Although single exposure to anemia or RBC transfusion alone was associated with risk, it was generally lower than that of anemia and RBC exposure in combination.

Although red blood cell transfusion has associated morbidity risk, there must be a tradeoff between adverse effects of low hematocrit during cardiac surgery and those of transfusion. The strong association of nadir hematocrit with preoperative hematocrit suggests the need for investigation and optimization before elective cardiac surgery.

Objective: Survivors of ascending aortic dissection repair frequently require downstream aortic interventions. Because of a paucity of data, we assessed early and long-term outcomes, and risk factors, of these distal procedures.Methods: From January 1993 to January 2011, 305 patients underwent 429 distal aortic interventions after acute type A (95% DeBakey type I) dissection repair performed 3.8 years earlier (median); 11% of interventions used an endovascular approach. Maximum aortic size was 5.9 AE 1.3 cm. Median follow-up was 3.6 years.Results: Hospital mortality was 6.1%. Risk factors included graft infection, concomitant coronary artery bypass grafting, combined open arch and descending procedures, and lower distal anastomotic site. Within 10 years, the probability of patients undergoing a reintervention was 38%, with a cumulative incidence of 55 per 100 patients; however, 40 (9.3%) were stage-II elephant trunks. Patients with larger aortic diameters distal to the initial repair, and a stage-I elephant trunk, were more likely to undergo distal interventions. Survival was 65% at 10 years. Higher body mass index, a longer time between reinterventions, graft infection, combined open arch and descending procedures, and lower distal anastomosis sites were risk factors. The extent of aorta replaced was not associated with increased morbidity or mortality, unless it involved a combined open arch and descending aorta procedure.Conclusions: Distal interventions after ascending aortic dissection repair are feasible, but they are associated with early morbidity and subsequent reinterventions. Rigorous follow-up with early reintervention is important for improving short-and long-term outcomes. An extended hybrid endovascular repair for initial dissection warrants study.

Decreasing oxygen delivery during and after cardiopulmonary bypass (CPB) can adversely affect patient outcomes. Balancing morbidities associated with anemia, red blood cell (RBC) transfusion, pharmaceuticals to prevent fibrinolysis, and reoperations for bleeding poses a dilemma. One would optimally balance these factors to minimize patient risk. Uncertainty in defining an optimal transfusion threshold, a trigger for reoperation, and a strategy for use of pharmaceuticals is evidenced by the considerable variability in clinical practice worldwide. 1,2 Therefore, to gain insight to inform surgical practice, we have brought together current knowledge of the association of preoperative anemia, intraoperative anemia, blood transfusion, and measures to address blood loss with adverse outcomes after cardiac surgery.

A sternal-sparing approach to surgery of the proximal aorta is safe when performed by an experienced surgeon and conserves hospital resources.

Patients with end-stage lung disease who are candidates for lung transplantation may acutely decompensate before a donor organ becomes available. In this scenario, extracorporeal life support (ECLS) may be considered as a bridge to transplant or as a bridge to decision. In the current chapter, we review the indications, techniques, and outcomes for bridging to lung transplantation with ECLS.

IMPORTANCE With continuing improvements in medical devices and more than a decade since the 2006 United Network for Organ Sharing (UNOS) allocation policy, it is pertinent to assess survival among patients on the heart transplantation waiting list, especially given the recently approved 2018 UNOS allocation policy.OBJECTIVES To assess survival outcomes among patients on the heart transplant waiting list during the past 3 decades and to examine the association of ventricular assist devices (VADs) and the 2006 UNOS allocation policy with survival. DESIGN, SETTING, AND PARTICIPANTSA retrospective cross-sectional used the UNOS database to perform an analysis of 95 323 candidates wait-listed for heart transplantation between January 1, 1987, and December 29, 2017. Candidates for all types of combined transplants were excluded (n = 2087). Patients were followed up from the time of listing to death, transplantation, or removal from the list due to clinical improvement. Competing-risk, Kaplan-Meier, and multivariable Cox proportional hazards regression analyses were used. MAIN OUTCOMES AND MEASURESThe analysis involved an unadjusted and adjusted survival analysis in which the primary outcome was death on the waiting list. Because of changing waiting list preferences and policies during the study period, the intrinsic risk of death for wait-listed candidates was assessed by individually analyzing, comparing, and adjusting for several candidate risk factors. RESULTSIn total, 95 323 candidates (72 915 men [76.5%]; mean [SD] age, 51.9 [12.0] years) were studied. In the setting of changes in listing preferences, 1-year survival on the waiting list increased from 34.1% in 1987-1990 to 67.8% in 2011-2017 (difference in proportions, 0.34%; 95% CI, 0.32%-0.36%; P < .001). The 1-year waiting list survival for candidates with VADs increased from 10.2% in 1996-2000 to 70.0% in 2011-2017 (difference in proportions, 0.60%; 95% CI, 0.58%-0.62%; P < .001). Similarly, in the setting of changing mechanical circulatory support indications, the 1-year waiting list survival for patients without VADs increased from 53.9% in 1996-2000 to 66.5% in 2011-2017 (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In the decade prior to the 2006 UNOS allocation policy, the 1-year waiting list survival was 51.1%, while in the decade after it was 63.9% (difference in proportions, 0.13%; 95% CI, 0.12%-0.14%; P < .001). In adjusted analysis, each time period after 1987-1990 had a marked decrease in waiting list mortality.CONCLUSIONS AND RELEVANCE This study found temporally associated increases in heart transplant waiting list survival for all patient groups (with or without VADs, UNOS status 1 and status 2 candidates, and candidates with poor functional status).

A substantial reduction in reoperation for bleeding cases followed implementation of a formalized hemostasis checklist. Our findings underscore the important influence of memory aids that focus attention on surgical techniques to improve patient outcomes in a complex, operative work environment.