Rationale: Few studies have outlined the impact of donor mechanism of death (MoD) on lung transplant (LTx) outcomes. This study aims to analyze all available data from the Organ Procurement and Transplant Network (OPTN) to identify the impact of changing trends in donor MoD on LTx outcomes. Method: This retrospective study analyzed 46,997 de-identified LTx records from January 1990 to April 2024 in the OPTN database. Transplants were stratified by donor mechanism of death and those with either electrical or sudden infantile death syndrome were excluded due to low volume. Survival was measured at 30,90, 180 day and 1,2,5, and 10 years. Results: Overall, intracranial hemorrhage was the most common donor mechanism of death followed by blunt injury and gun-shot wounds (n = 15,688, 11,644, 8,736, respectively). Stab wound donor MoD had the longest median survival time (6.779 years), followed by cardiovascular (6.190 years), while intracranial hemorrhage/stroke (5.309 years) and drowning (5.342 years) had the shortest. Short term survival until 180 days was significantly higher in drug intoxication MoD LTx followed by asphyxiation compared to all other MoD (180-day survival, 92.7% and 91.9% respectively). Short term survival was lowest amongst stab wound related MoD (180-day survival 88.62%). Survival at 1 and 2 years was highest amongst donor MoDs of natural causes (88.77%) and drug intoxication (79.4%) respectively. Survival at 5 years was highest amongst those with stab wounds (61.9%) followed by seizures (57.8%). In contrast, survival was lowest amongst those with donor MoD of intracranial hemorrhage (52%). 10-year survival is highest amongst those with cardiovascular related MoD LTx followed by stab wounds and lowest amongst drowning donor MoD. All findings were statistically significant with log-rank p-value <0.0001. Conclusion: Survival outcomes of recipients may be dependent on the MoD of the donor with drug intoxication and natural causes associated with higher short and medium-term survival rates. In contrast, stab wounds have the highest overall median survival. More data should be explored to understand the potential prognostic and donor selection implications of donor MoD on LTx recipient survival.

Purpose: Lung allocation policy is significant in determining lung transplantations (LTx). This study aims to evaluate the impact of LTx policy changes on geographic disparities in allocation and waitlist mortality (WLM).

OBJECTIVE:To evaluate the midterm survival, clinical, and hemodynamic outcomes of the On-X mechanical mitral valve, based on the 5-year results of the Prospective Randomized On-X Anticoagulation Clinical Trial (PROACT). METHOD:PROACT Mitral was a multicenter study evaluating 401 patients who underwent mitral valve replacement (MVR) with either Standard or Conform-X On-X mitral valves, comparing low-dose and standard-dose warfarin. Here we report prespecified secondary outcomes of survival, New York Heart Association (NYHA) functional classification, and valve hemodynamics as assessed by core lab-adjudicated echocardiography at 1, 3, and 5 years in the pooled population. RESULTS:Actuarial survival was 99.7% at 1 year, 95.1% at 3 years, and 92.4% at 5 years, with no significant difference between the Standard and Conform-X cuffs. Hemodynamic analysis revealed a mean transvalvular pressure gradient (MG) of 4.6 ± 2.0 mm Hg at 1 year, with no interaction between valve size and patient body surface area. MG values were consistent over time. Quality of life improved with 96.6% of patients in NYHA class I or II at the latest available follow-up of 3 or 5 years. There were no significant differences in survival, clinical, or hemodynamic outcomes between valve sizes. CONCLUSIONS:The On-X mechanical mitral valve demonstrated favorable survival, stable hemodynamics, and enhanced quality of life up to 5 years postimplantation. Derived from high-quality, rigorous randomized trial data, these findings can guide decision making in young patients requiring MVR.

Purpose: Antibody-mediated rejection (AMR) remains a diagnostic and therapeutic challenge in lung transplantation. Due to its unique ability to inhibit HLA antibodies, Belatacept was proposed as a potential strategy to treat AMR and prevent chronic lung allograft dysfunction. We report our experience using Belatacept as maintenance immunosuppression to prevent allograft dysfunction in patients diagnosed with AMR post-lung transplantation.

Purpose: Earlier studies have examined the relationship between donor-recipient race-matching (RM) in lung transplantations (LTx). We aim to update the findings using all available lung transplant data from Organ Procurement and Transplant Network (OPTN) as of September 1, 2022.

OBJECTIVES Spontaneous sternoclavicular joint infection (SSCJI) is a rare and poorly understood disease process. This study aims to identify factors guiding effective management strategies for SSCJI by using data mining. METHODS An Institutional Review Board-approved retrospective review of patients from 2 large hospitals (2010-2022) was conducted. SSCJI is defined as a joint infection without direct trauma or radiation, direct instrumentation or contiguous spread. An interdisciplinary team consisting of thoracic surgeons, radiologists, infectious disease specialists, orthopaedic surgeons, hospital information experts and systems engineers selected relevant variables. Small set data mining algorithms, utilizing systems engineering, were employed to assess the impact of variables on patient outcomes. RESULTS A total of 73 variables were chosen and 54 analysed against 11 different outcomes. Forty-seven patients [mean age 51 (22-82); 77% male] met criteria. Among them, 34 underwent early joint surgical resection (<14 days), 5 patients received delayed surgical intervention (>14 days) and 8 had antibiotic-only management. The antibiotic-only group had comparable outcomes. Indicators of poor outcomes were soft tissue fluid >4.5 cm, previous SSCJI, moderate/significant bony fragments, HgbA1c >13.9% and moderate/significant bony sclerosis. CONCLUSIONS This study suggests that targeted antibiotic-only therapy should be considered initially for SSCJI cases while concurrently managing comorbidities. Patients displaying indicators of poor outcomes or no symptomatic improvement after antibiotic-only therapy should be considered for surgical joint resection.

Purpose: Pneumatosis Intestinalis (PI) is a rare post-lung transplant complication that is characterized by the presence of gas within the wall of the small and large intestine. PI in lung transplant recipients has been previously described and is associated with disease of varying clinical trajectories. While several mechanisms have been proposed for the development of intramural gas: mechanical, bacterial, and pulmonary, the underlying pathology remains unclear. We present our experience in 22 lung transplant patients and underline risk factors, diagnostic findings, and management.

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Introduction: Socioeconomic disparities impact outcomes after cardiac surgery. At our institution, cardiac surgery cases from the safety-net, county funded hospital (CH), which primarily provides care for underserved patients, are performed at the affiliated university hospital. We aimed to investigate the association of socioeconomic factors and CH referral status with outcomes after coronary artery bypass grafting (CABG). Methods: The institutional Adult Cardiac Surgery database was queried for perioperative and demographic data from patients who underwent isolated CABG between January 2014 and June 2020. The primary outcome was major adverse cardiovascular event (MACE), a composite of postoperative myocardial infarction, stroke, or death. Secondary outcomes included individual complications. Chi-square, Wilcoxon rank-sum, and logistic regression analyses were used to compare differences between CH and non-CH cohorts. Results: We included 836 patients with 472 (56.5%) from CH. Compared to the non-CH cohort, CH patients were younger, more likely to be Hispanic, non-English speaking, and be completely uninsured or require state-specific financial assistance. CH patients were more likely to have a history of tobacco and drug use, liver disease, diabetes, prior myocardial infarction, and greater degrees of left main coronary and left anterior descending artery stenosis. CH cases were less likely to be elective. The incidence of MACE was significantly higher in the CH cohort (16.3% versus 8.2%, P 1/4 0.001). There were no significant differences in 30-d mortality, home discharge, prolonged mechanical ventilation, bleeding, sepsis, pneumonia, new dialysis requirement, cardiac arrest, or multiorgan system failure between cohorts. CH patients were more likely to develop renal failure and less likely to develop atrial fibrillation. On multivariable analysis, CH status (odds ratio 2.39, 95% confidence interval 1.25-4.55, P 1/4 0.008) was independently associated with MACE. Conclusions: CH patients undergoing CABG presented with greater comorbidity burden, more frequently required nonelective surgery, and are at significantly higher risk of postoperative MACE.

PURPOSE:During the COVID-19 pandemic, telemedicine become an effective alternative to in-person clinic visits for transplant patients in order to decrease the risk of exposure to patients and their healthcare providers.Our study evaluates patient satisfaction with telemedicine in lung, kidney, and liver transplant recipients.METHODS: A retrospective analysis was performed at the University of Maryland Lung Transplant center during the COVID-19 pandemic.The primary outcome was patient satisfaction with the clinical visit measured by Telemedicine Satisfaction Questionnaire.The telehealth clinics were conducted from March 2020 to October 2021.The survey was designed by the study team and content validity was tested with an expert panel and focus group discussions with patients. RESULTS:Beginning in March 2020, 148 lung, 953 kidney, and 631 liver transplant patients received the survey via email.A total of 649 (90 lung, 361 kidney, and 198 liver transplant patients) completed the survey.The response rate was 37%.Approximately 87% of lung patients considered that the care received via telehealth program was "very good" or "excellent".Similarly, 75% of kidney transplant patients and 74% of liver transplant patients considered that the care received via telehealth program was "very good" or "excellent".The majority of patients (85%) reported decreased travel-associated costs.CONCLUSIONS: High levels of satisfaction were seen in solid organ transplant patients after the implementation of a telehealth program in the context of the COVID-19 pandemic.The study showed a higher level of satisfaction among lung transplant patients in comparison to kidney or liver transplant patients.CLINICAL IMPLICATIONS: Our study suggests that a telehealth program may decrease travel-associated costs while maintaining high levels of satisfaction in a very complex transplant population.

PurposeThe COVID-19 pandemic resulted in a high incidence of respiratory failure requiring invasive management strategies including venovenous extracorporeal membrane oxygenation (VVECMO). COVID-19 infection resulted in more severe disease in patients with underlying comorbidities, such as those with limited access to healthcare. In this study, we describe our early experience with initiating a VVECMO program at a safety net hospital.MethodsPrior to the COVID-19 pandemic, patients needing VVECMO at our safety net hospital were transferred to the adjacent affiliated university hospital for centralized care. To meet the growing need of VVECMO services during the COVID-19 pandemic, we implemented a multidisciplinary VVECMO program at the safety net hospital. Data were obtained from chart review. Categorical data are presented as numbers with proportions and continuous variables as medians with interquartile ranges.ResultsFrom January 2021 through January 2022, 25 patients with COVID-19 were placed on VVECMO. Complete background characteristics and outcomes data are shown in Table 1. Median ECMO run time was 962 hours [375-1371]. 15 (60%) survived to hospital discharge with a median length of stay of 65 days [37-87]. Survival by Kaplan Meier method is shown in Figure 1.ConclusionVVECMO for COVID-19 can be a lifesaving therapy despite a high frequency of complications and long hospital stays. Strategies to improve access to VVECMO for safety net hospitals and underserved patients are warranted. The COVID-19 pandemic resulted in a high incidence of respiratory failure requiring invasive management strategies including venovenous extracorporeal membrane oxygenation (VVECMO). COVID-19 infection resulted in more severe disease in patients with underlying comorbidities, such as those with limited access to healthcare. In this study, we describe our early experience with initiating a VVECMO program at a safety net hospital. Prior to the COVID-19 pandemic, patients needing VVECMO at our safety net hospital were transferred to the adjacent affiliated university hospital for centralized care. To meet the growing need of VVECMO services during the COVID-19 pandemic, we implemented a multidisciplinary VVECMO program at the safety net hospital. Data were obtained from chart review. Categorical data are presented as numbers with proportions and continuous variables as medians with interquartile ranges. From January 2021 through January 2022, 25 patients with COVID-19 were placed on VVECMO. Complete background characteristics and outcomes data are shown in Table 1. Median ECMO run time was 962 hours [375-1371]. 15 (60%) survived to hospital discharge with a median length of stay of 65 days [37-87]. Survival by Kaplan Meier method is shown in Figure 1. VVECMO for COVID-19 can be a lifesaving therapy despite a high frequency of complications and long hospital stays. Strategies to improve access to VVECMO for safety net hospitals and underserved patients are warranted.

PURPOSE:Lung transplantation (LT) has been a gold standard treatment for end-stage lung disease due to Cystic Fibrosis (CF).In recent years, LT for CF is declining in many high-income countries due to the availability of CF transmembrane conductance regulator (CFTR) protein modulators.The aim of this study is to analyze the long-term outcomes of CF patients who underwent LT at a large academic medical center.METHODS: Data for this retrospective study was collected from our institutional database and United Network for Organ Sharing (UNOS) DonorNet following approval from the Institutional Review Board.The variables include donor and recipient sex, race, and age, recipient CF genotype, body mass index (BMI), albumin, pre-albumin, ischemic times, and the diagnoses of bronchiolitis obliterans syndrome (BOS) or restrictive allograft syndrome (RAS) from chronic lung allograft dysfunction (CLAD).The cohort was divided into two groups based on the development of the Lung Allocation Score (LAS): pre-LAS for 1994 -May 2005 and post-LAS for May 2005 -2020.The Kaplan-Meier method was employed for time-to-event (CLAD, death).Cox regression was conducted to assess the impact of risk factors on hazard.Group comparisons were performed using T-test, Chisquare test, and Wilcoxon-rank sum test.RESULTS: 872 LTs were performed from 1990 to 2020, with 126 being bilateral LTs for CF patients.The majority were female patients (66; 55%) and of white race (119; 94%).The mean age at LT was 29.1 AE 10.1 years.Group 1 (pre-LAS) consisted of 46 while group 2 (post-LAS) had 80 patients.In the 75 patients with CF genotype data, the predominant mutation was homozygous delta F508 (19; 25%).44 patients in group 2 had CLAD (24 BOS, 19 BOS/RAS, 1 RAS) at a median duration of 5.9 years (95%CI 3.5 -8.0 yrs.), while CLAD data for group 1 was incomplete.The median survival in group 1 was 8.0 years (95%CI 4.6 -10.2 yrs.) and 6.3 years (95%CI 3.8 -14.4 yrs.) in group 2. Notably, the median survival time was statistically affected by the age of the recipient at LT (p¼0.007) and displayed no statistical significance with the other variables analyzed.The actuarial survival of both groups 1 and 2 was plotted on a Kaplan-Meier graph.CONCLUSIONS: Lung transplantation extends life for CF patients with end-stage lung disease, but the median survival is still low.LT is still an option for CF patients with end-stage lung failure living in low-and mid-income countries where CFTR modulators are not freely available.Meanwhile, CLAD remains a significant cause of mortality.A larger cohort study is required to confirm the relationship between age at LT and median survival.CLINICAL IMPLICATIONS: Lung transplantation extends life for CF patients with end-stage lung disease, but the median survival is still low.LT is still an option for CF patients with end-stage lung failure living in low-and mid-income countries where CFTR modulators are not freely available.Meanwhile, CLAD remains a significant cause of mortality.A larger cohort study is required to confirm the relationship between age at LT and median survival.

The Ross Procedure (RP) is a technically complex opera-tion for aortic valve replacement (AVR) in selected pa-tients. We describe a novel approach to simulating this operation using explanted native hearts during heart transplantation. Consent was obtained. The aortic root is dissected away from the pulmonary artery (PA). The pulmonary autograft is harvested and then transferred into the aortic position, and coronary buttons are reimplanted. The explanted heart is submitted for pathologic analysis. Six explanted hearts have been used for simulation thus far. Participating trainees reported high degrees of satis-faction. This high-fidelity simulation is an effective way to increase trainee exposure to the RP.

Introduction: Anti-thymocyte globulin (ATG) is a polyclonal antibody formulation which has been used as a second-line therapy for chronic lung allograft dysfunction (CLAD). Limited data exist evaluating its efficacy; however, several single-center retrospective studies have variably demonstrated either improvement or stabilization of spirometry parameters after administration of ATG. ATG has been in use at UT Southwestern for treatment of CLAD since at least 2010; here, we seek to evaluate the effectiveness of this intervention at our center. Methods: A retrospective chart review was conducted of a total of 136 patients who underwent lung transplantation at UT Southwestern Medical Center between 2010 and 2022. Of these, 72 patients had received ATG specifically for treatment of CLAD, and the remaining 64 had never received ATG. Two separate analyses were performed: in the first, among those who received ATG for CLAD, spirometry data from the 6 months preceding and following ATG administration were reviewed and rates of change in FEV1 were calculated for each time period. Descriptive statistics were performed to summarize the baseline clinical characteristics and outcomes after ATG, with patients classified as having either a full response (positive rate of change in FEV1) or partial response (>20% attenuation in rate of FEV1 decline) to ATG. In the second analysis, survival was described among those who received ATG for CLAD and comparison was provided between propensity-score matched cohorts from the ATG and non-ATG groups. Results: Of the 63 patients who received ATG for treatment of CLAD (and had adequate spirometry measurements available to trend FEV1), 49 (77.8%) had at least a partial response to therapy; 8 (12.7%) experienced an overall improvement in FEV1. Response to ATG was found to be associated with a more rapid rate of pre-ATG decline in FEV1; no other baseline parameters were found to be predictive of a response to ATG. Median post-CLAD graft survival was 31.7 months among those who received ATG, and only baseline absolute neutrophil count was found to be associated with worse post-CLAD graft survival among this group. Conclusion: Anti-thymocyte globulin therapy, when given for CLAD, was associated with at least a modest attenuation in rate of FEV1 decline in most patients but only rarely preceded an absolute improvement in FEV1. Further study is warranted to better define the role for ATG in treatment of CLAD, a challenging disease state with limited therapeutics available.