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Objective: Prolonged mechanical ventilation after cardiac surgery significantly increases morbidity and mortality. The aim of this study is to establish the role of diaphragmatic pacing to decrease mechanical ventilation burden in high-risk patients undergoing cardiac surgery.

Methods: This is a prospective, randomized trial of temporary diaphragmatic pacing electrode use in patients undergoing cardiac surgery (NCT04899856). Prognostic enrichment strategy was used to identify patients at higher risk of prolonged mechanical ventilation by having inclusion criteria of prior open cardiac surgery, left ventricular ejection fraction less than 30%, history of stroke, intra-aortic balloon pump, or history of chronic obstructive pulmonary disease. Two electrodes were placed in each hemidiaphragm intraoperatively. On arrival to the intensive care unit, patients were randomized to immediate diaphragmatic pacing or standard of care.

Results: Forty patients received implants, with 19 in the treatment group and 21 in the standard of care group. Only 1 patient in the treatment group was on mechanical ventilation at 24 hours versus 4 patients in the standard of care group, resulting in a relative risk reduction of 71% being on mechanical ventilation at 24 hours postoperatively. Predictive enrichment strategy was used to identify patients most likely to respond to therapy of diaphragmatic pacing. In this analysis, median time on mechanical ventilation was 17.7 hours (interquartile range, 8.3-23.4) for the 15 patients in the standard of care group and 9.4 hours (interquartile range, 7.14-12.5) for the 13 patients in the treatment group, for an improvement of 8 hours with diaphragm pacing (P < .05).

Conclusions: Temporary diaphragmatic pacing improved weaning from mechanical ventilation by 8 hours with a significant reduction of prolonged mechanical ventilation. Multicenter randomized trials confirming diaphragmatic pacing as an Enhanced Recovery After Surgery tool to decrease mechanical ventilation may reduce length of stay, postoperative infections, and additive costs.

Objective: To identify clinicopathologic and genomic features associated with brain metastasis after resection of lung adenocarcinoma (LUAD) and to evaluate survival after brain metastasis.

Methods: Patients who underwent complete resection of stage I-IIIA LUAD between 2011 and 2020 were included. A subset of patients had broad-based panel next-generation sequencing performed on their tumors. Fine-Gray models for the development of brain metastasis were constructed, with death without brain metastasis as a competing risk.

Results: A total of 2660 patients were included. The median duration of follow-up was 71 months (95% confidence interval [CI], 69-73 months). The cumulative incidence of brain metastasis at 10 years was 9.8%. Among patients who developed a brain metastasis, the median time from surgery to brain metastasis was 21 months (interquartile range, 10-42 months). Higher maximum standardized uptake value of the primary tumor, neoadjuvant therapy, lymphovascular invasion, and stage III disease were associated with the development of brain metastasis. Among patients who underwent next-generation sequencing, a multivariable analysis identified neoadjuvant therapy, pathologic stage, and TP53 mutations as associated with development of brain metastasis. The median survival after brain metastasis was 18 months (95% CI, 13-24 months). Better performance status, lack of extracranial metastasis, stereotactic radiosurgery, and targeted therapy were associated with better survival after brain metastasis.

Conclusions: Brain metastasis is common after complete resection of LUAD and often occurs within 2 years. Markers of aggressive tumor biology, including higher maximum standardized uptake value, lymphovascular invasion, and TP53 mutations, and neoadjuvant therapy are associated with brain metastasis.

Objective: The transplantation of hearts from donors who experienced intracranial bleeding (ICB) has been associated with inferior long-term survival in both single-center analyses and, more recently, with the United Network for Ogan Sharing Registry. The purpose of this study was to further explore this relationship through propensity score matching in recipients receiving donor hearts from ICB and non-ICB donors in a large national registry.

Methods: We performed a retrospective cohort analysis of the United Network for Organ Sharing Registry Organ Procurement and Transplantation Network between 2006 and 2018 for adult candidates wait-listed for isolated heart transplantation. Recipients were stratified into 2 groups: ICB and non-ICB donors. Propensity score matching was performed to estimate causal effects by using observational data. Kaplan-Meier analysis was used to estimate survival posttransplant. Cox proportional hazards modeling was used to evaluate the independent effect of ICB as a cause of death.

Results: A total of 25,315 candidates met inclusion criteria. ICB heart donors (n = 5529) were older (median age, 42 vs 27 years; P < .001), less likely men (54.5% vs 75.2%; P < .001), and more often had a history of smoking (20.1% vs 11.7%; P < .001), and hypertension (34.2% vs 9.5%; P < .001). Before matching there was a significant difference in long-term posttransplant survival; for example, the non-ICB (60.7% [interquartile range, 59.5%-61.9%] vs 56.8% (interquartile range, 54.7%-59.0%]; P < .0001). However, when analyzing the propensity-score matched groups for outcomes, no difference was found between the cohorts both in terms of long-term survival as well as in rates of rejection.

Conclusions: In the largest propensity score matching analysis of heart transplants from donors who had experienced ICB, we found similar survival and rejection rates in heart transplant recipients.

Objective: To evaluate malnutrition and its association with outcomes in adult patients requiring venoarterial (VA) extracorporeal membrane oxygenation (ECMO).

Methods: Patients cannulated for VA ECMO between January 1, 2020, and January 1, 2023, were screened. Patients on ECMO for <48 hours or without a nutritional evaluation were excluded. Demographic and anthropometric data were collected retrospectively. Malnutrition assessments were conducted using the Global Leadership Initiative on Malnutrition framework. Outcomes analyzed were duration of ECMO and in-hospital mortality. Patients were stratified by admission and discharge nutritional status for analysis. Baseline characteristics were controlled for with propensity score matching.

Results: Data from 197 patients was analyzed. The cohort was 68% male. The median duration of ECMO was 139.5 hours (interquartile range [IQR], 94.8-257 hours), and mortality was 35%. Thirty-three patients presented with malnutrition, and 61 developed hospital-acquired malnutrition, for an incidence of 47.7%. Malnutrition at any point was associated with longer duration of ECMO (median, 180 hours [IQR, 107.8-335.8 hours] vs 120 hours [IQR, 90-185.8 hours]; P < .001). Patients with hospital-acquired malnutrition required a 50% longer duration of ECMO (median, 182.5 hours [IQR, 101.5-367 hours] vs 123 hours [IQR, 90.8-211.5 hours]; P < .001). Preexisting malnutrition was associated with a nonsignificant increase in mortality (48.2% vs 32.9%; P = .13), which was similar after 3:1 propensity score matching (43.3% vs 35.4%; P = .44).

Conclusions: In adult patients, malnutrition appears to be associated with prolonged duration of VA ECMO. Adequately powered studies are needed to further investigate the relationship between malnutrition and mortality.