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Wei B, Jiwani A. Commentary: Let's get rich-The use of hydrogen-rich solution for lung preservation. J Thorac Cardiovasc Surg 2019; 159:2119-2120. [PMID: 31672397 DOI: 10.1016/j.jtcvs.2019.09.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Benjamin Wei
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama-Birmingham Medical Center, Birmingham, Ala.
| | - Alisha Jiwani
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama-Birmingham Medical Center, Birmingham, Ala
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Balsara KR, Krupnick AS, Bell JM, Khiabani A, Scavuzzo M, Hachem R, Trulock E, Witt C, Byers DE, Yusen R, Meyers B, Kozower B, Patterson GA, Puri V, Kreisel D. A single-center experience of 1500 lung transplant patients. J Thorac Cardiovasc Surg 2018; 156:894-905.e3. [PMID: 29891245 DOI: 10.1016/j.jtcvs.2018.03.112] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 02/28/2018] [Accepted: 03/03/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Over the past 30 years, lung transplantation has emerged as the definitive treatment for end-stage lung disease. In 2005, the lung allocation score (LAS) was introduced to allocate organs according to disease severity. The number of transplants performed annually in the United States continues to increase as centers have become more comfortable expanding donor and recipient criteria and have become more facile with the perioperative and long-term management of these patients. We report a single-center experience with lung transplants, looking at patients before and after the introduction of LAS. METHODS We retrospectively reviewed 1500 adult lung transplants at a single center performed between 1988 and 2016. Patients were separated into 2 groups, before and after the introduction of LAS: group 1 (April 1988 to April 2005; 792 patients) and group 2 (May 2005 to September 2016; 708 patients). RESULTS Differences in demographic data were noted over these periods, reflecting changes in allocation of organs. Group 1 patient average age was 48 ± 13 years, and 404 subjects (51%) were male. Disease processes included emphysema (52%; 412), cystic fibrosis (18.2%; 144), pulmonary fibrosis (16.1%; 128) and pulmonary vascular disease (7.2%; 57). Double lung transplant (77.7%; 615) was performed more frequently than single lung transplant (22.3%; 177). Group 2 average age was 50 ± 14 years, and 430 subjects (59%) were male. Disease processes included pulmonary fibrosis (46%; 335), emphysema (25.8%; 188), cystic fibrosis (17.7%; 127) and pulmonary vascular disease (1.6%; 11). Double lung transplant (96.2%; 681) was performed more frequently than single lung transplant (3.8%; 27). Overall incidence of grade 3 primary graft dysfunction (PGD) in group 1 was significantly lower at 22.1% (175) than in group 2 at 31.6% (230) (P < .001). Nonetheless, overall hospital mortality was not statistically different between the 2 groups (4.4% vs 3.5%; P < .4). Most notably, survival at 1 year was statistically different at 646 (81.6%) for group 1 and 665 (91.4%) for group 2 (P < .02). CONCLUSIONS Patient demographics over the study period have changed with an increased number of fibrotic patients transplanted. In addition, more aggressive strategies with donor/recipient selection appear to have resulted in a higher incidence of primary graft dysfunction. This does not, however, appear to affect patient survival on index hospitalization or at 1 year. In fact, we have observed a significant improvement in survival at 1 year in the more recent era. This observation suggests that continued expansion of possible donors and recipients, coupled with a more sophisticated understanding of primary graft dysfunction and long-term chronic rejection, can lead to increased transplant volume and prolonged survival.
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Affiliation(s)
- Keki R Balsara
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo.
| | - Alexander S Krupnick
- Division of Cardiothoracic Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - Jennifer M Bell
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Ali Khiabani
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Masina Scavuzzo
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Elbert Trulock
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Chad Witt
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Roger Yusen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Bryan Meyers
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Benjamin Kozower
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Varun Puri
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Mo
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Simões EA, Cardoso PFG, Pêgo-Fernandes PM, Canzian M, Pazetti R, Braga KADO, Nepomuceno NA, Jatene FB. An experimental rat model of ex vivo lung perfusion for the assessment of lungs regarding histopathological findings and apoptosis: low-potassium dextran vs. histidine-tryptophan-ketoglutarate. J Bras Pneumol 2013; 38:461-9. [PMID: 22964930 DOI: 10.1590/s1806-37132012000400008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 06/05/2012] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To compare histopathological findings and the degree of apoptosis among rat lungs preserved with low-potassium dextran (LPD) solution, histidine-tryptophan-ketoglutarate (HTK) solution, or normal saline (NS) at two ischemia periods (6 h and 12 h) using an experimental rat model of ex vivo lung perfusion. METHODS Sixty Wistar rats were anesthetized, randomized, and submitted to antegrade perfusion via pulmonary artery with one of the preservation solutions. Following en bloc extraction, the heart-lung blocks were preserved for 6 h or 12 h at 4 ºC and then reperfused with homologous blood for 60 min in an ex vivo lung perfusion system. At the end of the reperfusion, fragments of the middle lobe were extracted and processed for histopathological examination. The parameters evaluated were congestion, alveolar edema, alveolar hemorrhage, inflammatory infiltrate, and interstitial infiltrate. The degree of apoptosis was assessed using the TdT-mediated dUTP nick end labeling method. RESULTS The histopathological examination showed that all of the lungs preserved with NS presented alveolar edema after 12 h of ischemia. There were no statistically significant differences among the groups in terms of the degree of apoptosis. CONCLUSIONS In this study, the histopathological and apoptosis findings were similar with the use of either LPD or HTK solutions, whereas the occurrence of edema was significantly more common with the use of NS.
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Simões EA, Pêgo-Fernandes PM, Cardoso PFG, Pazetti R, Werebe E, de Oliveira Braga KA, Menezes A, Nepomuceno N, Soares PRO, Correia AT, Jatene FB. Comparing the performance of rat lungs preserved for 6 or 12 hours after perfusion with low-potassium dextran or histidine-tryptophan-ketoglutarate. Transplant Proc 2011; 43:1520-4. [PMID: 21693228 DOI: 10.1016/j.transproceed.2010.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION In lung transplantation, graft dysfunction is a frequent cause of mortality; the etiopathogenesis is related to ischemia-reperfusion injury. We sought to compare the lung performance of rats after reperfusion after presentation with 3 solutions at 2 ischemia times. METHODS We randomized 60 male Wistar rats to undergo anterograde perfusion via the pulmonary artery with low-potassium dextran (LPD), histidine-tryptophan ketoglutarate (HTK), or saline. After extraction, the heart-lung blocks were preserved in a solution at hypothermia for 6 or 12 hours before perfusion with homologous blood for 60 minutes using ex vivo system Isolated Perfused Rat or Guinea Pig Lung System (Harvard Apparatus). Respiratory mechanics, pulmonary weight, pulmonary artery pressure (PAP), and relative lung oxygenation capacity (ROC) measurements were obtained every 10 minutes. RESULTS Comparing tidal volume (TV), compliance, resistance, ROC, PAP, and pulmonary weight the LPD, HTK, and saline group did not differ at 6 and 12 hours. The TV was higher in the lungs with 6-hour ischemia in the LPD, HTK, and saline groups. Compliance was higher in the lungs with 6-hour ischemia in the LPD and saline groups. There were no differences in ROC values comparing lungs with 6- versus 12-hour ischemia in the LPD group. A significant difference was observed between lungs in the HTK and saline groups. Resistance was higher in the lungs with 12-hour ischemia among the LPD, HTK, and saline groups. There was a gradual weight increase in the lungs, particularly those undergoing 12-hour ischemia, despite the absence of a significant difference between groups. CONCLUSION Rat lungs perfused with LPD and HTK preservation solutions showed similar reperfusion performances in this ex-vivo perfusion model.
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Affiliation(s)
- E A Simões
- Department of Cardiopneumology, Medical School, University of São Paulo, Heart Institute, Hospital das Clínicas, São Paulo, Brazil
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Hamakawa H, Sakai H, Takahashi A, Aoyama A, Zhang J, Chen F, Fujinaga T, Wada H, Date H, Bando T. Dynamic instability of central airways and peripheral airspace in rat lungs perfused with cold preservation solutions. Eur Surg Res 2011; 47:159-67. [PMID: 21952309 DOI: 10.1159/000330449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 06/17/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS For lung preservation, one of two types of solutions is commonly employed: Euro-Collins (EC) or low potassium dextran glucose (LPDG). These two solutions have been compared regarding biological, morphometrical and physiological outcomes in many experiments. However, the dynamic mechanics of perfused lung are not well understood because the dynamic characteristics cannot be assessed under static conditions; hence, the primary goal of the present study was to assess this in perfused rat lungs during the preservation period, comparing EC with LPDG at 0 or 9 h at 4°C. METHODS Lung impedance was measured using a forced oscillation technique. Lung resistance and elastance values were obtained by the fast Fourier transform algorithm. The instability of central airways and heterogeneity of ventilation were estimated. RESULTS In the EC group, airway resistance and instability were high after perfusion, and the lung elastance was high and more heterogeneous after cold storage. In contrast, those parameters were stable in the LPDG group during cold storage. CONCLUSION Such dynamic stability might facilitate the handling of lung grafts and eliminate injurious cyclic ventilation stress after reperfusion. Thus, we conclude that the impedance frequency characteristic represents a novel informative parameter for investigating lung preservation techniques.
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Affiliation(s)
- H Hamakawa
- Department of Thoracic Surgery, Kyoto University, Kyoto, Japan
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Soares PRO, Braga KADO, Nepomuceno NA, Pazetti R, Correia AT, Cardoso PFG, Bisceglijatene F, Pêgo-Fernandes PM. Comparison between Perfadex and locally manufactured low-potassium dextran solution for pulmonary preservation in an ex vivo isolated lung perfusion model. Transplant Proc 2011; 43:84-8. [PMID: 21335161 DOI: 10.1016/j.transproceed.2010.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Lung transplantation, a consolidated treatment for end-stage lung disease, utilizes preservation solutions, such as low potassium dextran (LPD), to mitigate ischemia-reperfusion injury. We sought the local development of LPD solutions in an attempt to facilitate access and enhance usage. We also sought to evaluate the effectiveness of a locally manufactured LPD solution in a rat model of ex vivo lung perfusion. METHODS We randomized the following groups \?\adult of male Wistar rats (n = 25 each): Perfadex (LPD; Vitrolife, Sweden); locally manufactured LPD-glucose (LPDnac) (Farmoterapica, Brazil), and normal saline solution (SAL) with 3 ischemic times (6, 12, and 24 hours). The harvested heart-lung blocks were flushed with solution at 4°C. After storage, the blocks were connected to an IL-2 Isolated Perfused Rat or Guinea Pig Lung System (Harvard Apparatus) and reperfused with homologous blood for 60 minutes. Respiratory mechanics, pulmonary artery pressure, perfusate blood gas analysis, and lung weight were measured at 10-minute intervals. Comparisons between groups and among ischemic times were performed using analysis of variance with a 5% level of significance. RESULTS Lungs preserved for 24 hours were nonviable and therefore excluded from the analysis. Those preserved for 6 hours showed better ventilatory mechanics when compared with 12 hours. The oxygenation capacity was not different between lungs flushed with LPD or LPDnac, regardless of the ischemic time. SAL lungs showed higher PCO(2) values than the other solutions. Lung weight increased over time during perfusion; however, there were no significant differences among the tested solutions (LPD, P = .23; LPDnac, P = .41; SAL, P = .26). We concluded that the LPDnac solution results in gas exchange were comparable to the original LPD (Perfadex); however ventilatory mechanics and edema formation were better with LPD, particularly among lungs undergoing 6 hours of cold ischemia.
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Affiliation(s)
- P R O Soares
- Laboratory of Thoracic Surgery Research, Department of Cardiopneumology, InCor, Clinics Hospital, University of São Paulo, Medical School, São Paulo, Brazil
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Marasco SF, Bailey M, McGlade D, Snell G, Westall G, Oto T, Pilcher D. Effect of donor preservation solution and survival in lung transplantation. J Heart Lung Transplant 2011; 30:414-9. [DOI: 10.1016/j.healun.2010.10.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Revised: 10/25/2010] [Accepted: 10/26/2010] [Indexed: 11/26/2022] Open
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Short- and long-term outcomes of 1000 adult lung transplant recipients at a single center. J Thorac Cardiovasc Surg 2011; 141:215-22. [DOI: 10.1016/j.jtcvs.2010.09.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 08/23/2010] [Accepted: 09/02/2010] [Indexed: 01/08/2023]
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Arnaoutakis GJ, Allen JG, Merlo CA, Baumgartner WA, Conte JV, Shah AS. Low potassium dextran is superior to University of Wisconsin solution in high-risk lung transplant recipients. J Heart Lung Transplant 2010; 29:1380-7. [PMID: 20634098 DOI: 10.1016/j.healun.2010.05.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Accepted: 05/29/2010] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The ideal solution for recovery of donor lungs remains unknown. Low potassium dextran (LPD) solution is most common, but University of Wisconsin (UW) solution is also used. The United Network for Organ Sharing (UNOS) database allows assessment of preservation solutions in a large cohort of lung transplant (LTx) patients. METHODS We retrospectively reviewed the UNOS data set for adult primary LTx patients (2005-2008) whose donor lungs were recovered with UW or LPD solution. Patients were stratified by UW vs LPD, and secondarily grouped by quartiles of the lung allocation score (LAS) to examine high-risk recipients. Kaplan-Meier (KM) short-term mortality (30 days, 90 days, 1 year) and rejection in the first year were examined for intervals with adequate follow-up. Cox proportional hazard regression using 11 variables examined all cause 1-year mortality. RESULTS Of 4,455 patients, 4,161 (93.4%) received LPD lungs and 294 (6.6%) received UW lungs, and 1,105 patients (24.8%) died during the study. There was no mortality difference based on flush solution with all patients examined together. However, patients in the upper 2 LAS quartiles (Q3: 37.8-45.4, Q4: > 45.4) receiving LPD lungs had greater 1-year survival of 81.5% vs 73.5% (p = 0.02). On multivariable analysis, flush with UW solution resulted in an increased risk of 1-year mortality (hazard ratio, 1.77. 95% confidence interval, 1.21-2.58; p = 0.003) vs LPD. Preservation solution did not affect rejection rates in the year after LTx. KM modeling demonstrated the effect of flush solution on survival (p = 0.02). CONCLUSIONS This study is the largest modern cohort to evaluate the effect of donor lung flush solutions on survival in adult LTx. UW solution increases the risk of 1-year mortality in high-risk LTx recipients.
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Affiliation(s)
- George J Arnaoutakis
- Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Thoracic organs: current preservation technology and future prospects; part 1: lung. Curr Opin Organ Transplant 2010; 15:150-5. [DOI: 10.1097/mot.0b013e3283373b7e] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ailawadi G, Lau CL, Smith PW, Swenson BR, Hennessy SA, Kuhn CJ, Fedoruk LM, Kozower BD, Kron IL, Jones DR. Does reperfusion injury still cause significant mortality after lung transplantation? J Thorac Cardiovasc Surg 2009; 137:688-94. [PMID: 19258089 DOI: 10.1016/j.jtcvs.2008.11.007] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 08/21/2008] [Accepted: 11/06/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Severe reperfusion injury after lung transplantation has mortality rates approaching 40%. The purpose of this investigation was to identify whether our improved 1-year survival after lung transplantation is related to a change in reperfusion injury. METHODS We reported in March 2000 that early institution of extracorporeal membrane oxygenation can improve lung transplantation survival. The records of consecutive lung transplant recipients from 1990 to March 2000 (early era, n = 136) were compared with those of recipients from March 2000 to August 2006 (current era, n = 155). Reperfusion injury was defined by an oxygenation index of greater than 7 (where oxygenation index = [Percentage inspired oxygen] x [Mean airway pressure]/[Partial pressure of oxygen]). Risk factors for reperfusion injury, treatment of reperfusion injury, and 30-day mortality were compared between eras by using chi(2), Fisher's, or Student's t tests where appropriate. RESULTS Although the incidence of reperfusion injury did not change between the eras, 30-day mortality after lung transplantation improved from 11.8% in the early era to 3.9% in the current era (P = .003). In patients without reperfusion injury, mortality was low in both eras. Patients with reperfusion injury had less severe reperfusion injury (P = .01) and less mortality in the current era (11.4% vs 38.2%, P = .01). Primary pulmonary hypertension was more common in the early era (10% [14/136] vs 3.2% [5/155], P = .02). Graft ischemic time increased from 223.3 +/- 78.5 to 286.32 +/- 88.3 minutes in the current era (P = .0001). The mortality of patients with reperfusion injury requiring extracorporeal membrane oxygenation improved in the current era (80.0% [8/10] vs 25.0% [3/12], P = .01). CONCLUSION Improved early survival after lung transplantation is due to less severe reperfusion injury, as well as improvements in survival with extracorporeal membrane oxygenation.
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Affiliation(s)
- Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, VA 22908-0679, USA
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McIlroy D, Pilcher D, Snell G. Does anaesthetic management affect early outcomes after lung transplant? An exploratory analysis. Br J Anaesth 2009; 102:506-14. [DOI: 10.1093/bja/aep008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Almenar M, Cerón J, Gómez MD, Peñalver JC, Jiménez MJ, Padilla J. Interleucina-8 en el lavado broncoalveolar del donante y su impacto en la disfunción primaria del injerto en el trasplante bipulmonar. Arch Bronconeumol 2009; 45:12-5. [DOI: 10.1016/j.arbres.2008.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2007] [Accepted: 02/20/2008] [Indexed: 11/30/2022]
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Interleukin 8 Concentrations in Donor Bronchoalveolar Lavage: Impact on Primary Graft Failure in Double Lung Transplant. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1579-2129(09)71782-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Carter YM, Gelman AE, Kreisel D. Pathogenesis, management, and consequences of primary graft dysfunction. Semin Thorac Cardiovasc Surg 2008; 20:165-72. [PMID: 18707651 DOI: 10.1053/j.semtcvs.2008.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2008] [Indexed: 12/31/2022]
Abstract
Primary graft dysfunction continues to be a major contributing factor to morbidity and mortality after lung transplantation. This condition is presumed to be the result of ischemia-reperfusion injury, which is associated with the release of endogenous substances that can activate the innate immune system. Primary graft dysfunction has been shown to be an independent risk factor for the development of bronchiolitis obliterans syndrome indicating that it can shape alloimmune responses. In this review, we focus on the classification, pathogenesis, possible prevention strategies, management and consequences of primary graft dysfunction.
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Affiliation(s)
- Yvette M Carter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri 63110-1013, USA
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Ferraro P, Martin J, Dery J, Prenovault J, Samson L, Coutu M, Chen LQ, Poirier C, Noiseux N, Duranceau A, Berthiaume Y. Late Retrograde Perfusion of Donor Lungs Does Not Decrease the Severity of Primary Graft Dysfunction. Ann Thorac Surg 2008; 86:1123-9. [DOI: 10.1016/j.athoracsur.2008.05.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 05/14/2008] [Accepted: 05/15/2008] [Indexed: 10/21/2022]
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Maury G, Langer D, Verleden G, Dupont L, Gosselink R, Decramer M, Troosters T. Skeletal muscle force and functional exercise tolerance before and after lung transplantation: a cohort study. Am J Transplant 2008; 8:1275-81. [PMID: 18444941 DOI: 10.1111/j.1600-6143.2008.02209.x] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We investigated the impact of lung transplantation and outpatient pulmonary rehabilitation after lung transplantation on skeletal muscle function and exercise tolerance. Skeletal muscle force (Quadriceps force, QF), exercise tolerance (six minute walking distance, 6MWD) and lung function were assessed in 36 patients before and after lung transplantation. Seventeen male and 19 female patients (age 57 +/- 4) showed skeletal muscle weakness before the transplantation. A further 32 +/- 21% reduction was seen 1.2 (interquartile range 0.9 to 2.0) months after LTX. The number of days on the intensive care unit was significantly related to the observed deterioration in muscle force after LTX. At this time point 6MWD was comparable to pre-LTX. Rehabilitation started 37 (IQR 29 to 61) days after LTX. 6MWD and QF improved significantly (140 +/- 91 m, and 35 +/- 48%, respectively; p < 0.05) with rehabilitation. QF remained below pre-LTX values. The evolution of the 6MWD with the transplantation and the subsequent rehabilitation was less in female compared to male subjects. We conclude that muscle strength deteriorates after lung transplantation, particularly in patients with long ICU stay. Outpatient pulmonary rehabilitation is feasible after lung transplantation and leads to recovery of skeletal muscle function. In female patients this recovery is significantly less compared to male recipients.
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Affiliation(s)
- G Maury
- Pneumology, Université Catholique de Louvain, Yvoir, Belgium
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Ganesh JS, Rogers CA, Banner NR, Bonser RS. Does the method of lung preservation influence outcome after transplantation? An analysis of 681 consecutive procedures. J Thorac Cardiovasc Surg 2007; 134:1313-21. [PMID: 17976468 DOI: 10.1016/j.jtcvs.2007.05.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2006] [Revised: 03/09/2007] [Accepted: 05/11/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Despite 50 years of lung preservation research, the optimal preservation technique is undefined. Using data from a national cohort, we investigated outcomes with different preservation methods after adult lung transplantation. METHODS Early (30-day), late (30-day to 3-year), and overall (3-year) mortalities, adjusted for differences in donor and recipient characteristics, were compared by using Cox regression. Intensive care unit length of stay and the number of rejection episodes were secondary outcomes. RESULTS Six hundred eighty-one eligible lung transplantations between July 1995 and June 2003 were preserved with Euro-Collins solution (n = 284), blood albumin (n = 139), core cooling (n = 107), or low potassium dextran solution (n = 151). There was significantly increased use of low potassium dextran solution over time (P < .001). Unadjusted 3-year survival was similar across the groups (P = .72), with the highest 3-year survival in the low potassium dextran group (62%; 95% confidence interval, 51%-72%) and the lowest in the blood albumin group (49%; 95% confidence interval, 39%-58%). Risk-adjusted early (P = .70), late (P = .27), and overall (P = .72) survival was similar across the groups and was not affected by ischemic time. Freedom from death caused by primary graft dysfunction was again highest in the low potassium dextran group (95%; 95% confidence interval, 90%-98%) and lowest in the blood albumin group (91%; 95% confidence interval, 85%-95%). There was no difference in intensive care unit length of stay. An increased incidence of rejection was apparent with increasing ischemic time (P = .067). CONCLUSION The methods of lung preservation in current use do not seem to affect early or midterm survival after transplantation, but increasing ischemic time might predispose to increased rejection.
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Affiliation(s)
- J Saravana Ganesh
- UK Cardiothoracic Transplant Audit, Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
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Hanusch C, Nowak K, Gill IS, Törlitz P, Rafat N, Mueller AM, Van Ackern KC, Yard B, Beck GC. Hypothermic preservation of lung allograft inhibits cytokine-induced chemoattractant-1, endothelial leucocyte adhesion molecule, vascular cell adhesion molecule-1 and intracellular adhesion molecule-1 expression. Clin Exp Immunol 2007; 149:364-71. [PMID: 17521323 PMCID: PMC1941947 DOI: 10.1111/j.1365-2249.2007.03417.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Organ dysfunction is a major clinical problem after lung transplantation. Prolonged cold ischaemia and reperfusion injury are believed to play a central role in this complication. The influence of cold preservation on subsequent warm reperfusion was studied in an isolated, ventilated and perfused rat lung. Rat lungs were flushed with cold Perfadex-solution and stored at 4 degrees C for different time periods. Thereafter lungs were perfused and ventilated for up to 3 h. Physiological parameters, production of inflammatory mediators and leucocyte infiltration were measured before and after perfusion. Lungs subjected to a cold ischaemia time of up to 6 h showed stable physiological conditions when perfused for 3 h. However, cold-ischaemia time beyond 6 h resulted in profound tissue oedema, thereby impairing ventilation and perfusion. Warm reperfusion and ventilation per se induced a strong inflammatory response, as demonstrated by a significant up-regulation of chemokines and adhesion molecules (cytokine-induced chemoattractant-1, intracellular adhesion molecule and endothelial leucocyte adhesion molecule), accompanied by enhanced leucocyte infiltration. Although the up-regulation of inflammatory mediators was blunted in lungs that were subjected to cold ischaemia, this did not influence leucocyte infiltration. In fact, cold ischaemia time correlated with leucocyte sequestration. Although cold preservation inhibits the expression of inflammatory mediators it does not affect leucocyte sequestration during warm reperfusion. Cold preservation might cause impairment of the endothelial barrier function, as evidenced by tissue oedema and profound leucocyte infiltration.
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Affiliation(s)
- C Hanusch
- Clinic of Anaesthesiology and Critical Care, University-Hospital Mannheim, University of Heidelberg, Germany
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22
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Bittner HB, Binner C, Dahlberg P, Mohr FW. Reducing Ischemia–Reperfusion Injury in Clinical Lung Transplantation. Transplant Proc 2007; 39:489-92. [PMID: 17362765 DOI: 10.1016/j.transproceed.2006.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Acute graft dysfunction secondary to ischemia-reperfusion injury (IRI) continues to be the most common cause of early mortality after lung transplantation. The perioperative management with aprotinin could decrease the incidence of severe IRI. METHODS A retrospective analysis was conducted of the data from 180 patients who underwent either single lung (56%) or bilateral sequential lung transplantation for similar end-stage lung disease between 1997 and 2005. The most recent 68 patients were managed perioperatively with the high-dose aprotinin infusion regimen (aprotinin group). The ISHLT grade III injury score was used for the diagnosis of severe IRI, which is based on a Pao(2)-FIo(2) ratio of less than 200 mmHg. RESULTS Grade III injury was observed in 18% of the patients who were not managed with aprotinin (control group, 152 grafts, 64% single transplants, 68% male, 54 +/- 8 years of age). Early ECMO support was required in 25% of these patients. The associated mortality rate was 40%. Despite significantly longer cold ischemic times (290 +/- 14 minutes vs 231 +/- 14 minutes), older donors (42 +/- 12 years of age), and more frequently observed severely elevated systolic PAP of greater than 60 mmHg (60% vs 48%) as well as more frequently required extracorporeal circulatory support (24%* vs 12%) in the aprotinin group, the incidence of severe IRI (8%) and associated mortality (9%) was markedly reduced. CONCLUSIONS The use of aprotinin in LTX surgery, which had strong beneficial effects on patient outcomes, significantly decreased the incidence of severe posttransplant IRI.
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Affiliation(s)
- H B Bittner
- Division of Thoracic and Cardiovascular Surgery, Heart Center Leipzig of the University of Leipzig, Leipzig, Germany.
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23
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Bertolotti A, Gómez C, Lascano E, Negroni J, Cuniberti L, Yannarelli G, Laguens R, Shiraishi J, Favaloro R. Effect of Preservation Solution on Graft Viability in Single-Lung Transplantation From Heart-Beating Donors in Pigs. Transplant Proc 2007; 39:355-7. [PMID: 17362729 DOI: 10.1016/j.transproceed.2007.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Low-potassium-dextran preservation solution Perfadex (PER) may provide better outcome of transplanted lungs than high-potassium Euro-Collins (EC) solution. However, there are no comparative studies of the recipient inflammatory response to the graft. PURPOSE The purpose of this study was to compare EC versus PER as preservation solutions with respect to the functional performance and inflammatory response in single-lung transplantation from heart-beating donors in pigs. MATERIALS AND METHODS The donor left lung flushed with the corresponding cold preservation solution was stored at 3 degrees C for 3 hours. We assessed hemodynamic values and pulmonary function in the recipient over a 2-hour reperfusion period calculated as percent of basal values, and expressed as mean of the reperfusion period. Interleukin-8 (IL-8) concentration in the donor was estimated in bronchoalveolar lavage fluid 2 hours after recipient reperfusion. Biopsies of the donor right lung and the transplanted lung were obtained to measure myeloperoxidase (MPO) activity. IL-8 and MPO values were expressed as percent of the donor value. We evaluated the wet/dry pulmonary weight ratio (W/D), polymorphonuclear neutrophil count (PMN), and a score of histological damage in the transplanted graft. RESULTS Pulmonary function evaluated by % static: 66.6 +/- 6.8 (EC), 82.3 +/- 10.2 (PER), and dynamic: 74.0 +/- 7.3 (EC), 89.3 +/- 7.7 (PER) compliances, as well as % IL-8: 562.5 +/- 168.6 (EC), 232.3 +/- 148.7 (PER), % MPO: 485.9 +/- 194.9 (EC), 140.8 +/- 21.1 (PER), W/D: 9.9 +/- 3.1 (EC), 6.8 +/- 1.4 (PER), PMN 13.5 +/- 6.8 (EC), 5.5 +/- 3.3 (PER) and the histological damage score: 3.0 +/- 1.5 (EC), 0.7 +/- 0.4 (PER) showed significant differences between the EC and the PER (P < .01). CONCLUSIONS PER affords good lung preservation with early graft function and modest evidences of inflammation, lung injury, and edema compared with the EC perfused lung.
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Affiliation(s)
- A Bertolotti
- Institute of Cardiology and Cardiovascular Surgery of the Favaloro Foundation, Buenos Aires, Argentina.
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Miñambres E, González-Castro A, Rabanal JM, Suberviola B, Ortega FJ, Zurbano F, Díaz-Regañón G, Llorca J. Estudio comparativo de dos soluciones de preservación en la función inicial del trasplante bipulmonar en humanos. Med Intensiva 2007; 31:1-5. [PMID: 17306134 DOI: 10.1016/s0210-5691(07)74763-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Compare the influence of two preservation liquids, Euro-Collins (EC) and Perfadex (P) in the pulmonary graft function in the initial phase of lung transplant in humans. DESIGN Retrospective study. SCOPE Lung transplant unit of the ICU of a university hospital. PATIENTS A total of 79 patients were subjected to a transplant of both lungs. The pulmonary grafts were preserved with EC in 23 cases and with P in 56 cases. VARIABLES OF INTEREST Pulmonary function was assessed on admission in the intensive care unit (ICU) with the PaO2/FiO2 ratio. Mortality, graft dysfunction stay in ICU and time of mechanical ventilation were also assessed at 30 days. RESULTS The PaO2/FiO2 ratio was significantly greater in the P group than in the EC both on admission (p<0.006) and at 12 hours (p=0.032) in the ICU. Graft dysfunction incidence was less in group P than in EC (p<0.045). There were no differences in regards to mortality at 30 days, stay in ICU and time of mechanical ventilation between both groups. CONCLUSION Preservation of the pulmonary graft with P as preservation liquid compared with EC is associated with better graft function in the initial phases of transplant of both lungs and with a decrease in the incidence of graft dysfunction.
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Affiliation(s)
- E Miñambres
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España.
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25
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Oto T, Griffiths AP, Rosenfeldt F, Levvey BJ, Williams TJ, Snell GI. Early outcomes comparing Perfadex, Euro-Collins, and Papworth solutions in lung transplantation. Ann Thorac Surg 2006; 82:1842-8. [PMID: 17062258 DOI: 10.1016/j.athoracsur.2006.05.088] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 05/18/2006] [Accepted: 05/18/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite improved surgical techniques and medical management, primary graft dysfunction (PGD) remains a major cause of early morbidity and mortality after lung transplantation. Different types of lung preservation solutions have been developed and applied to clinical use; however, the relative clinical efficacy of these solutions to prevent PGD remains controversial. This study aimed to investigate the effect of the three solutions most commonly used (Perfadex [Vitrolife, Göteborg, Sweden], Papworth, and Euro-Collins [Baxter Healthcare, Old Toongabbie NSW, Australia]) on posttransplant outcomes. METHODS Early outcomes from 157 consecutive lung transplants (113 bilateral and 44 single) performed at The Alfred Hospital were compared across three preservation solutions. RESULTS Posttransplant oxygenation (p = 0.57), pulmonary vascular resistance (p = 0.34), intubation hours (p = 0.66), intensive care unit days (p = 0.34), severe PGD (grade 3) (p = 0.70), 30-day mortality (p = 0.87), and 3-month % predicted forced expiratory volume in 1 second (p = 0.58) were not statistically different; however, Perfadex trended toward superiority among the three solutions. After adjustment of donor, recipient, and operative factors in multivariate analysis, Perfadex was significantly associated with the prevention of moderate to severe PGD (grade 2 to 3) at 48 hours posttransplant (odds ratio = 0.26 [0.10 to 0.72], p < 0.01) compared with Papworth (odds ratio = 0.75 [0.32 to 1.75], p = 0.51) and Euro-Collins (reference) solutions. CONCLUSIONS Although any advantageous effects of Perfadex on early posttransplant outcomes were generally subtle and statistically nonsignificant, Perfadex prevented moderate to severe PGD. Switching preservation solution from Euro-Collins (or Papworth) to Perfadex would appear to usefully contribute to a strategy to reduce PGD in lung transplantation.
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Affiliation(s)
- Takahiro Oto
- Heart and Lung Transplant Unit, The Alfred Hospital, Melbourne, Australia
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