1
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Aburahma K, de Manna ND, Kuehn C, Salman J, Greer M, Ius F. Pushing the Survival Bar Higher: Two Decades of Innovation in Lung Transplantation. J Clin Med 2024; 13:5516. [PMID: 39337005 PMCID: PMC11432129 DOI: 10.3390/jcm13185516] [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: 08/23/2024] [Revised: 09/13/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024] Open
Abstract
Survival after lung transplantation has significantly improved during the last two decades. The refinement of the already existing extracorporeal life support (ECLS) systems, such as extracorporeal membrane oxygenation (ECMO), and the introduction of new techniques for donor lung optimization, such as ex vivo lung perfusion (EVLP), have allowed the extension of transplant indication to patients with end-stage lung failure after acute respiratory distress syndrome (ARDS) and the expansion of the donor organ pool, due to the better evaluation and optimization of extended-criteria donor (ECD) lungs and of donors after circulatory death (DCD). The close monitoring of anti-HLA donor-specific antibodies (DSAs) has allowed the early recognition of pulmonary antibody-mediated rejection (AMR), which requires a completely different treatment and has a worse prognosis than acute cellular rejection (ACR). As such, the standardization of patient selection and post-transplant management has significantly contributed to this positive trend, especially at high-volume centers. This review focuses on lung transplantation after ARDS, on the role of EVLP in lung donor expansion, on ECMO as a principal cardiopulmonary support system in lung transplantation, and on the diagnosis and therapy of pulmonary AMR.
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Affiliation(s)
- Khalil Aburahma
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Nunzio Davide de Manna
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
| | - Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
| | - Mark Greer
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
- Department of Respiratory Medicine and Infectious Diseases, Hannover Medical School, 30625 Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany
- German Centre for Lung Research (DZL/BREATH), 35392 Hannover, Germany
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2
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Midyat L, Muise ED, Visner GA. Pediatric Lung Transplantation for Pulmonary Vascular Diseases: Recent Advances and Challenges. Clin Chest Med 2024; 45:761-769. [PMID: 39069336 DOI: 10.1016/j.ccm.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Pediatric lung transplantation for pulmonary vascular diseases has seen notable advancements and trends. Medical therapies, surgical options, and bridging techniques like extracorporeal membrane oxygenation and different forms of transplants have expanded treatment possibilities. Current challenges include ensuring patient adherence to post-transplant therapies, addressing complications like primary graft dysfunction and rejection, and conducting further research in less common conditions like pulmonary veno-occlusive disease and pulmonary vein stenosis. In this review article, the authors will explore the advancements, emerging trends, and persistent challenges in pediatric lung transplantation for pulmonary vascular diseases.
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Affiliation(s)
- Levent Midyat
- Division of Pulmonary Medicine, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, AOB Suite 3300, Pittsburgh, PA 15224, USA.
| | - Eleanor D Muise
- Division of Pulmonary Medicine, NYU Grossman School of Medicine, Hassenfeld Children's Hospital, 240 East 38th Street, 14th Floor, New York, NY 10016, USA
| | - Gary A Visner
- Division of Pulmonary Medicine, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, BCH 3121, Boston, MA 02115, USA
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3
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Nasir BS, Weatherald J, Ramsay T, Cypel M, Donahoe L, Durkin C, Schisler T, Nagendran J, Liberman M, Landry C, Overbeek C, Moore A, Ferraro P. Randomized trial of routine versus on-demand intraoperative extracorporeal membrane oxygenation in lung transplantation: A feasibility study. J Heart Lung Transplant 2024; 43:1005-1009. [PMID: 38423414 DOI: 10.1016/j.healun.2024.02.1454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 03/02/2024] Open
Abstract
In most centers, extracorporeal membrane oxygenation (ECMO) is the preferred means to provide cardiopulmonary support during lung transplantation. However, there is controversy about whether intraoperative venoarterial (VA) ECMO should be used routinely or selectively. A randomized controlled trial is the best way to address this controversy. In this publication, we describe a feasibility study to assess the practicality of a protocol comparing routine versus selective VA-ECMO during lung transplantation. This prospective, single-center, randomized controlled trial screened all patients undergoing lung transplantation. Exclusion criteria include retransplantation, multiorgan transplantation, and cases where ECMO is mandatory. We determined that the trial would be feasible if we could recruit 19 participants over 6 months with less than 10% protocol violations. Based on the completed feasibility study, we conclude that the protocol is feasible and safe, giving us the impetus to pursue a multicenter trial with little risk of failure due to low recruitment.
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Affiliation(s)
- Basil S Nasir
- Division of Thoracic Surgery, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada
| | - Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta and Mazankowski Heart Institute, Edmonton, Alberta, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marcelo Cypel
- Division of Thoracic Surgery, University Health Networks/Toronto General Hospital (UHN-TGH), Toronto, Ontario, Canada
| | - Laura Donahoe
- Division of Thoracic Surgery, University Health Networks/Toronto General Hospital (UHN-TGH), Toronto, Ontario, Canada
| | - Chris Durkin
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia-Vancouver General Hospital (UBC-VGH), Vancouver, British Columbia, Canada
| | - Travis Schisler
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia-Vancouver General Hospital (UBC-VGH), Vancouver, British Columbia, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, University of Alberta and Mazankowski Heart Institute, Edmonton, Alberta, Canada
| | - Moishe Liberman
- Division of Thoracic Surgery, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada
| | - Caroline Landry
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Quebec, Canada
| | - Charles Overbeek
- Department of Anesthesiology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada
| | - Alex Moore
- Department of Anesthesiology, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada
| | - Pasquale Ferraro
- Division of Thoracic Surgery, Centre Hospitalier de l'Universite de Montreal (CHUM), Montreal, Quebec, Canada
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4
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Tucker WD, Gannon WD, Petree B, Stokes JW, Kertai MD, Demarest CT, Lambright ES, Chae A, Lombard FW, Casey JD, Trindade AJ, Bacchetta M. Impact of anticoagulation intensity on blood transfusion for venoarterial extracorporeal membrane oxygenation during lung transplantation. J Heart Lung Transplant 2024; 43:832-837. [PMID: 38354763 DOI: 10.1016/j.healun.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 01/24/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
Venoarterial extracorporeal membrane oxygenation is increasingly used for mechanical circulatory support during lung transplant. Optimal intensity of intraoperative anticoagulation would be expected to mitigate thromboembolism without increasing bleeding and blood product transfusions. Yet, the optimal intensity of intraoperative anticoagulation is unknown. We performed a retrospective cohort study of 163 patients who received a bilateral lung transplant at a single center. We categorized the intensity of anticoagulation into 4 groups (very low to high) based on the bolus dose of unfractionated heparin given during lung transplant and compared the rates of intraoperative blood transfusions and the occurrence of thromboembolism between groups. When compared to the very low-intensity group, each higher intensity group was associated with higher red blood cell, fresh frozen plasma, and platelet transfusions. The occurrence of thromboembolism was similar across groups. These preliminary data suggest that lower intensity anticoagulation may reduce the rate of intraoperative blood transfusions, although further study is needed.
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Affiliation(s)
- William D Tucker
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Whitney D Gannon
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon Petree
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Caitlin T Demarest
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric S Lambright
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alice Chae
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Frederick W Lombard
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anil J Trindade
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee.
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5
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Huang Z, Zheng J, Wang M, Zeng S, Huang M, Peng S, Li J, Ji J, Chen Q, Xu X, Yang C, Peng G, Yang H. Heparin-free veno-arterial extracorporeal membrane oxygenation in lung transplantation: a retrospective cohort study. J Cardiothorac Surg 2024; 19:255. [PMID: 38643128 PMCID: PMC11031941 DOI: 10.1186/s13019-024-02721-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 03/29/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND In lung transplantation (LTx) surgery, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide mechanical circulatory support to patients with cardiopulmonary failure. However, the use of heparin in the administration of ECMO can increase blood loss during LTx. This study aimed to evaluate the safety of heparin-free V-A ECMO strategies. METHODS From September 2019 to April 2022, patients who underwent lung transplantation at the First Affiliated Hospital of Guangzhou Medical University were retrospectively reviewed. A total of 229 patients were included, including 117 patients in the ECMO group and 112 in the non-ECMO group. RESULT There was no significant difference in the incidence of thrombus events and bleeding requiring reoperation between the two groups. The in-hospital survival rate after single lung transplantation (SLTx) was 81.08%in the ECMO group and 85.14% in the Non-ECMO group, (P = 0.585). The in-hospital survival rate after double lung transplantation (DLTx) was 80.00% in the ECMO group and 92.11% in the Non-ECMO groups (P = 0.095). CONCLUSIONS In conclusion, the findings of this study suggest that the heparin-free V-A ECMO strategy in lung transplantation is a safe approach that does not increase the incidence of perioperative thrombotic events or bleeding requiring reoperation.
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Affiliation(s)
- ZhaoMin Huang
- Department of anesthesia, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120, China
| | - Jiayi Zheng
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Mingyang Wang
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Shaoting Zeng
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Miaoting Huang
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Shuyi Peng
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Jiajun Li
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Jiaming Ji
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Quan Chen
- The First Clinical Medical College, Guangzhou Medical University, No. 195 West Dongfeng Road, Yuexiu District, Guangzhou, 510120, China
| | - Xin Xu
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120, China
| | - Chao Yang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120, China
| | - GuiLin Peng
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120, China
| | - Hanyu Yang
- Department of anesthesia, The First Affiliated Hospital of Guangzhou Medical University, No. 151 Yanjiang Rd, Guangzhou, 510120, China.
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6
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Yang J, Xie X, Li J, Li Y, Li B, Wang C, Jiang P. Which strategy is better for lung transplantation: Cardiopulmonary bypass or extracorporeal membrane oxygenation? Perfusion 2024:2676591241242018. [PMID: 38557237 DOI: 10.1177/02676591241242018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background: In lung transplantation surgery, extracorporeal life support (ECLS) is essential for safety. Various support methods, including cardiopulmonary bypass (CPB) and off-pump techniques, are used, with extracorporeal membrane oxygenation (ECMO) gaining prominence. However, consensus on the best support strategy is lacking.Purpose: This article reviews risks, benefits, and outcomes of different support strategies in lung transplantation. By consolidating knowledge, it aims to clarify selecting the most appropriate ECLS modality.Research Design: A comprehensive literature review examined CPB, off-pump techniques, and ECMO outcomes in lung transplantation, including surgical results and complications.Study Sample: Studies, including clinical trials and observational research, focused on ECLS in lung transplantation, both retrospective and prospective, providing a broad evidence base.Data Collection and/or Analysis: Selected studies were analyzed for surgical outcomes, complications, and survival rates associated with CPB, off-pump techniques, and ECMO to assess safety and effectiveness.Results: Off-pump techniques are preferred, with ECMO increasingly vital as a bridge to transplant, overshadowing CPB. However, ECMO entails hidden risks and higher costs. While safer than CPB, optimizing ECMO postoperative use and monitoring is crucial for success.Conclusions: Off-pump techniques are standard, but ECMO's role is expanding. Despite advantages, careful ECMO management is crucial due to hidden risks and costs. Future research should focus on refining ECMO use and monitoring to improve outcomes, emphasizing individualized approaches for LT recipients.
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Affiliation(s)
- Jianbao Yang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Xinling Xie
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Jian Li
- Second Clinical Medical College, Lanzhou University, Lanzhou, Gansu, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Bin Li
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Cheng Wang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
| | - Peng Jiang
- Department of Thoracic Surgery, Lanzhou University Second Hospital, Lanzhou, Gansu, China
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7
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Jenkins JA, Verdiner R, Omar A, Farina JM, Wilson R, D’Cunha J, Reck Dos Santos PA. Donor and recipient risk factors for the development of primary graft dysfunction following lung transplantation. Front Immunol 2024; 15:1341675. [PMID: 38380332 PMCID: PMC10876853 DOI: 10.3389/fimmu.2024.1341675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/22/2024] [Indexed: 02/22/2024] Open
Abstract
Primary Graft Dysfunction (PGD) is a major cause of both short-term and long-term morbidity and mortality following lung transplantation. Various donor, recipient, and technical risk factors have been previously identified as being associated with the development of PGD. Here, we present a comprehensive review of the current literature as it pertains to PGD following lung transplantation, as well as discussing current strategies to mitigate PGD and future directions. We will pay special attention to recent advances in lung transplantation such as ex-vivo lung perfusion, thoracoabdominal normothermic regional perfusion, and up-to-date literature published in the interim since the 2016 ISHLT consensus statement on PGD and the COVID-19 pandemic.
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Affiliation(s)
- J. Asher Jenkins
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Ricardo Verdiner
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Ashraf Omar
- Division of Pulmonology and Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Juan Maria Farina
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Renita Wilson
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Jonathan D’Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
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8
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Laskey D, Housman B, Dawodu G, Scheinin S. Intraoperative Extracorporeal Support during Lung Transplantation: Not Just for the High-Risk Patient. J Clin Med 2023; 13:192. [PMID: 38202198 PMCID: PMC10779858 DOI: 10.3390/jcm13010192] [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: 09/24/2023] [Revised: 12/15/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
The use of intraoperative mechanical support during lung transplantation has traditionally been a controversial topic. Trends for intraoperative mechanical support strategies swing like a pendulum. Historically, cardiopulmonary bypass (CPB) was the modality of choice during transplantation. It provides full hemodynamic support including oxygenation and decarboxylation. Surgical exposure is improved by permitting the drainage of the heart and provides more permissive retraction. CPBs contain drainage reservoirs with hand-held pump suction catheters promoting blood conservation through collection and re-circulation. But CPB has its disadvantages. It is known to cause systemic inflammation and coagulopathy. CPB requires high doses of heparinization, which increases bleeding risks. As transplantation progressed, off-pump transplantation began to trend as a preferable option. ECMO, however, has many of the benefits of CPB with less of the risk. Outcomes were improved with ECMO compared to CPB. CPB has a higher blood transfusion requirement, a higher need for post-operative ECMO support, a higher re-intubation rate, high rates of kidney injury and need for hemodialysis, longer ICU stays, higher incidences of PGD grade 3, as well as overall in-hospital mortality when compared with ECMO use. The focus now shifts to using intraoperative mechanical support to protect the graft, helping to reduce ischemia-reperfusion injury and allowing for lung protective ventilator settings. Studies show that the routine use of ECMO during transplantation decreases the rate of primary graft dysfunction and many adverse outcomes including ventilator time, need for tracheostomy, renal failure, post-operative ECMO requirements, and others. As intraoperative planned ECMO is considered a safe and effective approach, with improved survival and better overall outcomes compared to both unplanned ECMO implementation and off-pump transplantation, its routine use should be taken into consideration as standard protocol.
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Affiliation(s)
- Daniel Laskey
- Thoracic Surgery Department, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, One Gustave L. Levy Place, Box 1023, New York, NY 10029, USA; (B.H.); (G.D.); (S.S.)
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9
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Serrao G, Vinayak M, Nicolas J, Subramaniam V, Lai AC, Laskey D, Kini A, Seethamraju H, Scheinin S. The Evaluation and Management of Coronary Artery Disease in the Lung Transplant Patient. J Clin Med 2023; 12:7644. [PMID: 38137713 PMCID: PMC10743826 DOI: 10.3390/jcm12247644] [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: 10/09/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
Lung transplantation can greatly improve quality of life and extend survival in those with end-stage lung disease. In order to derive the maximal benefit from such a procedure, patients must be carefully selected and be otherwise healthy enough to survive a high-risk surgery and sometimes prolonged immunosuppressive therapy following surgery. Patients therefore must be critically assessed prior to being listed for transplantation with close attention paid towards assessment of cardiovascular health and operative risk. One of the biggest dictators of this is coronary artery disease. In this review article, we discuss the assessment and management of coronary artery disease in the potential lung transplant candidate.
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Affiliation(s)
- Gregory Serrao
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (M.V.); (J.N.); (V.S.); (A.C.L.); (D.L.); (A.K.); (H.S.); (S.S.)
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10
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Hoeper MM. Extracorporeal Life Support in Pulmonary Hypertension: Practical Aspects. Semin Respir Crit Care Med 2023; 44:771-776. [PMID: 37709284 DOI: 10.1055/s-0043-1772752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Extracorporeal life support (ECLS), in particular veno-arterial extracorporeal membrane oxygenation, has emerged as a potentially life-saving treatment modality in patients presenting with pulmonary hypertension and right heart failure refractory to conventional treatment. Used mainly as a bridge to lung transplantation, ECLS is also being used occasionally as a bridge to recovery in patients with treatable causes of right heart failure. This review article describes indications, contraindications, techniques, and outcomes of the use of ECLS in patients with PH, focusing on practical aspects in the management of such patients.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- German Center for Lung Research (DZL), Member of the European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Hannover, Germany
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11
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Dolci G, Antonacci F, Salvaterra E, Daddi N, Pastore S, Barbera NA, Marrozzini C, Botta L, Bertoglio P, Solli P. Innovative use of Protek Duo during bilateral lung transplant with Veno-Arterial Extracorporeal Membrane Oxygenation assistance. Perfusion 2023; 38:1754-1756. [PMID: 36189688 PMCID: PMC10612372 DOI: 10.1177/02676591221131204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
V-A ECMO during bilateral lung transplantation is routinely used when extracorporeal support is needed, in particular in case of patients affected by pulmonary hypertension. We report the case of a patient successfully transplanted with V-A ECMO assistance using a percutaneous double lumen cannula as venous drainage (Protek Duo, CardiacAssist Inc., Pittsburgh, PA) and central aortic cannulation. The double lumen cannula allowed an optimal drainage of the venous system and effective emptying of right heart chambers.
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Affiliation(s)
- Giampiero Dolci
- Department Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Filippo Antonacci
- Department Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Elena Salvaterra
- Interventional Pulmonology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Niccolò Daddi
- Department Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Saverio Pastore
- Anaesthesiology and Intensive Care, Cardiothoracic and vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Niccolò Antonino Barbera
- Anaesthesiology and Intensive Care, Cardiothoracic and vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cinzia Marrozzini
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Botta
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Bertoglio
- Department Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Piergiorgio Solli
- Department Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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12
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Avtaar Singh SS, Das De S, Al-Adhami A, Singh R, Hopkins PMA, Curry PA. Primary graft dysfunction following lung transplantation: From pathogenesis to future frontiers. World J Transplant 2023; 13:58-85. [PMID: 36968136 PMCID: PMC10037231 DOI: 10.5500/wjt.v13.i3.58] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/11/2022] [Accepted: 02/17/2023] [Indexed: 03/16/2023] Open
Abstract
Lung transplantation is the treatment of choice for patients with end-stage lung disease. Currently, just under 5000 lung transplants are performed worldwide annually. However, a major scourge leading to 90-d and 1-year mortality remains primary graft dysfunction. It is a spectrum of lung injury ranging from mild to severe depending on the level of hypoxaemia and lung injury post-transplant. This review aims to provide an in-depth analysis of the epidemiology, pathophysiology, risk factors, outcomes, and future frontiers involved in mitigating primary graft dysfunction. The current diagnostic criteria are examined alongside changes from the previous definition. We also highlight the issues surrounding chronic lung allograft dysfunction and identify the novel therapies available for ex-vivo lung perfusion. Although primary graft dysfunction remains a significant contributor to 90-d and 1-year mortality, ongoing research and development abreast with current technological advancements have shed some light on the issue in pursuit of future diagnostic and therapeutic tools.
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Affiliation(s)
- Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, United Kingdom
| | - Sudeep Das De
- Heart and Lung Transplant Unit, Wythenshawe Hospital, Manchester M23 9NJ, United Kingdom
| | - Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom
- Department of Heart and Lung Transplant, Royal Papworth Hospital, Cambridge CB2 0AY, United Kingdom
| | - Ramesh Singh
- Mechanical Circulatory Support, Inova Health System, Falls Church, VA 22042, United States
| | - Peter MA Hopkins
- Queensland Lung Transplant Service, Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Philip Alan Curry
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow G81 4DY, United Kingdom
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13
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Melnyk V, Xu W, Ryan JP, Karim HT, Chan EG, Mahajan A, Subramaniam K. Utilization of machine learning to model the effect of blood product transfusion on short-term lung transplant outcomes. Clin Transplant 2023:e14961. [PMID: 36912861 DOI: 10.1111/ctr.14961] [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: 03/06/2022] [Revised: 11/29/2022] [Accepted: 03/01/2023] [Indexed: 03/14/2023]
Abstract
The objective of this study was to identify the relationship between blood product transfusion and short-term morbidity and mortality following lung transplantation utilizing machine learning. Preoperative recipient characterstics, procedural variables, perioperative blood product transfusions, and donor charactersitics were included in the model. The primary composite outcome was occurrence on any of the following six endpoints: mortality during index hospitalization; primary graft dysfunction at 72 h post-transplant or the need for postoperative circulatory support; neurological complications (seizure, stroke, or major encephalopathy); perioperative acute coronary syndrome or cardiac arrest; and renal dysfunction requiring renal replacement therapy. The cohort included 369 patients, with the composite outcome occurring in 125 cases (33.9%). Elastic net regression analysis identified 11 significant predictors of composite morbidity: higher packed red blood cell, platelet, cryoprecipitate and plasma volume from the critical period, preoperative functional dependence, any preoperative blood transfusion, VV ECMO bridge to transplant, and antifibrinolytic therapy were associated with higher risk of morbidity. Preoperative steroids, taller height, and primary chest closure were protective against composite morbidity.
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Affiliation(s)
- Vladyslav Melnyk
- Department of Anesthesiology, University of Alberta - Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Wen Xu
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Lung Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Lung Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aman Mahajan
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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14
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Chan EG, Hyzny EJ, Furukawa M, Ryan JP, Subramaniam K, Morrell MR, Pilewski J, Luketich JD, Sanchez PG. Intraoperative Support for Primary Bilateral Lung Transplantation: A Propensity-Matched Analysis. Ann Thorac Surg 2023; 115:743-749. [PMID: 35780817 DOI: 10.1016/j.athoracsur.2022.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/19/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Single-center studies support benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a method of intraoperative support. Propensity-matched data from a large cohort, however, are currently lacking. Therefore, our goal was to compare outcomes of intraoperative VA-ECMO and cardiopulmonary bypass (CPB) during bilateral lung transplantation (LTx) with a propensity analysis. METHODS We performed a retrospective analysis of 795 consecutive primary adult LTx patients (June 1, 2011-December 26, 2020) using no intraoperative support (n = 210), VA-ECMO (n = 150), or CPB (n = 197). Exclusion criteria included LTx on venovenous-ECMO, single/redo LTx, ex vivo lung perfusion, and concomitant solid-organ transplantation or cardiac procedure. Propensity analysis was performed comparing patients who underwent intraoperative CPB or VA-ECMO. RESULTS The propensity CPB group required more blood products at 72 hours (P = .02) and longer intensive care unit length of stay (P < .001) and ventilator dependence days (P < .001). There were no differences in cerebrovascular accident (P = 1), reintubation (P = .4), dialysis (P = .068), in-hospital mortality (P = .33), and 1-year (P = .67) and 3-year (P = .32) survival. The CPB group had a higher incidence of grade 3 primary graft dysfunction at 72 hours (P < .001). Neither support strategy was a predictor of 1- and 3-year mortality in our multivariable model (VA-ECMO, P = .72 and P = .57; CPB, P = .45 and P = .91, respectively). CONCLUSIONS Intraoperative VA-ECMO during lung transplantation was associated with fewer postoperative blood transfusions, shorter length of mechanical ventilation, and lower incidence of a grade 3 primary graft dysfunction at 72 hours. Although there were some differences in the postoperative course between the VA-ECMO and CPB groups, support type was not associated with differences in survival.
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Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric J Hyzny
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R Morrell
- Division of Pulmonary and Critical Care, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Joseph Pilewski
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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15
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Le Pavec J, Savale L, Prévot G, Montani D, Sitbon O, Fadel E, Humbert M, Mercier O. [Lung transplantation for severe pulmonary hypertension]. Rev Mal Respir 2023; 40 Suppl 1:e52-e57. [PMID: 36725440 DOI: 10.1016/j.rmr.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- J Le Pavec
- Service de Pneumologie et de Transplantation Pulmonaire, Groupe hospitalier Marie-Lannelongue-Paris Saint-Joseph, Le Plessis-Robinson, France; Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint-Joseph, Le Plessis-Robinson, France.
| | - L Savale
- Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint-Joseph, Le Plessis-Robinson, France; Service de Pneumologie, Hôpital Kremlin Bicêtre, AP-HP, Kremlin Bicêtre, France
| | - G Prévot
- Pôle des voies respiratoires-Hôpital Larrey, Centre Hopitalo-Universitaire, Toulouse, France
| | - D Montani
- Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint-Joseph, Le Plessis-Robinson, France; Service de Pneumologie, Hôpital Kremlin Bicêtre, AP-HP, Kremlin Bicêtre, France
| | - O Sitbon
- Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint-Joseph, Le Plessis-Robinson, France; Service de Pneumologie, Hôpital Kremlin Bicêtre, AP-HP, Kremlin Bicêtre, France
| | - E Fadel
- Service de Pneumologie et de Transplantation Pulmonaire, Groupe hospitalier Marie-Lannelongue-Paris Saint-Joseph, Le Plessis-Robinson, France; Université Paris-Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique et Transplantation Cardio-pulmonaire, Groupe Hospitalier Marie-Lannelongue -Paris Saint-Joseph, Le Plessis-Robinson, France
| | - M Humbert
- Université Paris-Saclay, Le Kremlin Bicêtre, France; UMR_S 999, Université Paris-Sud, Inserm, Groupe hospitalier Marie-Lannelongue-Saint-Joseph, Le Plessis-Robinson, France; Service de Pneumologie, Hôpital Kremlin Bicêtre, AP-HP, Kremlin Bicêtre, France
| | - O Mercier
- Service de Pneumologie et de Transplantation Pulmonaire, Groupe hospitalier Marie-Lannelongue-Paris Saint-Joseph, Le Plessis-Robinson, France; Université Paris-Saclay, Le Kremlin Bicêtre, France; Service de Chirurgie Thoracique et Transplantation Cardio-pulmonaire, Groupe Hospitalier Marie-Lannelongue -Paris Saint-Joseph, Le Plessis-Robinson, France
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16
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Hartwig M, van Berkel V, Bharat A, Cypel M, Date H, Erasmus M, Hoetzenecker K, Klepetko W, Kon Z, Kukreja J, Machuca T, McCurry K, Mercier O, Opitz I, Puri V, Van Raemdonck D. The American Association for Thoracic Surgery (AATS) 2022 Expert Consensus Document: The use of mechanical circulatory support in lung transplantation. J Thorac Cardiovasc Surg 2023; 165:301-326. [PMID: 36517135 DOI: 10.1016/j.jtcvs.2022.06.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The use of mechanical circulatory support (MCS) in lung transplantation has been steadily increasing over the prior decade, with evolving strategies for incorporating support in the preoperative, intraoperative, and postoperative settings. There is significant practice variability in the use of these techniques, however, and relatively limited data to help establish institutional protocols. The objective of the AATS Clinical Practice Standards Committee (CPSC) expert panel was to review the existing literature and establish recommendations about the use of MCS before, during, and after lung transplantation. METHODS The AATS CPSC assembled an expert panel of 16 lung transplantation physicians who developed a consensus document of recommendations. The panel was broken into subgroups focused on preoperative, intraoperative, and postoperative support, and each subgroup performed a focused literature review. These subgroups formulated recommendation statements for each subtopic, which were evaluated by the entire group. The statements were then developed via discussion among the panel and refined until consensus was achieved on each statement. RESULTS The expert panel achieved consensus on 36 recommendations for how and when to use MCS in lung transplantation. These recommendations included the use of veno-venous extracorporeal membrane oxygenation (ECMO) as a bridging strategy in the preoperative setting, a preference for central veno-arterial ECMO over traditional cardiopulmonary bypass during the transplantation procedure, and the benefit of supporting selected patients with MCS postoperatively. CONCLUSIONS Achieving optimal results in lung transplantation requires the use of a wide range of strategies. MCS provides an important mechanism for helping these critically ill patients through the peritransplantation period. Despite the complex nature of the decision making process in the treatment of these patients, the expert panel was able to achieve consensus on 36 recommendations. These recommendations should provide guidance for professionals involved in the care of end-stage lung disease patients considered for transplantation.
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Affiliation(s)
- Matthew Hartwig
- Division of Thoracic Surgery, Duke University Medical Center, Durham, NC.
| | | | | | | | - Hiroshi Date
- Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Michiel Erasmus
- University Academic Center Groningen, Groningen, The Netherlands
| | | | | | | | - Jasleen Kukreja
- University of California San Francisco, San Francisco, Calif
| | - Tiago Machuca
- University of Florida College of Medicine, Gainesville, Fla
| | | | - Olaf Mercier
- Université Paris-Saclay and Marie Lannelongue Hospital, Le Plessis-Robinson, France
| | | | - Varun Puri
- Washington University School of Medicine, St Louis, Mo
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17
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Fessler J, Finet M, Fischler M, Le Guen M. New Aspects of Lung Transplantation: A Narrative Overview Covering Important Aspects of Perioperative Management. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010092. [PMID: 36676041 PMCID: PMC9865529 DOI: 10.3390/life13010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/26/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
The management of lung transplant patients has continued to evolve in recent years. The year 2021 was marked by the publication of the International Consensus Recommendations for Anesthetic and Intensive Care Management of Lung Transplantation. There have been major changes in lung transplant programs over the last few years. This review will summarize the knowledge in anesthesia management of lung transplantation with the most recent data. It will highlight the following aspects which concern anesthesiologists more specifically: (1) impact of COVID-19, (2) future of transplantation for cystic fibrosis patients, (3) hemostasis management, (4) extracorporeal membrane oxygenation management, (5) early prediction of primary graft dysfunction, and (6) pain management.
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Affiliation(s)
- Julien Fessler
- Department of Anesthesiology and Pain Management, Hospital Foch, 92150 Suresnes, France
| | - Michaël Finet
- Department of Anesthesiology and Pain Management, Hospital Foch, 92150 Suresnes, France
| | - Marc Fischler
- Department of Anesthesiology and Pain Management, Hospital Foch, 92150 Suresnes, France
- Correspondence:
| | - Morgan Le Guen
- Department of Anesthesiology and Pain Management, Hospital Foch, 92150 Suresnes, France
- University Versailles-Saint-Quentin-en-Yvelines, 78000 Versailles, France
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18
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Cerier EJ, Lung K, Kurihara C, Bharat A. Lung Transplantation in COVID-19 patients: What we have learned so far. Clin Chest Med 2022; 44:347-357. [PMID: 37085224 PMCID: PMC9678827 DOI: 10.1016/j.ccm.2022.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Coronavirus-19 (COVID-19) can result in irrecoverable acute respiratory distress syndrome (ARDS) or life-limiting fibrosis for which lung transplantation is currently the only viable treatment. COVID-19 lung transplantation has transformed the field of lung transplantation, as before the pandemic, few transplants had been performed in the setting of infectious disease or ARDS. Given the complexities associated with COVID-19 lung transplantation, it requires strict patient selection with an experienced multidisciplinary team in a high-resource hospital setting. Current short-term outcomes of COVID-19 lung transplantation are promising. However, follow-up studies are needed to determine long-term outcomes and whether these patients may be predisposed to unique complications.
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19
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Halpern SE, Wright MC, Madsen G, Chow B, Harris CS, Haney JC, Klapper JA, Bottiger BA, Hartwig MG. Textbook outcome in lung transplantation: Planned venoarterial extracorporeal membrane oxygenation versus off-pump support for patients without pulmonary hypertension. J Heart Lung Transplant 2022; 41:1628-1637. [PMID: 35961827 PMCID: PMC10403788 DOI: 10.1016/j.healun.2022.07.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Planned venoarterial extracorporeal membrane oxygenation (VA ECMO) is increasingly used during bilateral orthotopic lung transplantation (BOLT) and may be superior to off-pump support for patients without pulmonary hypertension. In this single-institution study, we compared rates of textbook outcome between BOLTs performed with planned VA ECMO or off-pump support for recipients with no or mild pulmonary hypertension. METHODS Patients with no or mild pulmonary hypertension who underwent isolated BOLT between 1/2017 and 2/2021 with planned off-pump or VA ECMO support were included. Textbook outcome was defined as freedom from intraoperative complication, 30-day reintervention, 30-day readmission, post-transplant length of stay >30 days, 90-day mortality, 30-day acute rejection, grade 3 primary graft dysfunction at 48 or 72 hours, post-transplant ECMO, tracheostomy within 7 days, inpatient dialysis, reintubation, and extubation >48 hours post-transplant. Textbook outcome achievement was compared between groups using multivariable logistic regression. RESULTS Two hundred thirty-seven BOLTs were included: 68 planned VA ECMO and 169 planned off-pump. 14 (20.6%) planned VA ECMO and 27 (16.0%) planned off-pump patients achieved textbook outcome. After adjustment for prior BOLT, lung allocation score, ischemic time, and intraoperative transfusions, planned VA ECMO was associated with higher odds of textbook outcome than planned off-pump support (odds ratio 3.89, 95% confidence interval 1.58-9.90, p = 0.004). CONCLUSIONS At our institution, planned VA ECMO for isolated BOLT was associated with higher odds of textbook outcome than planned off-pump support among patients without pulmonary hypertension. Further investigation in a multi-institutional cohort is warranted to better elucidate the utility of this strategy.
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Affiliation(s)
| | - Mary C Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Gabrielle Madsen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Bryan Chow
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | | | - John C Haney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob A Klapper
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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20
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Iskender I, Pecoraro Y, Moreno Casado P, Kubisa B, Schiavon M, Faccioli E, Ehrsam J, Damarco F, Nosotti M, Inci I, Venuta F, Van Raemdonck D, Ceulemans LJ. Lung transplantation in patients with a history of anatomical native lung resection. Interact Cardiovasc Thorac Surg 2022; 35:6758257. [PMID: 36218975 PMCID: PMC9583932 DOI: 10.1093/icvts/ivac256] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES History of anatomical lung resection complicates lung transplantation (LTx). Our aim was to identify indications, intraoperative approach, and outcome in these challenging cases in a retrospective multicentre cohort analysis. METHODS Members of the ESTS Lung Transplantation Working Group were invited to submit data on patients undergoing LTx after a previous anatomical native lung resection between 01/2005 and 07/2020. The primary end-point was overall survival (Kaplan-Meier estimation). RESULTS Out of 2690 patients at 7 European centers, 26 (1%) patients (14 male; median age 33 years) underwent LTx after a previous anatomical lung resection. Median time from previous lung resection to LTx was 12 years. The most common indications for lung resection were infections (n = 17), emphysema (n = 5), lung tumour (n = 2), and others (n = 2). Bronchiectasis (cystic fibrosis (CF) or non-CF related) was the main indication for LTx (n = 21), followed by COPD (n = 5). Two patients with a previous pneumonectomy underwent contralateral single LTx and 1 patient with a previous lobectomy had ipsilateral single LTx. The remaining 23 patients underwent bilateral LTx. Clamshell incision was performed in 12 (46%) patients. Moreover, LTx was possible without extracorporeal life support in 13 (50%) patients. 90-day mortality was 8% (n = 2) and the median survival was 8.7 years. CONCLUSIONS History of anatomical lung resection is rare in LTx candidates. The majority of patients are young and diagnosed with bronchiectasis. Although the numbers were limited, survival after LTx in patients with previous anatomical lung resection, including pneumonectomy is comparable to reported conventional LTx for bronchiectasis.
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Affiliation(s)
- Ilker Iskender
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, KU Leuven, Leuven, Belgium
| | - Ylenia Pecoraro
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - Paula Moreno Casado
- Department of Thoracic Surgery, University Hospital Reina Sofia, Cordoba, Spain
| | - Bartosz Kubisa
- Department of Thoracic Surgery, Pomeranian Medical University of Szczecin, Szczecin, Poland
| | - Marco Schiavon
- Department of Thoracic Surgery, University of Padua, Padua, Italy
| | | | - Jonas Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Francesco Damarco
- Department of Thoracic Surgery, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Nosotti
- Department of Thoracic Surgery, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Federico Venuta
- Department of Thoracic Surgery, Policlinico Umberto I, University of Rome La Sapienza, Rome, Italy
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Lung Transplant Unit, KU Leuven, Leuven, Belgium
| | - Laurens J Ceulemans
- Corresponding author. Thoraxheelkunde, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium. Tel: +32-16346820; e-mail: (L.J. Ceulemans)
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21
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Jacob S, Ahmed MMES, Haddad OK, Orlando D, Landolfo C, Thomas M, Makey IA, Sareyyupoglu B, Landolfo K, Pham SM. Regression of Tricuspid Valve Regurgitation After Lung Transplant: A Single-Center Experience. Transplant Proc 2022; 54:2325-2328. [PMID: 36058747 DOI: 10.1016/j.transproceed.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 08/02/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although tricuspid regurgitation (TR) is common in candidates for lung transplant, no data or established guidelines exist regarding the need for surgical repair at the time of transplant. We aimed to evaluate the natural course of TR by assessing the incidence and extent of TR regression among patients who did not undergo tricuspid valve repair (TVR) concomitantly with lung transplant. METHODS We retrospectively identified adult patients who underwent lung transplant without TVR at our institution from 2001 through 2017. Pretransplant and posttransplant echocardiograms were reviewed to assess severity of TR, tricuspid annular plane systolic excursion, central venous pressure, mean pulmonary arterial pressure, and right ventricular size and function. RESULTS Among 553 included patients, 324 (58.7%) were men, the mean (SD) age was 61.9 years (12.7), and 417 (75.4%) had a double lung transplant. TR before transplant was reported as trivial in 265 patients (47.9%), mild in 235 (42.5%), moderate in 40 (7.2%), and severe in 13 (2.4%). After transplant, TR improved significantly overall (P < .001). TR improved in 193 patients: 158 patients (81.9%) by 1 grade and 35 patients (18.1%) by 2 or more grades. Additionally, of 53 patients with pretransplant moderate or severe TR, 44 (83%) had improvement to mild, trivial, or no TR. After transplant, 12 patients (2.2%) had no remaining TR. CONCLUSION The severity of TR improved or showed no change in most patients after lung transplant, which obviates the need for TVR among most lung transplant recipients.
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Affiliation(s)
- Samuel Jacob
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida.
| | - Magdy M El-Sayed Ahmed
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Osama K Haddad
- Department of Cardiothoracic Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - David Orlando
- Clinical Research Internship Study Program, Mayo Clinic School of Health Sciences, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Carolyn Landolfo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Mathew Thomas
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Ian A Makey
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Basar Sareyyupoglu
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Kevin Landolfo
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
| | - Si M Pham
- Department of Cardiothoracic Surgery Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
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22
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Experience with intraoperative extracorporeal membrane oxygenation in lung transplantation: intraoperative indicators. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.7266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Intraoperative extracorporeal membrane oxygenation (ECMO) is being used with increasing frequency in lung transplantation. However, the factors associated with the use of intraoperative ECMO in lung transplant patients are not yet conclusive. In this study, we aimed to determine the effective factors for providing intraoperative ECMO support in patients undergoing lung transplantation. In addition, we aimed to evaluate the effect of ECMO support on morbidity and mortality.
Methods: In this retrospective cohort study evaluating lung transplant patients, patients were divided into two groups: those who received intraoperative ECMO support and those who did not. Demographic data, the lung allocation score (LAS) and pulmonary arterial pressure (PAP), intraoperative data, postoperative complications, duration of mechanical ventilation (MV), length of stay (LOS) in intensive care and hospital, and mortality rates were recorded for both groups. Factors affecting entry to ECMO were analyzed by Multivariate Logistic Regression.
Results: In this period, 51.9% of 87 patients who underwent lung transplantation required intraoperative ECMO. The mean age, LAS, and PAP of the ECMO group were significantly higher than the non-ECMO group (P = 0.043, P = 0.007, and P = 0.007, respectively). In multivariate analysis, it was found that lower MAP averages were a predictive parameter in intraoperative ECMO requirements (OR: 1.091; CI: 1.009-1.179; P = 0.028). The ECMO group’s mechanical ventilation time and hospital mortality were significantly higher than the other group (P = 0.004 and P = 0.025, respectively).
Conclusion: Preoperative indicators of intraoperative ECMO support were determined as age, LAS, and PAP elevation. In addition, low MAP levels and high lactate levels were always determined as intraoperative indicators in lung transplantation until the transition to ECMO support.
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23
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Managing pulmonary arterial hypertension: how to select and facilitate successful transplantation. Curr Opin Organ Transplant 2022; 27:169-176. [PMID: 35649107 DOI: 10.1097/mot.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite improvements in available medical therapies, pulmonary arterial hypertension (PAH) remains a progressive, ultimately fatal disorder. Lung transplantation is a viable treatment option for PAH patients with advanced disease. RECENT FINDINGS Recent guidelines from the International Society of Heart and Lung Transplantation (ISHLT) have updated recommendations regarding time of referral and listing for lung transplantation in PAH. The new guidelines emphasize earlier referral for transplant evaluation to ensure adequate time for proper evaluation and listing. They also incorporate objective risk stratification criteria to assist in decision-making regarding timing of referral and listing. With regards to the transplant procedure, bilateral lung transplantation has largely supplanted heart-lung transplantation as the procedure of choice for transplantation for advanced PAH. Exceptions to this include patients with PAH because of congenital heart disease and those with concurrent LV dysfunction. Use of mechanical support via venoarterial ECMO initiated before transplantation and continued into the early postoperative period is emerging as a standard of care and may help to reduce early posttransplant mortality in this population. There has been increased recognition of the importance of WHO Group 3 pulmonary hypertension. Many of the lessons learned from PAH may be applied when transplanting patients with severe WHO Group 3 pulmonary hypertension. SUMMARY Patients with PAH present unique challenges with regards to transplantation that require a therapeutic approach distinct from other lung disorders. Lung transplantations for PAH are high-risk endeavors best performed at centers with expertise in management of both PAH and extracorporeal support.
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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Ruberto F, Alessandri F, Piazzolla M, Zullino V, Bruno K, Celli P, Diso D, Venuta F, Bilotta F, Pugliese F. Intraoperative use of extracorporeal CO 2 removal (ECCO 2R) and emergency ECMO requirement in patients undergoing lung transplant: a case-matched cohort retrospective study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:22. [PMID: 37386563 DOI: 10.1186/s44158-022-00050-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 05/10/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND The use of extracorporeal carbon dioxide removal (ECCO2R) is less invasive than extracorporeal membrane oxygenation (ECMO), and intraoperative control of gas exchange could be feasible. The aim of this study in intermediate intraoperative severity patients undergoing LT was to assess the role of intraoperative ECCO2R on emergency ECMO requirement in patients. METHODS Thirty-eight consecutive patients undergoing lung transplantation (LT) with "intermediate" intraoperative severity in the intervals 2007 to 2010 or 2011 to 2014 were analyzed as historical comparison of case-matched cohort retrospective study. The "intermediate" intraoperative severity was defined as the development of intraoperative severe respiratory acidosis with maintained oxygenation function (i.e., pH <7.25, PaCO2 >60 mmHg, and PaO2/FiO2 >150), not associated with hemodynamic instability. Of these 38 patients, twenty-three patients were treated in the 2007-2010 interval by receiving "standard intraoperative treatment," while 15 patients were treated in the 2011-2014 interval by receiving "standard intraoperative treatment + ECCO2R." RESULTS ECMO requirement was more frequent among patients that received "standard intraoperative treatment" alone than in those treated with "standard intraoperative treatment + ECCO2R" (17/23 vs. 3/15; p = 0.004). The use of ECCO2R improved pH and PaCO2 while mean pulmonary artery pressure (mPAP) decreased. CONCLUSION In intermediate intraoperative severity patients, the use of ECCO2R reduces the ECMO requirement.
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Affiliation(s)
- Franco Ruberto
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Alessandri
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Mario Piazzolla
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Veronica Zullino
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Katia Bruno
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Paola Celli
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Daniele Diso
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Venuta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Federico Bilotta
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Pugliese
- Department of General and Specialistic Surgery "Paride Stefanini", "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Anesthetic Management During Lung Transplantation - What's New in 2021? Thorac Surg Clin 2022; 32:175-184. [PMID: 35512936 DOI: 10.1016/j.thorsurg.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As outcomes of lung transplantation (LTx) are improving transplant centers are pushing boundaries. There has been a steady increase in the medical complexity of lung transplant candidates. Many transplant centers are listing older patients with comorbidities, and there has been a steady rise in the number of candidates supported with extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation. There has been a growing appreciation of the importance intraoperative management of potentially modifiable risk factors has on postoperative outcomes. Evidence suggests that LTx even in high-risk patients requiring perioperative ECMO can offer excellent results. This article outlines the current state-of-the-art intraoperative management of LTx.
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Trinh BN, Brzezinski M, Kukreja J. Early Postoperative Management of Lung Transplant Recipients. Thorac Surg Clin 2022; 32:185-195. [PMID: 35512937 DOI: 10.1016/j.thorsurg.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The early postoperative period after lung transplantation is a critical time. Prompt recognition and treatment of primary graft dysfunction can alter long-term allograft function. Cardiovascular, gastrointestinal, renal, and hematologic derangements are common and require close management to limit their negative sequelae.
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Affiliation(s)
- Binh N Trinh
- Division of Cardiothoracic Surgery, University of California, San Francisco, 500 Parnassus Avenue, Suite MUW-405, San Francisco, CA 94143-0118, USA
| | - Marek Brzezinski
- Department of Anesthesia, University of California, San Francisco, 500 Parnassus Avenue, Suite MUW-405, San Francisco, CA 94143-0118, USA
| | - Jasleen Kukreja
- Division of Cardiothoracic Surgery, University of California, San Francisco, 500 Parnassus Avenue, Suite MUW-405, San Francisco, CA 94143-0118, USA.
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Kuckelman J, Debarros M, Bueno R. Extended Resections for Lung Cancer. Surg Clin North Am 2022; 102:345-363. [DOI: 10.1016/j.suc.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kurihara C, Manerikar A, Querrey M, Felicelli C, Yeldandi A, Garza-Castillon R, Lung K, Kim S, Ho B, Tomic R, Arunachalam A, Budinger GRS, Pesce L, Bharat A. Clinical Characteristics and Outcomes of Patients With COVID-19-Associated Acute Respiratory Distress Syndrome Who Underwent Lung Transplant. JAMA 2022; 327:652-661. [PMID: 35085383 PMCID: PMC8796055 DOI: 10.1001/jama.2022.0204] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/07/2022] [Indexed: 02/03/2023]
Abstract
Importance Lung transplantation is a potentially lifesaving treatment for patients who are critically ill due to COVID-19-associated acute respiratory distress syndrome (ARDS), but there is limited information about the long-term outcome. Objective To report the clinical characteristics and outcomes of patients who had COVID-19-associated ARDS and underwent a lung transplant at a single US hospital. Design, Setting, and Participants Retrospective case series of 102 consecutive patients who underwent a lung transplant at Northwestern University Medical Center in Chicago, Illinois, between January 21, 2020, and September 30, 2021, including 30 patients who had COVID-19-associated ARDS. The date of final follow-up was November 15, 2021. Exposures Lung transplant. Main Outcomes and Measures Demographic, clinical, laboratory, and treatment data were collected and analyzed. Outcomes of lung transplant, including postoperative complications, intensive care unit and hospital length of stay, and survival, were recorded. Results Among the 102 lung transplant recipients, 30 patients (median age, 53 years [range, 27 to 62]; 13 women [43%]) had COVID-19-associated ARDS and 72 patients (median age, 62 years [range, 22 to 74]; 32 women [44%]) had chronic end-stage lung disease without COVID-19. For lung transplant recipients with COVID-19 compared with those without COVID-19, the median lung allocation scores were 85.8 vs 46.7, the median time on the lung transplant waitlist was 11.5 vs 15 days, and preoperative venovenous extracorporeal membrane oxygenation (ECMO) was used in 56.7% vs 1.4%, respectively. During transplant, patients who had COVID-19-associated ARDS received transfusion of a median of 6.5 units of packed red blood cells vs 0 in those without COVID-19, 96.7% vs 62.5% underwent intraoperative venoarterial ECMO, and the median operative time was 8.5 vs 7.4 hours, respectively. Postoperatively, the rates of primary graft dysfunction (grades 1 to 3) within 72 hours were 70% in the COVID-19 cohort vs 20.8% in those without COVID-19, the median time receiving invasive mechanical ventilation was 6.5 vs 2.0 days, the median duration of intensive care unit stay was 18 vs 9 days, the median post-lung transplant hospitalization duration was 28.5 vs 16 days, and 13.3% vs 5.5% required permanent hemodialysis, respectively. None of the lung transplant recipients who had COVID-19-associated ARDS demonstrated antibody-mediated rejection compared with 12.5% in those without COVID-19. At follow-up, all 30 lung transplant recipients who had COVID-19-associated ARDS were alive (median follow-up, 351 days [IQR, 176-555] after transplant) vs 60 patients (83%) who were alive in the non-COVID-19 cohort (median follow-up, 488 days [IQR, 368-570] after lung transplant). Conclusions and Relevance In this single-center case series of 102 consecutive patients who underwent a lung transplant between January 21, 2020, and September 30, 2021, survival was 100% in the 30 patients who had COVID-19-associated ARDS as of November 15, 2021.
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Affiliation(s)
- Chitaru Kurihara
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
| | - Adwaiy Manerikar
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
| | - Melissa Querrey
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
| | | | - Anjana Yeldandi
- Department of Pathology, Northwestern University, Chicago, Illinois
| | | | - Kalvin Lung
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
| | - Samuel Kim
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
| | - Bing Ho
- Division of Nephrology, Northwestern University, Chicago, Illinois
| | - Rade Tomic
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois
| | - Ambalavanan Arunachalam
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois
| | - G. R. Scott Budinger
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, Illinois
| | - Lorenzo Pesce
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Northwestern University, Chicago, Illinois
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Loor G, Huddleston S, Hartwig M, Bottiger B, Daoud D, Wei Q, Zhang Q, Ius F, Warnecke G, Villavicencio MA, Tirabassi B, Machuca TN, Van Raemdonck D, Frick AE, Neyrinck A, Toyoda Y, Kashem MA, Landeweer M, Chandrashekaran S. Effect of mode of intraoperative support on post-lung transplant primary graft dysfunction. J Thorac Cardiovasc Surg 2022; 164:1351-1361.e4. [DOI: 10.1016/j.jtcvs.2021.10.076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 10/31/2022]
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Sef D, Verzelloni Sef A, Trkulja V, Raj B, Lees NJ, Walker C, Mitchell J, Petrou M, De Robertis F, Stock U, McGovern I. Midterm outcomes of venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation: Comparison with nonbridged recipients. J Card Surg 2022; 37:747-759. [PMID: 35060184 DOI: 10.1111/jocs.16253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 11/28/2021] [Accepted: 12/24/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Davorin Sef
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Alessandra Verzelloni Sef
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Vladimir Trkulja
- Department of Pharmacology Zagreb University School of Medicine Zagreb Croatia
| | - Binu Raj
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Nicholas J. Lees
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Christopher Walker
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Jerry Mitchell
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Mario Petrou
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Ulrich Stock
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
| | - Ian McGovern
- Department of Anesthesia and Critical Care Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, Harefield Hospital London UK
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Reck Dos Santos P, D'Cunha J. Intraoperative support during lung transplantation. J Thorac Dis 2022; 13:6576-6586. [PMID: 34992836 PMCID: PMC8662508 DOI: 10.21037/jtd-21-1166] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/30/2021] [Indexed: 12/29/2022]
Abstract
The role of intraoperative mechanical support during lung transplantation (LTx) is essential to provide a safe hemodynamic and ventilatory status during critical intraoperative events. This hemodynamic and ventilatory stability is vital to minimize the odds of suboptimal outcomes, especially considering that, due to the scarcity of donors and the fact that more and more patients with significant comorbidities are being considered for this therapy, a more aggressive approach is often needed by the transplant centers. Hence, the attenuation of any potential injury that can happen during this complex event is paramount. While a thorough assessment of the donor and optimization of postoperative care is pursued, certainly protective intraoperative management would also contribute to better outcomes. Understanding each patient’s underlying anatomy and cardiopulmonary physiology, associated with awareness of critical events during a complicated procedure like LTx, is essential for a precise indication and safe use of support. Cardiopulmonary bypass (CPB) and veno-arterial extracorporeal membrane oxygenation (VA ECMO) have been the most common approaches used, with the latter gaining popularity more recently and we have used VA ECMO exclusively for the last decade. New technologies certainly contributed to more liberal use of VA ECMO intraoperatively, enabling a protecting and physiologic environment for the newly implanted grafts. In this setting, potential prophylactic use for lung protection during a critical period is also considered.
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Affiliation(s)
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
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Andreasson A, Hoetzenecker K. Commentary: Why a routine venoarterial extracorporeal membrane oxygenation support strategy is a good idea in lung transplantation. J Thorac Cardiovasc Surg 2021; 164:1363-1364. [PMID: 34930581 DOI: 10.1016/j.jtcvs.2021.12.008] [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: 12/03/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 10/31/2022]
Affiliation(s)
- Anders Andreasson
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Konrad Hoetzenecker
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria.
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Ruszel N, Kiełbowski K, Piotrowska M, Kubisa M, Grodzki T, Wójcik J, Kubisa B. Central, peripheral ECMO or CPB? Comparsion between circulatory support methods used during lung transplantation. J Cardiothorac Surg 2021; 16:341. [PMID: 34838067 PMCID: PMC8627075 DOI: 10.1186/s13019-021-01719-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 11/06/2021] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease, cystic fibrosis and usual interstitial pneumonia are three most common indications for lung transplantation (LuTx) in Poland. As a result of irreversible destruction of pulmonary parenchyma and extended respiratory insufficiency that appear afterwards, it is crucial to estimate the reserve of gas exchange in each lung before and during surgery. Altering conditions of gas exchange require adaptation in circulatory system as well. In some of the cases the use of extracorporeal life support appears to be necessary to undergo the transplantation successfully. Cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) used during operation allow to replace the function of heart and lung, but they are also related to complications in the form of acute kidney failure, bleeding, heart arrhythmias or thromboembolic complications. METHODS We reviewed 77 LuTx from 2009 to 2020 performed at the Department of Thoracic Surgery and Transplantation. 40/77 (51%) patients required intraoperative extracorporeal assistance: 8 required CBP and 32 required ECMO. In the ECMO group 14/32 (44%) patients had peripheral cannulation and 18/32 (56%) had central one. We have calculated the survival rates and reviewed postoperative complications after lung transplantations. Cumulative Kaplan-Meier survival curves were calculated. Differences between the groups were evaluated by the Chi- square analysis for discontinuous variables and t-test for continuous variables. RESULTS The use of intraoperative central extracorporeal membrane oxygenator was associated with increased survival rates comparing to patients without external support (30-days, 1-year, 3-years, 5-years rates: 78%, 66%, 66%, 66% vs 83%, 65%, 59%, 44% respectively). Furthermore, survival was enhanced comparing to peripheral ECMO or cardiopulmonary bypass as well (50%, 41%, 41%, 33%; 75%, 50%, 50%, 38% respectively). Acute kidney injury and thromboembolic complications occurred statistically more often in case of patients that underwent lung transplantation with support devices (p = 0.005, p = 0.02 respectively). Frequency of other complications was comparable among groups. CONCLUSIONS The use of central extracorporeal membrane oxygenation should be favorized over peripheral cannulation or cardiopulmonary bypass. CPB should be no longer used during LuTx. Trial registration Not applicable.
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Affiliation(s)
- Nikola Ruszel
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland.
| | - Kajetan Kiełbowski
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland
| | - Maria Piotrowska
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland
| | - Michał Kubisa
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland
| | - Tomasz Grodzki
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland
| | - Janusz Wójcik
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland
| | - Bartosz Kubisa
- Department of Thoracic Surgery and Transplantation, Independent Public Regional Hospital, Pomeranian Medical University, Sokołowskiego 11 Street, Szczecin-Zdunowo, Poland
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Fessler J, Vallée A, Guirimand A, Sage E, Glorion M, Roux A, Brugière O, Parquin F, Zuber B, Cerf C, Vasse M, Pascreau T, Fischler M, Ichai C, Guen ML. Blood Lactate During Double-Lung Transplantation: A Predictor of Grade-3 Primary Graft Dysfunction. J Cardiothorac Vasc Anesth 2021; 36:794-804. [PMID: 34879926 DOI: 10.1053/j.jvca.2021.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Many prognostic factors of grade-3 primary graft dysfunction at postoperative day 3 (PGD3-T72) have been reported, but intraoperative blood lactate level has not been studied. The present retrospective study was done to test the hypothesis that intraoperative blood lactate level (BLL) could be a predictor of PGD3-T72 after double-lung transplantation. DESIGN Retrospective monocentric cohort study. SETTING Foch University Hospital, Suresnes, France. PARTICIPANTS Patients having received a double-lung transplantation between 2012 and 2019. Patients transplanted twice during the study period, having undergone a multiorgan transplantation, or cardiopulmonary bypass, and those under preoperative extracorporeal membrane oxygenation, were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Analysis was performed on a cohort of 449 patients. Seventy-two (16%) patients had a PGD3-T72. Blood lactate level increased throughout surgery to reach a median value of 2.2 (1.6-3.2) mmol/L in the No-PGD3-T72 group and 3.4 (2.3-5.0) mmol/L in the PGD3-T72 group after second lung implantation. The best predictive model for PGD3-T72 was obtained adding a lactate threshold of 2.6 mmol/L at the end of surgery to the clinical model, and the area under the curve was 0.867, with a sensitivity = 76.9% and specificity = 85.4%. Repeated-measures mixed model of BLL during surgery remained significant after adjustment for covariates (F ratio= 4.22, p < 0.001 for interaction). CONCLUSIONS Blood lactate level increases during surgery and reaches a maximum after the second lung implantation. A value below the threshold of 2.6 mmol/L at the end of surgery has a high negative predictive value for the occurrence of a grade-3 primary graft dysfunction at postoperative day 3.
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Affiliation(s)
- Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France.
| | - Alexandre Vallée
- Department of Clinical Research and Innovation, Hôpital Foch, Suresnes, France
| | - Avit Guirimand
- Department of Anesthesiology, Hôpital Marie-Lannelongue, Le Plessis Robinson, France
| | - Edouard Sage
- Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France; Department of Thoracic Surgery, Hôpital Foch, Suresnes, France
| | - Matthieu Glorion
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Antoine Roux
- Department of Pneumology, Hôpital Foch, Suresnes, France,; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Olivier Brugière
- Department of Pneumology, Hôpital Foch, Suresnes, France,; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - François Parquin
- Department of Thoracic Surgery, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
| | - Benjamin Zuber
- Department of Intensive Care Medicine, Hôpital Foch, Suresnes, France
| | - Charles Cerf
- Department of Intensive Care Medicine, Hôpital Foch, Suresnes, France
| | - Marc Vasse
- Department of Clinical Biology, Hôpital Foch, Suresnes, France; INSERM UMRS-1176, Université Paris-Sud, Orsay
| | - Tiffany Pascreau
- Department of Clinical Biology, Hôpital Foch, Suresnes, France; INSERM UMRS-1176, Université Paris-Sud, Orsay
| | - Marc Fischler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France.
| | - Carole Ichai
- Department of Intensive Care, Hôpital Pasteur, Nice, France; IRCAN INSERM, Nice, France
| | - Morgan Le Guen
- Department of Anesthesiology, Hôpital Foch, Suresnes, France; Université Versailles-Saint-Quentin-en-Yvelines, Versailles, France
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez A, Eiras M, Sandoval E, Sarralde J, Quintana-Villamandos B, Vicente Guillén R. Documento de consenso SEDAR/SECCE sobre el manejo de ECMO. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Zarragoikoetxea I, Pajares A, Moreno I, Porta J, Koller T, Cegarra V, Gonzalez AI, Eiras M, Sandoval E, Aurelio Sarralde J, Quintana-Villamandos B, Vicente Guillén R. SEDAR/SECCE ECMO management consensus document. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:443-471. [PMID: 34535426 DOI: 10.1016/j.redare.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 12/14/2020] [Indexed: 06/13/2023]
Abstract
ECMO is an extracorporeal cardiorespiratory support system whose use has been increased in the last decade. Respiratory failure, postcardiotomy shock, and lung or heart primary graft failure may require the use of cardiorespiratory mechanical assistance. In this scenario perioperative medical and surgical management is crucial. Despite the evolution of technology in the area of extracorporeal support, morbidity and mortality of these patients continues to be high, and therefore the indication as well as the ECMO removal should be established within a multidisciplinary team with expertise in the area. This consensus document aims to unify medical knowledge and provides recommendations based on both the recent bibliography and the main national ECMO implantation centres experience with the goal of improving comprehensive patient care.
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Affiliation(s)
- I Zarragoikoetxea
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - A Pajares
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - I Moreno
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - J Porta
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - T Koller
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - V Cegarra
- Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - A I Gonzalez
- Servicio de Anestesiología y Reanimación, Hospital Puerta de Hierro, Madrid, Spain
| | - M Eiras
- Servicio de Anestesiología y Reanimación, Hospital Clínico Universitario de Santiago, La Coruña, Spain
| | - E Sandoval
- Servicio de Cirugía Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Aurelio Sarralde
- Servicio de Cirugía Cardiovascular, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - B Quintana-Villamandos
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - R Vicente Guillén
- Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Bermudez CA, Crespo MM, Shlobin OA, Cantu E, Mazurek JA, Levine D, Gutsche J, Kanwar M, Dellgren G, Bush EL, Heresi GA, Cypel M, Hadler R, Kolatis N, Franco V, Benvenuto L, Mooney J, Pipeling M, King C, Mannem H, Raman S, Knoop C, Douglas A, Mercier O. ISHLT consensus document on lung transplantation in patients with connective tissue disease: Part II: Cardiac, surgical, perioperative, operative, and post-operative challenges and management statements. J Heart Lung Transplant 2021; 40:1267-1278. [PMID: 34404570 DOI: 10.1016/j.healun.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/09/2023] Open
Abstract
Patients with connective tissue disease (CTD) present unique surgical, perioperative, operative, and postoperative challenges related to the often underlying severe pulmonary hypertension and right ventricular dysfunction. The International Society for Heart and Lung Transplantation-supported consensus document on lung transplantation in patients with CTD standardization addresses the surgical challenges and relevant cardiac involvement in the perioperative, operative, and postoperative management in patients with CTD.
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Affiliation(s)
- Christian A Bermudez
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Oksana A Shlobin
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Edward Cantu
- Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy A Mazurek
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Deborah Levine
- Division of Pulmonary and Critical Care Medicine, University of Texas Health Science Center San Antonio, Texas
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Göran Dellgren
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Errol L Bush
- Division of Thoracic Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Marcello Cypel
- Division of Thoracic Surgery, Toronto General Hospital UHN, Toronto, Ontario, Canada
| | - Rachel Hadler
- Division of Critical Care, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Nicholas Kolatis
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco Medical Center, San Francisco, California
| | - Veronica Franco
- Department of Cardiology, The Ohio State university Wexner Medical Center, Columbus, Ohio
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical center, New York, New York
| | - Joshua Mooney
- Division of Pulmonary and Critical Care Medicine, Stanford Health Care, Palo Alto, California
| | - Matthew Pipeling
- Division of Pulmonary and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Christopher King
- Department of Pulmonary and Critical Care Medicine, Inova Fairfax Hospital, Falls Church, Virginia
| | - Hannah Mannem
- Division of Pulmonary and Critical Care Medicine, University of Virginia, Charlottesville, Virginia
| | - Sanjeev Raman
- Division of Pulmonary Medicine, University of Utah, Salt Lake City, Utah
| | | | - Aaron Douglas
- Division of Anesthesiology and Critical Care, Cleveland Clinic, Cleveland, Ohio
| | - Olaf Mercier
- Department of Thoracic Surgery, Université Paris-Saclay, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Chizinga M, Machuca TN, Shahmohammadi A, Patel DC, Innabi A, Alzghoul B, Scheuble V, Pipkin M, Mehrad B, Pelaez A, Lin C, Gomez-Manjarres D. Lung transplantation for acute exacerbation of interstitial lung disease. Thorax 2021; 77:364-369. [PMID: 34226204 DOI: 10.1136/thoraxjnl-2020-215681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 06/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute exacerbations of interstitial lung diseases (AE-ILD) have a high mortality rate with no effective medical therapies. Lung transplantation is a potentially life-saving option for patients with AE-ILD, but its role is not well established. The aim of this study is to determine if this therapy during AE-ILD significantly affects post-transplant outcomes in comparison to those transplanted with stable disease. METHODS We conducted a retrospective study of consecutive patients with AE-ILD admitted to our institution from 2015 to 2018. The comparison group included patients with stable ILD listed for lung transplant during the same period. The primary end-points were in-hospital mortality for patients admitted with AE-ILD and 1-year survival for the transplanted patients. RESULTS Of 53 patients admitted for AE-ILD, 28 were treated with medical therapy alone and 25 underwent transplantation. All patients with AE-ILD who underwent transplantation survived to hospital discharge, whereas only 43% of the AE-ILD medically treated did. During the same period, 67 patients with stable ILD underwent transplantation. Survival at 1 year for the transplanted patients was not different for the AE-ILD group versus stable ILD group (96% vs 92.5%). The rates of primary graft dysfunction, post-transplant hospital length-of-stay and acute cellular rejection were similar between the groups. CONCLUSION Patients with ILD transplanted during AE-ILD had no meaningful difference in overall survival, rate of primary graft dysfunction or acute rejection compared with those transplanted with stable disease. Our results suggest that lung transplantation can be considered as a therapeutic option for selected patients with AE-ILD.
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Affiliation(s)
- Mwelwa Chizinga
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Tiago N Machuca
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Abbas Shahmohammadi
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Divya C Patel
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Ayoub Innabi
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Bashar Alzghoul
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Vanessa Scheuble
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Mauricio Pipkin
- Department of Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Borna Mehrad
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Andres Pelaez
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
| | - Christine Lin
- Department of Medicine, University of Florida Health, Gainesville, Florida, USA
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Klapper JA, Hicks AC, Ledbetter L, Poisson J, Hartwig MG, Hashmi N, Welsby I, Bottiger BA. Blood product transfusion and lung transplant outcomes: A systematic review. Clin Transplant 2021; 35:e14404. [PMID: 34176163 DOI: 10.1111/ctr.14404] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 12/01/2022]
Abstract
The perioperative transfusion of blood products has long been linked to development of acute lung injury and associated with mortality across both medical and surgical patient populations.1,2 The need for blood product transfusion during and after lung transplantation is common and, in many instances, unavoidable. However, this practice may potentially be modifiable.3 In this systematic review, we explore and summarize what is known regarding the impact of blood product transfusion on outcomes following lung transplantation, highlighting the most recent work in this area. Overall, the majority of the literature consists of single center retrospective analyses or the work of multicenter working groups referencing the same database. In the end, there are a number of remaining questions regarding blood product transfusion and their downstream effects on graft function and survival.
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Affiliation(s)
- Jacob A Klapper
- Division of Cardiothoracic Surgery, Duke University, Durham, North California, USA
| | - Anne C Hicks
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Leila Ledbetter
- Duke University, Medical Center Library, Durham, North California, USA
| | - Jessica Poisson
- Department of Pathology, Duke University, Durham, North California, USA
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Duke University, Durham, North California, USA
| | - Nazish Hashmi
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Brandi A Bottiger
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
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Pellenc Q, Girault A, Roussel A, Aguir S, Cerceau P, Longrois D, Mal H, Mordant P, Castier Y. Preclosing of the femoral artery allows total percutaneous venoarterial extracorporeal membrane oxygenation and prevents groin wound infection after lung transplantation. Eur J Cardiothorac Surg 2021; 58:371-378. [PMID: 32083665 DOI: 10.1093/ejcts/ezaa039] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 01/14/2020] [Accepted: 01/17/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES In lung transplantation (LT), femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) usually requires an open approach that may be associated with severe groin wound infection. In endovascular aortic procedures, preclosing of the femoral artery (PFA) with vascular closure devices allows the percutaneous insertion and withdrawal of large-bore cannulae. We sought to evaluate whether this innovative technique could be applied in the specific setting of LT to achieve total percutaneous VA-ECMO and decrease groin wound infection. METHODS We conducted a retrospective study of a prospective database including patients who underwent LT in our centre from January 2011 to December 2017. Patients who underwent peripheral VA-ECMO using the PFA technique after January 2014 (PFA group, n = 106) were compared to those who underwent peripheral VA-ECMO using open cannulation and/or decannulation before January 2014 (non-PFA group, n = 48). The primary end point was the rate of technical success defined as total percutaneous VA-ECMO. Secondary end points included groin wound infections and delayed vascular complications. RESULTS The PFA technique was technically successful in 98 patients (92.5%). As compared with the non-PFA group, the PFA group was characterized by a similar rate of vascular complications (16.6% vs 11.3%, P = 0.360) and a decreased rate of groin wound infection (18.9% vs 0%, P < 0.001). In multivariate analysis, risk factors associated with vascular complications following PFA included female sex, peripheral arterial disease and ECMO duration. CONCLUSIONS In LT patients, PFA is associated with a high rate of total percutaneous VA-ECMO, thus preventing the occurrence of groin wound infection.
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Affiliation(s)
- Quentin Pellenc
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Antoine Girault
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Arnaud Roussel
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Sonia Aguir
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Pierre Cerceau
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Bichat Hospital, Paris University, Paris, France
| | - Hervé Mal
- Service de Pneumologie B et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Pierre Mordant
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
| | - Yves Castier
- Service de Chirurgie Vasculaire, Thoracique, et Transplantation Pulmonaire, Bichat Hospital, Paris University, Paris, France
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Campo-Canaveral De La Cruz JL, Dunne B, Lemaitre P, Rackauskas M, Pozniak J, Watanabe Y, Mariscal A, Yeung J, Yasufuku K, Pierre A, de Perrot M, Waddell TK, Cypel M, Keshavjee S, Donahoe L. Deceased-donor lobar lung transplant: A successful strategy for small-sized recipients. J Thorac Cardiovasc Surg 2021; 161:1674-1685. [DOI: 10.1016/j.jtcvs.2020.04.166] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Revised: 03/13/2020] [Accepted: 04/04/2020] [Indexed: 02/03/2023]
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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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Anesthetic management in lung transplantation: Our single-center experience. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:191-200. [PMID: 34104513 PMCID: PMC8167475 DOI: 10.5606/tgkdc.dergisi.2021.9490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 06/16/2020] [Indexed: 11/25/2022]
Abstract
Background
In this study, we aimed to discuss our anesthesia management strategies, experiences, and outcomes in patients undergoing lung transplantation.
Methods
Between December 2016 and December 2018, a total of 53 patients (43 males, 10 females; mean age: 46.1±13 years; range, 14 to 64 years) undergoing lung transplantation in our center were included. The anesthesia technique, patients" characteristics, and perioperative clinical and follow-up data were recorded. The stage of lung disease was assessed using the New York Heart Association functional classification.
Results
Two patients underwent single lung transplantation, while 51 patients underwent double lung transplantation. Idiopathic pulmonary fibrosis was the most common indication in 41.5% of the patients. All patients had end-stage lung disease (Class IV) and 79% were oxygen-dependent. The extracorporeal membrane oxygenation support was given to 32 patients.
Conclusion
The anesthetic management of lung transplantation is challenging, either due to the deterioration of the recipient"s physical performance and the complexity of the surgical techniques used. In general, a kind of mechanical support may be needed and extracorporeal membrane oxygenation is the first choice in the majority of patients. A close communication should be maintained between the surgeons, perfusion technicians, and anesthesiologists to ensure an optimal multidisciplinary approach and to achieve successful outcomes.
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Ohsumi A, Date H. Perioperative circulatory support for lung transplantation. Gen Thorac Cardiovasc Surg 2021; 69:631-637. [PMID: 33666866 PMCID: PMC7934122 DOI: 10.1007/s11748-021-01610-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Extracorporeal membrane oxygenation (ECMO) has recently replaced cardiopulmonary bypass (CPB) as the preferred option for providing circulatory support during lung transplantation. This review aimed to summarize the previous data and to address the relative use of ECMO and CPB during lung transplantation. METHODS The database was searched in PubMed (Medline) using the following keywords: lung transplantation, extracorporeal membrane oxygenation, and cardiopulmonary bypass, for all relevant reports which were written in English and were published between 2000 and 2020. REVIEW Several reports have revealed that intraoperative use of ECMO is associated with lower blood product transfusion requirements, shorter ventilator support, and shorter length of hospital stay. During recent years, preoperative ECMO has also been used with favorable outcomes as a bridge to lung transplantation in critically ill patients. CONCLUSIONS The use of ECMO during lung transplantation seems to reduce postoperative complications and improve short-term outcomes, relative to CPB. However, additional data should be collected through large multicenter randomized controlled trials. Furthermore, preoperative ECMO as a bridge to lung transplantation appears to provide favorable outcomes, although additional data are also needed from experienced transplant centers.
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Affiliation(s)
- Akihiro Ohsumi
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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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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Schwarz S, Hoetzenecker K, Klepetko W. Procedural mechanical support for lung transplantation. Curr Opin Organ Transplant 2021; 26:309-313. [PMID: 33782246 DOI: 10.1097/mot.0000000000000873] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The use of procedural mechanical support during lung transplantation (LTx) varies between centers and the optimal support strategy is still controversially discussed. The two main questions are if cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) should be preferred and whether mechanical support should be reserved for specific patient groups or a routine use can be recommended. RECENT FINDINGS Recent cohort studies have consistently shown that LTx on CPB leads to inferior outcomes when compared to venoarterial (va)-ECMO. Thus, ECMO should be preferred in lung transplantation except for special indications. Despite its higher invasiveness, ECMO offers some pivotal advantages over off-pump lung transplantation. It has been shown to remarkably reduce rates of primary graft dysfunction, supporting the concept of a routine intraoperative ECMO use in LTx. SUMMARY Although randomized-controlled trials addressing this question are still lacking, current evidence appears to favor the routine use of ECMO support during lung transplantation.
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Affiliation(s)
- Stefan Schwarz
- Department of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
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Evolution of Recipient Characteristics Over 3 Decades and Impact on Survival After Lung Transplantation. Transplantation 2021; 105:e387-e394. [PMID: 33988333 DOI: 10.1097/tp.0000000000003756] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lung transplantation (LTx) is a definitive treatment for end-stage lung disease. Herein, we reviewed our center experience over three decades to examine the evolution of recipient characteristics and contemporary predictors of survival for LTx. METHODS We retrospectively reviewed the data of LTx procedures performed at our institution from 1/1990 to 1/2019 (n=1819). The cohort is divided into three eras; I: 1990-1998 (n=152), II: 1999-2008 (n=521), III: 2009-2018 (n=1146). Uni- and multivariate analyses of survival in era III were performed. RESULTS Pulmonary fibrosis has become the leading indication for LTx (13% in Era I, 57% in Era III). Median recipient age increased (Era I: 46 years - Era III: 61 years) as well as intraoperative mechanical circulatory support (Era I: 0% - Era III: 6%). Higher lung allocation score (LAS) was associated with primary graft dysfunction (PGD) (p<0.0001), postoperative ECMO (p<0.0001), and in-hospital mortality (p=0.002). In Era III, hypoalbuminemia, thrombocytopenia, and high PGD grade were multivariate predictors of early mortality. The 5-year survival in Era II (55%) and III (55%) were superior to Era I (40%, p<0.001). Risk factors for late mortality in era III included recipient age, chronic allograft dysfunction, renal dysfunction, high MELD score, and single LTx. CONCLUSIONS In this longitudinal single-center study, recipient characteristics have evolved to include sicker patients with greater complexity of procedures and risk for postoperative complications but without significant impact on hospital mortality or long-term survival. With advancing surgical techniques and perioperative management, there is room for further progress in the field.Supplemental Visual Abstract; http://links.lww.com/TP/C191.
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Mondadori DC, Lorenzi W, Caramori ML, Andrade CF, Saueressig MG. Impact of extracorporeal membrane oxygenation in lung transplantation. ACTA ACUST UNITED AC 2021; 47:e20200207. [PMID: 33503133 PMCID: PMC7889321 DOI: 10.36416/1806-3756/e20200207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Diego Corsetti Mondadori
- . Serviço de Cirurgia Torácica, Grupo de Transplante Pulmonar do Hospital de Clínicas de Porto Alegre - HCPA - Porto Alegre (RS) Brasil
| | - William Lorenzi
- . Serviço de Cirurgia Torácica, Grupo de Transplante Pulmonar do Hospital de Clínicas de Porto Alegre - HCPA - Porto Alegre (RS) Brasil
| | - Marlova Luzzi Caramori
- . Serviço de Cirurgia Torácica, Grupo de Transplante Pulmonar do Hospital de Clínicas de Porto Alegre - HCPA - Porto Alegre (RS) Brasil
| | - Cristiano Feijó Andrade
- . Serviço de Cirurgia Torácica, Grupo de Transplante Pulmonar do Hospital de Clínicas de Porto Alegre - HCPA - Porto Alegre (RS) Brasil
| | - Maurício Guidi Saueressig
- . Serviço de Cirurgia Torácica, Grupo de Transplante Pulmonar do Hospital de Clínicas de Porto Alegre - HCPA - Porto Alegre (RS) Brasil
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The Effect of Additional Stepwise Venous Inflow on Differential Hypoxia of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 66:803-808. [PMID: 31425264 PMCID: PMC7316147 DOI: 10.1097/mat.0000000000001052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Use of femoral-femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support during lung transplantation can be inadequate for efficient distribution of oxygenated blood into the coronary circulation. We hypothesized that creating a left-to-right shunt flow using veno-arterio-venous (VAV) ECMO would alleviate the differential hypoxia. Total 10 patients undergoing lung transplantation were enrolled in this study. An additional inflow cannula was inserted into the right internal jugular (RIJ) vein for VAV ECMO. During left one-lung ventilation using a 1.0 inspired oxygen fraction (FiO2), the left-to-right shunt flow was incrementally increased from 0 to 500, 1,000, and 1,500 ml/min. The arterial oxygen partial pressure (PaO2) and oxygen saturation (SaO2) were measured at the proximal ascending aorta and right radial artery. The ascending aorta gas analysis revealed that six patients had a PaO2/FiO2 ratio less than 200 mm Hg at a 0 ml/min shunt flow. The PaO2 (SaO2) values were 48.5 ± 14.8 mm Hg (80.9 ± 11.6%) at the ascending aorta and 77.8 ± 69.7 mm Hg (83.3 ± 13.2%) at the right radial artery. As the left-to-right shunt flow rate increased over 1,000 ml/min, the PaO2 and SaO2 values for the ascending aorta and right radial artery significantly increased. In conclusion, femoral-femoral VA ECMO can produce suboptimal coronary oxygenation in patients unable to tolerate one-lung ventilation. A left-to-right shunt using VAV ECMO can alleviate the differential hypoxia.
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