Background The development of a ventricular septal defect(VSD) after myocardial infarction(MI) is an uncommon but highly lethal complication. We examined the Society of Thoracic Surgeons(STS) database to characterize patients undergoing surgical repair of post-MI VSD and to identify risk factors for poor outcomes. Methods This was a retrospective review of the STS database to identify adult(≥18 years) patients who underwent post-MI VSD repair between 1999–2010. Patients with congenital heart disease were excluded. The primary outcome was operative mortality. The covariates in the current STS model for predicted coronary artery bypass(CABG) operative mortality were incorporated in a logistic regression model in this cohort. Results There were 2,876 patients included. Mean age was 68±11 years, and 1,624(56.5%) were men. 215(7.5%) patients had prior CABG surgery, 950(33%) had prior percutaneous intervention, and 1,869(65.0%) were supported preoperatively with an intra-aortic balloon pump. Surgical status was urgent in 1,007(35.0%) and emergent in 1,430(49.7%). Concomitant CABG was performed in 1,837(63.9%). Operative mortality was 54.1%(1,077/1,990) if repair was ≤7 days from MI, and 18.4%(158/856) if >7 days from MI. Multivariable analysis identified several factors associated with increased odds of operative mortality. Conclusions In the largest study to date to examine post-MI VSD repair, ventricular septal rupture remains a devastating complication. As alternative therapies emerge to treat this condition, these results will serve as a benchmark for future comparisons.

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Background The leading causes of constrictive pericarditis have changed over time leading to a commensurate change in the indications and complexity of surgical pericardiectomy. We evaluated our single-center experience to define the etiologies, risk factors, and outcomes of pericardiectomy in a modern cohort. Methods We retrospectively reviewed our institutional database for all patients who underwent total or partial pericardiectomy. Demographic, co-morbid, operative, and outcome data were evaluated. Survival was assessed by the Kaplan-Meier method. Multivariable Cox proportional hazards regression models examined risk factors for mortality. Results From 1995–2010, 98 adults underwent pericardiectomy for constrictive disease. The most common etiologies were idiopathic (n=44), postoperative (n=30), and post-radiation (n=17). Total pericardiectomy was performed in 94 cases, most commonly through a sternotomy (n=93). Thirty-three cases were redo sternotomies, 34 underwent a concomitant procedure, and 34 required cardiopulmonary bypass. Overall in-hospital, 1-year, 5-year, and 10-year survival rates were 92.9%, 82.5%, 64.3%, and 49.2%, respectively. Survival differed sharply by etiology with idiopathic, postoperative, and post-radiation 5-year survivals of 79.8%, 55.9%, and 11.0%, respectively (p<0.001). On multivariable analysis, only the need for cardiopulmonary bypass (HR: 21.2, p=0.02) was predictive of 30-day mortality while post-radiation etiology (HR: 3.19, p=0.02) and hypoalbuminemia (HR: 0.57, p=0.03) were associated with increased 10-year mortality. Conclusions Although survival varies significantly by etiology, pericardiectomy continues to be a safe operation for constrictive pericarditis. Post-radiation pericarditis and hypoalbuminemia are significant risk factors for decreased long-term survival.

Introduction: Although several studies have evaluated risk factors for mortality after lung transplantation (LTx), few studies have focused on the highest risk recipients. We undertook this study to evaluate the impact of high lung allocation scores (LAS), ventilator support, and extracorporeal membrane oxygenation (ECMO) support on outcomes after LTx. Methods: We retrospectively reviewed all LTx recipients in the United Network for Organ Sharing database. Primary stratification was by recipient acuity at the time of LTx. The three strata consisted of: (1) recipients in the highest LAS quartile (LAS≥48.4); (2) those requiring ventilator support; and (3) those requiring ECMO support. The primary outcome was 1-year mortality. Subgroup analysis focused on temporal trends. Results: From 05/2005-06/2011, 9,267 adult patients underwent LTx. Prior to LTx, 1,874 (20.2%) were in the highest LAS quartile, 526 (5.7%) required ventilator support, and 122 (1.3%) required ECMO support. On unadjusted analysis, ventilator and ECMO support were both associated with decreased 1-year survival compared to those in the highest LAS quartile (High LAS: 81.0% vs. Vent: 67.7% vs. ECMO: 57.6%, p<0.001 for each comparison). These differences persisted on adjusted analysis (Ventilator support, HR: 1.99, p<0.001; ECMO support, HR: 3.03, p<0.001). Increasing annual center volume was associated with decreased mortality. In patients bridged to LTx with ECMO support, 1-year survival improved over time (Coefficient: 8.03%/year, p=0.06). Conclusions: High acuity LTx recipients, particularly those bridged with ventilator or ECMO support, have increased short-term mortality after LTx. However, since the introduction of the LAS, high-risk patients have demonstrated improving outcomes, particularly at high volume centers.

Background Acute kidney injury requiring renal replacement therapy (RRT) is associated with increased mortality after cardiac surgery. Studies examining the impact of RRT after lung transplantation (LTx) are limited. We evaluated risk factors and outcomes associated with RRT after LTx. Methods We retrospectively reviewed all LTx recipients in the United Network for Organ Sharing database. Preoperative renal function was stratified by glomerular filtration rate (GFR) as determined by the Modification of Diet in Renal Disease formula (strata: ≥90, 60 to 90, and <60 mL · min−1 · 1.73m−2). Primary outcomes were 30-day, 1-year, and 5-year survival and need for post-LTx RRT. Risk adjusted multivariable Cox proportional hazards regression examined mortality. A multivariable logistic regression model evaluated risk factors for RRT. Results From 2001 to 2011, 12,108 patients underwent LTx. After LTx, 655 patients (5.51%) required RRT. Patients requiring post-LTx RRT had decreased survival at 30 days (96.7% versus 76.0%, p < 0.001), 1 year (85.5% versus 35.8%, p < 0.001), and 5 years (56.4% versus 20.0%, p < 0.001). These differences persisted on multivariable analysis at 30 days (hazard ratio [HR] 7.98 [6.16 to 10.33], p < 0.001), 1 year (HR 7.93 [6.84 to 9.19], p < 0.001), and 5 years (HR 5.39 [4.75 to 6.11], p < 0.001). Preoperative kidney function was an important predictor of post-LTx RRT for a GFR of 60 to 90 (odds ratio 1.42 [1.16 to 1.75], p = 0.001) and a GFR less than 60 (odds ratio 2.68 [2.07 to 3.46], p < 0.001]. High center volume was protective. Conclusions In the largest study to evaluate acute kidney injury after LTx, the incidence of RRT is 5.51%. The need for post-LTx RRT dramatically increases both short- and long-term mortality. Several variables, including preoperative renal function, are predictors of post-LTx RRT and could be used to identify transplant candidates at risk for acute kidney injury.