Architectural remodeling of lung allografts in acute and chronic rejection

The mesenchymal and extracellular matrix alterations that occur in acute and chronic rejection of the lung allograft were studied immunohistochemically, utilizing a wide panel of antibodies. In early rejection, perivascular and peribronchiolar mononuclear infiltrates were associated with basement membrane disruption of the vessels and airways and an ingrowth of muscle-specific actin-, vimentin-positive, desmin-negative spindle cells accompanied by type IV collagenase-positive histiocytes. Subsequent fibrous scarring was manifested by perforation and reduplication of the basement membrane of airways and vessels and dense collagen deposition, primarily type III. As has been suggested in idiopathic pulmonary fibrosis, the fragmentation of basement membranes and the deposition of collagen IV and laminin by mesenchymal cells in vessels and airways may reflect the irreversible fibrosis responsible for allograft dysfunction.

Lung transplantation for cystic fibrosis

Significant progress has been made since the first successful human heart-lung transplantation (HLT) for pulmonary vascular disease performed in 1981. The refinement of surgical techniques, use of cyclosporin as the main immunosuppressant, technique of distant organ procurement to expand the donor organ pool, and improved diagnosis and management of pulmonary infection and rejection have all contributed to this accomplishment. This has inevitably coincided with the extension of this procedure to other groups of patients with end stage heart and lung disease. Initially, HLT was offered to patients with cardiac disease associated with pulmonary hypertension. Because of the success, consideration was given to transplantation for parenchymal pulmonary diseases, initially pulmonary fibrosis and emphysema, and then suppurative lung disease such as in cystic fibrosis (CF). However, the application of HLT to patients with CF lagged behind because of concern related to the risk of sepsis, the systemic nature of the disease, malnourishment, and fear of recurrence of the epithelial CF defect in the transplanted lungs.

[The bronchial arteries and their anastomoses with the coronary arteries]

We studied bronchial arteries (BA) and their anastomoses with coronary arteries in 53 adult subjects (30 female and 23 male, mean age 82) and one 2 month old child. Each subject had 1 to 4 BAs, born from an area on the anterior side of the descending aorta measuring less than 2 cm in diameter in 62 percent of the cases and never exceeding 4 cm in the other cases. In 6 cases BAs vascularize the left auricle; more than half of all cases had an anastomose with the coronary arteries: 11 with the right coronary artery and 9 with the left one. These anastomoses preserve the vascularization of the carina after a cardio-pulmonary transplantation. The may have a function of vascular supply in some coronarian patients and the study of associated coronary pathology gives confirmation of it in one fourth of the cases.

Lung transplantation in cystic fibrosis

Lung transplantation has emerged in the last decade as a valid therapeutic endeavor for patients with end-stage lung disease. Although the presence of highly resistant organisms in the airway and sinuses of patients with cystic fibrosis (CF) increases the perioperative risk of infection following lung transplantation, transplant procedures can be undertaken in properly selected CF patients with acceptable morbidity and mortality at experienced centers. The introduction of a modification in the technique of double-lung transplantation has resulted in improved operative survival of CF patients undergoing lung transplantation. Whereas problems with posttransplant obliterative bronchiolitis, infection, and lymphoproliferative disorders contribute to morbidity, it is clear that lung transplantation can offer CF patients with end-stage lung disease improvement in both the quality and quantity of life. The most serious impediment to more widespread application of this therapy in CF is the inadequate number of donor organs.

Emergency department presentation and care of heart and heart/lung transplant recipients

STUDY OBJECTIVE

Heart and heart/lung transplants are accepted forms of therapy for patients with end-stage cardiac or pulmonary disease. These patients are likely to present postoperatively to the emergency department. To our knowledge, there have been no previous reports in the medical literature of the ED presentation of these patients.

DESIGN

We conducted a retrospective review of the records of all patients who had received a heart or a heart/lung transplant at Stanford University Medical Center from 1988 through 1990 and who had at least one ED visit.

MEASUREMENTS AND RESULTS

Between the time of operation and April 1, 1991, 131 ED visits were recorded. Fever was the single most common presenting complaint, for 48 (37%) of the visits. Difficulty in breathing (13%); gastrointestinal symptoms of nausea, vomiting, or diarrhea (10%); and chest pain (9%) were other common reasons for presentation.

CONCLUSION

The transplant patient, by virtue of requiring chronic immunosuppression, is susceptible to infection with a spectrum of opportunistic organisms. When fever or other symptoms suggest infection, appropriate cultures and aggressive diagnostic procedures (eg, lumbar puncture, bronchoscopy) should be performed.

Differences in left ventricular filling patterns in heart and heart-lung transplant recipients as assessed by Doppler echocardiography of transmitral flow

The conventional surgical technique of orthotopic heart transplantation involves reconstruction of atria from donor and recipient components. The mechanical function of the atria is thus likely to be altered either by this anatomic disruption or by the autonomic denervation, which also occurs as a result of transplantation. We investigated 18 subjects with Doppler echocardiography of transmitral flow, to assess the contributions of passive and active filling of the left ventricle in six normal subjects, six heart transplant recipients, and six heart-lung transplant recipients. The ratio of passive transmitral flow to active flow was significantly higher in isolated heart transplant recipients than in normal subjects (p < 0.001), suggesting a reduced active, late diastolic component to left ventricular filling. This was not due to denervation, because the ratio in heart-lung recipients was lower than that in normal subjects (p < 0.01). These data suggest that anatomic rather than neural dysfunction is responsible for a major change in transmitral flow characteristics after isolated heart transplantation; whether the resulting change in pattern of left ventricular filling is clinically important deserves further investigation.

Communication between the two pleural cavities after major cardiothoracic surgery: relevance to percutaneous intervention

The authors describe evidence of communication between the two pleural cavities after major cardiothoracic surgery (combined heart and lung transplantation, heart transplantation, and correction of complex congenital heart disease) performed in three patients. In two patients, unilateral lung biopsy caused a symptomatic bilateral pneumothorax. This was successfully treated with insertion of a single chest tube in one patient and two chest tubes in the other patient. In the third patient, simultaneous evacuation of large bilateral pleural effusions was performed by means of unilateral thoracentesis because of the presence of a common pleural cavity.

A prostacyclin analogue reduces free radical generation in heart-lung transplantation

The mechanism by which prostacyclin acts to prevent in vivo reperfusion injury is still uncertain. This study was therefore undertaken to assess the effect of a stable prostacyclin analogue (OP 41483-alpha-CD [OP]) on oxygen-derived free radicals after heart-lung transplantation. OP was administered to the heart-lung graft through the pulmonary artery for 25 minutes encompassing the reperfusion process. Free radicals were directly measured by electron spin resonance spectroscopy. The radical intensities of pulmonary venous blood were significantly lower in the OP group than in the control group, suggesting that fewer free radicals were generated in the lungs of the OP group. The cardiac and respiratory function were better in the OP group than in the control group. The lung is the primary source of oxygen free radical attack, and the beneficial action of OP on free radical generation is almost exclusively restricted to the lung and does not apply to the heart. This result suggested that OP probably is effective in inhibiting free radical generation from the endothelium.

Transplantation in Australia--50 years of progress

OBJECTIVE

To review the history of clinical transplantation practice in Australia.

DATA SOURCES AND STUDY SELECTION

The first major source was published reports, chiefly in The Medical Journal of Australia (129 articles). The second source was personal communication with those involved in early and current transplantation programs.

DATA EXTRACTION AND SYNTHESIS

The first known transplant of each organ in Australia and the results of current programs have been documented.

CONCLUSIONS

Transplantation of the kidney, liver, heart, lung, pancreas, cornea, or bone marrow are available and accepted therapies for an increasing number of suitable patients, limited mainly by the number of donors.

In-storage hypothermic perfusion for heart and lung transplantation

The authors developed a new waterproof-packed infusion device for easy and sterile in-storage hypothermic perfusion during organ transportation for heart and lung transplantation. They examined the accessibility and efficacy of this infusion device for portable heart and lung preservation in canine transplant models. Sixteen heart and bilateral lung blocks were preserved by an in-storage hypothermic perfusion technique using the infusion device with University of Wisconsin solution. Of 16 dog recipients, 5 underwent orthotopic heart transplantation with cardiopulmonary bypass, and 5 dogs received left lung transplantation; the remaining heart and lung blocks were intrathoracically transplanted into 6 dogs. Functional status and histology of 11 heart and 11 lung allografts were evaluated by post-transplant course, hemodynamic parameters, arterial blood gas measurements, microscopic examination, and so on. Eleven transplanted hearts showed good cardiac performance and maintained systemic circulation after weaning from cardiopulmonary bypass. Eleven transplanted lungs had excellent respiratory function, and all five dogs with left lung transplantation survived for 5-46 days (mean: 18.8 days). These results suggest that in-storage hypothermic perfusion with this waterproof-packed infusion device can be a useful technique for long-term organ preservation in heart and lung transplantation.

Size matching in lung transplantation

Volume concordance between donor lungs and the chest cavities of transplant recipients has important perioperative and postoperative implications. Between December 1987 and August 1991, 90 patients underwent lung transplantation in the Joint Marseilles-Montreal Lung Transplantation Program: 51 patients had double lung transplants, 19 patients had single lung transplants, and 20 patients had heart-lung transplants. There were 18 children (age range, 7 to 17 years) and 72 adults (age range, 18 to 58 years). Size matching was based on measurement of the submammary thoracic perimeter. Patient age (+/- 2 years) was also taken into consideration in children. Airway anastomoses were bronchial except for all heart-lung transplant patients and two double lung transplant patients, who had tracheal anastomoses. Occasional differences between donor and receiver bronchial diameters in children (greater donor size twice and smaller donor size once) required bronchoplasty in three instances. Healing was normal in these three instances, and no bronchial stenoses were noted. Performance of separate sutures rather than continuous running sutures on the cartilaginous anterior portion facilitated correction of airway diameter inequalities in adults. Excess volume was noted in three patients during closure of the thorax. In one patient, donor and recipient thoracic perimeters were similar. In two patients, however, donor size was greater by more than 20%. This was corrected by pneumoreduction with a surgical stapler. Lung size was decreased by 10% to 40% with use of this technique. Thoracic closure was facilitated and hemodynamic instability was thus corrected. No functional abnormalities were noted after surgery once the differences in lung size were corrected.(ABSTRACT TRUNCATED AT 250 WORDS)

Heart-lung transplantation in a 16-month-old infant

A 16-month-old boy who had a heart-lung transplantation is doing well 16 months postoperatively. The HLT can be a successful treatment for very young patients. Most of the postoperative management can be assessed with noninvasive techniques. Normally, the allograph grows with the recipient.

Intermediate-term results of heart-lung transplantation for cystic fibrosis

Between September, 1984, and March, 1991, 79 patients underwent heart-lung transplantation for end-stage cystic fibrosis at the Harefield Hospital. Short-term outcome has already been reported, and we now present intermediate-term results. The overall actuarial patient survival was 69% at 1 year, 52% at 2 years, and 49% at 3 years. 17 patients had diabetes mellitus with a survival of 62% to 1 year and 51% to 2 years. 23 patients had one or more other possible high-risk factors, and survival of these patients was 64% at 1 year and 57% at 2 years, compared with 71% and 49%, respectively, in the low-risk group (n = 56). Pseudomonas aeruginosa infection was the most common respiratory infection encountered postoperatively. 92% of patients had at least one episode of acute rejection during the first 3 postoperative months. Lung function was greatly improved after transplantation, the mean forced expiratory volume in 1 s and forced vital capacity increasing from 22% and 35% predicted, respectively, preoperatively to 68% and 70% predicted, respectively, by the sixth postoperative month. This improvement was maintained at 1, 2, and 3 years after transplantation. Lymphoproliferative disorders (4 patients) were successfully treated. Obliterative bronchiolitis developed in 17 patients and the cumulative probability of getting this complication at 1, 2, and 3 years postoperatively was 17%, 23%, and 48%, respectively. Overall, 7 patients were retransplanted. There was no coronary artery disease in the 37 patients who underwent coronary angiography at 1 year, 14 at 2 years, and 9 at 3 years after surgery. 58 patients donated their hearts for subsequent "domino" heart transplantation. Our 5 1/2-year experience with heart-lung transplantation is encouraging but the shortage of donor organs and the complication of obliterative bronchiolitis are the two main obstacles to be overcome.

[Treatment of dilated cardiomyopathy in childhood]

Authors reviewed available information concerning etiology and pathophysiology of dilated cardiomyopathy. Diagnostic criteria and current poor results of conservative treatment are discussed. Between August 1984 and August 1991 67 children with various types of cardiomyopathy underwent heart and heart and lung transplantation at Harefield Hospital, U.K. Dilated cardiomyopathy was the indication for transplantation in 47 patients (mean age at operation was 6.5 years, range 0.3-4.8 years). Eighty-one percent actuarial survival at 4 years after operation represents reasonable progress in the treatment of this severe acquired disease. Currently, early transplantation is recommended in children with dilated cardiomyopathy and with low shortening fraction of left ventricle (below 0.13), without any improvement after 3 months of conservative treatment, will familial trait of dilated cardiomyopathy and/or with severe myocardial fibrosis.

[Outcome of patients with Eisenmenger syndrome. Apropos of 62 cases followed-up for an average of 16 years]

In an era when heart-lung transplantation offers a therapeutic option for patients with Eisenmenger's syndrome, it is important to assess the natural history of this condition. With this objective the authors studied 62 patients followed-up by the same cardiologist. The average follow-up period was 16 years, but 22 patients were followed up for over 20 years. The average age at death was 29 years. It differed significantly for genetically normal patients (31 years for 21 fatalities) compared with a population of trisomics (21 years for 6 fatalities). Half the patient population lived for over 30 years. Fourteen of the 27 deaths occurred during the third decade and only 4 before the age of 20. The probability of surviving 10 more years for a 20 years old genetically normal patient was 56%. The causes of death in the 19 cases in which it could be established were: 5 sudden deaths, 4 right heart failures, 3 massive haemoptyses, 3 pulmonary emboli, 2 pneumonias and 2 peroperative deaths. The functional disability was nearly always minimal or mild, enabling the patient to work: 24 of the 45 non-trisomic patients had full-time jobs. Pregnancy was a poor prognosis factor and could be lethal (2 deaths due to pulmonary embolism in the post-partum period). A heart-lung transplantation would only seem to be justified in patients with severe symptoms, polycythaemia, irreversible right heart failure and/or haemoptysis.

Single lung transplantation for severe emphysema

Lung transplantation is effective therapy for patients with severe obstructive lung disease. We reviewed seven patients with severe emphysema (age, 48 +/- 5 years; forced expiratory volume in 1 second [FEV1] 0.76 +/- 0.26 liters) who received single-lung transplants (SLT) at our institution between August 1989 and September 1990. Studies to assess the adequacy of cardiac function before transplantation showed moderately reduced right ventricular function (by multiple gated acquisition, 34 +/- 6%), moderately elevated pulmonary artery pressure (25 +/- 3 mm Hg), and normal left ventricular function (by multiple gated acquisition 65% +/- 12%) and coronary arteriograms. Time on the waiting list before transplantation was reduced compared with heart-lung transplant (HLT) recipients (waiting time, 2.9 +/- 1.5 months for SLT, 9.6 +/- 10.2 months for HLT). Six of the SLT recipients are currently alive (after transplantation interval, 17 +/- 5 months); the remaining recipient died of pulmonary embolism 21 days after SLT. Number of ventilator days, intensive care unit days, and days to hospital discharge after transplantation did not differ significantly from HLT recipients. Cardiopulmonary bypass was necessary in four SLT recipients. Pulmonary function was markedly improved after SLT (FEV1, 1.78 +/- 0.73 L/min after SLT versus 0.75 +/- 0.3 L/min before SLT; p less than 0.01), and functional status is correspondingly improved.

CONCLUSIONS

SLT constitutes effective therapy for patients with severe emphysema, including those with moderate reduction of right ventricular function; and SLT offers distinct advantages over HLT, including decreased waiting time before transplantation, improved donor organ utilization, and less frequent need for cardiopulmonary bypass.

Heart-lung transplantation for cystic fibrosis

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