Citations

Abstract Rationale: Mechanical ventilation is frequently required in heart transplant patients to support recovery, but prolonged ventilation may increase the risk of complications and mortality. This study is done to find the impact of pre-transplant ventilation duration on early post-transplant outcomes, including mortality, ICU stay, infection, and respiratory complications. Methods: This retrospective analysis includes 52 heart transplant recipients from Mayo Clinic (2019-2023) who required pre-transplant mechanical ventilation. We analyzed ventilation duration's relationship with ICU and hospital stay, infection rates, respiratory complications, mortality, and baseline demographics. Chi-squared and Mann-Whitney U tests were used to evaluate associations between co-morbidities, ventilation duration, and outcomes. Results: The mean age at transplant was 48.9±14 years. Average ventilation duration was 12.8±14.2 days (Median: 7 days), ICU stay was 24.8± 20.9 days (Median: 15.0 days), and hospital stay was 58±40.8 days (Median: 48 days). Of the patients, 5 (9.6%) did not survive. There was no statistically significant association between mortality and ventilation duration, with a mean duration of 12.7±14.6 days (Median: 7 days) for survivors and 13.6±11.5 days (Median: 21 days) for non-survivors (p>0.05). Patients with infections 23 (44.2%) or respiratory complications 17 (32.7%) had longer ventilation durations (mean 16.3±17.8 days, Median: 9 and 10 days, respectively) compared to those without complications (mean 10±10.2 days, Median: 6 and 5 days, p>0.05). Infection was associated with extended ICU stays (mean 27.5±22.3 days, Median: 18 days with infection vs. 22.7±19.9 days, Median: 15 days without infection). None of the individual co-morbidities (diabetes, hypertension, stroke, chronic kidney disease) significantly impacted mortality or ventilation duration (p > 0.05). Conclusions: Prolonged ventilation is associated with increased rates of infections and respiratory complications but not with mortality in this cohort. Although co-morbidities did not significantly impact ventilation duration or mortality, infection remains a critical factor related to extended ICU stay. Future research should explore preventative strategies for infections in ventilated heart transplant recipients to improve outcomes.

Abstract Rationale: Early management after heart transplantation is essential for survival and quality of life, but we lack data on how initial clinical measures might predict patient outcomes. This study investigates whether early postoperative hemodynamic and clinical parameters can predict 1-year mortality and complications. Methods: We conducted a retrospective study of 550 heart transplant patients treated at the Mayo Clinic from 2019 to 2023. Demographic, hemodynamic, and clinical data, including Central Venous Pressure (CVP), Pulmonary Arterial Pressure (PAP), cardiac index, Pulmonary Artery Pulsatility Index (PaPi), blood pressure, heart rate, and Vasoactive-Inotropic Score (VIS), were collected. Key outcomes included 1-year mortality, Intensive Care Unit (ICU) and hospital stay durations, and complications such as respiratory issues and Acute Kidney Injury (AKI). Patients were divided into quartiles based on VIS scores to compare clinical outcomes. Logistic regression assessed how each parameter predicted 1-year mortality. Results: The patients’ mean age was 53.3±13.1 years, with 391 (71.1%) male and an average Body Mass Index (BMI) of 27.5±4.9. The median ICU stay was 9 days (Interquartile Range [IQR]: 4-22.8), and the median hospital stay was 35 days (IQR: 17-57.8). Within one year, 28 (5.1%) patients experienced mortality and ICU readmission occurred in 52 (9.5%) patients. Higher VIS quartiles were associated with worse outcomes. Logistic regression revealed three significant predictors of 1-year mortality: higher CVP (p=0.0305) and lower Systolic Blood Pressure (SBP) (p=0.0484) were linked to increased mortality risk, while each unit increase in VIS (p=0.0355) raised mortality odds by 6% (Odds Ratio [OR]: 1.06, 95% Confidence Interval [CI]: 1.004-1.113). Additionally, respiratory complications were seen in 177 (32.2%) patients, and AKI in 407 (74.0%) patients. AKI significantly predicted mortality (OR=2.50, p=0.044), while both ICU readmission (OR=2.98, p<0.001) and AKI (OR=3.49, p<0.001) predicted respiratory complications. Conclusions: Early postoperative hemodynamic and clinical parameters, especially higher VIS scores, are significant indicators of 1-year mortality in heart transplant patients. These findings highlight the importance of early assessment to identify high-risk patients and potentially guide post-transplant management strategies.

Abstract Introduction:AFOP is a pattern of lung injury with intra-alveolar fibrin balls and organizing pneumonia. In 2013, the ATS/ERS revised their classification of idiopathic-interstitial-pneumonia to include acute-fibrinous-organizing-pneumonia(AFOP) in their rare histologic patterns. Methods: MEDLINE(PubMed), EMBASE, and Cochrane were searched for AFOP-related case reports/case series. Mesh terms used included (“acute fibrinous and organizing pneumonia” OR AFOP OR “acute fibrinous organizing pneumonia” OR (“acute fibrinous” AND “organizing pneumonia”) OR (“acute fibrinous” AND “organizing pneumonia”). A total of 177 patients were synthesized in these 169 articles, 9 of which were case series and the rest individual case reports. A quality review and data extraction was done on Covidence using a JBI checklist.Results:Mean age of 52.2 +/- 17.4 years with 55% of them were males. The associations were; malignancy (16%), smoking (14%), organ transplant (13%), Hypertension (10%), and use of immunosuppressive agents (6%) were frequent risk factors. Cough (73%), shortness of breath (71%), and fever (61%) were found highly frequent symptoms. Predominant radiological findings were multifocal infiltrates/consolidation (50%) and ground glass appearance (39%). Leukocytosis and inflammatory markers were elevated in most cases. Transbronchial/EBUS (32%), open surgical (29%), imaging-guided (22%), and VATS (14%) were common modes of lung biopsy. Treatment is usually steroids (88%) and antibiotics (69%). Death occurred in 23% of the cases, clinical or radiological improvement was achieved in 69%, while only three recurrences were reported. Most cases are either idiopathic or associated with myelodysplastic syndrome as causative factors reported by authors. DiscussionAFOP presents non-specific symptoms and a community-acquired pneumonia-like clinical picture. Treatment included antibiotics, corticosteroids, and other immunosuppressants with variable outcomes. Discontinuation of suspected drug was the sole treatment strategy reported in some cases. Partial lobectomy/lesion resection was a successful treatment in some instances with localized disease.The survival in AFOP was significantly worse than obliterative bronchiolitis (median time to death 101 vs. 294 days; P = 0.02). A statistically non-significant trend towards higher mortality associated with higher body mass index (BMI) and a long interval between symptom onset and diagnosis of AFOP was reported by Kim et al. in a cohort from South Korea. Conclusion:AFOP being a rare histological pattern of acute lung injury, is a relatively new entity that requires a better clinical and radiologic understanding for the clinical challenge it poses. This systematic review will be able to provide answers to clinicians to think in that direction and manage acute lung injury accordingly.

Abstract Rationale: Pulmonary alveolar proteinosis (PAP) is a rare lung disorder characterized by the accumulation of surfactant in the alveoli, primarily seen in autoimmune PAP (aPAP), which accounts for over 90% of cases. The COVID-19 pandemic has highlighted the potential for viral infections to exacerbate or induce PAP, complicating diagnosis and treatment. Objective: This study aims to provide updated clinical and demographic characteristics of patients with pulmonary alveolar proteinosis (PAP) and to analyze trends in the use of whole lung lavage before the COVID-19 pandemic, as well as assess the impact of the pandemic on WLL utilization. Methods: Using data from the National Inpatient Sample from 2017 to 2021, the authors identified PAP, other diagnoses, and procedures. using the respective ICD-10 codes. Statistical analysis was performed on the trends of whole lung lavage and other outcomes across the five years. Results: A total of 3,030 hospitalized PAP patients were included in the study, with demographic and clinical characteristics reported for the cohort. Although the use of WLL increased from 11.55% pre-pandemic to 14.67% during the pandemic, this difference was not statistically significant. However, there was a significant rise in the incidence of acute respiratory failure during the pandemic (35.7% vs. 45.78%, p = 0.02). While transbronchial lung biopsies increased and open lung biopsies declined, these trends were not statistically significant. Conclusion: In recent years, despite a decline in the use of WLL for treating PAP and open lung biopsies for diagnosis, the rates have risen due to the impact of the COVID-19 pandemic.

Abstract Rationale: Mechanical circulatory support (MCS) devices, including Extracorporeal Membrane Oxygenation (ECMO) and Impella are essential in managing complex heart transplant cases. Identifying predictors for MCS utilization can improve patient selection and perioperative planning. This study aims to refine MCS allocation by analyzing pre-transplant predictors for each device, thereby optimizing clinical decision-making in critical care. Methods: This retrospective study included 594 heart transplant patients from 2019-2024 (mean age: 63 ± 1.41 years, 29% female, mean left ventricular ejection fraction (LVEF): 36.5 ± 33.23%, mean body mass index (BMI): 32.23 ± 4.497 kg/m²). Variables assessed included age, gender, BMI, smoking status, comorbidities (e.g., chronic kidney disease, hypertension, diabetes), heart failure etiology, and hemodynamic parameters (cardiac index, LVEF, PAPi). Multivariate logistic regression models estimated odds ratios (OR) and 95% confidence intervals (CI) for the likelihood of ECMO and Impella use based on pre-transplant variables. Results: 1. ECMO Use: ECMO was significantly associated with younger age (<40 years), elevated pulmonary artery pressure (PAPi <1.5; OR = 2.70, 95% CI: 1.13-6.48), and reduced cardiac index (<2.2 L/min/m²; OR = 3.12, 95% CI: 1.50-6.49). Male patients also had a higher likelihood of ECMO requirement (OR = 0.54, 95% CI: 0.29-1.00). These findings suggest ECMO may be required for younger, hemodynamically compromised patients. 2. Impella Use: Impella use was significantly associated with smoking history (OR = 3.72, 95% CI: 1.71-8.58), hypertension (OR = 2.08, 95% CI: 1.02-4.43), and low baseline LVEF (<25%; OR = 2.20, 95% CI: 1.18-4.07). Patients with chronic kidney disease or diabetes also had increased odds of requiring Impella, indicating its relevance for high-risk patients with vascular or metabolic burdens. Conclusions: This study identifies distinct pre-transplant predictors that influence MCS allocation in heart transplant patients. ECMO is associated with younger age and lower cardiac index, while Impella is more likely to be used in patients with vascular or metabolic comorbidities. These insights can enhance precision in MCS allocation, supporting optimal outcomes in critical care management.

Abstract Rationale: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a pulmonary condition characterised by neuroendocrine cell proliferation along respiratory bronchioles resulting in tumourlet formation which may progress to pulmonary carcinoid. DIPNECH is a rare and under-recognised condition that predominantly affects females, with an estimated worldwide incidence of 5-6 people per million population. Given it's rarity and the poor understanding around the pathogenesis and treatment of this condition, we undertook the largest international case series to date of DIPNECH patients. We aim to further characterise this patient cohort to better understand the clinical features, identify common pulmonary function test (PFT) patterns and radiographic findings and describe current treatment practices. Methods: We collated data from 17 centres across 8 different countries comprising a total of 258 patients. Data collected included patient demographics, smoking history, symptoms, co-morbidities, pathological diagnosis, imaging findings, PFT pattern and therapies. Results: In total 258 patients were identified. The median age was 65 (SD+/- 10.6). 241 (93%) were female. 39% (n= 94/243) were ex-smokers. 79% (n=186/234) of patients reported pulmonary symptoms with cough being the most common symptom reported in 81% (n=151/186) of patients. Many patients were polysymptomatic, with cough and dyspnoea being the most common combination of symptoms described. (50.54%; n=94/186). Complete spirometry pattern was documented for 180 patients (69.78%) with an obstructive pattern being the most commonly observed (n=76/180; 42%). 27.5% (n=41/139) had clinically significant FEV1 reversibility post bronchodilator administration. Pathology specimens were available in 219 cases. Most common pathological features were neuroendocrine hyperplasia which was observed in 75% (n=165/219) and tumourlets in 74% (n=162/219) of cases. Carcinoid, either typical or atypical, was observed in 64% (n=141/219) of samples. 252 patients had computed tomography (CT) imaging performed. Pulmonary nodules were the most common feature identified in 99.60% of cases (248/250). Mosaic attenuation (69.30%; n=50/173) and airway dilatation (28.90%; n=50/173) were also frequently reported. There was no significant correlation between symptoms (cough, dyspnoea, wheeze) and airway dilatation (p=0.496), mosaic attenuation (p=0.496) and PFT pattern (p=0.837). There was a significant association between presence of symptoms and mosaic attenuation on CT (p=0.003). Conclusions: DIPNECH, while a rare disorder, is understudied. This international case series is the largest performed to date and highlights the complexity in management of these patients.

Abstract Rationale: Patients with fibrotic interstitial lung disease (F-ILD) often report high symptom burden with significant impact on their health-related quality of life. Self-reported disease experience may be unique or difficult to quantify yet have implications for functional and survival outcomes. We hypothesize that self-reported mood or affect may be associated with changes in lung function and predict mortality. Methods: This is a post-hoc analysis of a prospective cross-sectional study assessing changes in patient-reported outcome measures (PROM), lung function, and mortality incidence in patients with f-ILD. Serial measures of lung function and PROMs (baseline, 3, 6, and 12 months) were obtained over a 3-year period. The Positive and Negative Affect Scale (PANAS) is a 20-item questionnaire reflecting acute or immediate mood at the time of assessment, with higher scores for each domain highlighting greater positive or negative affect. A ratio of the Positive over the Negative score was used to summarize overall mood, with higher ratios reflecting more positive affect. PANAS scores at the time of lung function measures were assessed for their association with percent predicted forced vital capacity (FVC%) and diffusion capacity for carbon monoxide (DLCO%). Baseline PANAS scores were used to predict of all-cause mortality over the three-year study period. Results: One-hundred and eighty seven patients were included (mean age 69, female 37%, non-IPF f-ILD 67%). PANAS Negative scores were higher (16.9 vs 14.5, P = 0.01)with lower PANAS Ratio scores (2.5 vs 2.2, P = 0.08) in patients with non-IPF f-ILD, suggesting more negative affect or mood. A mixed effects model for repeated measures with each subject as a random effect found changes in the PANAS Positive score (point estimate 0.16, (0.01-0.32), P = 0.038) and Ratio score (1.43 (0.15-2.72), P = 0.029) were associated with changes in FVC% but not DLCO%. Baseline PANAS Negative (hazard ratios 1.06 (1.02-1.10), P = 0.002) and Ratio scores (HR 0.76 (0.61-0.95), P = 0.014) after adjusting for age, sex, FVC%, and diagnosis type (IPF vs non-IPF), were associated with increased all-cause mortality. Conclusions: Measured changes in self-reported mood or affect appear to be associated with changes in lung function and predict all-cause mortality. Direct assessments of patient disease experience may not only reflect symptom burden or disease progression but serve as targets of comprehensive management strategies or correlates of treatment efficacy given their potential association with lung function and survival.

Abstract Rationale Immune checkpoint inhibitors (ICI) have become standard care for many cancers. Their mechanism of action mediates immune related adverse events including ICI pneumonitis. Diagnosis of this is difficult to differentiate from infectious and radiation pneumonitis as it is a diagnosis of exclusion often requiring bronchoscopy and imaging interpreted by expert radiologists. This study investigates the use of CALIPER, a computer-aided lung informatics program, in identifying differences between Computed Tomography (CT) patterns in ICI, radiation, and infectious pneumonitis that may aid in diagnosis noninvasively. Methods CT images of ten patients with ICI pneumonitis, ten patients with infectious pneumonitis, and nine patients with radiation pneumonitis, all diagnosed by clinical expertise and evaluation with bronchoalveolar lavage, were analyzed with CALIPER. CALIPER classified each CT voxel into either vessel-related structures (VRS), normal, mild low-attenuation area (LAA), moderate LAA, severe LAA, reticular (R), honeycomb (HC) or ground-glass (GG) features. Each lung was divided into upper, middle, and lower lobes. Exploratory analyses explored the relationship between CALIPER components and diagnosis, comparing ICI and radiation pneumonitis with infectious pneumonitis. Diagnosis was analyzed using multinomial logistic regression adjusted for presence of pleural effusion. Additionally, diagnosis was assessed as infectious versus a pooled group of radiation and ICI pneumonitis and analyzed using logistic regression adjusted for pleural effusion. Due to the exploratory nature of analysis, no correction was applied for multiplicity of testing. Results Twenty-nine patients were analyzed. ICI pneumonitis patients had less moderate low attenuation in the left upper (p = 0.016) and middle peripheral lung (p = 0.038), and radiation pneumonitis patients had less moderate low attenuation in the left upper peripheral lung (p = 0.031). When comparing the pooled group of ICI and radiation pneumonitis images with infectious pneumonitis, there was more moderate LAA in left upper (0.012) and middle (0.034) peripheral lung in the pooled group compared to infectious pneumonitis. There was no association with VRS, GG, HC, R, mild, or severe LAA patterns. Conclusions Although areas of moderate low attenuation were more prevalent for infectious pneumonitis, these results taken in the context of low sample size, exploratory analysis, and lack of clinical reasoning to support these findings make them likely insignificant. Based on this limited exploratory analysis, it is unlikely that we can solely use CALIPER as noninvasive evaluation to differentiate radiation and ICI pneumonitis from infectious pneumonitis. This highlights the need for a more robust program to aid in noninvasive diagnosis.

Abstract Rationale: Lymphoid Interstitial Pneumonia (LIP) is a rare interstitial lung disease characterized as a benign lymphoproliferative pulmonary condition. It is often associated with autoimmune conditions such as Sjögren's syndrome, immune dysregulatory syndromes, and common variable immunodeficiency. The incidence and prevalence of LIP remain unclear. While fluorodeoxyglucose (FDG) Positron Emission Tomography (PET/CT) findings have been documented for various diffuse parenchymal lung diseases, data specific to LIP is limited. This study aims to assess the utility of PET/CT in the evaluation of malignancy in patients with LIP, in addition to describing PET/CT findings in patients with known LIP who underwent PET/CT for any reason. Methods: This retrospective study involved a reviewof electronic medical records within the Mayo Clinic Enterprise to identify patients with an established diagnosis of LIP who had undergone PET/CT. Using ICD code J84.2, we identified patients with a diagnosis of LIP, and further selected for those who had undergone PET/CT between 2009 and 2023. We analyzed descriptive statistics, including the mean and prevalence of common PET/CT findings. Results: We identified 10 patients, all of whom had anestablished expert diagnosis of LIP and had undergone PET/CT for any reason. The mean age was 66 years, and all patients were female. Six of the ten patients (60%) underwent a lung biopsy, and six (60%) exhibited FDG uptake in the lungs, with maximum standard uptake value (SUVmax) uptake ranging from 2.0 to 8.2. Six of the imaging studies (60%) showed abnormal FDG uptake in one or more lymph nodes, with SUV maximum ranging from 2.4 to 7.8, and four (40%) demonstrated extrapulmonary FDG uptake. Four patients were diagnosed with a malignancy, the majority being MALT, with one being lung squamous cell carcinoma (SCC). Conclusion: Given the rarity of LIP, there is limiteddata on the utility and findings of PET/CT in these patients. Our study reveals that in patients with LIP, despite abnormal parenchyma in the background of inflammatory disease, malignancy was still likely in abnormally hypermetabolic regions. In this study, lymphoma was the most common malignancy isolated in patients with LIP. Nonetheless, malignancy other than lymphoma can occur, namely squamous cell carcinoma (SCC), and PET positivity can occur in LIP patients even in the absence of tissue proven malignancy. In patients with LIP, SUVmax does not appear to be a differentiating factor between those later diagnosed with lymphoma (SUVmax 2.0-8.2) and SCC (SUVmax=3.1).

Abstract Rationale: Tracheostomies are commonly placed to facilitate weaning from ventilators in ICU patients who fail extubation. Once these patients are successfully weaned from mechanical ventilation and transferred out of the ICU however, management of the tracheostomies are frequently left to the floor teams that are less experienced in managing them. This can delay downsizing/removing tracheostomies when appropriate or in exchanging them when they cannot be safely removed. This report details the number and type of patients with tracheostomies and describes their tracheostomy management after placement.in a small university hospital that did not have a dedicated tracheostomy team. Methods: We reviewed the charts of all patients with tracheostomies who were in the hospital on a single day (7/22/2024). Patients were categorized based on which service placed the initial trach, the reason for the tracheostomy placement, the time from the initial trach placement, and the most recent exchange date. Results: Twelve patients with tracheostomies were in the hospital on that day (4% of all hospitalized patients); six were still in the ICU and 6 were on the floor. The time from initial tracheostomy placement ranged from 10 days to 2.5 years. The primary indications for tracheostomy included respiratory failure (n=5), cerebrovascular accidents (CVA) (n=4), and trauma (n=3). Eight tracheostomies were placed by the Surgery/Trauma service, three by the ENT service, and one by an outside hospital. At the time of data collection 5 of the 12 patients had not yet received a first trach exchange with an average time from tracheostomy placement of >20 days. Three of the 12 patients had had their trach downsized at least once. At least 4 patients had not had a documented tracheostomy exchange for at least 2 months. Conclusion: Our findings emphasize the diverse clinical situations requiring tracheostomy and their impact on patient care in and out of the ICU. The study highlights the importance of continuous assessment throughout a patient's hospital stay. In at least four cases, tracheostomy exchange intervals exceeded the recommended monthly timeframe. Research indicates that tracheostomy teams improve patient safety and outcomes through standardized protocols, suggesting a need for further investigation into team dynamics and their role in recovery.