Lung transplantation in patients 70 years old or older: Have outcomes changed after implementation of the lung allocation score?

ObjectiveThe objective of the present study was to evaluate whether the outcomes of lung transplantation in patients aged 70 years or older have changed after implementation of the lung allocation score in May 2005.MethodsPatients aged 70 years or older undergoing primary lung transplantation from 1995 to 2009 were identified from the United Network for Organ Sharing registry. The primary stratification was the pre-lung allocation score era versus lung allocation score era. Risk-adjusted multivariate Cox regression and Kaplan-Meier analyses were conducted to evaluate the effect of age 70 years or older on 1-year post-transplant mortality compared with a reference cohort of patients aged 60 to 69 years.ResultsOf the overall 15,726 adult lung transplantation patients in the study period, 225 (1.4%) were 70 years old or older and 4634 (29.5%) were 60 to 69 years old. The patients aged 70 years or older were a larger cohort of overall lung transplantation patients in the lung allocation score era compared with before the lung allocation score era (3.1% vs 0.3%, P < .001). In the risk-adjusted Cox analysis, age 70 years or older was a significant risk factor for 1-year post-lung transplantation mortality in the pre-lung allocation score era (hazard ratio, 2.00; 95% confidence interval, 1.10-3.62, P = .02) but not in the lung allocation score era (hazard ratio, 1.02; 95% confidence interval, 0.71-1.46; P = .92). Similarly, Kaplan-Meier 1-year survival was significantly reduced in patients 70 years old or older versus 60 to 69 years old in the pre-lung allocation score era (56.7% vs 76.3%, P = .006) but not in the lung allocation score era (79.0% vs 80.0%, P = .72).ConclusionsRecipients aged 70 years or older were a larger proportion of overall lung transplantation patients after implementation of the lung allocation score. Although associated with significantly increased post-lung transplantation mortality in the pre-lung allocation score era, age 70 years or older is currently associated with outcomes comparable to those of patients aged 60 to 69 years. Therefore, age 70 years or older should not serve as an absolute contraindication to lung transplantation in the lung allocation score era

Concordance of Treatment Effect: An Analysis of The Society of Thoracic Surgeons Intermacs Database

BACKGROUND: The Society of Thoracic Surgeons (STS) Intermacs Registry represents a real-world data source of durable, left ventricular assist devices that can address knowledge gaps not informed through randomized clinical trials. We sought to compare survival with contemporary left ventricular assist device technologies using multiple analytic approaches to assess concordance of treatment effects and to validate prior STS Intermacs observations. METHODS: Patients (aged \u3e 19 years) enrolled into STS Intermacs between August 2017 - June 2019 were stratified by device type (centrifugal device with hybrid levitation [CF-HL] or full magnetic levitation [CF-FML]). The primary outcome was 1-year survival assessed by three statistical methodologies (multivariable regression, propensity score matching, and instrumental variable analysis). RESULTS: Of 4,448 patients, 2,012 (45.2%) received CF-HL and 2,436 (54.8%) received CF-FML. One-year survival for CF-FML was 88% vs. 79% for CF-HL (overall p \u3c .001), with a hazard ratio for mortality of 3.18 for CF-HL (p\u3c0.0001) after risk adjustment. With propensity score matching (n=1400 each cohort), 1-year survival was 87% for CF-FML vs. 80% for CF-HL, with a hazard ratio of 3.20 for mortality with CF-HL (p\u3c0.0001) after risk adjustment. With an instrumental variable analysis, the probability of receiving CF-HL was associated with a hazard ratio of 3.11 (p\u3c0.0001). CONCLUSIONS: Statistical methodology using propensity score matching and instrumental variable analysis increased the robustness of observations derived from real-world data and demonstrates the feasibility of performing comparative effectiveness research using STS Intermacs. These analyses provide additional evidence supporting a survival benefit of CF-FML versus CF-HL

Anatomic segmentectomy for stage I non–small-cell lung cancer: Comparison of video-assisted thoracic surgery versus open approach

ObjectivesAnatomic segmentectomy is increasingly being considered as a means of achieving an R0 resection for peripheral, small, stage I non–small-cell lung cancer. In the current study, we compare the results of video-assisted thoracic surgery (n = 104) versus open (n = 121) segmentectomy in the treatment of stage I non–small-cell lung cancer.MethodsA total of 225 consecutive anatomic segmentectomies were performed for stage IA (n = 138) or IB (n = 87) non–small-cell lung cancer from 2002 to 2007. Primary outcome variables included hospital course, complications, mortality, recurrence, and survival. Statistical comparisons were performed utilizing the t test and Fisher exact test. The probability of overall and recurrence-free survival was estimated with the Kaplan-Meier method, with significance being estimated by the log-rank test.ResultsMean age (69.9 years) and gender distribution were similar between the video-assisted thoracic surgery and open groups. Average tumor size was 2.3 cm (2.1 cm video-assisted thoracic surgery; 2.4 cm open). Mean follow-up was 16.2 (video-assisted thoracic surgery) and 28.2 (open) months. There were 2 perioperative deaths (2/225; 0.9%), both in the open group. Video-assisted thoracic surgery segmentectomy was associated with decreased length of stay (5 vs 7 days, P < .001) and pulmonary complications (15.4% vs 29.8%, P = .012) compared with open segmentectomy. Overall mortality, complications, local and systemic recurrence, and survival were similar between video-assisted thoracic surgery and open segmentectomy groups.ConclusionsVideo-assisted thoracic surgery segmentectomy can be performed with acceptable morbidity, mortality, recurrence, and survival. The video-assisted thoracic surgery approach affords a shorter length of stay and fewer postoperative pulmonary complications compared with open techniques. The potential benefits and limitations of segmentectomy will need to be further evaluated by prospective, randomized trials

HVAD to HeartMate 3 left ventricular assist device exchange: Best practices recommendations

The HeartWare HVAD System (Medtronic) is a durable implantable left ventricular assist device that has been implanted in approximately 20,000 patients worldwide for bridge to transplant and destination therapy indications. In December 2020, Medtronic issued an Urgent Medical Device Communication informing clinicians of a critical device malfunction in which the HVAD may experience a delay or failure to restart after elective or accidental discontinuation of pump operation. Moreover, evolving retrospective comparative effectiveness studies of patients supported with the HVAD demonstrated a significantly higher risk of stroke and all-cause mortality when compared with a newer generation of a commercially available durable left ventricular assist device. Considering the totality of this new information on HVAD performance and the availability of an alternate commercially available device, Medtronic halted the sale and distribution of the HVAD System in June 2021. The decision to remove the HVAD from commercial distribution now requires the use of the HeartMate 3 left ventricular assist system (Abbott, Inc) if a patient previously implanted with an HVAD requires a pump exchange. The goal of this document is to review important differences in the design of the HVAD and HeartMate 3 that are relevant to the medical management of patients supported with these devices, and to assess the technical aspects of an HVAD-to-HeartMate 3 exchange. This document provides the best available evidence that supports best practices

Heat Shock Proteins: Pathogenic Role in Atherosclerosis and Potential Therapeutic Implications

Heat shock proteins (HSPs) are a highly conserved group of proteins that are constitutively expressed and function as molecular chaperones, aiding in protein folding and preventing the accumulation of misfolded proteins. In the arterial wall, HSPs have a protective role under normal physiologic conditions. In disease states, however, HSPs expressed on the vascular endothelial cell surface can act as targets for detrimental autoimmunity due to their highly conserved sequences. Developing therapeutic strategies for atherosclerosis based on HSPs is challenged by the need to balance such physiologic and pathologic roles of these proteins. This paper summarizes the role of HSPs in normal vascular wall processes as well as in the development and progression of atherosclerosis. The potential implications of HSPs in clinical therapies for atherosclerosis are also discussed

Novel method for transaxillary Impella 5.0 implantation in patients with tortuous arterial anatomy

Abstract A novel method of transaxillary Impella 5.0 implantation utilizing a vascular sheath can overcome difficult arterial anatomy and provide mechanical support for patients in critical cardiogenic shock

CAN PLACENTAL HISTOPATHOLOGICAL LESIONS BE A GUIDE TO MATERNAL AND NEONATAL OUTCOMES IN PATIENTS WITH PREECLAMPSIA?

Objective: The aim of this study was to investigate the predictive role of massive perivillous fibrinoid deposition (MPFD), syncytial knots, and accompanying histopathological features of placentas of preeclampsia (PE) on maternal and neonatal outcomes. Matherials and methods: A retrospective clinicopathological study was conducted in a tertiary unit. In the study, 51 pregnant women admitted with PD and 55 normotensive healthy pregnant women matched for age and gestational age were compared. Information regarding clinical characteristics, neonatal findings, and placental properties such as syncytial knots, vascular structure density, placental area, volume, and weight) was retrieved. Results: Massive perivillous fibrinoid deposition, syncytial knots and decreased vessels in terminal villi were significantly frequent in the PE group compared to the controls. However, these histopathological findings were not associated with clinical and neonatal outcomes. Conclusions: Syncytial knot and perivillous fibrin deposition are significant microscopic findings of preeclampsia. However, the presence and amount of fibrin deposition were not correlated with perinatal outcome