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Kim JS, Gupta R. Lung transplantation in pulmonary sarcoidosis. J Autoimmun 2023:103135. [PMID: 37923622 DOI: 10.1016/j.jaut.2023.103135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/12/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology and variable clinical course. Pulmonary sarcoidosis is the most common presentation and accounts for most morbidity and mortality related to sarcoidosis. While sarcoidosis generally has good outcomes, few patients experience chronic disease. A minority of patients progress to a specific phenotype of sarcoidosis referred to advanced pulmonary sarcoidosis (APS) which includes advanced fibrosis, pulmonary hypertension and respiratory failure, leading to high morbidity and mortality. In patients with advanced disease despite medical therapy, lung transplantation may be the last viable option for improvement in quality of life. Though post-transplant survival is similar to that of other end-stage lung diseases, it is imperative that patients are evaluated and referred early to transplant centers with experience in APS. A multidisciplinary approach and clinical experience are crucial in detecting the optimal timing of referral, initiating comprehensive transplantation evaluation and listing, discussing surgical approach, and managing perioperative and post-transplant care. This review article seeks to address these aspects of lung transplantation in APS.
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Affiliation(s)
- Jin Sun Kim
- Lewis Katz School of Medicine, Department of Thoracic Medicine and Surgery, Philadelphia, PA, USA.
| | - Rohit Gupta
- Lewis Katz School of Medicine, Department of Thoracic Medicine and Surgery, Philadelphia, PA, USA
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2
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Lee J, Schellenberg SJ, Chung LIY, Bharat A, Chae YK. Current and future role of double-lung transplantation for bilateral lung cancer. Transplant Rev (Orlando) 2023; 37:100772. [PMID: 37356213 PMCID: PMC10276654 DOI: 10.1016/j.trre.2023.100772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/06/2023] [Accepted: 06/14/2023] [Indexed: 06/27/2023]
Abstract
Technological advances have progressively enhanced the survival rate of lung transplant recipients and expanded its indications for various diseases, including the recent coronavirus disease 2019 (COVID-19). However, according to the International Society for Heart and Lung Transplantation, lung cancer constituted a mere 0.1% of the indications for lung transplantation over the past two decades. This statistic has remained stagnant, and numerous lung cancer patients continue to be excluded from lung transplantation candidacy. Contrary to the general exclusion of lung cancer patients from transplantation, the post-transplant survival rate for these patients is not inferior to that of patients with non-cancerous diseases. Furthermore, lung transplantation may offer curative treatment for patients with bilateral lung cancer whose respiratory insufficiency has advanced independently of cancer progression. This review aims to elucidate and examine the role of double lung transplantation (DLT) in bilateral lung cancer. We summarize the established indications for lung transplantation, appropriate histologic or molecular subtypes of lung cancer for transplantation, technical advances to minimize recurrence, post-DLT survival outcomes for lung cancer patients, and related translational research. We suggest that although DLT for bilateral lung cancer presents challenges, it may be considered a potential treatment option in select circumstances.
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Affiliation(s)
- Jeeyeon Lee
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea
| | | | | | - Ankit Bharat
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Young Kwang Chae
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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3
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Kim HJ, Shin SW, Park S, Kim HY. A Review of Anesthesia for Lung Transplantation. J Chest Surg 2022; 55:293-300. [PMID: 35924536 PMCID: PMC9358164 DOI: 10.5090/jcs.22.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Lung transplantation is the only treatment option for patients with end-stage lung disease. Although more than 4,000 lung transplants are performed every year worldwide, the standardized protocols contain no guidelines for monitoring during lung transplantation. Specific anesthetic concerns are associated with lung transplantation, especially during critical periods, including anesthesia induction, the initiation of positive pressure ventilation, the establishment and maintenance of one-lung ventilation, pulmonary artery clamping, pulmonary artery unclamping, and reperfusion of the transplanted lung. Anesthetic management according to the special risks associated with a patient’s existing lung disease and surgical stage is the most important factor. Successful anesthesia in lung transplantation can improve hemodynamic stability, oxygenation, ventilation, and outcomes. Therefore, anesthesiologists must have expertise in transesophageal echocardiography, extracorporeal life support, and cardiopulmonary anesthesia and understand the pathophysiology of end-stage lung disease and the drugs administered. In addition, communication among anesthesiologists, surgeons, and perfusionists during surgery is important to achieve optimal patient results.
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Affiliation(s)
- Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang-Wook Shin
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
| | - Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
- Department of Anesthesia and Pain Medicine, Pusan National University School of Medicine, Yangsan, Korea
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4
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Magoon R, Jose J. Primary graft dysfunction following lung transplant: Unknowns best ushered by knowns. Acta Anaesthesiol Scand 2022; 66:651-652. [PMID: 35218201 DOI: 10.1111/aas.14055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/02/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Rohan Magoon
- Department of Cardiac Anaesthesia Dr. Ram Manohar Lohia Hospital Atal Bihari Vajpayee Institute of Medical Sciences (ABVIMS) New Delhi India
| | - Jes Jose
- Department of Cardiac Anesthesiology Sri Jayadeva Institute of Cardiovascular Sciences and Research Bengaluru India
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Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a devastating complication in the acute postoperative lung transplant period, associated with high short-term mortality and chronic rejection. We review its definition, pathophysiology, risk factors, prevention, treatment strategies, and future research directions. RECENT FINDINGS New analyses suggest donation after circulatory death and donation after brain death donors have similar PGD rates, whereas donors >55 years are not associated with increased PGD risk. Recipient pretransplant diastolic dysfunction and overweight or obese recipients with predominant abdominal subcutaneous adipose tissue have increased PGD risk. Newly identified recipient biomarkers and donor and recipient genes increase PGD risk, but their clinical utility remains unclear. Mixed data still exists regarding cold ischemic time and PGD risk, and increased PGD risk with cardiopulmonary bypass remains confounded by transfusions. Portable ex vivo lung perfusion (EVLP) may prevent PGD, but its use is limited to a handful of centers. Although updates to current PGD treatment are lacking, future therapies are promising with targeted therapy and the use of EVLP to pharmacologically recondition donor lungs. SUMMARY There is significant progress in defining PGD and identifying its several risk factors, but effective prevention and treatment strategies are needed.
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Coster JN, Loor G. Extracorporeal life support during lung transplantation. Indian J Thorac Cardiovasc Surg 2021; 37:476-483. [PMID: 33935384 PMCID: PMC8075835 DOI: 10.1007/s12055-021-01175-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 11/29/2022] Open
Abstract
Lung transplantation surgeries are performed without extracorporeal life support (ECLS) by using an off-pump technique; however, in cases of hypoxemia or hemodynamic instability, intraoperative ECLS may be required. Cardiopulmonary bypass (CPB) has traditionally been the standard practice for ECLS but has been associated with an increased risk of bleeding in the perioperative period, increased transfusion requirements, prolonged postoperative intubation, and possibly primary graft dysfunction. More recently, because of the flexibility of using extracorporeal membrane oxygenation (ECMO) in bridging to transplantation and during postoperative recovery, its use has increased. CPB and ECMO each has advantages and disadvantages; however, because comparisons of CPB and ECMO have been limited to small retrospective observational and single-institution studies, more research is required to determine the superiority of one modality. In this review, we critically examine the pros and cons of performing lung transplantation surgery off-pump or by using the ECLS modalities of ECMO and CPB support during lung transplantation surgery.
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Affiliation(s)
- Jenalee Nicole Coster
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Division of Cardiothoracic Surgery, CHI St. Luke’s Health—Baylor St. Luke’s Medical Center, Houston, TX USA
| | - Gabriel Loor
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Division of Cardiothoracic Transplantation and Circulatory Support, CHI St. Luke’s Health—Baylor St. Luke’s Medical Center, Houston, TX USA
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Houston, TX USA
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Parikh AN, Merritt TC, Carvajal HG, Shepard MS, Canter MW, Abarbanell AM, Eghtesady P, Nath DS. A comparison of cardiopulmonary bypass versus extracorporeal membrane oxygenation: Does intraoperative circulatory support strategy affect outcomes in pediatric lung transplantation? Clin Transplant 2021; 35:e14289. [PMID: 33714228 DOI: 10.1111/ctr.14289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Data on adult lung transplantation suggest perioperative benefits of intraoperative extracorporeal membrane oxygenation (ECMO) compared to cardiopulmonary bypass (CPB). Information regarding their pediatric counterparts, however, is limited. This study compares outcomes of intraoperative ECMO versus CPB in pediatric lung transplantation. METHODS We reviewed all pediatric lung transplants at our institution from 2014 to 2019 and compared those supported intraoperatively on ECMO (n = 13) versus CPB (n = 22), plus a conditional analysis excluding re-transplantations (ECMO [n = 13] versus CPB [n = 20]). We evaluated survival, surgical times, intraoperative transfusions, postoperative support, complications, and duration of hospitalization. RESULTS Total time on ECMO support was significantly less than that of CPB support (P = .018). Intraoperatively, the ECMO group required fewer transfusions of fresh-frozen plasma (8.9 [5.8-22.3] vs 16.6 [11.4-39.0] mL/kg, P = .049) and platelets (4.2 [0.0-6.7] vs 8.0 [3.5-14.0] mL/kg, P = .049). When excluding re-transplantations, patients on ECMO required fewer packed red blood cells intraoperatively (12.6 [2.1-30.7] vs 28.2 [14.0-54.0] mL/kg, P = .048). There were no differences in postoperative support requirements, complications, or mortality at one, six, and twelve months. CONCLUSIONS Intraoperative ECMO support during pediatric lung transplantation appears to decrease intraoperative transfusion requirements when compared to CPB. Data from additional institutions may strengthen these observations.
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Affiliation(s)
- Amisha N Parikh
- Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Taylor C Merritt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Horacio G Carvajal
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mark S Shepard
- The Heart Center, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Matthew W Canter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Aaron M Abarbanell
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Pirooz Eghtesady
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Dilip S Nath
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
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8
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Syrett AJ, Huang A. Transfusion and Primary Graft Dysfunction After Lung Transplantation: All About the Ratio? J Cardiothorac Vasc Anesth 2020; 34:3033-3035. [PMID: 32782190 DOI: 10.1053/j.jvca.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew J Syrett
- Department of Anesthesia and Pain Management, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Alexander Huang
- Department of Anesthesia and Pain Management, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.
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9
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Heid CA, Khoury MK, Maaraoui K, Liu C, Peltz M, Wait MA, Ring WS, Huffman LC. Acute Kidney Injury in Patients Undergoing Cardiopulmonary Bypass for Lung Transplantation. J Surg Res 2020; 255:332-338. [PMID: 32599452 DOI: 10.1016/j.jss.2020.05.072] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/14/2020] [Accepted: 05/24/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is often used to support patients undergoing lung transplantation who are intolerant of anatomic manipulation or single lung ventilation during the procedure. However, CPB may be associated with adverse outcomes. We evaluated the hypothesis that CPB is associated with increased acute kidney injury (AKI) and postoperative mortality after lung transplantation. MATERIALS AND METHODS This was a retrospective review of our institutional lung transplant database at the University of Texas Southwestern Medical Center from 2012 to 2018. Patients were grouped based on their need for CPB. The primary outcome was AKI within 48 h of transplantation, which was defined as Kidney Disease Improving Global Outcomes stage 1 or greater. Secondary outcomes included all-cause mortality. RESULTS A total of 426 patients underwent lung transplantation with 39.0% (n = 166) requiring CPB. There were no differences in demographics and comorbidities, including baseline renal function, between CPB and no CPB. CPB use was higher in recipients with interstitial lung diseases and primary pulmonary hypertension. Median lung allocation score was higher in those needing CPB (47 [interquartile range, 40-59] versus 39 [interquartile range, 35-47]). Patients requiring CPB were significantly more likely to experience AKI (61.44% versus 36.5.3%, P < 0.01) and postoperative hemodialysis (6.6% versus 0.4%, P < 0.01). On multivariable analysis, CPB was significantly associated with postoperative AKI (odds ratio, 1.66; 95% CI, 1.01-2.75; P = 0.04). Thirty-day mortality was higher in patients undergoing CPB (4.2% versus 0.8%, P = 0.03). CONCLUSIONS CPB for lung transplantation is associated with a higher incidence of AKI, renal failure requiring hemodialysis, and 30-d mortality. CPB should be used selectively for lung transplantation.
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Affiliation(s)
- Christopher A Heid
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Mitri K Khoury
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Kayla Maaraoui
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Charles Liu
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthias Peltz
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael A Wait
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - W Steves Ring
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lynn C Huffman
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
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10
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Lau CL, Beller JP, Boys JA, Zhao Y, Phillips J, Cosner M, Conaway MR, Petroni G, Charles EJ, Mehaffey JH, Mannem HC, Kron IL, Krupnick AS, Linden J. Adenosine A2A receptor agonist (regadenoson) in human lung transplantation. J Heart Lung Transplant 2020; 39:563-570. [PMID: 32503727 DOI: 10.1016/j.healun.2020.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 12/20/2019] [Accepted: 02/06/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Currently, there are no clinically approved treatments for ischemia-reperfusion injury after lung transplantation. Pre-clinical animal models have demonstrated a promising efficacy of adenosine 2A receptor (A2AR) agonists as a treatment option for reducing ischemia-reperfusion injury. The purpose of this human study, is to conduct a Phase I clinical trial for evaluating the safety of continuous infusion of an A2AR agonist in lung transplant recipients. METHODS An adaptive, two-stage continual reassessment trial was designed to evaluate the safety of regadenoson (A2AR agonist) in the setting of lung transplantation. Continuous infusion of regadenoson was administered to lung transplant recipients that was started at the time of skin incision. Adverse events and dose-limiting toxicities, as pre-determined by a study team and assessed by a clinical team and an independent safety monitor, were the primary end-points for safety in this trial. RESULTS Between January 2018 and March 2019, 14 recipients were enrolled in the trial. Of these, 10 received the maximum infused dose of 1.44 µg/kg/min for 12 hours. No dose-limiting toxicities were observed. The steady-state plasma regadenoson levels sampled before the reperfusion of the first lung were 0.98 ± 0.46 ng/ml. There were no mortalities within 30 days. CONCLUSIONS Regadenoson, an A2AR agonist, can be safely infused in the setting of lung transplantation with no dose-limiting toxicities or drug-related mortality. Although not powered for the evaluation of secondary end-points, the results of this trial and the outcome of pre-clinical studies warrant further investigation with a Phase II randomized controlled trial.
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Affiliation(s)
- Christine L Lau
- Department of Surgery, University of Maryland, Baltimore, Maryland.
| | - Jared P Beller
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Joshua A Boys
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of California, San Diego, California
| | - Yunge Zhao
- Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Jennifer Phillips
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Michael Cosner
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mark R Conaway
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Gina Petroni
- Public Health Sciences, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Eric J Charles
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J H Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Hannah C Mannem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Irving L Kron
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, University of Arizona Health Sciences, Tucson, Arizona
| | | | - Joel Linden
- Division of Developmental Immunology, La Jolla Institute for Immunology and Department of Pharmacology, University of California, San Diego, California
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Hayanga JWA, Chan EG, Musgrove K, Leung A, Shigemura N, Hayanga HK. Extracorporeal Membrane Oxygenation in the Perioperative Care of the Lung Transplant Patient. Semin Cardiothorac Vasc Anesth 2020; 24:45-53. [PMID: 31893982 DOI: 10.1177/1089253219896123] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung transplantation (LT) is definitive therapy for end-stage lung disease. Donor allocation based on medical urgency has led to an increased trend in the transplantation of sicker and older patients. Mechanical ventilation (MV) formerly was the only method of bridging high-acuity patients to LT. When the physiological demands of ventilatory support exceeds the capability of MV, extracorporeal membrane oxygenation (ECMO) may become necessary. Recent improvements in ECMO technology and component design have led to a resurgence of interest in its use before, during, and after LT. Survival with ECMO as a bridge to LT has improved over time, now with many centers reporting little or no difference in outcomes, and some even reporting better outcomes, as compared with MV. Extracorporeal life support may also be used intraoperatively. In many studies to date, ECMO or cardiopulmonary bypass (CPB) has been reserved for patients who became hemodynamically unstable during the procedure or patients who could not tolerate single-lung ventilation. Both methods of support are fraught with potential complications. However, multiple studies comparing ECMO with CPB have shown that intraoperative use of ECMO resulted in improved outcomes and overall survival as well as lower rates of bleeding complications. In order to further reduce complications associated with ECMO, planned intraoperative ECMO use is occasionally reserved for high-risk patients who might otherwise require CPB. Future studies will need to improve patient selection to fully take advantage of the use of ECMO in LT while minimizing its costs.
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Affiliation(s)
| | - Ernest G Chan
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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12
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Effect of left ventricular diastolic dysfunction on development of primary graft dysfunction after lung transplant. Curr Opin Anaesthesiol 2019; 33:10-16. [PMID: 31789901 DOI: 10.1097/aco.0000000000000811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is one of the most common complications after lung transplant and is associated with significant early and late morbidity and mortality. The cause of primary graft dysfunction is often multifactorial involving patient, donor, and operational factors. Diastolic dysfunction is increasingly recognized as an important risk factor for development of PGD after lung transplant and here we examine recent evidence on the topic. RECENT FINDINGS Patients with end-stage lung disease are more likely to suffer from cardiovascular disease including diastolic dysfunction. PGD as result of ischemia-reperfusion injury after lung transplant is exacerbated by increased left atrial pressure and pulmonary venous congestion impacted by diastolic dysfunction. Recent studies on relationship between diastolic dysfunction and PGD after lung transplant show that patients with diastolic dysfunction are more likely to develop PGD with worse survival outcome and complicated hospital course. SUMMARY Patients with diastolic dysfunction is more likely to suffer from PGD after lung transplant. From the lung transplant candidate selection to perioperative and posttransplant care, thorough evaluation and documentation diastolic dysfunction to guide patient care are imperative.
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13
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Rady N, Kini A, Go JA, Al Othman B, Lee AG. Bilateral central retinal/ophthalmic artery occlusion and near-complete ophthalmoplegia after bilateral lung transplant. Am J Ophthalmol Case Rep 2019; 16:100569. [PMID: 31788576 PMCID: PMC6880121 DOI: 10.1016/j.ajoc.2019.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/18/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022] Open
Abstract
PURPOSE Recognize a rare yet existing risk of severe visual loss as a postoperative complication of bilateral lung transplant. OBSERVATIONS A 62-year-old male had undergone bilateral lung transplant for end-stage idiopathic pulmonary fibrosis and emphysema overlap syndrome. The operation was initially off-pump; however, during the left lung transplantation, cardiopulmonary bypass conversion was necessary to maintain intraoperative hemodynamic stability. On post-operative day 4, shortly after extubation and full recovery from sedation, the patient reported bilateral no light perception vision. There were no other associated neurologic symptoms. A computed tomographic (CT) of the head, cranial magnetic resonance (MR) scan of the head, MR angiogram of the circle of Willis and neck were negative. Neuro-ophthalmologic examination revealed no light perception vision in both eyes(OU). The pupils were non-reactive to light (amaurotic pupils). The intraocular pressure measured 18 mm Hg OU, and complete bilateral ophthalmoplegia was present. The fundus exam showed bilateral pallid optic disc edema, cherry red spots, with arteriolar attenuation, and mildly dilated and tortuous veins. Stroke work up was negative. CONCLUSIONS AND IMPORTANCE A case of post-operative visual loss and ophthalmoplegia carrying significant and permanent quality of life implications. It questions the role disruption of homeostasis during cardiopulmonary bypass contributes for this outcome.
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Affiliation(s)
- Nadine Rady
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Ashwini Kini
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6550 Fannin St, Houston, TX, 77030, USA
| | - Jonathan A. Go
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Bayan Al Othman
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6550 Fannin St, Houston, TX, 77030, USA
| | - Andrew G. Lee
- School of Medicine, National University of Ireland, Galway, Ireland
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6550 Fannin St, Houston, TX, 77030, USA
- Department of Ophthalmology, Neurology and Neurosurgery, Weill Cornell Medicine, 1305 York Ave, New York, NY, 10021, USA
- Department of Ophthalmology, University of Texas Medical Branch, 700 University Blvd, Galveston, TX, 77555, USA
- University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA
- Texas A and M College of Medicine, 8447 Bryan Rd, Bryan, TX, 77807, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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14
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Taka H, Miyoshi K, Kurosaki T, Douguchi T, Itoh H, Sugimoto S, Yamane M, Kobayashi M, Kasahara S, Oto T. Lung transplantation via cardiopulmonary bypass: excellent survival outcomes from extended criteria donors. Gen Thorac Cardiovasc Surg 2019; 67:624-632. [PMID: 30659507 DOI: 10.1007/s11748-019-01067-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/11/2019] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The role of intraoperative cardiopulmonary bypass (CPB) in lung transplant (LTx) surgery is controversial. CPB enables slow pulmonary reperfusion and initial ventilation with low oxygen concentrations, both theoretically protective of transplanted lungs. In this study, we explored clinical outcomes following extended criteria donor LTx surgery implementing a thoroughly protective allograft reperfusion strategy using CPB. METHODS Thirty-nine consecutive adult patients who underwent bilateral LTx with elective CPB and protective allograft reperfusion were reviewed. Bilaterally implanted lungs were reperfused simultaneously, via slow CPB flow reduction and initial ventilation with 21% oxygen and nitric oxide, followed by a brief modified ultrafiltration. During weaning from CPB, mean pulmonary arterial pressure was strictly maintained at 10-15 mmHg by controlling CPB and pulmonary flow. The clinical outcomes in 23 patients who received lungs from extended criteria donors (ECD group) were elucidated and compared to 16 patients undergoing LTx from standard criteria donors (SCD group). RESULTS No life-threatening deterioration was observed to graft functionality during the first 72 h after LTx in the ECD group; however, only one patient required post-transplant extracorporeal membrane oxygenation. In three of 23 ECD LTx patients (12%), surgical revision for bleeding was required. Survival outcomes for the ECD group were favorable, with 100% survival at 6-months, 87.0% at 1-year, and 80.7% at 5-years. Outcomes in the ECD group were comparable to those in the SCD group. CONCLUSIONS Despite a certain extent of risk associated with full-dose heparinization, use of CPB does not undermine survival outcomes after ECD LTx surgery if protective allograft reperfusion is securely performed.
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Affiliation(s)
- Hirosh Taka
- Department of Clinical Engineering, Okayama University Hospital, Okayama, Japan
| | - Kentaroh Miyoshi
- Department of Thoracic Surgery, Okayama Medical Center/Okayama University Hospital, 2-5-1, Shikata-cho, kita-ku, Okayama, 700-8558, Japan.
| | - Takeshi Kurosaki
- Department of Thoracic Surgery/Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Takuma Douguchi
- Department of Clinical Engineering, Okayama University Hospital, Okayama, Japan
| | - Hideshi Itoh
- Department of Medical Engineering, Faculty of Health Sciences, Junshin Gakuen University, Fukuoka, Japan
| | - Seiichiro Sugimoto
- Department of Thoracic Surgery/Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Masaomi Yamane
- Department of Thoracic Surgery/Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Motomu Kobayashi
- Department of Anesthesiology, Okayama University Hospital, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Takahiro Oto
- Department of Thoracic Surgery/Organ Transplant Center, Okayama University Hospital, Okayama, Japan
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15
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Oechslin P, Zalunardo MP, Inci I, Schlaepfer M, Grande B. Established and potential predictors of blood loss during lung transplant surgery. J Thorac Dis 2018; 10:3845-3848. [PMID: 30069385 DOI: 10.21037/jtd.2018.05.165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lung transplantation is an established therapeutic procedure for end stage lung diseases. Its success may be impaired by perioperative complications. Intraoperative blood loss and the resulting blood transfusion are among the most common complications. The various factors contributing to increased blood loss during lung transplantation are only scarcely investigated and not yet completely understood. This is in sharp contrast to other surgical fields, as in orthopedic surgery, liver transplantation and cardiac surgery the contributors to blood loss are well identified. This narrative review article aims to highlight the acknowledged factors influencing blood loss in lung transplantation (such as double vs. single lung transplant) and to discuss potential factors that may be of interest for further research or helpful to develop strategies targeting risk factors in order to minimize blood loss during lung transplantation and finally improve patient outcome.
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Affiliation(s)
- Pascal Oechslin
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Marco P Zalunardo
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Departement of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin Schlaepfer
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.,Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Bastian Grande
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.,Simulation Center, University Hospital Zurich, Zurich, Switzerland
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16
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Diamond JM, Arcasoy S, Kennedy CC, Eberlein M, Singer JP, Patterson GM, Edelman JD, Dhillon G, Pena T, Kawut SM, Lee JC, Girgis R, Dark J, Thabut G. Report of the International Society for Heart and Lung Transplantation Working Group on Primary Lung Graft Dysfunction, part II: Epidemiology, risk factors, and outcomes—A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1104-1113. [DOI: 10.1016/j.healun.2017.07.020] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022] Open
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17
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Morrison MI, Pither TL, Fisher AJ. Pathophysiology and classification of primary graft dysfunction after lung transplantation. J Thorac Dis 2017; 9:4084-4097. [PMID: 29268419 DOI: 10.21037/jtd.2017.09.09] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The term primary graft dysfunction (PGD) incorporates a continuum of disease severity from moderate to severe acute lung injury (ALI) within 72 h of lung transplantation. It represents the most significant obstacle to achieving good early post-transplant outcomes, but is also associated with increased incidence of bronchiolitis obliterans syndrome (BOS) subsequently. PGD is characterised histologically by diffuse alveolar damage, but is graded on clinical grounds with a combination of PaO2/FiO2 (P/F) and the presence of radiographic infiltrates, with 0 being absence of disease and 3 being severe PGD. The aetiology is multifactorial but commonly results from severe ischaemia-reperfusion injury (IRI), with tissue-resident macrophages largely responsible for stimulating a secondary 'wave' of neutrophils and lymphocytes that produce severe and widespread tissue damage. Donor history, recipient health and operative factors may all potentially contribute to the likelihood of PGD development. Work that aims to minimise the incidence of PGD in ongoing, with techniques such as ex vivo perfusion of donor lungs showing promise both in research and in clinical studies. This review will summarise the current clinical status of PGD before going on to discuss its pathophysiology, current therapies available and future directions for clinical management of PGD.
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Affiliation(s)
- Morvern Isabel Morrison
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Thomas Leonard Pither
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Andrew John Fisher
- Institute of Transplantation, Freeman Hospital, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
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18
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Magouliotis DE, Tasiopoulou VS, Svokos AA, Svokos KA, Zacharoulis D. Extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation: a meta-analysis. Gen Thorac Cardiovasc Surg 2017; 66:38-47. [PMID: 28918471 DOI: 10.1007/s11748-017-0836-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/11/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND We reviewed the available literature on patients undergoing lung transplantation supported by cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO). METHODS A systematic literature search was performed in three databases, in accordance with the PRISMA guidelines. Meta-analyses were used to compare the outcomes of ECMO and CPB procedures. RESULTS Seven observational studies met the inclusion criteria incorporating 785 patients. ECMO support showed lower rate of primary graft dysfunction, bleeding, renal failure requiring dialysis, tracheostomy, intraoperative transfusions, intubation time, and hospital stay. Total support time was greater for the ECMO-supported group. No difference was reported between operative and ischemic time. CONCLUSIONS The present study indicates that the intraoperative use of ECMO is associated with increased efficacy and safety, regarding short-term outcomes, compared to CPB. Well-designed, randomized studies, comparing ECMO to CPB, are necessary to assess their clinical outcomes further.
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Affiliation(s)
| | - Vasiliki S Tasiopoulou
- Department of Surgery, Faculty of Medicine, University of Thessaly, Viopolis, Larissa, Greece
| | - Alexis A Svokos
- Department of Obstetrics and Gynecology, Riverside Regional Medical Center, Newport News, VA, USA
| | - Konstantina A Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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19
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Abstract
Anesthesia for lung transplantation is both a demand ing and rewarding experience. Success requires team- work, experience, knowledge of cardiorespiratory patho physiology and its anesthetic implications, appropriate use of noninvasive and invasive monitoring, and the ability to respond quickly and effectively to life- threatening perioperative events. Specific issues in clude management of a patient with end-stage lung and heart disease, lung isolation and one-lung ventilation, perioperative respiratory failure, pulmonary hyperten sion, and acute right ventricular failure. Recent ad vances include greater understanding of dynamic hyper inflation ("gas-trapping") during mechanical ventilation, perioperative use of inhaled nitric oxide and treatment of acute right ventricular failure. Successful anesthetic management leads to greater hemodynamic stability, improvement in gas exchange and a reduction in need for cardiopulmonary bypass, all of which should lead to improved patient outcome.
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Affiliation(s)
- Paul S. Myles
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Australia
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20
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Abstract
Lung transplantation is the only therapeutic option for more than 3,000 individuals in the United States with end-stage lung disease. Innovations in anesthetic and surgical techniques have expanded the indications for lung transplantation. Presently, the major limiting factor in the number of lung transplantations that are performed is the availability of suitable donor organs. Lung transplantation includes a number of surgical procedures, including single-lung, double-lung, bilateral-sequential-single-lung, heart-lung, and lobar transplantation. Patients undergoing lung transplantation present a variety of challenges to the anesthesia team. Critical periods include induction of anesthesia, initiation of positive pressure ventilation, establishment and maintenance of one-lung ventilation, pulmonary artery clamping, pulmonary artery unclamping, and reperfusion of the transplanted lung. Pharmacologic advances have been an important factor in the continued development and success of lung transplantation. Newer immunosuppressive agents have improved the prevention and management of post-transplant rejection. Selective pulmonary vasodilators that are administered via inhalation affect the anesthetic management during the surgical procedure. Technologic advances in monitoring have also been valuable in lung transplantation. Transesophageal echocardiography is commonly used to evaluate intraoperative ventricular function. Continuous cardiac output, mixed venous oxygen saturation, continuous arterial blood gas monitoring, and the bispectral index have also been used to monitor the patient during lung transplantation. Anesthetic management of lung transplantation requires a thorough understanding of end-stage lung disease and pharmacologic and technical considerations that may not be applicable in any other part of anesthetic practice.
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Affiliation(s)
- Allen Miranda
- Department of Anesthesiology, University of Wisconsin Hospitals and Clinics, Madison, WI
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Abstract
Major strides have been made in lung transplantation during the 1990s and it has become an established treatment option for patients with advanced lung disease. Due to improvements in organ preservation, surgical techniques, postoperative intensive care, and immunosuppression, the risk of perioperative and early mortality (less than 3 months after transplantation) has declined [1]. The transplant recipient now has a greater chance of realizing the benefits of the long and arduous waiting period.Despite these improvements, suboptimal long-term outcomes continue to be shaped by issues such as opportunistic infections and chronic rejection. Because of the wider use of lung transplantation and the longer life span of recipients, intensivists and ancillary intensive care unit (ICU) staff should be well versed with the care of lung transplant recipients.In this clinical review, issues related to organ donation will be briefly mentioned. The remaining focus will be on the critical care aspects of lung transplant recipients in the posttransplant period, particularly ICU management of frequently encountered conditions. First, the groups of patients undergoing transplantation and the types of procedures performed will be outlined. Specific issues directly related to the allograft, including early graft dysfunction from ischemia-reperfusion injury, airway anastomotic complications, and infections in the setting of immunosuppression will be emphasized. Finally nonpulmonary aspects of posttransplant care and key pharmacologic points in the ICU will be covered.
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Makdisi G, Makdisi PB, Wang IW. New horizons of non-emergent use of extracorporeal membranous oxygenator support. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:76. [PMID: 27004223 DOI: 10.3978/j.issn.2305-5839.2016.02.04] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The expansion of the extra corporeal membrane oxygenation (ECMO) use and its indication is strikingly increased in the past few years. ECMO use expanded to lung transplantation, difficult general thoracic resections, transcatheter aortic valve replacement (TAVR) and LVAD implantation. Here we will discuss the indications and the outcomes of non-emergent use of ECMO.
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Affiliation(s)
- George Makdisi
- 1 Gulf Coast Cardiothoracic Surgery Institute, Tampa General Hospital, Tampa, FL, USA ; 2 Mayo Clinic College of Medicine, Rochester, MN, USA ; 3 Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
| | - Peter B Makdisi
- 1 Gulf Coast Cardiothoracic Surgery Institute, Tampa General Hospital, Tampa, FL, USA ; 2 Mayo Clinic College of Medicine, Rochester, MN, USA ; 3 Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
| | - I-Wen Wang
- 1 Gulf Coast Cardiothoracic Surgery Institute, Tampa General Hospital, Tampa, FL, USA ; 2 Mayo Clinic College of Medicine, Rochester, MN, USA ; 3 Indiana University School of Medicine, Division of Cardiothoracic Surgery, Indiana University Health, Methodist Hospital, Indianapolis, IN, USA
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23
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Mohite PN, Sabashnikov A, Patil NP, Garcia-Saez D, Zych B, Zeriouh M, Romano R, Soresi S, Reed A, Carby M, De Robertis F, Bahrami T, Amrani M, Marczin N, Simon AR, Popov AF. The role of cardiopulmonary bypass in lung transplantation. Clin Transplant 2016; 30:202-9. [DOI: 10.1111/ctr.12674] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Prashant N. Mohite
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Nikhil P. Patil
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Diana Garcia-Saez
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Bartlomeij Zych
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Mohamed Zeriouh
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Rosalba Romano
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Simona Soresi
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Anna Reed
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Martin Carby
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Toufan Bahrami
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Mohamed Amrani
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Nandor Marczin
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Andre R. Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
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24
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Moreno P, Alvarez A, Carrasco G, Redel J, Guaman HD, Baamonde C, Algar FJ, Cerezo F, Salvatierra A. Lung transplantation for cystic fibrosis: differential characteristics and outcomes between children and adults. Eur J Cardiothorac Surg 2015; 49:1334-43. [DOI: 10.1093/ejcts/ezv377] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/10/2015] [Indexed: 12/19/2022] Open
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25
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Bennett SC, Beal EW, Dumond CA, Preston T, Ralston J, Pope-Harman A, Black S, Hayes Jr D, Whitson BA. Mechanical circulatory support in lung transplantation: Cardiopulmonary bypass, extracorporeal life support, and ex-vivo lung perfusion. World J Respirol 2015; 5:78-92. [DOI: 10.5320/wjr.v5.i2.78] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 03/15/2015] [Accepted: 04/20/2015] [Indexed: 02/06/2023] Open
Abstract
Lung transplant is the standard of care for patients with end-stage lung disease refractory to medical management. There is currently a critical organ shortage for lung transplantation with only 17% of offered organs being transplanted. Of those patients receiving a lung transplant, up to 25% will develop primary graft dysfunction, which is associated with an 8-fold increase in 30-d mortality. There are numerous mechanical lung assistance modalities that may be employed to help combat these challenges. We will discuss the use of mechanical lung assistance during lung transplantation, as a bridge to transplant, as a treatment for primary graft dysfunction, and finally as a means to remodel and evaluate organs deemed unsuitable for transplant, thus increasing the donor pool, improving survival to transplant, and improving overall patient survival.
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Cerón Navarro J, de Aguiar Quevedo K, Ansótegui Barrera E, Jordá Aragón C, Peñalver Cuesta JC, Mancheño Franch N, Vera Sempere FJ, Padilla Alarcón J. Functional Outcomes After Lung Transplant in Chronic Obstructive Pulmonary Disease. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2014.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Cerón Navarro J, de Aguiar Quevedo K, Ansótegui Barrera E, Jordá Aragón C, Peñalver Cuesta JC, Mancheño Franch N, Vera Sempere FJ, Padilla Alarcón J. Resultados funcionales del trasplante pulmonar en la enfermedad pulmonar obstructiva crónica. Arch Bronconeumol 2015; 51:109-14. [DOI: 10.1016/j.arbres.2014.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 06/17/2014] [Accepted: 06/18/2014] [Indexed: 11/24/2022]
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No-clamp technique for pulmonary artery and venous anastomoses in lung transplantation. J Heart Lung Transplant 2014; 33:1133-8. [DOI: 10.1016/j.healun.2014.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 05/15/2014] [Accepted: 05/28/2014] [Indexed: 11/18/2022] Open
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Liu Y, Liu Y, Su L, Jiang SJ. Recipient-related clinical risk factors for primary graft dysfunction after lung transplantation: a systematic review and meta-analysis. PLoS One 2014; 9:e92773. [PMID: 24658073 PMCID: PMC3962459 DOI: 10.1371/journal.pone.0092773] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 02/25/2014] [Indexed: 01/08/2023] Open
Abstract
Background Primary graft dysfunction (PGD) is the main cause of early morbidity and mortality after lung transplantation. Previous studies have yielded conflicting results for PGD risk factors. Herein, we carried out a systematic review and meta-analysis of published literature to identify recipient-related clinical risk factors associated with PGD development. Method A systematic search of electronic databases (PubMed, Embase, Web of Science, Cochrane CENTRAL, and Scopus) for studies published from 1970 to 2013 was performed. Cohort, case-control, or cross-sectional studies that examined recipient-related risk factors of PGD were included. The odds ratios (ORs) or mean differences (MDs) were calculated using random-effects models Result Thirteen studies involving 10042 recipients met final inclusion criteria. From the pooled analyses, female gender (OR 1.38, 95% CI 1.09 to 1.75), African American (OR 1.82, 95%CI 1.36 to 2.45), idiopathic pulmonary fibrosis (IPF) (OR 1.78, 95% CI 1.49 to 2.13), sarcoidosis (OR 4.25, 95% CI 1.09 to 16.52), primary pulmonary hypertension (PPH) (OR 3.73, 95%CI 2.16 to 6.46), elevated BMI (BMI≥25 kg/m2) (OR 1.83, 95% CI 1.26 to 2.64), and use of cardiopulmonary bypass (CPB) (OR 2.29, 95%CI 1.43 to 3.65) were significantly associated with increased risk of PGD. Age, cystic fibrosis, secondary pulmonary hypertension (SPH), intra-operative inhaled nitric oxide (NO), or lung transplant type (single or bilateral) were not significantly associated with PGD development (all P>0.05). Moreover, a nearly 4 fold increased risk of short-term mortality was observed in patients with PGD (OR 3.95, 95% CI 2.80 to 5.57). Conclusions Our analysis identified several recipient related risk factors for development of PGD. The identification of higher-risk recipients and further research into the underlying mechanisms may lead to selective therapies aimed at reducing this reperfusion injury.
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Affiliation(s)
- Yao Liu
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Yi Liu
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Lili Su
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Shu-juan Jiang
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
- * E-mail:
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Rozé H, Thumerel M, Barandon L, Dromer C, Perrier V, Jougon J, Velly JF, Ouattara A. Cardiopulmonary Bypass During a Second-Lung Implantation Improves Postoperative Oxygenation After Sequential Double-Lung Transplantation. J Cardiothorac Vasc Anesth 2013; 27:467-73. [DOI: 10.1053/j.jvca.2012.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Indexed: 11/11/2022]
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Diamond JM, Porteous MK, Cantu E, Meyer NJ, Shah RJ, Lederer DJ, Kawut SM, Lee J, Bellamy SL, Palmer SM, Lama VN, Bhorade SM, Crespo M, Demissie E, Wille K, Orens J, Shah PD, Weinacker A, Weill D, Arcasoy S, Wilkes DS, Ware LB, Christie JD. Elevated plasma angiopoietin-2 levels and primary graft dysfunction after lung transplantation. PLoS One 2012; 7:e51932. [PMID: 23284823 PMCID: PMC3526525 DOI: 10.1371/journal.pone.0051932] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 11/14/2012] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Primary graft dysfunction (PGD) is a significant contributor to early morbidity and mortality after lung transplantation. Increased vascular permeability in the allograft has been identified as a possible mechanism leading to PGD. Angiopoietin-2 serves as a partial antagonist to the Tie-2 receptor and induces increased endothelial permeability. We hypothesized that elevated Ang2 levels would be associated with development of PGD. METHODS We performed a case-control study, nested within the multi-center Lung Transplant Outcomes Group cohort. Plasma angiopoietin-2 levels were measured pre-transplant and 6 and 24 hours post-reperfusion. The primary outcome was development of grade 3 PGD in the first 72 hours. The association of angiopoietin-2 plasma levels and PGD was evaluated using generalized estimating equations (GEE). RESULTS There were 40 PGD subjects and 79 non-PGD subjects included for analysis. Twenty-four PGD subjects (40%) and 47 non-PGD subjects (59%) received a transplant for the diagnosis of idiopathic pulmonary fibrosis (IPF). Among all subjects, GEE modeling identified a significant change in angiopoietin-2 level over time in cases compared to controls (p = 0.03). The association between change in angiopoietin-2 level over the perioperative time period was most significant in patients with a pre-operative diagnosis of IPF (p = 0.02); there was no statistically significant correlation between angiopoietin-2 plasma levels and the development of PGD in the subset of patients transplanted for chronic obstructive pulmonary disease (COPD) (p = 0.9). CONCLUSIONS Angiopoietin-2 levels were significantly associated with the development of PGD after lung transplantation. Further studies examining the regulation of endothelial cell permeability in the pathogenesis of PGD are indicated.
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Affiliation(s)
- Joshua M Diamond
- Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Lung transplantation on cardiopulmonary support: Venoarterial extracorporeal membrane oxygenation outperformed cardiopulmonary bypass. J Thorac Cardiovasc Surg 2012; 144:1510-6. [DOI: 10.1016/j.jtcvs.2012.07.095] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 04/28/2012] [Accepted: 07/31/2012] [Indexed: 02/02/2023]
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Lee JC, Diamond JM, Christie JD. Critical care management of the lung transplant recipient. CURRENT RESPIRATORY CARE REPORTS 2012; 1:168-176. [PMID: 32288970 PMCID: PMC7102351 DOI: 10.1007/s13665-012-0018-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Lung transplantation provides the prospect of improved survival and quality of life for patients with end stage lung and pulmonary vascular diseases. Given the severity of illness of such patients at the time of surgery, lung transplant recipients require particular attention in the immediate post-operative period to ensure optimal short-term and long-term outcomes. The management of such patients involves active involvement of a multidisciplinary team versed in common post-operative complications. This review provides an overview of such complications as they pertain to the practitioners caring for post-operative lung transplant recipients. Causes and treatment of conditions affecting early morbidity and mortality in lung transplant recipients will be detailed, including primary graft dysfunction, cardiovascular and surgical complications, and immunologic and infectious issues. Additionally, lung donor management issues and bridging the critically ill potential lung transplant recipient to transplantation will be discussed.
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Affiliation(s)
- James C. Lee
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Joshua M. Diamond
- Penn Lung Transplant Program, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, 826 West Gates Pavilion, 3400 Spruce Street, Philadelphia, PA 19104 USA
| | - Jason D. Christie
- Department of Biostatistics and Epidemiology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104 USA
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Burdett C, Butt T, Lordan J, Dark JH, Clark SC. Comparison of single lung transplant with and without the use of cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2012; 15:432-6; discussion 436. [PMID: 22714587 DOI: 10.1093/icvts/ivs264] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Many centres avoid using cardiopulmonary bypass (CPB) for lung transplant due to concerns over aggravated lung reperfusion injury and excessive blood loss. We reviewed our 23-years' experience of single lung transplantation. METHODS A retrospective review of single lung transplants at our institution (1987-2010), examining differences in allograft function and postoperative complications between CPB and non-bypass (non-CPB) cases. RESULTS Two hundred and fifty-nine single lung transplants were undertaken. Fifty-three (20.5%) with CPB. There was no difference demographically between the two groups. No difference existed in preoperative PO(2)/FiO(2). At 1 and 24 h, the postoperative PO(2)/FiO(2) ratio was no different (mean 2.95 and 3.24 in non-CPB cases; 3.53 and 3.75 in CPB patients, P = 0.18 and P = 0.34, respectively). Extubation time was not influenced by the use of CPB. Postoperative blood loss was greater in the CPB group. The usage of fresh frozen plasma and platelets was similar (P = 0.64 and 0.41, respectively). More blood was transfused during postoperative care of CPB patients (P = 0.02). CONCLUSIONS Fears of poor postoperative lung function after CPB appear unfounded. We could detect no difference in function or extubation time. Although the use of CPB increases postoperative bleeding and the need for transfusion, it may be used safely to facilitate lung transplantation.
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Rozé H, Sigonney R, Barandon L, Jougon J, Ouattara A. [Place of traditional CBP in bipulmonary transplantation]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31 Suppl 1:S8-S11. [PMID: 22721523 DOI: 10.1016/s0750-7658(12)70046-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Initially double-lung transplantation (DLT) was performed with airway anastomosis at the tracheal bifurcation requiring a cardiopulmonary bypass (CBP). Complications related to ischemia of the bronchi and trachea around the carina prompted adoption of sequential single lung implantations as the method of choice for DLT. In different studies, CPB was associated with an increase in postoperative morbidity but this was probably due to the selection of more severe patients. Moreover, important progress in the technology of CPB has occurred. Therefore, the systematic use of CPB during sequential lung transplantation might have some interest by limiting the occurrence of ventilation and perfusion injuries. This article discusses the potential beneficial effects of CPB during double-lung transplantation.
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Affiliation(s)
- H Rozé
- CHU de Bordeaux, Service d'anesthésie réanimation 2, F-33600 Pessac, France. hadrien.roze@chu- bordeaux.fr
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Rabanal Llevot JM, Cimadevilla Calvo B, Cifrian Martinez JM, Ruisanchez Villar C, Mons Lera R. [Effect of nebulised iloprost combined with inhaled nitric oxide and oral sildenafil on lung transplant patients. Therapeutic efficacy in pulmonary hypertension during surgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:142-149. [PMID: 22985755 DOI: 10.1016/j.redar.2012.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2010] [Accepted: 02/10/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES There is a high incidence of pulmonary hypertension during the lung transplant peri-operative period, and could lead to a haemodynamic deterioration that may require the need of extracorporeal circulation. Our aim was to study the haemodynamic effects on the pulmonary and systemic circulation of the combination of inhaled nitric oxide and iloprost and oral sildenafil in patients with severe pulmonary hypertension during lung transplant surgery. PATIENTS AND METHODS Seventeen patients received 10μg of nebulised iloprost during the peri-operative period of the lung transplant when their mean pulmonary pressure exceeded 50mmHg. AU the patients received 50mg of oral sildenafil 30min before anaesthetic induction, 20ppm of inhaled nitric oxide after tracheal intubation. The haemodynamic and respiratory variables were recorded at baseline (after anaesthetic induction), prior to the administering of iloprost, and at 5 and 30min after it was given. RESULTS The administering of iloprost significantly reduced the pulmonary arterial pressure and significantly increases the cardiac Índex and the right ventrícular ejection fractíon. There were no signíficant changes occurred in the systemic arterial pressure. CONCLUSIONS The triple combination significantly reduces the pulmonary pressures in the lung transplant peri-operative and should be considered when there is severe pulmonary hypertension during the surgery or during the immediate post-operative period of lung transplantation.
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Affiliation(s)
- J M Rabanal Llevot
- Servicio de Anestesiología y Reanimación, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España.
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Lapar DJ, Hajzus VA, Zhao Y, Lau CL, French BA, Kron IL, Sharma AK, Laubach VE. Acute hyperglycemic exacerbation of lung ischemia-reperfusion injury is mediated by receptor for advanced glycation end-products signaling. Am J Respir Cell Mol Biol 2011; 46:299-305. [PMID: 21980055 DOI: 10.1165/rcmb.2011-0247oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The effects of acute hyperglycemia on lung ischemia-reperfusion (IR) injury and the role of receptor for advanced glycation end-products (RAGE) signaling in this process are unknown. The objective of this study was twofold: (1) evaluate the impact of acute hyperglycemia on lung IR injury; and (2) determine if RAGE signaling is a mechanism of hyperglycemia-enhanced IR injury. We hypothesized that acute hyperglycemia worsens lung IR injury through a RAGE signaling mechanism. C57BL/6 wild-type (WT) and RAGE knockout (RAGE (-/-)) mice underwent sham thoracotomy or lung IR (1-h left hilar occlusion and 2-h reperfusion). Acute hyperglycemia was established by dextrose injection 30 minutes before ischemia. Lung injury was assessed by measuring lung function, cytokine expression in bronchoalveolar lavage fluid, leukocyte infiltration, and microvascular permeability via Evans blue dye. Mean blood glucose levels doubled in hyperglycemic mice 30 minutes after dextrose injection. Compared with IR in normoglycemic mice, IR in hyperglycemic mice significantly enhanced lung dysfunction, cytokine expression (TNF-α, keratinocyte chemoattractant, IL-6, monocyte chemotactic protein-1, regulated upon activation, normal T cell expressed and secreted), leukocyte infiltration, and microvascular permeability. Lung injury and dysfunction after IR were attenuated in normoglycemic RAGE (-/-) mice, and hyperglycemia failed to exacerbate IR injury in RAGE (-/-) mice. Thus, this study demonstrates that acute hyperglycemia exacerbates lung IR injury, whereas RAGE deficiency attenuates IR injury and also prevents exacerbation of IR injury in an acute hyperglycemic setting. These results suggest that hyperglycemia-enhanced lung IR injury is mediated, at least in part, by RAGE signaling, and identifies RAGE as a potential, novel therapeutic target to prevent post-transplant lung IR injury.
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Affiliation(s)
- Damien J Lapar
- Department of Surgery, University of Virginia Health System, P.O. Box 801359, Charlottesville, VA 22908, USA
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LaPar DJ, Laubach VE, Emaminia A, Crosby IK, Hajzus VA, Sharma AK, Sumner HM, Webb DV, Lau CL, Kron IL. Pretreatment strategy with adenosine A2A receptor agonist attenuates reperfusion injury in a preclinical porcine lung transplantation model. J Thorac Cardiovasc Surg 2011; 142:887-94. [PMID: 21762933 DOI: 10.1016/j.jtcvs.2011.06.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 06/02/2011] [Accepted: 06/09/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Adenosine A(2A) receptor activation after lung transplantation attenuates ischemia-reperfusion injury by reducing inflammation. However, the effect of adenosine A(2A) receptor activation in donor lungs before transplant remains ill defined. This study compares the efficacy of 3 different treatment strategies for adenosine A(2A) receptor agonist in a clinically relevant porcine lung transplantation model. METHODS Mature porcine lungs underwent 6 hours of cold ischemia before allotransplantation and 4 hours of reperfusion. Five groups (n = 6/group) were evaluated on the basis of treatment with ATL-1223, a selective adenosine A(2A) receptor agonist: thoracotomy alone (sham), transplant alone (ischemia-reperfusion), donor pretreatment via ATL-1223 bolus (ATL-D), recipient treatment via ATL-1223 infusion (ATL-R), and a combination of both ATL-1223 treatments (ATL-D/R). Lung function and injury were compared. RESULTS Blood oxygenation was significantly higher among ATL-D, ATL-R, and ATL-D/R groups versus ischemia-reperfusion (392.0 ± 52.5, 428.9 ± 25.5, and 509.4 ± 25.1 vs 77.2 ± 17.0 mm Hg, respectively, P < .001). ATL-1223-treated groups had lower pulmonary artery pressures (ATL-D = 30.5 ± 1.8, ATL-R = 30.2 ± 3.3, and ATL-D/R = 29.3 ± 4.5 vs IR = 45.2 ± 2.1 mm Hg, P < .001) and lower mean airway pressures versus ischemia-reperfusion (ATL-D = 9.1 ± 0.8, ATL-R = 9.1 ± 2.6, and ATL-D/R = 9.6 ± 1.3 vs IR = 21.1 mm Hg, P < .001). Likewise, ATL-1223-treated groups had significantly lower lung wet/dry weight, proinflammatory cytokine expression, and lung injury scores by histology compared with ischemia-reperfusion. All parameters of lung function and injury in ATL-1223-treated groups were similar to sham (all P > .05). CONCLUSIONS Pretreatment of donor lungs with ATL-1223 was as efficacious as other treatment strategies in protecting against ischemia-reperfusion injury. If necessary, supplemental treatment of recipients with ATL-1223 may provide additional protection. These results support the development of pharmacologic A(2A)R agonists for use in human clinical trials for lung transplantation.
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Affiliation(s)
- Damien J LaPar
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908, USA
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Abstract
Lung transplantation is a surgical option for patients who fail optimization of medical treatment for the severe symptoms that result from COPD. This review will discuss patient selection, transplant listing, and the surgical technique for transplantation in COPD. Furthermore, it will describe transplant outcomes and its effects on recipient survival, pulmonary function, exercise capacity, respiratory muscle function, and quality of life. The respective roles of transplantation and lung volume reduction surgery as therapies for advanced disease will be outlined.
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Affiliation(s)
- Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
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Prolonged venoarterial extracorporeal membrane oxygenation after transplantation restores functional integrity of severely injured lung allografts and prevents the development of pulmonary graft failure in a pig model. J Thorac Cardiovasc Surg 2009; 137:1493-8. [DOI: 10.1016/j.jtcvs.2008.11.064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 10/22/2008] [Accepted: 11/15/2008] [Indexed: 11/18/2022]
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Abstract
Although significant gains have been made in improving lung function and survival in cystic fibrosis (CF), ultimately respiratory failure is the leading cause of mortality in these patients. For CF patients with end stage lung disease, lung transplantation is an option for treatment. The field of lung transplantation has progressed markedly in the last 20 years. Nonetheless it remains a technically complex and challenging procedure, and patients are at risk for numerous short term and long term complications. Potential transplant recipients must be physically and psychologically prepared for the arduous process involved in lung transplantation. This article will review the history of lung transplantation, indications for transplantation, surgical techniques, and complications of transplantation.
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Carter YM, Gelman AE, Kreisel D. Pathogenesis, management, and consequences of primary graft dysfunction. Semin Thorac Cardiovasc Surg 2008; 20:165-72. [PMID: 18707651 DOI: 10.1053/j.semtcvs.2008.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2008] [Indexed: 12/31/2022]
Abstract
Primary graft dysfunction continues to be a major contributing factor to morbidity and mortality after lung transplantation. This condition is presumed to be the result of ischemia-reperfusion injury, which is associated with the release of endogenous substances that can activate the innate immune system. Primary graft dysfunction has been shown to be an independent risk factor for the development of bronchiolitis obliterans syndrome indicating that it can shape alloimmune responses. In this review, we focus on the classification, pathogenesis, possible prevention strategies, management and consequences of primary graft dysfunction.
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Affiliation(s)
- Yvette M Carter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri 63110-1013, USA
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Yuan SM, Shinfeld A, Raanani E. Cardiopulmonary bypass as an adjunct for the noncardiac surgeon. J Cardiovasc Med (Hagerstown) 2008; 9:338-55. [PMID: 18334888 DOI: 10.2459/jcm.0b013e3282eee889] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiac and Thoracic Surgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Factors Related to Postoperative Mortality in Lung Transplantation for Emphysema. Transplant Proc 2007; 39:3317-22. [DOI: 10.1016/j.transproceed.2007.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Accepted: 09/11/2007] [Indexed: 11/18/2022]
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Feltracco P, Serra E, Barbieri S, Salvaterra F, Rizzi S, Furnari M, Brezzi M, Rea F, Ori C. Anesthetic Concerns in Lung Transplantation for Severe Pulmonary Hypertension. Transplant Proc 2007; 39:1976-80. [PMID: 17692670 DOI: 10.1016/j.transproceed.2007.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Lung transplantation has become a consolidated treatment for patients with severe pulmonary hypertension (PH). Several difficulties are encountered during the procedure in such candidates, who are still recognized as more severely affected by perioperative morbility and mortality than those undergoing lung transplantation for other diseases. Right ventricular (RV) enlargement with tricuspid regurgitation, small left ventricle (LV) with an asymmetric hypetrophic wall, interventricular septal shift toward the left, with ventricular stiffness and diastolic incompetence, are typical preoperative echocardiographic findings of end-stage PH. A smooth induction and tracheal intubation will help prevent hypertensive crisis in highly susceptible candidates. Uncompensated vasodilatation or myocardial depression caused by anesthetics and mechanical ventilation may be responsible for acute RV dysfunction associated with low systemic blood pressure. Resuscitation and emergency adoption of cardiopulmonary by-pass (CPB) has been described for near-fatal anesthesia induction. Cardiovascular instability can develop after institution of one-lung ventilation and pulmonary artery clamping. An acute increase in pulmonary pressure results in a decrease in RV ejection fraction and then in acute RV failure. Interdependence of the right and left ventricles occurs such that RV function can alter LV function. Early detection of impending circulatory and/or respiratory deterioration is warranted to prevent an irreversible decline in cardiac output, resulting in hazardous cardiac arrest. Inhaled nitric oxide represents the first choice for treatment of PH and RV failure associated with systemic hypotension during lung transplantation. Intraoperative situations requiring CPB must be identified before development of systemic shock, which represents a late ominous sign of RV failure.
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Affiliation(s)
- P Feltracco
- Department of Pharmacology and Anesthesia, University Hospital of Padova, Padova, Italy.
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Saitoh M, Tsuchida M, Koike T, Satoh K, Haga M, Aoki T, Toyabe SI, Hayashi JI. Ultrafiltration attenuates cardiopulmonary bypass-induced acute lung injury in a canine model of single-lung transplantation. J Thorac Cardiovasc Surg 2007; 132:1447-54. [PMID: 17140974 PMCID: PMC7127439 DOI: 10.1016/j.jtcvs.2006.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Revised: 07/19/2006] [Accepted: 08/07/2006] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate the effects of cardiopulmonary bypass and ultrafiltration on graft function in a canine single-lung transplantation model. METHODS Fifteen left single-lung transplantations were done in weight-mismatched canine pairs. The animals were divided into 3 groups: group 1, in which transplantation was done without cardiopulmonary bypass; group 2, in which transplantation was done with cardiopulmonary bypass and in which the cardiopulmonary bypass flow was decreased slowly with controlled pulmonary artery pressure; and group 3, in which transplantation was done with cardiopulmonary bypass and ultrafiltration. Hemodynamic parameters and lung function were monitored for 6 hours after reperfusion. The grafts were harvested for histologic studies, myeloperoxidase assay, and real-time quantitative reverse transcription-polymerase chain reaction of mRNA encoding interleukin 6. RESULTS The hemodynamic parameters were similar among the 3 groups. In group 1 PaO2 and alveolar to arterial gradient for O2 levels were excellent throughout the 6-hour observation period, but in group 2 they progressively deteriorated. However, ultrafiltration significantly (P = .02) improved the PaO2 level in group 3. On histology, interstitial edema and polynuclear cell infiltration were most marked in group 2 and significantly worse than in groups 1 and 3. Myeloperoxidase assay and real-time quantitative reverse transcription-polymerase chain reaction showed increased myeloperoxidase activity and interleukin 6 gene expression in group 2 grafts compared with group 1 grafts. Myeloperoxidase activity and interleukin 6 gene expression were suppressed with ultrafiltration. CONCLUSIONS Cardiopulmonary bypass had negative effects on the graft, but ultrafiltration attenuated acute lung dysfunction by reducing the inflammatory response.
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Affiliation(s)
- Masayuki Saitoh
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Masanori Tsuchida
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
- Address for reprints: Masanori Tsuchida, MD, Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata City 951-8510, Japan.
| | - Terumoto Koike
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Koichi Satoh
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Manabu Haga
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Tadashi Aoki
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Shin-ichi Toyabe
- Department of Medical Informatics, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Jun-ichi Hayashi
- Division of Thoracic and Cardiovascular Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
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Hartwig MG, Appel JZ, Cantu E, Simsir S, Lin SS, Hsieh CC, Walczak R, Palmer SM, Davis RD. Improved results treating lung allograft failure with venovenous extracorporeal membrane oxygenation. Ann Thorac Surg 2006; 80:1872-9; discussion 1879-80. [PMID: 16242472 DOI: 10.1016/j.athoracsur.2005.04.063] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2005] [Revised: 04/23/2005] [Accepted: 04/26/2005] [Indexed: 12/11/2022]
Abstract
BACKGROUND Primary graft failure remains a significant source of mortality after lung transplantation. Extracorporeal membrane oxygenation (ECMO) provides treatment for affected recipients. We hypothesized that venovenous membrane oxygenation provides a safer alternative than venoarterial support for lung recipients suffering from primary graft failure. METHODS We conducted an analysis of 522 patients who underwent lung transplantation from April 1992 to July 2004. Twenty-three (4.5%) patients required membrane oxygenation secondary to primary graft failure unresponsive to conventional treatment. Of these recipients, 15 (65%) were treated with venoarterial, while 8 (35%) underwent venovenous membrane oxygenation. RESULTS Median days to initiation and duration of membrane oxygenation did not differ between groups. Eight of 15 patients (53%) from the venoarterial group were successfully weaned from life support, with one surviving greater than 45 days. This lone long-term survivor required retransplantation 4 days after initial transplant. In contrast, all venovenous patients were weaned from support, with 7 of 8 surviving greater than 30 days. The 30-day survival for venovenous recipients (88%) approximates that of all lung recipients at our center (94%, p = 0.42). Noted complications for ECMO patients included renal failure (n = 16), neurologic catastrophes (n = 8), sepsis (n = 5), and hemorrhage (n = 10). The venoarterial recipients suffered 30 of 39 total complications. Most of the complications for venovenous recipients involved renal failure, but by hospital discharge these patients demonstrated a mean creatinine of 0.9 mg/dL. CONCLUSIONS For lung recipients with primary graft failure, venovenous membrane oxygenation provides better outcomes, with fewer complications, than venoarterial membrane oxygenation.
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Affiliation(s)
- Matthew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Vicente R, Morales P, Ramos F, Solé A, Mayo M, Villalain C. Perioperative Complications of Lung Transplantation in Patients With Emphysema and Fibrosis: Experience From 1992–2002. Transplant Proc 2006; 38:2560-2. [PMID: 17098002 DOI: 10.1016/j.transproceed.2006.08.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Our objective was to describe the incidence of perioperative complications of lung transplantation among patients with emphysema and fibrosis and the morbidity and mortality risk factors. MATERIALS AND METHODS We performed a retrospective study of 111 lung transplant patients engrafted from 1992 to 2002 for emphysema (n = 65) or lung fibrosis (n = 46). This descriptive study included the most frequent complications during the perioperative period in the intensive care unit. RESULTS The most frequent intraoperative complications were reperfusion syndrome, hemodynamic instability, and cardiac arrhythmias. Among patients with emphysema, the follow-up of postoperative complications proved statistically significant on univariate analysis for an association of patient mortality with prolonged intubation (P = .005), rejection (P = .0001), hemorrhage (P = .0001), sepsis (P = .0001), renal failure (P = .001), and implantation response (P = .014). Mortality among these patients was 16.9%. Mechanical ventilation for over 48 hours and postoperative hemorrhage were the variables with the greatest predictive value for mortality in the postoperative period. Among patients with fibrosis, the complication-related mortality were reperfusion syndrome (P = .039), implantation response (P = .039), renal failure (P = .013), rejection (P = .016), and sepsis (P < .001). The mortality rate was 23.9% with sepsis (P = .000) being the most frequent cause of death in the immediate postoperative period. CONCLUSIONS The most frequent intraoperative complications were reperfusion syndrome and hemodynamic instability. The most frequent postoperative complications were implantation response, sepsis, prolonged intubation, hemorrhage, and renal failure.
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Affiliation(s)
- R Vicente
- Department of Anesthesia and Critical Care and Lung Transplant Unit, La Fe University Hospital, Valencia, Spain.
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Lau CL, Hoganson DM, Meyers BF, Damiano RJ, Patterson GA. Use of an apical heart suction device for exposure in lung transplantation. Ann Thorac Surg 2006; 81:1524-5. [PMID: 16564318 PMCID: PMC4160742 DOI: 10.1016/j.athoracsur.2005.02.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2005] [Revised: 02/09/2005] [Accepted: 02/17/2005] [Indexed: 11/29/2022]
Abstract
Cardiopulmonary bypass is not necessary for the performance of bilateral sequential lung transplantation in most circumstances. Inadequate exposure to the left hilum is occasionally the sole indication for institution of cardiopulmonary bypass. We report the use of a suction heart positioning device to allow lifting of the heart for improvement of left hilar exposure. This technique has decreased the need for cardiopulmonary bypass when bypass is indicated due to difficult operative exposure.
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Affiliation(s)
- Christine L Lau
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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50
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Dalibon N, Geffroy A, Moutafis M, Vinatier I, Bonnette P, Stern M, Loirat P, Bisson A, Fischler M. Use of cardiopulmonary bypass for lung transplantation: a 10-year experience. J Cardiothorac Vasc Anesth 2006; 20:668-72. [PMID: 17023286 DOI: 10.1053/j.jvca.2006.01.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The use of cardiopulmonary bypass (CPB) for lung transplantation (LTx) has been reported previously. This study reports the authors' experience of planned and unplanned use of cardiopulmonary bypass for LTx. DESIGN Case series. SETTING A university teaching hospital. PARTICIPANTS Patients undergoing LTx. INTERVENTIONS A retrospective analysis of the charts of all patients having undergone LTx over the last 10 years. MEASUREMENTS AND MAIN RESULTS Among 140 LTx, 23 (16%) were performed with the use of CPB. CPB was planned in 11 cases and unplanned in the 12 other cases. The use of CPB is associated with a longer period of postoperative mechanical ventilation, more pulmonary edema, more blood transfusion requirement, and an increase in postoperative mortality at 48 hours and 1 month. Surgical difficulties related to the dissection of the native left lung and acute right ventricular failure are the main reasons for unscheduled use of CPB. CONCLUSION Scheduled and unscheduled CPB for LTx are associated with an increased mortality at 1 month and 1 year.
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Affiliation(s)
- Nicolas Dalibon
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
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