoperative initiation of extracorporeal membrane oxygenation (ECMO) were the strongest correlates of operative mortality on the multivariate analysis. Among postoperative factors, cardiac arrest and renal failure requiring dialysis were the strongest predictors of risk-adjusted operative mortality. Type of operation or surgical center had no association to mortality after risk adjustment.

Conclusion: Prolonged ventilation following cardiac surgery is associated with a five-fold increase in operative mortality. In these patients, operative mortality is associated with older age, intraoperative initiation of ECMO, postoperative cardiac arrest, and renal failure requiring dialysis.
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http://dx.doi.org/10.1111/jocs.14118DOI Listing
September 2019

Matchmaking Just Got Easier: Impact of Phenotypic Donor-Recipient Likeness in Heart Transplantation.

Ann Thorac Surg 2020 01 27;109(1):102-109. Epub 2019 Jun 27.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: Phenotypic matching in heart transplantation, where donors and recipients are matched based on physical characteristics, has been previously limited to only analyzing individual variables such as sex and age. This study examines the effects of phenotypic matching utilizing multiple factors simultaneously.

Methods: Adult patients undergoing heart transplantation between 2006 and 2016 were identified from the Organ Procurement and Transplantation Network database. Phenotypic matching was defined based on six factors: body mass index difference >30%, age difference >30%, height difference >7%, non-identical ABO blood grouping, race, and sex. A value between 0 and 1 mismatched characteristics was considered phenotypically like matching, whereas 2-6 mismatches was considered phenotypically unlike matching. The primary study endpoint was 1-year survival. Risk-adjusted mortality was examined with multivariable Cox regression models.

Results: During the study period, 20,052 adult patients underwent heart transplantation, of whom 9595 (47.9%) were phenotypically like and 10,457 (52.1%) were phenotypically unlike matched. No differences in 1-year survival were seen between like and unlike matched patients (risk-adjusted odds ratio 1.05, 95% confidence interval 0.96-1.15, P = .305) after controlling for clinically relevant covariates. Subgroup analyses did not demonstrate survival differences after stratification based on hospital transplant volume and initial waitlist status. Phenotypically like matched patients had longer waiting times compared with unlike matched patients overall (225 days vs 192 days, P < .001).

Conclusions: Waiting for a phenotypically matched heart provides no survival benefit and exposes patients to prolonged waitlist times. These findings challenge the notion that a perfect donor heart exists, when in fact this concept may be a misnomer.
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http://dx.doi.org/10.1016/j.athoracsur.2019.04.125DOI Listing
January 2020

Foetal right atrial aneurysm and aortic coarctation with left ventricular dysfunction.

Cardiol Young 2019 Jul 21;29(7):1002-1004. Epub 2019 Jun 21.

Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Aneurysms of the right atrium are rare in the paediatric population. We report a case of a foetal diagnosis of right atrial aneurysm with associated atrial tachycardia in foetal and postnatal life. Unique to our case are the findings of isolated pericardial effusion without hydrops fetalis and the development of aortic coarctation in postnatal life.
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http://dx.doi.org/10.1017/S1047951119001306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715513PMC
July 2019

Appraisal of hepatitis C viremic donors: how far could we expand the heart donor pool?

J Cardiovasc Med (Hagerstown) 2019 08;20(8):572-574

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

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http://dx.doi.org/10.2459/JCM.0000000000000824DOI Listing
August 2019

Children's Heart Assessment Tool for Transplantation (CHAT) Score: A Novel Risk Score Predicts Survival After Pediatric Heart Transplantation.

World J Pediatr Congenit Heart Surg 2019 05;10(3):296-303

1 Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA.

Background: Given the shortage of donor organs in pediatric heart transplantation (HTx), pretransplant risk stratification may assist in organ allocation and recipient optimization. We sought to construct a scoring system to preoperatively stratify a patient's risk of one-year mortality after HTx.

Methods: The United Network for Organ Sharing database was queried for pediatric (<18 years) patients undergoing HTx between 2000 and 2016. The population was randomly divided in a 4:1 fashion into derivation and validation cohorts. A multivariable logistic regression model for one-year mortality was constructed within the derivation cohort. Points were then assigned to independent predictors ( P < .05) based on relative odds ratios (ORs). Risk groups were established based on easily applicable, whole-integer score cutoffs.

Results: A total of 5,700 patients underwent HTx; one-year mortality was 10.7%. There was a similar distribution of variables between derivation (n = 4,560) and validation (n = 1,140) cohorts. Of the 12 covariates included in the final model, nine were allotted point values. The low-risk (score 0-9), intermediate-risk (10-20), and high-risk (>20) groups had a 5.18%, 10%, and 28% risk of one-year mortality ( P < .001), respectively. Both intermediate-risk (OR = 2.46, 95% confidence interval [95% CI]: 1.93-3.15; P < .001) and high-risk (OR = 9.24, 95% CI: 6.92-12.35; P < .001) scores were associated with an increased risk of one-year mortality when compared to the low-risk group.

Conclusions: The Children's Heart Assessment Tool for Transplantation score represents a pediatric-specific, recipient-based system to predict one-year mortality after HTx. Its use could assist providers in identification of patients at highest risk of poor outcomes and may aid in pretransplant optimization of these children.
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http://dx.doi.org/10.1177/2150135119830089DOI Listing
May 2019

Outcomes after heart transplantation in sensitized patients bridged with ventricular assist devices.

J Card Surg 2019 Jun 2;34(6):474-481. Epub 2019 May 2.

Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.

Objective: Sensitization has been associated with worse outcomes following heart transplantation (HTx). The use of ventricular assist devices (VAD) is a risk factor for the development of sensitization. We investigated the impact of left ventricular assist devices (LVAD) and sensitization in HTx recipients.

Methods: We queried the UNOS database for all heart transplants performed from January 2000 through December 2016. Patients were considered highly sensitized and included if panel-reactive antibody (PRA) activity was 25% or higher. Patients were separated by pretransplant LVAD utilization and subgroup analysis was performed by device type (HeartMate II or HeartWare). Outcomes included Kaplan-Meier survival and episodes of rejection within 1 year of HTx.

Results: Of 18 009 recipients, 2434 (14%) were highly sensitized. 1055 (43.3%) were bridged with a VAD. In multivariate analysis, LVAD use did not impact 1-year (hazards ratio [HR], 1.30; P = 0.052) or 5-year survival (HR, 1.18; P = 0.112) in highly sensitized recipients. Furthermore, episodes of rejection were not affected by LVAD status (P = 0.765). Of the 1055 sensitized LVAD-bridged transplant recipients, 624 (59%) were implanted with a HeartMate II and 99 (9.4%) were bridged with a HeartWare device. In multivariate analysis, no differences were observed in 1-year survival (HR, 0.86; P = 0.664), 5-year survival (HR, 1.35; P = 0.209), or episodes of rejection (P = 0.497).

Conclusions: The use of ventricular assist devices did not impact survival or rejection within 1 year of HTx in highly sensitized patients. Highly sensitized recipients have similar outcomes regardless of prior LVAD support or type of LVAD used as a bridge to transplantation.
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http://dx.doi.org/10.1111/jocs.14066DOI Listing
June 2019

Racial Disparities in Patients Bridged to Heart Transplantation With Left Ventricular Assist Devices.

Ann Thorac Surg 2019 10 26;108(4):1122-1126. Epub 2019 Apr 26.

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Left ventricular assist devices (LVADs) are an effective therapy in bridging patients with end-stage heart failure to heart transplantation. The aim of this study was to identify the role of race in survival of patients bridged to heart transplantation with a LVAD.

Methods: The United Network of Organ Sharing database was queried for all adult heart transplant recipients (age 18 years or older) who were bridged to transplantation with a LVAD from 2005 to 2018. Patients were stratified based on their race, with whites as the reference group. Demographic characteristics, 5-year survival, and graft failure after transplantation were assessed with χ test, analysis of variance, Kaplan-Meier survival analyses, log-rank tests, and Cox proportional hazards modeling or logistic regression modeling as appropriate.

Results: Patients (N = 6476) successfully bridged with a LVAD to heart transplantation were identified. There were 4263 whites, 1536 African Americans, 508 Hispanics, and 169 Asians. Compared with whites, African Americans had higher body mass indexes, were more likely to be women, pay with private insurance, and be working for income at the time of transplantation. African Americans were found to have increased odds of graft failure (odds ratio 1.27, P = .048) compared with whites. In addition, African Americans were found to have increased risk of mortality at 5 years (hazard ratio 1.26, P = .003).

Conclusions: The African American race is associated with increased rates of graft failure after transplantation and decreased 5-year survival compared with the white race. Given these findings, directed clinical attention may be warranted in African American patients bridged to heart transplantation with a LVAD.
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http://dx.doi.org/10.1016/j.athoracsur.2019.03.073DOI Listing
October 2019

Valve-sparing aortic root replacement in children: Outcomes from 100 consecutive cases.

J Thorac Cardiovasc Surg 2019 03 10;157(3):1100-1109. Epub 2018 Dec 10.

Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Md.

Objective: Valve-sparing root replacement is an attractive alternative to composite mechanical or biologic prostheses for aortic root aneurysms in children. Data on outcomes in pediatric patients are limited. We present our institutional experience with 100 consecutive pediatric valve-sparing aortic root procedures.

Methods: All children who underwent valve-sparing root replacement at our institution from May 1997 to August 2017 were identified, and echocardiographic and clinical data were reviewed. The primary end point was mortality, and secondary end points included complications, further interventions, and subsequent valvular dysfunction.

Results: Median age at operation was 13.6 years (interquartile range, 9.42-15.9); 51 patients (51%) had Marfan syndrome, and 39 patients (39%) had Loeys-Dietz syndrome. Mean preoperative maximum sinus diameter was 4.4 ± 0.71 cm (z score 7.3 [5.7-9.3]). Most patients (n = 80, 80%) underwent reimplantation procedures with a Valsalva graft. Four patients (4%) underwent David I reimplantation with a straight-tube graft, 13 patients (13%) underwent a Yacoub remodeling procedure, and 3 patients (3%) underwent a Florida sleeve procedure. Perioperative valve-sparing root replacement mortality was 2% (n = 2). Six patients required late reintervention for development of pseudoaneurysms. Eight patients underwent additional aortic surgery. Average time to reoperation was 7.23 ± 4.56 years. Of the 84 patients undergoing a reimplantation procedure, 5 (5.9%) underwent late valve replacement versus 5 (33.3%) of the 15 patients who received a remodeling procedure (P = .001).

Conclusions: Valve-sparing root replacement is a safe and effective option for children with aortic root aneurysms in children. The reimplantation procedure is preferred. Late aortic insufficiency and pseudoaneurysm formation remain late concerns.
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http://dx.doi.org/10.1016/j.jtcvs.2018.09.148DOI Listing
March 2019

A Net Mold-Based Method of Biomaterial-Free Three-Dimensional Cardiac Tissue Creation.

Tissue Eng Part C Methods 2019 04;25(4):243-252

2 Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Maryland.

Ischemic cardiomyopathy poses a significant public health burden due to the irreversible loss of functional cardiac tissue. Alternative treatment strategies include creation of three-dimensional (3D) cardiac tissues to both replace and augment injured native tissue. In this study, we utilize a net mold-based method to create a biomaterial-free 3D cardiac tissue and compare it to current methods using biomaterials. Cardiomyocytes, fibroblasts, and endothelial cells were combined using a hanging drop method to create spheroids. For the net mold patch method, spheroids were seeded into a net mold-based system to create biomaterial-free 3D cardiac patches. For the gel patch, spheroids were embedded in a collagen gel. Immunohistochemistry revealed increased alignment, vascularization, collagen I expression, cell viability, and higher density of cells in the net mold patch compared with the gel patch. Furthermore, testing in a left anterior descending artery ligation rat model found increased ejection fraction and smaller scar area following implantation of the net mold patch. We present a novel and simple reproducible method to create biomaterial-free 3D net mold patches that may potentially improve the treatment of heart failure in the future.
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http://dx.doi.org/10.1089/ten.TEC.2019.0003DOI Listing
April 2019

Impact of Traumatically Brain-Injured Donors on Outcomes After Heart Transplantation.

J Surg Res 2019 08 22;240:40-47. Epub 2019 Mar 22.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: Heart transplant recipients of traumatically brain-injured (TBI) donors have been reported to have inferior survival and increased rates of cardiac allograft vasculopathy in single-center studies. This study sought to examine the impact of TBI donors on outcomes after heart transplantation across all transplantation centers.

Methods: We identified all adult heart transplants performed during 2007-2016 in the OPTN database. Recipients were dichotomized based on donor cause of death (TBI versus non-TBI), propensity-scored across 22 variables with known associations with mortality, and matched 1:1 without replacement. The primary endpoint was all-cause mortality. Secondary endpoints were conditional survival and rates of cardiac allograft vasculopathy.

Results: In total, 20,244 patients underwent heart transplantation. TBI was the primary cause of death in 53.4% of donors (10,816/20,244), and among TBI donors, blunt injury (59.6%; 6443/10,816) and gunshot wound (35%; 3781/10,816) were the most common mechanisms of injury. Propensity matching generated 6919 pairs (all absolute mean differences < 0.07). Risk-adjusted survival was similar between recipients of TBI donors and non-TBI donors at 5 y (78.1% versus 77.5%, log-rank P = 0.34). Risk-adjusted survival conditional on 1-y survival was also similar at 5 y (86.2% versus 86.1%, log-rank P = 0.74). The 5-y risk-adjusted rates of cardiac allograft vasculopathy did not differ either (30.6% versus 30.4%; log-rank P = 0.78).

Conclusions: In the largest analysis of TBI donors in heart transplantation, we found similar survival and rates of cardiac allograft vasculopathy to those who received hearts from non-TBI donors out to 5 y. These findings should allay concerns over continued transplantation with this unique donor population.
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http://dx.doi.org/10.1016/j.jss.2019.02.049DOI Listing
August 2019

Early Outcomes After Heart Transplantation in Recipients Bridged With a HeartMate 3 Device.

Ann Thorac Surg 2019 08 14;108(2):467-473. Epub 2019 Mar 14.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: Left ventricular assist devices are increasingly used as bridge-to-transplantation in eligible patients. The HeartMate 3 (HM3; Abbott Laboratories, Abbot Park, IL) is the latest device to obtain US Food and Drug Administration approval as bridge-to-transplantation. This study examines early outcomes of transplant recipients after HM3 in comparison with recipients bridged with the HeartMate 2 (HM2; Abbott Laboratories) and HeartWare Ventricular Assist System (HVAD; Medtronic, Minneapolis, MN) devices.

Methods: Using the Organ Procurement and Transplantation Network database, we identified all adult patients who were slated for bridge-to-transplantation with a continuous-flow left ventricular assist devices (HM2, HVAD, or HM3) between April 1, 2015 and January 31, 2018. The primary endpoint was all-cause mortality 6 months after transplantation. The independent influence of the bridging device on outcomes was determined using Cox proportional hazard models.

Results: Patients (N = 1,978) were successfully bridged to transplantation with the HM2 (n = 881), HVAD (n = 920), or HM3 (n = 177) device. Six-month mortality rates were similar across these devices (HM2, 5.9%; HVAD, 7.7%; HM3, 4.7%; log-rank p = 0.30). On average HM2 patients were on a left ventricular assist device for 2 months longer (p < 0.01). The HVAD had the lowest rate of device exchange before transplant (p = 0.01). The HM3 had no events of pump thrombosis (p < 0.01). HVAD patients had the lowest rate of device malfunction before to transplant (p < 0.01). Panel reactive antibodies at the time of transplantation were lower for HM3 patients (p < 0.01); however rates of graft rejection at 6 months were not different (p = 0.25).

Conclusions: The HM3 device provides excellent early outcomes as a bridge to transplantation and may be associated with a reduction in comorbidities. Longer follow-up is needed to better define differences between durable left ventricular assist devices.
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http://dx.doi.org/10.1016/j.athoracsur.2019.01.084DOI Listing
August 2019

Spontaneous Aortoesophageal Fistula in an Acute Type B Aortic Dissection and a Right-Sided Arch.

Ann Vasc Surg 2019 Jul 11;58:377.e13-377.e15. Epub 2019 Feb 11.

Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

Primary aortoesophageal fistula (AEF) in the absence of prosthetic graft replacement or aortic endovascular therapy can develop as a rare but life-threatening complication of acute aortic dissection. This case demonstrates that primary AEF should be maintained on the clinical differential of a patient presenting with massive gastrointestinal bleed in the context of an aortic dissection.
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http://dx.doi.org/10.1016/j.avsg.2018.11.015DOI Listing
July 2019

Size Mismatching Increases Mortality After Lung Transplantation in Preadolescent Patients.

Ann Thorac Surg 2019 07 11;108(1):130-137. Epub 2019 Feb 11.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Background: The effect of size mismatch between donor and recipient in pediatric lung transplantation (PLTx) is currently unknown. Previous studies in adults have suggested that oversized allografts are associated with improved outcomes after lung transplantation. We investigated this relationship to quantify its effect on posttransplant outcomes in children.

Methods: The United Network of Organ Sharing database was queried for preadolescent (age <13 years) patients undergoing PLTx. Donor-to-recipient height, weight, and predictive total lung capacity (pTLC; ages 4 to 13; pTLC = 0.160 x exp[0.021 x height]) ratios were calculated. Exploratory analysis was performed to identify disjoint intervals at which survival was statistically different. Patients were categorized as well-matched, undersized, or oversized. Multivariate Cox proportional hazard regression modeling assessed the adjusted effect of mismatching on mortality. Survival analysis was performed using the Kaplan-Meier method.

Results: The analysis included 540 children. One-year mortality was higher with a height mismatch of 5% or less (hazard ratio [HR], 2.97; p = 0.001) and above 5% (HR, 2.22; p = 0.009). Similarly, 1-year mortality was worse with weight mismatch of 10% or less (HR, 1.99; p = 0.035) and above 10% (HR, 2.04; p = 0.028). On unadjusted analysis, a pTLC ratio of less than 0.9 was associated with worse survival (p = 0.017). This finding persisted after multivariate risk adjustment (HR, 2.93; p = 0.02). Contrary to findings in adults, an oversized allograft (pTLC ratio > 1.1) was not associated with improved survival (HR, 1.95; p = 0.147).

Conclusions: In preadolescent children undergoing PLTx, size mismatching is associated with increased death. Our findings differ from studies in adults, which demonstrated improved survival associated with oversized allografts. Accordingly, well-matched allografts should be prioritized when assessing donor-recipient pairs for transplantation.
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http://dx.doi.org/10.1016/j.athoracsur.2019.01.015DOI Listing
July 2019

Association of preoperative spinal drain placement with spinal cord ischemia among patients undergoing thoracic and thoracoabdominal endovascular aortic repair.

J Vasc Surg 2019 08 28;70(2):393-403. Epub 2019 Jan 28.

Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD. Electronic address:

Objective: Spinal cord ischemia (SCI) is among the most devastating complications of thoracic endovascular aortic repair (TEVAR). Spinal fluid drainage has been proposed as a viable means to reduce SCI, but few data exist to support its routine use. This study investigated the association of preoperative spinal fluid drainage with the risk of SCI after TEVAR.

Methods: The Vascular Quality Initiative TEVAR module was queried for adult patients (≥18 years) undergoing TEVAR (coverage of zones 0-5) between September 2014 and March 2018 (inclusive). Patients with preoperative spinal malperfusion, aortic rupture on presentation, and connective tissue disorders were excluded. One-to-one propensity matching was used to balance patients on 44 separate dimensions by the nearest neighbor principle to compare those with vs those without preoperative spinal drainage. The primary end point was SCI still present at the time of discharge. Secondary outcomes were 30-day mortality and prolonged intensive care unit stay (>7 days).

Results: Among 4287 patients who underwent TEVAR (mean age, 67.1 [standard deviation, 13.7] years; 1665 [38.8%] women and 2622 [61.2%] men), 2076 had a spinal drain placed. Propensity matching yielded 1292 pairs with adequate covariate balance (all 44 absolute standardized differences <0.1). In the 2584 propensity-matched patients, spinal drain placement was associated with a reduced risk of SCI (1.5% vs 2.5%; risk-adjusted odds ratio [OR], 0.47; 95% confidence interval [CI], 0.24-0.89; P = .02). The rates of 30-day mortality (4.5% vs 5.0%; risk-adjusted OR, 0.67; 95% CI, 0.44-1.01; P = .05) and prolonged intensive care unit stay (7.0% vs 5.7%; risk-adjusted OR, 1.10; 95% CI, 0.84-1.45; P = .48) did not differ on the basis of spinal drain placement. The crossover rate was 10% (127/1292), and those with postoperative drain placement had a 20% (26/127) SCI rate on discharge.

Conclusions: Among patients undergoing thoracic and thoracoabdominal endovascular aortic repair, preoperative placement of a spinal drain, compared with no drain, was associated with reduced risk of SCI. Cerebrospinal fluid drainage as a rescue measure does not provide the same protection offered by routine preoperative placement. Further investigation, including randomized controlled trials, is needed to more definitively determine the role for spinal drainage in TEVAR.
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http://dx.doi.org/10.1016/j.jvs.2018.10.112DOI Listing
August 2019

Educational research and training innovation in cardiothoracic surgery: A year in review.

J Thorac Cardiovasc Surg 2019 04 19;157(4):1722-1727. Epub 2018 Dec 19.

Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Md.

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http://dx.doi.org/10.1016/j.jtcvs.2018.12.020DOI Listing
April 2019