Publications by authors named "Si M Pham"

104 Publications

Outcomes After Lung Retransplantation: A Single-Center Retrospective Cohort Study.

J Cardiothorac Vasc Anesth 2021 Aug 22. Epub 2021 Aug 22.

Department of Transplantation, Mayo Clinic, Jacksonville, FL; Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL. Electronic address:

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http://dx.doi.org/10.1053/j.jvca.2021.08.025DOI Listing
August 2021

Utilization of ECMO in vascular surgery: A presentation of two cases.

Int J Surg Case Rep 2021 Aug 29;85:106141. Epub 2021 Jun 29.

Department of Surgery, Division of Vascular Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a form of temporary mechanical circulatory support commonly used during cardiothoracic interventions. Malperfusion during complex vascular procedures remains a significant risk that may potentially lead to multiple complications. Here, we report two cases highlighting the efficacy of VA-ECMO in both planned and emergent vascular interventions.

Presentation Of Case: In our first case, VA-ECMO was used to support an 82-year-old male during a high-risk thoracoabdominal aortic aneurysm repair. Our second case details an emergent pulmonary embolectomy in which VA-ECMO was used as a bridge to cardiopulmonary bypass. In both cases, the procedures were well-tolerated, and the patients were discharged 17 days postoperatively.

Discussion: VA-ECMO has been increasingly used as a form of post-operative circulatory support following cardiothoracic and vascular interventions. However, only few instances of perioperative VA-ECMO use have been reported in the field of vascular surgery.

Conclusion: The presented cases highlight that the perioperative use of VA-ECMO may be a viable modality for required perfusion during complex planned or emergent vascular procedures.
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http://dx.doi.org/10.1016/j.ijscr.2021.106141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8329508PMC
August 2021

Impella flow pump reinsertion after axillary graft thrombectomy: Technical points in replacing axillary Impella.

SAGE Open Med Case Rep 2021 12;9:2050313X211032401. Epub 2021 Jul 12.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA.

Axillary Impella devices are increasingly employed for long-term support of patients with systolic heart failure and shock. Axillary access allows for awake support and ambulation, which carries an inherent risk of disconnection or malposition. We report a series of two cases where device replacement due to dysfunction and malposition can be completed safely through the original axillary graft using axillary graft thrombectomy, given that the clot burden could be a major source of morbidity to the patient.
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http://dx.doi.org/10.1177/2050313X211032401DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278451PMC
July 2021

Bilateral lung transplantation for pulmonary artery aneurysm with severe pulmonary hypertension: An evolution or a revolution?

J Card Surg 2021 Aug 16;36(8):3000-3002. Epub 2021 May 16.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

The surgical treatment of pulmonary hypertension (PH), with or without pulmonary artery aneurysm, has evolved during the last 40 years from heart-lung transplants to bilateral lung transplants as the treatment of choice for PH patients with preserved right and left ventricular function and without complex cardiac abnomalies.
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http://dx.doi.org/10.1111/jocs.15654DOI Listing
August 2021

Heart-lung transplant in congenitally corrected transposition of the great arteries and dextrocardia patient.

SAGE Open Med Case Rep 2021 12;9:2050313X20987449. Epub 2021 Feb 12.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA.

A 53-year-old male patient was presented to our institution with the clinical picture of biventricular failure. The echocardiogram revealed congenitally corrected transposition of the great arteries, dextrocardia with situs solitus, atrioventricular discordance and ventriculoatrial discordance, severe systemic and mitral valves regurgitation, and severe pulmonary hypertension (mean pulmonary artery pressure: 51 mm Hg). He underwent heart-lung transplant. He was discharged on postoperative day 25 with left ventricular ejection fraction of 60%-65%, and with oxygen independency.
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http://dx.doi.org/10.1177/2050313X20987449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887666PMC
February 2021

Strategic application of modular risk components to safely increase lung transplantation volume.

J Card Surg 2020 Sep 27;35(9):2177-2184. Epub 2020 Jul 27.

Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.

Objectives: Considerable growth of individual lung transplant programs remains challenging. We hypothesized that the systematic implementation of modular risk components to a lung transplantation program would allow for expeditious growth without increasing mortality.

Methods: All consecutive patients placed on the lung transplantation waitlist were reviewed. Patients were stratified by an 18-month period surrounding the systematic implementation of the modular risk components Era 1 (1/2014-6/2015) and Era 2 (7/2015-12/2016). Modular risk components were separately evaluated for donors, recipients, and perioperative features.

Results: One hundred and thirty-two waitlist patients (Era 1: 48 and Era 2: 84) and 100 transplants (Era 1: 32 and Era 2: 68) were identified. There was a trend toward decreased waitlist mortality (P = .07). In Era 2, the use of ex vivo lung perfusion (P = .05) and donor-recipient over-sizing (P = .005) significantly increased. Moreover, transplantation with a lung allocation score greater than 70 (P = .05), extracorporeal support (P = .06), and desensitization (P = .008) were more common. Transplant rate significantly improved from Era 1 to Era 2 (325 vs 535 transplants per 100 patient years, P = .02). While primary graft dysfunction (PGD) grade 3 at 72 hours (P = .05) was significantly higher in Era 2, 1-year freedom from rejection was similar (86% vs 90%, P = .69) and survival (81% vs 95%, P = .02) was significantly greater in Era 2.

Conclusions: The systematic implementation of a modular risk components to a lung transplantation program can result in a significant increase in center volume. However, measures to mitigate an expected increase in the incidence of PGD must be undertaken to maintain excellent short and midterm outcomes.
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http://dx.doi.org/10.1111/jocs.14874DOI Listing
September 2020

Safe Lung Flush Technique During Recovery From Donors After Circulatory Death.

Ann Thorac Surg 2021 04 4;111(4):e297-e299. Epub 2020 Nov 4.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Donation after circulatory death is defined as donation after cardiac arrest and circulatory cessation. The number of circulatory death donors is growing and significantly increases the organ donor pool. Shortening the warm ischemia time is pivotal in the outcomes and survival after transplant. We describe simplified and safe technique for lung flush during lung recovery from donors after circulatory death.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.064DOI Listing
April 2021

Lung Transplantation Using a Hybrid Extracorporeal Membrane Oxygenation Circuit.

ASAIO J 2020 Nov/Dec;66(10):e123-e125

From the Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Extracorporeal circulation (ECC) support using intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LTx) is now a routine practice for many high volume centers. Circuits that are dedicated to ECMO alone can be expensive and do not allow full cardiopulmonary bypass (CPB) to be performed. We describe our technique of instituting venoarterial ECMO during LTx using a less-expensive hybrid circuit that facilitates easy and immediate conversion to full CPB if needed, without interruption of ECC.
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http://dx.doi.org/10.1097/MAT.0000000000001157DOI Listing
March 2021

Left ventricular assist devices in the elderly: Marching forward with cautions.

J Card Surg 2020 Dec 28;35(12):3409-3411. Epub 2020 Sep 28.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Congestive heart failure is highly prevalent in the elderly population and left ventricular assist device (LVAD) has been increasingly used in this population. LVAD therapy is more costly than medical treatment but it increases the survival and quality of life of the elderly patients with low disease acuity. Therefore careful selection of candidates and implementation of LVAD therapy earlier in the course of the disease is crucial to improve outcomes. With the technical advances and improvement in clinical management, the financial burden of LVAD therapy in the elderly will become less, making this therapy more economically feasible.
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http://dx.doi.org/10.1111/jocs.15079DOI Listing
December 2020

Intraoperative management of a hybrid extracorporeal membrane oxygenation circuit for lung transplantation.

J Card Surg 2020 Dec 16;35(12):3560-3563. Epub 2020 Sep 16.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Background: The use of extracorporeal circulation (ECC) for intraoperative cardiopulmonary support during lung transplantation has been increasing in the recent years. Our group previously described a novel hybrid extracorporeal membrane oxygenation (ECMO) circuit for use in lung transplantation.

Technique: Our approach for intraoperative management of our novel hybrid ECMO circuit for lung transplantation is driven by two main goals: The first is to deliver management that ensures an appropriate balance between the native and ECMO cardiac outputs in order to provide a stable environment that promotes attenuation of ischemic-reperfusion injury during implantation. The second is to provide a stable hemodynamic environment that results in an appropriate global perfusion guided by multiple monitors and an organ systems-based approach during implantation.

Comments: Our novel technique for intraoperative management of this circuit during lung transplantation is described.
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http://dx.doi.org/10.1111/jocs.15029DOI Listing
December 2020

Characteristics and Long-Term Outcomes of Patients With Prior Coronary Artery Bypass Grafting Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction.

Am J Cardiol 2020 11 28;135:1-8. Epub 2020 Aug 28.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.

Limited data are available on characteristics and long-term outcomes of patients with coronary artery bypass grafts (CABG) undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI). Between January 2000 to December 2014, we identified STEMI patients with prior CABG undergoing primary percutaneous coronary intervention from 3 sites. Kaplan-Meier methods to estimate survival and major adverse cardiac events (MACE) were employed and compared to a propensity matched cohort of non-CABG STEMI patients. Independent predictors of outcomes were analyzed with Cox modeling. Of the 3,212 STEMI patients identified, there were 296 (9.2%) CABG STEMI patients, having nearly similar frequencies of culprit graft (47.6%) versus culprit native (52.4%) as the infarct-related artery (IRA). At 10 years, the adjusted survival was 44% in CABG STEMI versus 55% in non-CABG STEMI (HR 1.26; 95%CI 0.86 to 1.87; p = 0.72). Survival free of MACE was lower for CABG STEMI (graft IRA, 37%; native IRA, 46%) as compared to non-CABG STEMI controls (63%) (p = 0.02). Neither CABG history nor IRA (native vs graft) was independently associated with death or MACE in multivariable analysis. Temporal trends showed no significant change in death or MACE rates of CABG STEMI patients over time. In conclusion, long term survival of CABG STEMI patients is not significantly different than matched STEMI patients without prior CABG; however, CABG STEMI patients were at significantly higher risk for MACE events.
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http://dx.doi.org/10.1016/j.amjcard.2020.08.039DOI Listing
November 2020

Negative pressure ventilation as a bridge to lung transplant.

Oxf Med Case Reports 2020 Aug 10;2020(8):omaa056. Epub 2020 Aug 10.

Department of Transplantation, Mayo Clinic, Jacksonville, FL 32224 USA.

Recent years have witnessed evolution of lung allocation strategies to prioritize sicker recipients. In the pre-transplant period, this has translated into increased utilization of invasive extracorporeal or mechanical ventilatory support as a bridge to lung transplantation. The morbidity associated with these strategies warrants consideration to less invasive respiratory support modalities. Herein, we present a case highlighting successful bridge to lung transplantation with a relatively non-invasive negative pressure ventilator.
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http://dx.doi.org/10.1093/omcr/omaa056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416820PMC
August 2020

Three-dimensional printing facilitates surgical planning for resection of an atypical cardiac myxoma.

J Card Surg 2020 Oct 27;35(10):2863-2865. Epub 2020 Jul 27.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Background: Cardiac myxomas are common and account for 50% of primary intracardiac tumors. Atypical locations of cardiac myxoma increase the risk of intraoperative iatrogenic injuries. Herein, we report a case of using three-dimensional printing (3D) to facilitate the removal of an atypical cardiac myxoma in a 63-year-old woman.

Methods And Results: Mass in the high posterior atrial septum was confirmed through imaging. Due to the potential involvement of the mass to surrounding vital structures, 3D printing of the cardiac mass was performed. The tumor was completely resected via median sternotomy and the resulting defect was repaired with the bovine pericardium. The patient had an uncomplicated postoperative course except for the development of sick sinus syndrome. One-year follow-up showed no tumor recurrent.

Conclusion: 3D printing technology in patients with atypical cardiac tumors enhances our understanding of the extent of the tumor invasion and facilitates planning the operation to avoid intraoperative complications.
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http://dx.doi.org/10.1111/jocs.14896DOI Listing
October 2020

Absorbable antibiotic beads as an adjuvant therapy in treating ventricular assist devices driveline infection: A case report.

J Card Surg 2020 Aug 11;35(8):2073-2076. Epub 2020 Jul 11.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Background: Ventricular assist devices driveline infections are common, recalcitrant, and carry high morbidity and mortality. Herein, we reported a patient with driveline infection that was successfully treated with a combination of systemic antibiotics, surgical debridement, and instillation of absorbable antibiotic beads to the wound bed.

Methods And Results: A 39-year-old man with nonischemic cardiomyopathy underwent insertion of a continuous flow left ventricular assist device. Four years postoperatively, the patient presented with clinical, laboratory, and radiologic signs of driveline tract infection. He underwent extensive surgical debridement, installation of absorbable antibiotic beads that consisted of calcium sulfate, vancomycin, and tobramycin, into the wound bed, and systemic antibiotics. The patient was free of infection 9 month postoperatively.

Conclusion: Absorbable calcium sulfate antibiotic beads may serve as a beneficial adjunct to surgical debridement and systemic antibiotics for the treatment of ventricular assist device driveline infection, and merit further investigation.
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http://dx.doi.org/10.1111/jocs.14778DOI Listing
August 2020

Commentary: Rage against the machine (ventilator that is).

J Thorac Cardiovasc Surg 2020 11 5;160(5):1397-1398. Epub 2020 Apr 5.

Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, Fla. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.03.070DOI Listing
November 2020

Less Invasive Approach to Left Ventricular Assist Device Implantation May Improve Survival in High-Risk Patients.

Innovations (Phila) 2020 May/Jun;15(3):243-250. Epub 2020 May 7.

12297 Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA.

Objective: Despite improvement in outcomes after left ventricular assist device (LVAD) implantation over the past 2 decades, high-risk recipients continue to have a prohibitive rate of morbidity and mortality. We hypothesized that a less invasive approach to LVAD implantation would be associated with improved survival compared to a conventional approach in this high-risk cohort.

Methods: All consecutive LVAD recipients (2013 to 2017) that underwent centrifugal LVAD implantation were retrospectively reviewed. Patients were classified as high-risk if INTERMACS 1 or required temporary VAD/venoarterial extracorporeal membrane oxygenation prior to durable VAD implantation. Patients were stratified into 3 groups: left thoracotomy with hemi-sternotomy (LTHS) high-risk, conventional sternotomy (CS) high-risk, and non-high-risk. The primary outcome was 1-year survival.

Results: A total of 57 patients (LTHS high-risk: 11, CS high-risk: 12, non-high-risk: 34) were identified. Preoperative right ventricular failure scores, HeartMate-II mortality scores, and end-organ dysfunction were similar between the 2 high-risk groups. While operative time was similar between the 3 groups, cardiopulmonary bypass time was significantly shorter in the LTHS high-risk group compared to other groups. There was a trend toward decreased intensive care unit length of stay and ventilator time in LTHS high-risk compared to CS high-risk patients. Moreover, between these 2 groups, there was a significant decrease in temporary right VAD support (50% vs 0%, = 0.014), and 1-year survival was significantly higher in the LTHS group (42% vs 91%, = 0.025).

Conclusions: Less invasive LVAD implantation appears to be associated with improved survival compared to conventional LVAD implantation in high-risk patients.
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http://dx.doi.org/10.1177/1556984520918959DOI Listing
April 2021

Kidney transplantation on extracorporeal life support for primary cardiac allograft dysfunction.

J Card Surg 2020 Mar 4;35(3):725-728. Epub 2020 Feb 4.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Patients undergoing heart-kidney transplants who have primary graft dysfunction (PGD) of the heart are at risk of losing both organs, which may cause reluctance on the part of the transplant team to proceed with transplanting the kidney while the transplanted heart is being supported by mechanical device. We describe a case series in which 2 patients received kidney transplants while on veno-arterial ECMO support for PGD after heart transplant. Both patients are alive more than 1 year following transplant, with good cardiac and renal function and no signs of cardiac rejection. Kidney transplant surgery is safe for patients on veno-arterial ECMO support for cardiac PGD. It allows the heart recipient to receive a kidney from the same donor with both immunologic and survival advantages.
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http://dx.doi.org/10.1111/jocs.14451DOI Listing
March 2020

Use of Omental Flap for Treating Cardiocutaneous Fistula After Ventricular Aneurysm Repair.

Ann Thorac Surg 2020 08 24;110(2):e127-e128. Epub 2020 Jan 24.

Department of Cardiothoracic Surgery, Mayo Clinic Florida, Jacksonville, Florida. Electronic address:

Infection of an endoventricular patch used for left ventricular aneurysm repair with formation of cardiocutaneous fistula is a rare but potentially serious complication. We report an adult patient who developed a cardiocutaneous fistula 1 year after repair of a third left ventricular aneurysm. The patient was successfully treated with a redo operation using a bovine pericardial patch with omental flap coverage. He is alive and well 10 years later.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.061DOI Listing
August 2020

Electric shock-induced cardiac injuries requiring surgical intervention: Case series and a brief review.

J Card Surg 2020 Feb 28;35(2):488-491. Epub 2019 Nov 28.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Background: Electric shock-induced cardiac injuries, such as myocardial infarction, thrombosis, and dissection, are rare. Few cases have been previously reported. The right coronary artery is most often affected because of its proximity to the chest wall.

Aims: To study the extend of electrical injuries on cardiac tissues and its surgical management.

Materials And Methods: We conducted a retrospective study on our patients in the last five years, looking for cardiac electrical injuries treated surgically in our department, we identified three cases.

Result: Our three-case series, reported herein, showed that multiple cardiac tissues are susceptible to electrical injuries, specifically the left coronary artery, inferior vena cava, and right ventricular free wall. In our series, the first patient was a 32-year-old man with triple vessel thrombosis and dissection who survived the electric shock. The second patient was a 23-year-old man who had an inferior vena cava burn and bruising; his heart was used for transplantation. After the transplant, the recipient had a left coronary artery dissection and underwent coronary artery bypass grafting. The third patient was a 30-year-old man (potential heart donor) who had a hematoma of the right ventricular free wall, possible coronary artery dissection, inferior vena cava bruising, and tissue damage. His heart was not used for transplant because of quality concerns.

Conclusion: We recommend that any person who sustains high voltage (500 V or more) electric shock should be evaluated carefully in the emergency department, including with echocardiography and cardiac catheterization, if indicated, to determine the extent of the injury and the viability of the heart, for patients who do not survive as a donor organ.
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http://dx.doi.org/10.1111/jocs.14382DOI Listing
February 2020

Successful lung transplantation from a donor with lung and ovarian masses.

J Surg Case Rep 2019 Nov 5;2019(11):rjz307. Epub 2019 Nov 5.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA.

Declining a donor when there is a reasonable possibility that the abnormality on chest imaging could be benign carries the risk of losing out on potentially usable lungs in an already parched landscape of donor organ availability. Cautiously aggressive attitudes to acceptance of borderline donors can help bridge the significant discrepancy that exists between the demand and availability of donor organs. Herein, we present a case highlighting successful bilateral lung transplantation from a relatively imperfect donor.
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http://dx.doi.org/10.1093/jscr/rjz307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6830262PMC
November 2019

Incidence, Management, and Outcomes of Chylothorax after Lung Transplantation: A Single-center Experience.

Cureus 2019 Jul 22;11(7):e5190. Epub 2019 Jul 22.

Cardiothoracic Surgery, Mayo Clinic, Jacksonville, USA.

Background The objective of this study was to determine the incidence and outcomes of chylothorax after lung transplantation. Methods We conducted a retrospective review of our institutional lung transplant registry of 504 adult transplantations done from 2001 to 2015 and identified seven patients (1.38%) with chylothorax. Electronic health records were then analyzed to determine demographics, indications for surgery, management, and outcomes. Survival curves were plotted using the Kaplan-Meier method. Results Chylothorax presented in the first week in four (62.5%) patients, and approximately one month later in the remaining three. Nonsurgical management was initially attempted in all patients and succeeded in three (42.9%). Elective surgical ligation of the thoracic duct (LTD) was successful in two (66.7%) out of three patients in whom it was performed. One patient required emergent reoperation for clamshell thoracotomy dehiscence from severe chylothorax. Thoracic duct embolization was attempted but unsuccessful in two patients. Subsequently, one of these patients received a peritoneal-venous shunt and the other underwent LTD. Chylothorax permanently resolved in six patients (85.7%). There were no mortalities directly related to chylothorax. The median time to resolution was 11 days (range: 7-60). The mean survival in months for chylothorax patients was 29.2 (SE 3.1) and 78.2 (SE 2.9) for the remaining patients ( = 0.37). The median survival was not reached for the chylothorax group and was 71.8 months (95% CI: 58.0-83.9) for the rest. Conclusion Chylothorax is rare after lung transplantation but can lead to major comorbidities and prolonged hospital stay. In our experience, nonsurgical management was successful in up to 40% of patients. LTD should be considered in those who fail conservative management.
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http://dx.doi.org/10.7759/cureus.5190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649881PMC
July 2019

Less invasive left ventricular assist device implantation may reduce right ventricular failure.

Interact Cardiovasc Thorac Surg 2019 10;29(4):592-598

Department of Cardiothoracic Surgery, New York University Langone Health, New York, NY, USA.

Objectives: Right ventricular (RV) failure after left ventricular assist device (LVAD) implantation continues to be a morbid complication. In this study, we hypothesized that a less invasive approach to implantation would preserve RV function relative to a conventional sternotomy (CS) approach.

Methods: All patients (2013-2017) who underwent LVAD implantation were reviewed. Patients were stratified by surgical approach: less invasive left thoracotomy with hemi-sternotomy (LTHS) and CS. The primary outcome was severe RV failure.

Results: Eighty-three patients (LTHS: 37, CS: 46) were identified. The median Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score was significantly worse in the LTHS compared to the CS cohort, and there was a trend towards higher RV failure scores and HeartMate II mortality scores. Preoperative RV dysfunction, in pulmonary artery pulsatility index and RV stroke work index were similar between the 2 groups. Though operative time did not significantly differ between the 2 groups, cardiopulmonary bypass time was significantly shorter in the LTHS group (61 vs 95 min, P < 0.001). The incidence of postoperative severe RV failure was significantly reduced in the LTHS group (16% vs 39%, P = 0.030), along with the need for temporary right ventricular assist device (3% vs 26%, P = 0.005). Improvement in RV function, along with a change in pulmonary artery pulsatility index, was significantly greater in the LTHS cohort. There was a trend towards improved Kaplan-Meier 1-year survival in the LTHS cohort (91% vs 56%, P = 0.056).

Conclusions: In this cohort, less invasive LVAD implantation appears to be associated with reduced postoperative RV failure, and equivalent or improved survival compared to conventional LVAD implantation.
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http://dx.doi.org/10.1093/icvts/ivz143DOI Listing
October 2019

Extracorporeal membrane oxygenation as a salvage therapy for patients with severe primary graft dysfunction after heart transplant.

Clin Transplant 2019 05 14;33(5):e13538. Epub 2019 Apr 14.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Background: Severe primary graft dysfunction (PGD) is the leading cause of early death after heart transplant.

Aim: To examine the outcomes of heart transplant recipients who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for severe PGD.

Methods: We reviewed electronic health records of adult patients who underwent heart transplant from November 2005 through June 2015. We defined severe PGD according to International Society for Heart and Lung Transplantation consensus statements.

Results: Of 1030 heart transplant patients, 31 (3%) had severe PGD and required VA-ECMO. The mean (range) age was 59 (43-69) years. Fifteen patients (48%) underwent prior sternotomy and 10 (32%) received a left ventricular assist device as a bridge to transplant. Severe PGD manifested as failure to wean from cardiopulmonary bypass in 20 patients (65%) and as severe hemodynamic instability in the immediate postoperative period in 10 (32%), including cardiac arrest in 3 (10%). Twenty-five patients (81%) were successfully weaned from VA-ECMO, and 19 (61%) were discharged; the other 12 (39%) died.

Conclusions: Although VA-ECMO is a common method for providing mechanical circulatory support to patients with PGD, multicenter studies are needed to assess factors associated with successful outcomes and improved survival of these patients.
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http://dx.doi.org/10.1111/ctr.13538DOI Listing
May 2019

Triple bridge of mechanical circulatory support to heart transplantation listing: A case report.

SAGE Open Med Case Rep 2019 5;7:2050313X19834816. Epub 2019 Mar 5.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL, USA.

A 60-year-old male patient presented to an outside hospital with severe cardiogenic shock. A triple bridge of mechanical circulatory support was utilized to transition him to heart transplantation listing. Initially, coronary artery disease was percutaneously treated and Impella 2.5 was used as mechanical circulatory support for 5 days followed by the second Impella 2.5 for 4 days. Veno-arterial extracorporeal membrane oxygenation support was deployed for 16 days. This was exchanged for HeartWare ventricular assist device support as the third stage of mechanical circulatory support to heart transplantation listing. The patient experienced acute renal failure which was managed by continuous renal replacement therapy then intermittent hemodialysis with eventual complete recovery of the renal function. He was discharged home 56 days after HeartWare ventricular assist device implantation with stable hemodynamic, intact neurologic status and fully recovered renal function. Currently, the patient is listed for heart transplantation.
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http://dx.doi.org/10.1177/2050313X19834816DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404238PMC
March 2019

TEE-guided transatrial inferior vena cava and hepatic veins thrombectomy during double lung transplantation in a VV ECMO-supported patient.

J Card Surg 2018 12 7;33(12):870-871. Epub 2018 Dec 7.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

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http://dx.doi.org/10.1111/jocs.13957DOI Listing
December 2018

Ambulation With Femoral Arterial Cannulation Can Be Safely Performed on Venoarterial Extracorporeal Membrane Oxygenation.

Ann Thorac Surg 2019 May 30;107(5):1389-1394. Epub 2018 Nov 30.

Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York.

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support can be associated with significant deconditioning due to the requirement for strict bedrest as a result of femoral arterial cannulation. To address this issue, we evaluated our experience with ambulation in patients with peripheral femoral cannulation for VA-ECMO.

Methods: All patients that were peripherally cannulated for VA-ECMO over a 2-year period were retrospectively reviewed. Patients that ambulated at least once while supported with VA-ECMO were included in the analysis. The primary outcomes were safety and feasibility of ambulation, defined as the absence of major bleeding, vascular, or decannulation events.

Results: Of 104 patients placed on VA-ECMO, 15 ambulated with a femoral arterial cannula. Forty-six percent of patients were placed on VA-ECMO for decompensated heart failure, and 54% for massive pulmonary embolism. Twenty-seven percent of patients were cannulated during active cardiopulmonary resuscitation. The median length of time from cannulation to out of bed was 3 (range, 0 to 26) days. The median length of time from cannulation to initial ambulation was 4 (range, 1 to 42) days. The median distance of the first postcannulation walk was 300 feet. Neither flow nor speed decreased during or after ambulation. There were no major bleeding events, vascular complications, or decannulation events associated with ambulation. The median intensive care unit length of stay and hospital length of stay were 12 and 21 days, respectively. One-year survival was 100% for ambulating patients.

Conclusions: Ambulating patients supported with VA-ECMO, despite femoral arterial cannulation, appears feasible and safe in carefully selected patients.
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http://dx.doi.org/10.1016/j.athoracsur.2018.10.048DOI Listing
May 2019

Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease.

Ann Thorac Surg 2018 12 17;106(6):1709-1715. Epub 2018 Sep 17.

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

Background: Cardiac surgery for structural heart disease has poor outcomes in the presence of cardiogenic shock or advanced heart failure. We applied venoarterial extracorporeal membrane oxygenation (ECMO) to restore end-organ function and resuscitate patients before high-risk cardiac operation.

Methods: Twelve patients with cardiogenic shock and end-organ failure were evaluated for cardiac surgery. The average Society of Thoracic Surgeons mortality risk was 24% ± 13%. Patients were peripherally cannulated on ECMO for 7 ± 4 days, before undergoing operation for prosthetic mitral stenosis (n = 4), ruptured papillary muscle (n = 4), ischemic ventricular septal defect (n = 3), or severe aortic stenosis (n = 1).

Results: Mean age was 61 ± 8 years. Comorbidities included acute renal failure (n = 11), inotrope requirement (n = 10), intraaortic balloon pump (n = 8), severe acidosis (n = 6), high-dose vasopressor requirement (n = 8), and cardiac arrest (n = 1). With ECMO support, vasopressor requirement, central venous pressure, creatinine, lactate, pH, pulmonary hypertension, and The Society of Thoracic Surgeons mortality risk and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II all improved significantly. Care was withdrawn in 1 patient on ECMO with initially unknown anoxic brain injury. No patients required dialysis at discharge. Complications included 1 permanent stroke. All operative patients survived to hospital discharge. Average length of follow-up was 420 days, with 2 patient deaths at 76 and 230 days and 6 patients surviving over 1 year.

Conclusions: ECMO can be used as a bridge to heart valve or septal defect surgery in severely decompensated patients. Through recovery of end-organ function, ECMO may allow surgical correction of structural heart disease in patients considered inoperable or convert a salvage situation to an elective operation.
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http://dx.doi.org/10.1016/j.athoracsur.2018.07.038DOI Listing
December 2018

Successful Resuscitation with Extracorporeal Membrane Oxygenation in a Case with Prolonged Cardiac Arrest.

Chin Med Sci J 2018 Jun;33(2):127-129

Department of Cardiac Surgery, University of Maryland School of Medicine,Baltimore, MD 21201, USA.

This case study describes a 25-year-old patient who had a witnessed cardiac arrest in the medical intensive care unit. The patient received 107 minutes of cardiopulmonary resuscitation before the veno-arterial extracorporeal membrane oxygenation was initiated. During extracorporeal life support, the patient's cardiac function improved. The patient was weaned from extracorporeal membrane oxygenation on day 6 and was discharged without physical and neurological complications on day 28. The successful resuscitation in this case attributed to high-quality CCPR and timely ECMO support.
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http://dx.doi.org/10.24920/31807DOI Listing
June 2018

Minimally Invasive Left Ventricular Assist Device Implantation: Implementation Early in a Surgical Career.

Innovations (Phila) 2018 May/Jun;13(3):218-221

Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD USA.

Objective: Several centers have presented minimally invasive surgical approaches to centrifugal left ventricular assist device implantation. Although minimally invasive implantation has been successfully performed by experienced surgeons, at large implanting centers, it is unknown whether these techniques are widely adoptable. We evaluated the experience of a surgeon early in his career with conventional and minimally invasive approaches to device implantation.

Methods: All consecutive left ventricular assist device implantations by a single surgeon in the first year of practice (2015-2016) were retrospectively reviewed. Patients were stratified by standard approach, conventional full sternotomy versus a minimally invasive approach, left anterior thoracotomy and upper hemisternotomy. Demographics, perioperative variables, and short-term outcomes were compared using Wilcoxon rank-sum test.

Results: Thirteen patients were identified: six performed via the standard approach and seven performed via the minimally invasive approach. Preoperative demographics were comparable in both groups. However, there was significantly more preoperative right ventricle dysfunction in the minimally invasive group (P = 0.01). Although operative time was significantly longer in the minimally invasive cohort, there was a trend toward decreased cardiopulmonary bypass time. Six-month survival in both groups was 100%.

Conclusions: Compared with conventional sternotomy, minimally invasive ventricular assist device implantation, performed by a surgeon in his first year of practice, had similar perioperative outcomes and excellent survival. Based on these data, minimally invasive implantation may be a feasible strategy for device implantation even early in a surgeon's career.
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http://dx.doi.org/10.1097/IMI.0000000000000505DOI Listing
December 2018

Direct Ultrasound of the Pulmonary Artery Helps Diagnose a Rare Cause of Right Ventricular Failure After Heart Transplantation: A Case Report.

A A Pract 2018 Apr;10(8):189-191

From the Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia; and Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.

Pulmonary artery anastomosis stenosis is a rare cause of right ventricular failure after orthotopic heart transplantation. In this case report, direct ultrasound of the pulmonary artery helped diagnose stenosis at a location not visible on transesophageal echocardiography or even with standard epicardial ultrasound views. It is important to evaluate all vascular anastomoses after heart or lung transplantation because surgical revision of these lesions is facile, but if left undiagnosed, significant morbidity or mortality is likely.
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http://dx.doi.org/10.1213/XAA.0000000000000656DOI Listing
April 2018
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