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Melvin Hardy posted an update 6 months ago
In the era of direct-acting antiviral therapies, hepatitis C positive organs offer a strategy to expand the donor pool. Heart failure patients with concomitant renal insufficiency benefit from combined heart/kidney transplant. In 2017, we began utilizing organs from hepatitis C donors for heart/kidney transplants.
Characteristics and outcomes of heart/kidney transplants were collected at our institution from 2012 through 2019. We determined patient cohorts by donor hepatitis C antibody status, antibody positive (HCV+) versus antibody negative (HCV-). Outcomes of interest include survival, postoperative allograft function, and waitlist time. Summary and descriptive statistics, as well as survival analyses, were performed.
Thirty-nine patients underwent heart/kidney transplantation from 2012-2019. Twelve patients received HCV+ organs, while 27 patients received HCV- organs with minimal differences in donor and recipient cohort characteristics. Recipients who consented to receive HCV+ organs had a shorter time, the results suggest that HCV+ donors are an important source of transplantable organs for heart-kidney transplantation.
Even in the extended-criteria era, the reasons for declining lung donors are not always clear. Furthermore, it has not been determined how many actual declined lungs would be retrieved by ex-vivo lung perfusion (EVLP) beyond that already achieved in centers with an existing high utilization rate.
This retrospective study reviewed all lung donor referrals between 2014-2018, including detailed formal referrals and preliminary notifications. This study categorized reasons for lung donor non-acceptance and estimated how many declined grafts could have been theoretically retrievable by using EVLP.
In total, 966 lung donor candidates were referred, including 313 transplanted donors, 336 declined donors after detailed referrals (Group A) and 258 preliminary declined. In the Group A, the primary reasons for refusal were lung quality issues (49%), general medical issues (25%), and organization issues (26%), combined with secondary reasons in many cases. Main lung quality issues were an extensive smoking history, abnormal chest radiography and underlying lung disease. Although 73 declined lung donors had indications for EVLP, the retrievable lungs decreased to only 30 cases after considering the details of all clinical contraindications and organizational issues. However, 59 intended donation after circulatory death donors did not progress to death after withdrawal of cardiorespiratory support in the required timeframe, and EVLP may have an emerging additional role here.
Based on commonly cited criteria for EVLP indication, the number of EVLP retrievable lung donors represented only a small portion of declined donor lungs referred to our center from the state donation network.
Based on commonly cited criteria for EVLP indication, the number of EVLP retrievable lung donors represented only a small portion of declined donor lungs referred to our center from the state donation network.
Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well-investigated in the surgical literature.
Between 1997-2019, 775 patients presented with acute type A aortic dissection and 80 (10%) presented with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed.
Fifty-nine (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting and 18 (23%) received non-operative management. In-hospital mortality of all comers was 40.0% and 81.3% were neuro-related. Among the 45 (56%) patients in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion, 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. There were 6 (55%) and 10 (36%) comatose patients in the ICA and CCA group, respectively (p=0.28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. LF3 order In contrast, 79% patients with unilateral or bilateral CCA occlusion survived to hospital discharge (p <0.001) and only 3 (11%) had a neurological death (p <0.001).
ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurological outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.
ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurological outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.
The utility of adjuvant chemotherapy (AC) following neoadjuvant therapy and curative intent surgery for clinical IIIA non-small cell lung cancer (NSCLC) is not defined. We sought to evaluate the contribution of AC to overall survival (OS) in patients with cIIIA NSCLC who underwent neoadjuvant therapy followed by curative intent surgical resection.
The National Cancer Database (NCDB) was queried from 2010 to 2016 for patients with cIIIA NSCLC who underwent curative intent surgical resection following neoadjuvant therapy. Patients were grouped by receipt of AC and OS was calculated using the Kaplan-Meier (KM) method. The association between mortality and AC was evaluated using Cox regression. 90-day landmark and propensity score matched (PSM) analyses were performed to address bias associated with early post-operative morbidity/mortality.
3847 patients met inclusion criteria, 780 received AC (20.2%). In the unadjusted cohort there was no difference in 5-year OS between the AC and no AC groups (42.8% vs. 43.9%, p=0.105). Cox regression demonstrated a decreased risk of mortality in pN>0 patients receiving AC (HR 0.79 CI 0.68-0.92, p < 0.003), while no difference was seen in node negative patients (HR 0.95 CI 0.78-1.17 p=0.64). In the propensity score matched groups OS was significantly increased in pN>0 patients who received AC (5-yr OS 42.4% vs. 37%, p<0.01), while no survival benefit was seen in those who were pN0.
For patients with completely resected cIIIA NSCLC following neoadjuvant therapy, AC is associated with an increase in overall survival for patients with residual pathologic lymph node involvement.
For patients with completely resected cIIIA NSCLC following neoadjuvant therapy, AC is associated with an increase in overall survival for patients with residual pathologic lymph node involvement.