OBJECTIVES:Allocation out-of-sequence (AOOS) is an allocation pathway that allows organ procurement organizations (OPOs) to bypass the standard match-run sequence to expedite organ placement and avoid organ wastage amidst donor, recipient, or logistical constraints. Amidst increasing use of AOOS in recent years, we sought to characterize its impact on lung utilization in the contemporary era. METHODS:We performed a retrospective analysis using United Network for Organ Sharing data from June 2021 to December 2024 to examine the association between OPO-level AOOS and lung nonuse. RESULTS:Among 10,350 lung donors, 931 (9.0%) were allocated out-of-sequence, with OPO-level rates of AOOS ranging from 1.2% to 28.9%. Observed-to-expected lung yield ratios were comparable across OPOs stratified by AOOS use, with no significant difference among low-, medium-, and high-AOOS groups (0.96 vs 0.97 vs 0.92; p=0.728). Among 20,462 individual lungs recovered for transplantation, 2,003 (9.8%) ultimately not used. After adjusting for donor characteristics and temporal trends, AOOS was not significantly associated with lung nonuse (incidence rate ratio 1.00, 95% confidence interval 0.94-1.06, p=0.883). CONCLUSION:These findings indicate that further revision of lung allocation policy is required to optimize lung utilization and mitigate use of alternative allocation pathways.

BACKGROUND:Primary graft dysfunction (PGD) remains a major cause of post-heart transplant morbidity and mortality. Prior studies have focused on predictors of developing PGD. Less is known about factors associated with post-PGD recovery. METHODS:We queried the Scientific Registry of Transplant Recipients for adult heart transplants between September 2023 and December 2025. Severe PGD was defined as dependence on new extracorporeal membrane oxygenation or ventricular assist device support at 24 hours post-transplant. Outcomes were compared across donor type (donation after circulatory death [DCD] vs donation after brain death [DBD]) and procurement/preservation strategies (normothermic regional perfusion (NRP), ex-vivo heart perfusion (EVP), static cold storage). The primary outcome was overall survival. Secondary outcomes included graft failure and 30-day survival. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding. RESULTS:Among 7059 heart transplant recipients, 462 (6.5%) developed severe PGD, which was associated with significantly worse survival. Among patients with severe PGD, DCD recipients had higher unadjusted survival compared with DBD (1-year survival 84.1% vs. 65.1% [log-rank P=0.001]). In IPTW-adjusted analyses DCD transplants were associated with improved survival (adjusted hazard ratio, 0.44; 95% CI, 0.23-0.85; P=0.014). Preservation strategy was not associated with survival after adjustment. DCD was associated with higher odds of 30-day survival in unadjusted analyses. CONCLUSION:Compared with DBD, DCD recipients with severe PGD demonstrated improved survival. Preservation strategy was not independently associated with survival, though subgroup analyses were limited by small numbers. Among predictors of early recovery, ventricular support devices at 24 hours were independently associated with lower odds of 30-day survival compared with ECMO.

OBJECTIVE:The United States' experience with heart transplantation following donation after circulatory death (DCD HT) has expanded since clinical adoption in 2019. We aimed to examine a large institution's outcomes associated with DCD HT versus HT following donation after brain death (DBD). METHODS:Adult heart recipients and corresponding donors at a single quaternary academic center from January 2019 to October 2024 were included. Recipient and donor data were extracted from the institution's electronic medical record and the United Network for Organ Sharing registry, respectively. The primary outcome was overall survival. RESULTS:In total, 553 heart donors and recipients met inclusion criteria, including 404 (73%) DBD and 149 (27%) DCD recipients. Recipients of DCD allografts were less likely to have an intra-aortic balloon pump before transplant, but there was no significant difference in waitlist status at the time of transplant between the 2 groups. DCD allografts had increased total ischemic time (defined by United Network for Organ Sharing registry as time between donor explant and re-perfusion in the recipient) (5.7 vs 3.7 hours; P < .001) and distance to travel (381 vs 299 miles; P = .001) compared with DBD allografts. Unadjusted Kaplan-Meier survival analysis demonstrated no significant difference between DCD and DBD recipients' cumulative survival (log-rank P = .14). The rate of severe primary graft dysfunction was not significantly different between groups (12% DCD vs 11% DBD; P = .65). CONCLUSIONS:Cardiac allografts from DCD donors perform similarly to a contemporary population of DBD allografts. The rate of severe primary graft dysfunction and the unadjusted cumulative survival were not significantly different between DCD and DBD cohorts.

Background: The impact of continuous distribution on allocation of multiorgan transplantation (MOT) involving lungs remains unexplored. Here we characterize how continuous distribution has affected lung-involved MOT. Methods: We conducted a retrospective study using the United Network for Organ Sharing database. Adults listed for lung-MOT between March 9, 2021, and March 8, 2025, were included. The lung allocation score (LAS) era included the 24 months prior to March 9, 2023, and the composite allocation score (CAS) era comprised 24 months after March 9, 2023. Primary outcomes included transplantation rate, waitlist mortality, and 6-month composite outcome (graft rejection and death) assessed with Kaplan-Meier methods and Poisson regression to estimate transplantation rate and waitlist mortality. Post-transplantation survival was modeled using Cox proportional hazards. Results: Among 498 lung-MOT candidates listed for transplantation during the study period (274 heart-lung, 106 lung-liver, and 101 lung-kidney), 349 underwent transplantation (205 heart-lung, 77 lung-liver, and 60 lung-kidney). The transplantation rate per 100 patient-years increased significantly for all combinations under CAS (heart-lung, 90.5 vs 172.9; lung-liver, 57.9 vs 254.5; lung-kidney, 118.8 vs 194.2; P < .05 for all), while waitlist mortality remained similar between eras (heart-lung, 8.0 vs 19.4; lung-liver, 15.1 vs 18.9; lung-kidney, 23.8 vs 36.0; P > .05 for all). The six-month post-transplantation composite outcome was comparable in the 2 eras (87.0% vs 87.6%; P = .832) Conclusions: The transition from LAS to CAS enhanced access to transplantation for lung-MOT, while waitlist mortality remained similar. Short-term post-transplant composite outcomes did not differ between eras, supporting the feasibility of CAS for lung-MOT candidates without negatively impacting early outcomes.

Background:Lungs from older donation after circulatory death (DCD) donors are underutilized; however, these organs may represent an opportunity to expand the donor pool. Herein, we evaluated utilization and outcomes of lung transplants using lungs from older DCD donors. Methods:Using national data from 2016 to 2024, we identified all adult DCD donors and corresponding isolated lung transplant recipients. Multivariable logistic regression was used to identify predictors of lung utilization. Kaplan-Meier and Cox proportional hazards methods were used to compare graft survival between recipients of lungs from DCD donors <55 and ≥55 years. Results:Among 10,769 older (age ≥ 55) DCD donors identified, lungs were transplanted from only 302 (2.8%) with significant organ procurement organization- and center-level variation in use. Just one center exceeded 50 transplants using older DCD donors over the study period. Utilization increased over time (7 cases in 2016 vs 111 in 2024; p < 0.001). Ex-vivo lung perfusion (odds ratio 5.93) and higher PaO₂/FiO₂ ratio (odds ratio 1.33 per 50-point increase) were independently associated with transplantation of older DCD donor lungs. One- and three-year graft survival were similar between age groups; older donor age was not associated with increased risk of graft failure in adjusted models. Conclusions:Lungs from older DCD donors remain underutilized despite comparable outcomes. Their use is highly concentrated among a small number of centers and organ procurement organizations, suggesting that local behaviors and infrastructure strongly influence disposition. Broader adoption of ex-vivo lung perfusion and strategic recipient matching may support safe expansion of this untapped donor pool.

BACKGROUND:Out-of-sequence (OOS) allocation is a mechanism by which donor organs are offered outside the standard match run, typically to expedite the placement of hard-to-match or time-sensitive allografts. Rising OOS rates are described in abdominal organ transplantation, but limited data exist regarding OOS practices in heart transplantation. METHODS:The United Network for Organ Sharing (UNOS) was used to identify all adult heart transplant recipients and corresponding donors between January 2015 and March 2024. The Potential Transplant Recipient file was then used to classify each donation as either in-sequence or out-of-sequence. We assessed temporal trends and practice patterns in relation to OOS allocation. Additionally, we evaluated donor and recipient characteristics and post-transplant survival outcomes. RESULTS:Within the study period, there were 25,608 heart transplantations, of which 509 (2%) were from OOS donors. OOS allocation increased 2-fold over the study period (1.4%-3.1%). Use varied across Organ Procurement Organizations (OPOs) (0-5.4%) and transplant centers (0-16.7%), with a small subset of OPOs accounting for the majority of OOS allocations. Recipients of OOS-allocated allografts were more likely to be nonhospitalized older females with type O blood group. There was no significant difference in overall survival rates between OOS and in-sequence recipients at 1 year (93.1% vs 91.6%, respectively). CONCLUSIONS:OOS heart allocation, while rare, is increasing, and varies by geography and OPO. The OOS mechanism may provide an opportunity to improve organ recovery and support transplant access for harder-to-match candidates. However, standardization of OOS practices is needed to ensure equity in transplant access.

Importance Allocation out of sequence (AOOS) allows organ procurement organizations (OPOs) to offer organs outside of standard allocation and bypass those atop the match run. AOOS may allow OPOs to successfully place medically complex organs; however, increasing use of AOOS also raises concern for inefficiencies within the allocation process and may exacerbate systemic inequities. Objective To characterize patterns of lung AOOS among organ procurement organizations and transplant centers and compare lung transplant characteristics and outcomes between in-sequence and AOOS groups. Design, Setting, and Participants In this retrospective cohort study, the United Network for Organ Sharing registry was queried for lung transplants performed between September 1, 2021, and June 30, 2024. Data were linked to the Potential Transplant Recipient file to identify all offers for included donor lungs. These data were analyzed from October 2024 to February 2025. Participants included adult donors who donated at least 1 lung for transplant and corresponding primary isolated lung transplant recipients. The final cohort included 7914 lung donor-recipient pairs. Exposure(s) Lung AOOS vs in sequence, defined by match-run refusal codes for donor lung offers. Main Outcome(s) and Measure(s) Donor and recipient characteristics, posttransplant outcomes, and OPO-level and transplant center-level rates of lung AOOS. Results Overall, 7914 lung transplants were included, of which 558 used AOOS (7.1%). Rates of lung AOOS ranged from 0% to 30% among OPOs and 0% to 50% among transplant centers. Use of lung AOOS increased in the continuous distribution era (10% vs 4%; P < .001). Donors of AOOS lungs were more likely to donate after circulatory death and had lower partial pressure of oxygen/fraction of inspired oxygen ratios, longer ischemic times, and longer travel distances. AOOS recipients were less likely to require pretransplant hospitalization, intensive care, and ventilator or extracorporeal membrane oxygenation support. On multivariable analysis, lung AOOS was associated with lower odds of prolonged intubation and early acute rejection and shorter posttransplant hospital length of stay. Conclusions AOOS is increasingly used in lung transplant and is associated with transplant of medically complex lungs into lower acuity recipients. Further investigation is needed to understand how AOOS affects lung utilization, especially in the era of continuous distribution.

OBJECTIVE:To evaluate characteristics and outcomes of patients bridged to orthotopic heart transplantation with microaxial left ventricular assist device (ma-LVAD) versus durable LVAD (d-LVAD). METHODS:This was a single-center retrospective cohort study in which characteristics outcomes of patients undergoing orthotopic heart transplantation between May 2019 and May 2024 who were bridged with ma-LVAD versus d-LVAD, were compared. RESULTS:Over the study period, the percentage of patients bridged with ma-LVAD increased from 0% to 20%. Patients bridged with d-LVAD were more likely to have history of hypertension (80% vs 65%; P = .03), a higher body mass index (32.53 vs 28.15; P < .0001), and anti-human leukocyte antigens antibodies (54% vs 36%; P = .02) before transplant, otherwise groups were similar in their baseline characteristics. Unadjusted Kaplan-Meier analysis demonstrated no difference in survival between these 2 bridging strategies. However, postoperative blood product use (3 vs 0 units; P < .0001), moderate or severe primary graft dysfunction (27% vs 14%; P = .04), and delayed sternal closure (45% vs 9%; P < .0001) were all higher among those bridged with d-LVAD versus ma-LVAD. Rejection on the first postoperative biopsy was reported in a 60% in the d-LVAD group versus 33% in the ma-LVAD group (P = .0006). Postoperative intensive care unit (7 vs 6 days; P = .03) and overall postoperative length of stay (17 vs 12 days; P = .002) were greater in patients bridged with d-LVAD versus ma-LVAD, respectively. CONCLUSIONS:The use of ma-LVAD compared with d-LVAD as a bridging strategy was not associated with differences in survival. However, bridging with ma-LVAD compared with d-LVAD was associated with lower morbidity after orthotopic heart transplantation.

Purpose As rates of lung transplants in the US grow, waitlist mortality increases. While the literature reports similar survival outcomes of DBD and DCD transplants, research should investigate improvements to DCD lung recovery protocols to increase the total number recovered. Recently, Choi et al. presented donor variables indicative of ultimate lung recovery1. However, expansion of DCD lung transplants requires a comparison of these indicators to DBD donors for application of similar parameters to increase the rate of DCD lung recovery to ensure that viable DCD organs are not discarded due to overly stringent donor and organ requirements. Methods We performed a retrospective analysis of United Network for Organs Sharing (UNOS) Organ Procurement and Transplantation Network/UNOS STAR (Standard Analysis and Research) database. Donors who donated ≥1 organ from 10/1999-01/2019 were extracted and stratified according to DBD and DCD status. Associated characteristics of potential DCD and DBD lung donors were compared, and a multivariable logistic regression model with ≥1 transplanted lung was constructed to evaluate the independent effects of important predictors. Results Our data included 179,228 potential lung donors, 162,157 DBD (31,486 donated, 19.4% recovery) and 17,071 DCD (526 donated, 3.1% recovery). Odds of lung non-use between DBD and DCD donors were significantly associated with blood type, alcohol use, cause of death, smoking history, drug use, death circumstance, ethnicity, gender, hypertension, cancer, age, and lung pO2 on 100% P/F ratio (P <.001 for all variables). A multivariable regression analysis showed that the odds of a potential DCD donating lungs is 75% lower than (P<.001) that of a potential DBD when the cause of death (COD) is stroke, head trauma (44% lower P=.076), CNS tumor (22% lower P=.174) or MVA (69% lower P=.183). A history of diabetes for over 10 years was strongly associated with non-use for DCD lungs (OR, 0.87, P=.71), whereas an under 10-year history was associated with increased use (OR 2.33, P=.008, OR 1.07 P=.819).Lungs from donors ages 40-49 are more likely to be procured than those <30 or >50 in both DBD and DCD. However, likelihood of procurement is 1.84 [95% 1.42, 2.38, p<0.001] times higher in 40-49-year-old vs. <30-year-old donors when comparing DBD vs. DCD, and 2.43 [95% 1.83, 3.22, p<0.001] times higher than patients >50 in DBD vs DCD donors. In addition, for each era, the odds for procuring DCD vs. DBD lungs consistently improved [95% 1.46-2.57, p<0.001].Rejected DCD lungs were associated with donors with higher cardiopulmonary function. Left ventricular ejection fractions in discarded DCD lung donors were higher than those of discarded DBD lung donors (DCD 56.9% ± 13.6 vs. DBD 51.3% ±17.3 P = <.001). Similar non-use patterns were identified for lung PO2 on 100% O2 (DCD 189.4 ± 121.3 vs. DBD 150.0 ± 106.2 P = <.001), and when the P/F ratio was above 350.00 (DCD 13.5% vs. DBD 7.7% P = <.001). Conclusion Despite literature reporting comparable survival of DCD and DBD organs, this study highlights discrepancies in lung procurement practices that evaluate donor characteristics differently in DBD and DCD donors. Further study should investigate whether similar discrepancies exist in the procurement process of other organs.

Objective: Randomized data support transplantation of hearts from donors after circulatory death. This may lead to a sizeable increase in the donor pool. Regional variations in donors after circulatory death heart use were examined to help elucidate barriers to donor pool expansion. Methods: The United Network for Organ Sharing deceased donor dataset was queried for adult (age ≥ 18 years) donors after circulatory death donors of at least 1 organ between January 2020 and December 2023. Donors were stratified by the extent their respective cardiac allografts progressed through the donation process. United Network for Organ Sharing region-level use rates and annual trends were assessed. Results: Of 17,239 adult donors after circulatory death donors who donated at least 1 organ for transplant during the study period, 1196 (9.4%) were heart donors. Regional donors after circulatory death heart donor pursuit rates ranged from 97% to 100%, consent attainment rates from 94% to 99%, and heart recovery rates from 5% to 10%. The transplantation rate of recovered organs ranged from 90% to 97%. Multivariable logistic regression demonstrated United Network for Organ Sharing region to be independently associated with donors after circulatory death heart use after controlling for baseline differences in donor risk. Conclusions: Transplantation of donors after circulatory death heart allografts has increased in the United States since 2020, but the overall number of hearts procured and transplanted from donors after circulatory death donors remains low. The operational barriers to transplantation of donors after circulatory death hearts require further investigation. Further, significant regional variation exists regarding rates of progression of donors after circulatory death hearts through the donation process. Sharing of successful practices among Organ Procurement Organizations and transplant centers will facilitate maximal use of this new donor pool.

Background Heart transplantation following donation after circulatory death (DCD HT) has short-term survival outcomes comparable to donation after brain death and has led to a significant increase in transplantation volume. The U.S. experience with the normothermic regional perfusion (NRP) DCD HT procurement method has not been evaluated. Objectives The aim of this study was to examine short-term outcomes associated with NRP vs direct procurement and perfusion (DPP) methods used during DCD HT in the United States. Methods The UNOS (United Network for Organ Sharing) registry was queried for all adult (age ≥18 years) heart recipients and corresponding donors of controlled DCD HT from January 2019-December 2023. Transplantations were stratified by NRP or DPP reperfusion methods. The primary outcome was overall survival. Results A total of 918 heart donors and recipients met inclusion criteria, including 622 (68%) DPP and 296 (32%) NRP transplantations. Unadjusted Kaplan-Meier survival analysis demonstrated improved short-term survival associated with NRP (log-rank P = 0.005). After adjustment, DCD HT with NRP was independently associated with improved survival (HR: 0.39 [95% CI: 0.22-0.70]; P = 0.002). A propensity-matched analysis similarly demonstrated a cumulative survival benefit to NRP (log-rank P = 0.006). Conclusions In this largest national series of DCD HT procurement perfusion strategies, NRP is associated with improved short-term survival as compared with DPP. This study evaluates the U.S. early experience with DCD HT, and longer-term follow-up data are needed to further assess the impact of DPP and NRP methods on post-heart transplantation outcomes.

Central MessagePatient selection and timing of interventions are key considerations in patients being considered for bridge to heart transplantation with VA ECMO.See Article page 711. Patient selection and timing of interventions are key considerations in patients being considered for bridge to heart transplantation with VA ECMO. See Article page 711. Modern outcomes of patients bridged to heart transplant (orthotopic heart transplantation [OHT]) with venoarterial extracorporeal membrane oxygenation (ECMO) continue to be poor.1Moonsamy P. Axtell A.L. Ibrahim N.E. Funamoto M. Tolis G. Lewis G.D. et al.Survival after heart transplantation in patients bridged with mechanical circulatory support.J Am Coll Cardiol. 2020; 75: 2892-2905Crossref PubMed Scopus (30) Google Scholar The 2018 update to the heart allocation system places ECMO and temporary ventricular assist device (VAD) support in Status 1 priority. In this modern context, it is increasingly valuable to understand the outcomes of OHT in various subsets of patients bridged with ECMO to guide patient selection in this high-risk population. In the current issue of the Journal, Ivey-Miranda and colleagues2Ivey-Miranda J.B. Maulion C. Farrero-Torres M. Griffin M. Posada-Martinez E.L. Testani J.M. et al.Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenation.J Thorac Cardiovasc Surg. 2023; 165: 711-720Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar present a novel analysis of the United Network for Organ Sharing registry seeking to further elucidate this important issue. Among patients who underwent OHT, subsets of patients who underwent transplantation on ECMO versus being decannulated before transplant were compared. The decannulated before transplant group, 90% of whom were transitioned to some form of more durable circulatory support, demonstrate survival comparable to that of patients who never required ECMO support. This trend was supported by a propensity score–matched analysis of patients transitioned from ECMO to VAD versus those on ECMO at the time of transplant, with similar outcomes between groups. Further subanalysis showed a sequential increase in hazard after OHT in patients on ECMO with added risk factors, such as mechanical ventilation and renal impairment. The authors should be commended for performing a sound analysis of a powerful database. The conclusions from this analysis have important implications for the transplant surgeon: Patients bridged to transplant with ECMO are a heterogeneous cohort. As risk factors, such as renal impairment and prolonged waitlist time, accumulate, potential survival after OHT decreases drastically. However, patients undergoing transplantation before developing risk factors and those who can transition to durable VAD or other form of mechanical support may undergo transplantation with similar risk as patients who never required ECMO. This conclusion also raises an important discussion about the use of ECMO as a bridge to durable left ventricular assist device (LVAD) as a bridge to eventual OHT (“bridge to bridge”).3Fitzgerald D. Ging A. Burton N. Desai S. Elliott T. Edwards L. The use of percutaneous ECMO support as a ‘bridge to bridge’ in heart failure patients: a case report.Perfusion. 2010; 25: 321-325Crossref PubMed Scopus (11) Google Scholar Preoperative ECMO is a known risk factor for impaired survival after LVAD implantation.4Loyaga-Rendon R.Y. Boeve T. Tallaj J. Lee S. Leacche M. Lotun K. et al.Extracorporeal membrane oxygenation as a bridge to durable mechanical circulatory support.Circ Heart Fail. 2020; 13: e006387PubMed Google Scholar However, potential improvement versus continued downtrend in end-organ function while on ECMO has similar implications in this analysis, revealing that outcomes with ECMO as a bridge to LVAD versus OHT are subject to the same patient factors.5Durinka J.B. Bogar L.J. Hirose H. Brehm C. Koerner M.M. Pae W.E. et al.End-organ recovery is key to success for extracorporeal membrane oxygenation as a bridge to implantable left ventricular assist device.ASAIO J. 2014; 60: 189-192Crossref PubMed Scopus (25) Google Scholar A recent landmark analysis by DeFilippis and colleagues6DeFilippis E.M. Clerkin K. Truby L.K. Francke M. Fried J. Masoumi A. et al.ECMO as a bridge to left ventricular assist device or heart transplantation.JACC Heart Fail. 2021; 9: 281-289Crossref PubMed Scopus (28) Google Scholar found similar 1-year survival after OHT versus durable LVAD outcomes in patients bridged with ECMO. All of these analyses support the conclusion that patients requiring ECMO for cardiogenic shock are high risk for any advanced therapy, and outcomes are best with any approach before the sequelae of prolonged ECMO support set in. Shorter wait-list times for patients requiring ECMO driven by the new allocation system, ex vivo perfusion, and donation after cardiac death may shift the trend toward transplantation rather than durable LVAD in the coming years, and further analysis of “bridge-to-bridge” approaches is necessary. Risk stratification of patients listed for heart transplantation while supported with extracorporeal membrane oxygenationThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2PreviewExtracorporeal membrane oxygenation (ECMO) is used to support patients in severe cardiogenic shock. In the absence of recovery, these patients may need to be listed for heart transplant (HT), which offers the best long-term prognosis. However, posttransplantation mortality is significantly elevated in patients who receive ECMO. The objective of the present study was to describe and risk-stratify different profiles of patients listed for HT supported by ECMO. Full-Text PDF

Central MessageAlthough reoperative total arch replacements carry increased risk compared with first-time procedures, they can be performed safely and routinely at experienced centers.See Article page XXX. Although reoperative total arch replacements carry increased risk compared with first-time procedures, they can be performed safely and routinely at experienced centers. See Article page XXX. Since first described by De Bakey and Cooley in 1957,1De Bakey M.E. Crawford E.S. Cooley D.A. Morris Jr., G.C. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft.Surg Gynecol Obstet. 1957; 105: 657-664PubMed Google Scholar the global experience with total arch replacement (TAR) has grown dramatically. Advancements in neuroprotective and circulation-management strategies, including the widespread adoption of hypothermic circulatory arrest with adjunctive cerebral perfusion methods, have facilitated the repair of complex aortic arch pathology. In recent years, there has been an increasing need for TAR procedures in patients with previous cardiac operations.2Gaudino M. Girardi L.N. Rahouma M. Leonard J.R. Di Franco A. Lau C. et al.Editor’s choice—aortic re-operation after replacement of the proximal aorta: a systematic review and meta-analysis.Eur J Vasc Endovasc Surg. 2018; 56: 515-523https://doi.org/10.1016/j.ejvs.2018.06.038Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar These reoperative procedures are associated with significantly greater risk due the hazards of sternal re-entry as well as more advanced disease and a greater comorbidity burden. Improvements in surgical techniques and patient selection has enabled complex redo procedures to be performed with acceptable rates of morbidity and mortality. In this issue of the Journal, Ram and colleagues3Ram E. Lau C. Dimagli A. Chu N.Q. Soletti Jr., G. Gaudino M. et al.Reoperative total arch replacement after previous cardiovascular surgery: outcomes in 426 consecutive patients.J Thorac Cardiovasc Surg. August 30, 2023; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (1) Google Scholar examined the relative risks associated with reoperative TAR operations compared with primary procedures through a retrospective review of 426 consecutive patients from their own high-volume institutional aortic clinical dataset. Although the reoperative cohort was younger, they had a significantly greater burden of comorbidities, including a 10-fold greater likelihood of having a diagnosed connective tissue disorder. Reoperative procedures were more complex and more frequently required elephant trunk grafting or supra-aortic vessel debranching. Reoperative mortality and major morbidity outcomes were similarly greater in the redo group, as was long-term mortality and the need for subsequent reoperation. Although these procedures are clearly greater risk, the short- and longer-term outcomes remained excellent. It should be noted, however, that these findings are not necessarily generalizable to all centers and are likely the result of the tremendous experience of clinicians at this high-volume institution. The high proportion of reoperative patients with previous type A dissection repairs in this case series has important clinical implications. These results highlight the challenges of managing patients with chronic dissections and the frequent need for reintervention on the downstream aorta. Although not directly assessed in this single-center study, the high proportion of reoperative patients with previous proximal aortic pathology suggests that these patients, especially those with connective tissue disorders, may be best served in high-volume aortic centers of excellence using a multidisciplinary team-based model. It is further conceivable that a more aggressive approach at the time of the index procedure may reduce the need for future reintervention, potentially improving long-term outcomes, although this remains a topic of debate among global experts. Although the increased risks associated with cardiac surgical reoperation are by no means a novel finding, this case series demonstrates that reoperative TAR procedures can be performed safely with very acceptable outcomes when performed in the hands of experts. Previous studies have demonstrated that reoperative cardiac surgical patients do best when a protocol-driven approach is used encompassing preoperative imaging, resternotomy, and cannulation strategies.4Lapar D.J. Ailawadi G. Harris D.A. Hajzus V.A. Lau C.L. Kern J.A. et al.A protocol-driven approach to cardiac reoperation reduces mortality and cardiac injury at the time of resternotomy.Ann Thorac Surg. 2013; 96: 865-870https://doi.org/10.1016/j.athoracsur.2013.03.061Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The authors should be congratulated for their excellent outcomes and long-term commitment to this challenging patient population. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Reoperative total arch replacement after previous cardiovascular surgery: Outcomes in 426 consecutive patientsThe Journal of Thoracic and Cardiovascular SurgeryPreviewTotal aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR. Full-Text PDF

Background: The outcomes associated with receipt of adjuvant radiation in patients after surgery for MPM are poorly understood. Objective: The objective of this study was to use 2 registries to compare the outcomes of patients receiving adjuvant radiation or no radiation after definitive surgery for pathologic stage I-III MPM. Methods: Patients with resected pathologic stage I-III MPM were identified from the Duke University registry (1996-2016) and National Cancer Database (NCDB) (2004-2015). The primary outcome was overall survival. Propensity score-matched and landmark subgroup analyses were performed. Results: A total of 212 institutional and 1615 NCDB patients met criteria. In both cohorts, patients who underwent radiation were more likely to have margin-negative resection and more advanced pathologic stage. At a landmark time of 4.4 and 4.7 months from surgery, Duke [hazard ratio (HR) 1.14; 95% confidence interval (CI) 0.62-2.11] and NCDB patients (HR 0.97; 95% CI 0.81-1.17) who received adjuvant radiation did not experience improved survival compared to those who did not receive radiation in multivariable analysis. Duke patients who received radiation had similar incidence of recurrence and time to both overall recurrence and ipsilateral recurrence (HR 0.87; 95% CI 0.43-1.77) compared to those who did not. Duke patients experienced 100 grade 1/2, 21 grade 3/4, and one grade 5 toxicity events during radiation. Conclusions: In this dual registry analysis of patients with resected stage I-III MPM, the receipt of adjuvant hemithoracic radiation was not associated with improved survival compared to no radiation.

BACKGROUND Public interest in stratifying hospital performance has led to the proliferation of commercial, consumer -oriented hospital rankings. In cardiac surgery, little is known about how these rankings correlate with clinical registry quality ratings.METHODS The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was queried for isolated coronary artery bypass grafting or coronary artery bypass grafting/valve patients at hospitals among the top 100 U.S. News & World Report (USNWR) Cardiology & Heart Surgery rankings from 2016 to 2020. Hospitals were grouped into deciles by risk-adjusted observed/expected (O/E) ratios for morbidity and mortality using the STS 2018 risk models. Agreement between STS Adult Cardiac Surgery Database and USNWR ranked deciles was calculated by Bowker symmetry test. The association between each center's annual change in STS O/E ratio and change in USNWR ranking was modeled in repeated measures regression analysis.RESULTS Inclusion criteria were met by 524393 patients from 149 hospitals that ranked in USNWR top 100 at least once during the study period. There was no agreement between USNWR ranking and STS major morbidity and mortality O/E ratio (P > .50 for all years). Analysis of patients undergoing surgery at the 65 hospitals that were consistently ranked in the top 100 during the study period demonstrated no association between annual change in hospital ranking and change in O/E ratio (P all > .3).CONCLUSIONS There was no agreement between annual USNWR hospital ranking and corresponding risk-adjusted STS morbidity or mortality. Furthermore, annual changes in USNWR rankings could not be accounted for using clin-ical outcomes. These findings suggest that factors unrelated to key surgical outcomes may be driving consumer -directed rankings.

Background: Although SABR is increasingly emerging as an alternative to surgery for node-negative non-small cell lung cancer, there is poor understanding of patients who may most benefit SABR compared to surgery. Objective: This study examined the relationship between tumor size and the comparative outcomes of SABR and sublobar resection in patients with node-negative non-small cell lung cancer. Results: A total of 59,949 patients met study criteria: 19,888 (33%) underwent SABR, 33,052 (55%) wedge resection, and 7009 (12%) segmental resection. In multivariable regression, a significant 3-way interaction was found between histology, tumor size, and type of treatment. After stratification by histology, a significant interaction between tumor size and treatment was preserved for patients with adenocarcinoma and squamous cell carcinoma. Sublobar resection was associated with greater survival compared to SABR for tumor sizes greater than 6 and 8 mm for patients with adenocarcinoma and squamous cell carcinoma, respectively. SABR was associated with similar survival compared to sublobar resection for patients with papillary and large cell histology. Conclusions: In this National Cancer Database analysis, sublobar resection was associated with greater survival compared to SABR for lesions >6or 8 mm in patients with adenocarcinoma or squamous cell carcinoma; however, SABR was associated with similar survival compared to sublobar resection in patients with aggressive tumors including papillary and large cell histology. Histologic diagnosis in patients with even small tumors may enable better treatment selection in those who cannot tolerate lobectomy.

BACKGROUND:Heart donation after donor brain death from cardiac arrest despite successful resuscitation may be associated with worse recipient outcomes due to potential graft ischemia or underlying rhythmic/structural defects. However, selected grafts from such donors often have normal cardiac function and anatomy. We investigated whether a cardiovascular mechanism of donor brain death (CV-DBD) was associated with worse recipient outcomes.METHODS:We queried the United Network for Organ Sharing (UNOS) database for first-time, single-organ, adult (age 18+) heart transplant recipients and their associated donors between January 2005 and March 2021. Recipients were stratified by donor status (CV-DBD vs. non-CV-DBD). We performed multivariable Cox proportional hazards modeling to ascertain whether receiving a CV-DBD graft was independently associated with mortality.RESULTS:Of 35,833 included recipients, 2,702 (7.5%) received CV-DBD grafts. The associated donors were significantly more likely to be female, older, and have a history of diabetes, hypertension, and substance use (all p < .001). On unadjusted Kaplan-Meier analysis, CV-DBD recipients had a significantly reduced median survival than non-CV-DBD recipients (12.0 vs. 13.1 years, log-rank p = .04). However, after adjusting for donor/recipient age, recipient comorbidities, annualized center volume, and transplantation era, CV-DBD organ status was not associated with recipient mortality (hazard ratio: 1.05, 95% confidence interval: 0.96-1.13, p = .28).CONCLUSION:In this analysis of over 35,000 heart transplants, CV-DBD status was not associated with adjusted recipient survival. Donor brain death due to cardiac arrest should not be an absolute contraindication to heart donation, although graft function should be carefully assessed before transplantation.