Journal of Thoracic and Cardiovascular Surgery最新文献

Objective: Primary graft dysfunction (PGD) after lung transplantation (LTx) is associated with increased mortality. Retrospective studies have reported inconsistent PGD incidence when comparing intraoperative Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) and off-pump LTx. To address this, we initiated a prospective, randomized trial comparing intraoperative support techniques in LTx.

Methods: This trial compares intraoperative VA ECMO and off-pump LTx outcomes at 90 days. Six centers are currently enrolling.

Inclusion criteria: Age > 18 years, bilateral LTx with mean pulmonary artery pressure < 35 mmHg.

Exclusion criteria: Multiorgan transplant, donation after circulatory death, re-transplantation, planned postoperative ECMO, previous lung surgery or pleurodesis, preoperative ECMO or mechanical ventilation. Patients were randomized 1:1 to VA ECMO or off-pump with an intention to treat analysis. The primary endpoint was PGD grade 3 at 48-72 hours and 15 secondary endpoints were studied. Sample size estimation: 228 patients to detect a 15% absolute risk reduction in PGD grade 3 at 48-72 hours.

Results: The interim analysis includes 75 patients. Of these, 44(58.6%) were randomized to VA ECMO, and 31(41.3%) to off-pump LTx. Four patients (12.9%) crossed over from off-pump to VA ECMO. There was no significant difference between groups in PGD grade 3 at 48-72 hours. VA ECMO 6 (13.6%) versus off-pump 6 (19.4%), p=0.506. No significant differences were observed in the safety profile and secondary endpoints. There was significantly more fresh frozen plasma and platelet transfusion in the VA ECMO group.

Conclusions: In this interim analysis of the VIP BOLT trial, no significant primary endpoint difference was noted between VA ECMO and off-pump LTx. Continued enrollment is needed to ensure the study is adequately powered.

Objective: Advanced donor age has been associated with inferior outcomes after heart transplantation. Recent use of a 10°C static cold storage (SCS) has been shown to improve heart transplant recipient outcomes compared to traditional ice storage. This study evaluates the pertinence of donor age on post-transplant outcomes in cardiac allografts stored at 10°C.

Methods: All adult heart transplant patients, whose allografts were preserved with either 10°C or Ice SCS from a single institution from 6/2023 to 12/2024 were reviewed. Recipients receiving a multiorgan transplant or with congenital heart disease were excluded. Allografts from donor age <18 years were also excluded. Patients were divided into three groups based on donor age: 18-30, 30-40, and >40 years old. Outcomes included rates of severe primary graft dysfunction (PGD), and 30-, 90-, and 180-day mortality, and other clinical outcomes. A subgroup analysis was performed by comparing outcomes between donor ages 41-45 vs >45 years old.

Results: 411 adult heart transplant recipients (10°C SCS = 135; ice = 276; median age 58.3 [48.6-64.9] years; 25.1% female) were compared across donor-age strata <30 (n=179), 30-40 (n=137), and >40 years (n=95). Modeling donor age continuously, 10°C attenuated the age-related risk versus ice for both outcomes: severe PGD OR per year 0.91 (95% CI 0.83-0.97; p=0.02) and 90-day mortality OR per year 0.89 (95% CI 0.81-0.97; p=0.006). After covariate balancing, 10°C was associated with lower odds of severe PGD in donors aged 30-40 (OR 0.15, 95% CI 0.02-0.68; Holm-adjusted p=0.03) and >40 (OR 0.20, 95% CI 0.03-0.81; Holm-adjusted p=0.04), with no difference for <30 (OR 0.91, 95% CI 0.36-2.32; Holm-adjusted p=0.23). In a post-hoc split of ≥40 (40-45 vs ≥45), severe PGD was more frequent with ice in ≥45 (8.7% vs 0%); these exploratory findings were not multiplicity-adjusted.

Conclusions: The use of 10°C SCS for cardiac allografts may mitigate the association between increased donor age and inferior post-transplant outcomes and possibly expand the donor pool.

Background: Borderline left ventricle (LV) represents a spectrum of defects, from mild to severe left heart hypoplasia, often with other cardiac anomalies. Decision-making regarding primary biventricular (BiV) repair is challenging. We sought to identify risk factors associated with adverse outcome following neonatal primary BiV repair for borderline LV.

Methods: Retrospective review of neonatal primary BiV repair for borderline LV between 2001 and 2022. The primary outcome was composite of death, transplant, conversion to single ventricle, pulmonary vascular resistance ≥3 wood units, and left atrial mean pressure >15mmHg. Logistic regression was used to identify associations. Secondary outcome was left heart re-intervention (LHRI), analyzed using competing risk regression. Risk score to predict probability of composite outcome was developed.

Results: Among 238 neonates, 133(56.0%) were males. Median age was 6 (4-10) days. Median follow-up was 1.6 (0.3-5.5) years. The composite outcome occurred in 48 (20.2%) patients. 62(26.2%) patients required LHRI. Mitral valve (MV) area z score < -2 [aHR 3.09, (CI: 1.33,7.21), p:0.009] and endocardial fibroelastosis (EFE) [aHR 2.91, (CI: 1.08,7.87), p:0.04] were associated with the composite outcome. LHRI was associated with MV A-P diameter z score < -2 [aHR 2.45, (CI: 1.27,4.72), p 0.007] and EFE [aHR 2.54, (CI: 1.09,5.91), p:0.03]. Risk scores ranged from 1 (18% predicted risk) to 4 (86% predicted risk).

Conclusion: Mitral valve dimensions and EFE presence are associated with adverse outcomes after BiV repair and can guide frequency of surveillance. Risk stratification may assist with decision-making on initial management strategy.