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Ex vivo lung perfusion (EVLP) has demonstrated encouraging short- and medium-term outcomes with limited data available on its long-term outcomes. This study assesses (1) EVLP long-term outcomes and (2) EVLP era-based sub-analysis in addition to secondary outcomes of recipients with EVLP-treated donor lungs compared with recipients of conventionally preserved donor lungs in unmatched and propensity score-matched cohorts. Double lung transplants performed between 1st January 2012 and 31st December 2021 were included. A total of 57 recipients received EVLP-treated lungs compared to 202 unmatched and 57 matched recipients who were subjected to non-EVLP-treated lungs. The EVLP group had a significantly lower mean PaO2/FiO2 ratio and significantly higher mean BMI than the non-EVLP group in the unmatched and matched cohorts. The proportion of smoking history in the unmatched cohort was significantly higher in the EVLP group, while a similar smoking history was demonstrated in the matched cohorts. No difference was demonstrated in overall freedom from death and retransplantation between the groups in the unmatched and matched cohorts (unmatched: hazard ratio (HR) 1.28, 95% confidence interval (CI) 0.79-2.07, P = 0.32; matched: HR 1.06, 95% CI 0.59-1.89). P = 0.89). In the unmatched cohort, overall freedom from chronic allograft dysfunction (CLAD) was significantly different between the groups (HR 1.64, 95% CI 1.07-2.52, P = 0.02); however, the cumulative CLAD incidence was similar (HR 0.72, 95% CI 0.48-1.1, P = 0.13). In the matched cohort, the overall freedom from CLAD (HR 1.69, 95% CI 0.97-2.95, P = 0.06) and cumulative CLAD incidence (HR 0.91, 95% CI 0.37-2.215, P = 0.83) were similar between the groups. The EVLP era sub-analysis of the unmatched cohort in 2012-2014 had a significantly higher cumulative CLAD incidence in the EVLP group; however, this was not demonstrated in the matched cohort. All secondary outcomes were similar between the groups in the unmatched and matched cohorts. In conclusion, transplantation of marginal donor lungs after EVLP evaluation is non-detrimental compared to conventionally preserved donor lungs in terms of mortality, retransplantation, cumulative CLAD incidence, and secondary outcomes. Although the unmatched EVLP era of 2012-2014 had a significantly higher cumulative CLAD incidence, no such finding was demonstrated in the matched cohort of the same era.

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The number of lung transplantations is limited due to the shortage of donor lungs fulfilling the standard criteria. The ex vivo lung perfusion (EVLP) technique provides the ability of re-evaluating and potentially improving and treating marginal donor lungs. Accordingly, the technique has emerged as an essential tool to increase the much-needed donor lung pool. One of the major EVLP protocols, the Lund protocol, characterized by high pulmonary artery flow (100% of cardiac output [CO]), an open atrium, and a cellular perfusate, has demonstrated encouraging short-EVLP duration results. However, the potential of the longer EVLP duration of the protocol is yet to be investigated, a duration which is considered necessary to rescue more marginal donor lungs in future. This study aimed to achieve stable 8-h EVLP using an open-atrium cellular model with three different pulmonary artery flows in addition to determining the most optimal flow in terms of best lung performance, including lung electrolytes and least lung edema formation, perfusate and tissue inflammation, and histopathological changes, using the porcine model. EVLP was performed using a flow of either 40% (n = 6), 80% (n = 6), or 100% (n = 6) of CO. No flow rate demonstrated stable 8-h EVLP. Stable 2-h EVLP was observed in all three groups. Insignificant deterioration was observed in dynamic compliance, peak airway pressure, and oxygenation between the groups. Pulmonary vascular resistance increased significantly in the 40% group (p < .05). Electrolytes demonstrated an insignificant worsening trend with longer EVLP. Interleukin-8 (IL-8) in perfusate and tissue, wet-to-dry weight ratio, and histopathological changes after EVLP were insignificantly time dependent between the groups. This study demonstrated that stable 8-h EVLP was not feasible in an open-atrium cellular model regardless of the flow of 40%, 80%, or 100% of CO. No flow was superior in terms of lung performance, lung electrolytes changes, least lung edema formation, minimal IL-8 expression in perfusate and tissue, and histopathological changes.

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Background: Inverted left atrial appendage (ILAA) is a rare condition following cardiac surgery. Failure to recognize the condition or making misdiagnosis of a tumour, a thrombus or vegetation can lead to unnecessary and potentially adverse events. We present a case of ILAA after surgical repair of an atrial septal defect (ASD) in a young female. Case summary: A 3-year-old caucasian female was admitted for surgical repair of an ASD. The intraoperative course was uneventful until the opening of the right atrium (RA) after the commencement of cardiopulmonary bypass (CPB) and vacuum application, where the inferior vena cava (IVC) cannula was seen displaced in the RA. Cannula was repositioned, and ASD was repaired. On post-CPB transesohageal echocardiography (TEE), a newly developed mass was revealed in the left atrium (LA). The heart was re-arrested, and LA was re-assessed with unexpected finding of ILAA. ILAA was everted. RA was closed and CPB weaned off. Repeated post-CPB TEE showed no mass in the LA. No recurrence of mass was demonstrated on follow-up transthoracic echocardiography (TTE). Discussion: The incidence of ILAA is rare. Therefore, it is usually forgotten and not anticipated as a complication during heart surgery using CPB. In our case, dislodgement of the IVC cannula into the RA in combination with vacuum application in the setting of an ASD may have resulted in ILAA. This has not been reported in previous cases. ILAA should be suspected on intraoperative TEE if the mass is newly developed. Visual inspection of the left atrium appendage (LAA) in situ is recommended before chest closure.

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Intrathoracic splenosis is a rare diagnosis that is usually made after an invasive procedure. Most cases report concomitant rupture of the spleen and left hemidiaphragm with autotransplantation of splenic tissue into the left hemithorax. We report a case of intrathoracic splenosis with no evidence of diaphragmatic rupture. The mechanism may be explained by hematogenous spread. The patient underwent video-assisted thoracoscopic surgery for diagnosis, which could have been avoided if splenosis was suspected.

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BACKGROUND: An aberrant coronary artery is a rare clinical occurrence with an incidence of 0.05-1.2%. Often it is an incidental finding detected on coronary angiography or at autopsy. However, symptomatic patients can experience angina, arrhythmia, sudden death or non-specific symptoms such as dyspnoea and syncope. At present, there are no guidelines or dedicated studies assessing the treatment of an aberrant coronary artery leaving management options for these patients controversial. METHODS: Selected international cardiothoracic surgeons were surveyed electronically in November 2016 to determine whether consensus exists on different management aspects for patients with an aberrant coronary artery arising from the contralateral sinus with an interarterial course. RESULTS: For asymptomatic patients with either an aberrant left main coronary artery (ALMCA) arising from the contralateral sinus or an aberrant right main coronary artery (ARMCA) arising from the contralateral sinus, there was no consensus on surgical correction of the anomaly. If myocardial ischaemia was demonstrated on either coronary angiography with fractional flow reserve measurements and/or stress myocardial perfusion scan, surgical correction was the consensus between the surveyed surgeons. If surgery was deemed appropriate, coronary artery bypass surgery utilising the internal mammary artery was marginally preferred by the respondents in patients with an ALMCA whilst unroofing of the coronary ostium was preferred in patients with an ARMCA. Although no consensus was reached, a large proportion of respondents would not treat a patient over the age of 30 years differently compared to those under 30 years old. CONCLUSIONS: For symptomatic patients or if myocardial ischaemia is demonstrated on either coronary angiography with fractional flow reserve measurements and/or stress myocardial perfusion scan, surgical correction is indicated.

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BACKGROUND: A substantial body of evidence demonstrates that myocardial revascularisation using bilateral internal mammary arteries (BIMA) improves long-term survival compared with single/left internal mammary artery (LIMA) grafting. To date, limited analyses have been made regarding other short-term and long-term outcomes in BIMA strategy. OBJECTIVES: The primary aim of the present review is to update the difference in long-term survival between BIMA and LIMA grafting and to thoroughly investigate other secondary short-term and long-term clinical outcomes between these two grafting procedures. METHODS: Electronic searches were performed using three databases from their inception to November 2015. Relevant studies comparing long-term survival between BIMA and LIMA grafting were identified. Data were extracted by two independent reviewers and analysed according to predefined clinical outcomes. RESULTS: Twenty-nine observational studies were identified, with a total of 89 399 patients. Overall, BIMA cohort had significantly improved long-term survival compared with LIMA cohort (HR 0.78; p<0.00001). BIMA cohort also had significantly reduced hospital mortality rates (1.2% vs 2.1%, p=0.04), cerebrovascular accidents (1.3% vs 2.9%, p=0.0003) and need for revascularisation (4.8% vs 10%, p=0.005), although the incidence of deep sternal wound infection (DSWI) was increased (1.8% vs 1.4%, p=0.0008) in this grafting strategy. Long-term cardiac-free, myocardial infarction-free and angina-free survivals were also superior for the BIMA cohort. CONCLUSIONS: BIMA grafting is associated with enhanced overall long-term outcomes compared with LIMA grafting. While the BIMA cohort demonstrates an increased incidence of DSWI, the survival benefits and other morbidity advantages outweigh this short-term risk.

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