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von Dossow V, Hulde N, Starke H, Schramm R. How Would We Treat Our Own Cystic Fibrosis With Lung Transplantation? J Cardiothorac Vasc Anesth 2024; 38:626-634. [PMID: 38030425 DOI: 10.1053/j.jvca.2023.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
Lung transplantation is the only therapy for patients with end-stage lung disease. In advanced lung diseases such as cystic fibrosis (CF), life expectancy increases, and it is important to recognize extrapulmonary comorbidities. Cardiovascular involvement, including pulmonary hypertension, right-heart failure, and myocardial dysfunction, are manifest in the late stages of CF disease. Besides right-heart failure, left-heart dysfunction seems to be underestimated. Therefore, an optimal anesthesia and surgical management risk evaluation in this high-risk patient population is mandatory, especially concerning the perioperative use of mechanical circulatory support. The use of an index case of an older patient with the diagnosis of cystic fibrosis demonstrates the importance of early risk stratification and strategy planning in a multidisciplinary team approach to guarantee successful lung transplantation.
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Affiliation(s)
- Vera von Dossow
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
| | - Nikolai Hulde
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany.
| | - Henning Starke
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
| | - Rene Schramm
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center Bad Oeynhausen, University Clinic of Ruhr-University Bochum, Bochum, Germany
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2
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Salman J, Ius F, Sommer W, Siemeni T, Kuehn C, Avsar M, Boethig D, Molitoris U, Bara C, Gottlieb J, Welte T, Haverich A, Hoeper MM, Warnecke G, Tudorache I. Mid-term results of bilateral lung transplant with postoperatively extended intraoperative extracorporeal membrane oxygenation for severe pulmonary hypertension. Eur J Cardiothorac Surg 2018; 52:163-170. [PMID: 28329232 DOI: 10.1093/ejcts/ezx047] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Accepted: 01/24/2017] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES In severe pulmonary hypertension, diastolic dysfunction of the left ventricle causes significant morbidity and mortality after lung transplantation, which may be successfully reversed using a protocol based on perioperative veno-arterial extracorporeal membrane oxygenation (ECMO) and early extubation. Here, we present echocardiographic data and mid-term outcomes. METHODS The records of lung transplanted patients at our institution between May 2010 and January 2016 were retrospectively reviewed. Echocardiography data were collected preoperatively, at discharge, 3 and 12 months after transplantation. RESULTS During the study period, 717 patients underwent lung transplantation at our institution, 38 (5%) patients being transplanted for severe pulmonary hypertension. All patients underwent bilateral lung transplantation on veno-arterial ECMO cannulated in the groin, through a sternum sparing thoracotomy in 36 (95%) patients. Extubation was performed early, after a median of 2 days, and awake ECMO was extended for at least 5 days after transplantation. The survival at 3 months, 1 year and 5 years was not different in comparison to patients transplanted for other underlying diseases ( P = 0.45). At 1 year, tricuspid valve regurgitation had disappeared in all patients. The median of the left ventricular end-diastolic dimension improved from 40 (32-44) mm preoperatively to 45 (44-47) mm at 12 months after lung transplantation ( P < 0.05). The median of the proximal right ventricular outflow diameter decreased to 25 (23-27) mm after 12 months, compared to 48 (43-51) mm preoperatively ( P < 0.05). CONCLUSIONS The routine application of a prophylactic postoperative veno-arterial ECMO protocol in patients with severe pulmonary hypertension undergoing lung transplantation decreases postoperative mortality and favours achievement of normal cardiac function after 1 year.
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Affiliation(s)
- Jawad Salman
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Wiebke Sommer
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Thierry Siemeni
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Kuehn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Ulrich Molitoris
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christoph Bara
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Centre for Lung Research (DZL/BREATH), Hannover, Germany
| | - Igor Tudorache
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.,German Centre for Lung Research (DZL/BREATH), Hannover, Germany
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3
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Porteous MK, Ky B, Kirkpatrick JN, Shinohara R, Diamond JM, Shah RJ, Lee JC, Christie JD, Kawut SM. Diastolic Dysfunction Increases the Risk of Primary Graft Dysfunction after Lung Transplant. Am J Respir Crit Care Med 2017; 193:1392-400. [PMID: 26745666 DOI: 10.1164/rccm.201508-1522oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
RATIONALE Primary graft dysfunction (PGD) is a significant cause of early morbidity and mortality after lung transplant and is characterized by severe hypoxemia and infiltrates in the allograft. The pathogenesis of PGD involves ischemia-reperfusion injury. However, subclinical increases in pulmonary venous pressure due to left ventricular diastolic dysfunction may contribute by exacerbating capillary leak. OBJECTIVES To determine whether a higher ratio of early mitral inflow velocity (E) to early diastolic mitral annular velocity (é), indicative of worse left ventricular diastolic function, is associated with a higher risk of PGD. METHODS We performed a retrospective cohort study of patients in the Lung Transplant Outcomes Group who underwent bilateral lung transplant at our institution between 2004 and 2014 for interstitial lung disease, chronic obstructive pulmonary disease, or pulmonary arterial hypertension. Transthoracic echocardiograms obtained during evaluation for transplant listing were analyzed for E/é and other measures of diastolic function. PGD was defined as PaO2/FiO2 less than or equal to 200 with allograft infiltrates at 48 or 72 hours after reperfusion. The association between E/é and PGD was assessed with multivariable logistic regression. MEASUREMENTS AND MAIN RESULTS After adjustment for recipient age, body mass index, mean pulmonary arterial pressure, and pretransplant diagnosis, higher E/é and E/é greater than 8 were associated with an increased risk of PGD (E/é odds ratio, 1.93; 95% confidence interval, 1.02-3.64; P = 0.04; E/é >8 odds ratio, 5.29; 95% confidence interval, 1.40-20.01; P = 0.01). CONCLUSIONS Differences in left ventricular diastolic function may contribute to the development of PGD. Future trials are needed to determine whether optimization of left ventricular diastolic function reduces the risk of PGD.
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Affiliation(s)
- Mary K Porteous
- 1 Department of Medicine.,2 Center for Clinical Epidemiology and Biostatistics, and
| | - Bonnie Ky
- 1 Department of Medicine.,2 Center for Clinical Epidemiology and Biostatistics, and.,3 Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N Kirkpatrick
- 4 Department of Medicine, University of Washington, Seattle, Washington; and
| | | | - Joshua M Diamond
- 1 Department of Medicine.,2 Center for Clinical Epidemiology and Biostatistics, and
| | - Rupal J Shah
- 5 Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Jason D Christie
- 1 Department of Medicine.,2 Center for Clinical Epidemiology and Biostatistics, and
| | - Steven M Kawut
- 1 Department of Medicine.,2 Center for Clinical Epidemiology and Biostatistics, and.,3 Penn Cardiovascular Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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4
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Watanabe T, Adachi O, Suzuki Y, Notsuda H, Niikawa H, Matsuda Y, Noda M, Sado T, Hoshikawa Y, Akiba M, Tatebe S, Saiki Y, Okada Y. Lung Transplant for Pulmonary Arterial Hypertension After Arterial Switch Operation. Ann Thorac Surg 2015; 100:e133-4. [PMID: 26652570 DOI: 10.1016/j.athoracsur.2015.08.046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/10/2015] [Accepted: 08/14/2015] [Indexed: 11/15/2022]
Abstract
Pulmonary arterial hypertension after arterial switch operation for transposition of the great arteries is an infrequent but life-threatening complication. We report successful lung transplantation in a case of pulmonary hypertension after arterial switch operation. Cardiopulmonary bypass outflow was established through the right subclavian and femoral arteries because of the previous arterial switch operation. Abnormal anatomy and severe pleural and pericardial adhesions as a result of previous operations resulted in prolonged graft ischemic and operation times. Despite delayed left heart adaptation and primary graft dysfunction requiring prolonged extracorporeal membrane oxygenation, the recipient was eventually discharged without activity limitations.
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Affiliation(s)
- Tatsuaki Watanabe
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan.
| | - Osamu Adachi
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yasuto Suzuki
- Department of Pediatrics, Kushiro Red Cross Hospital, Kushiro, Japan
| | - Hirotsugu Notsuda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Hiromichi Niikawa
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yasushi Matsuda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Masafumi Noda
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Tetsu Sado
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Yasushi Hoshikawa
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Miki Akiba
- Division of Organ Transplantation, Tohoku University Hospital, Sendai, Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshinori Okada
- Department of Thoracic Surgery, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
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5
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Lung transplantation for severe pulmonary hypertension--awake extracorporeal membrane oxygenation for postoperative left ventricular remodelling. Transplantation 2015; 99:451-8. [PMID: 25119128 DOI: 10.1097/tp.0000000000000348] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bilateral lung transplantation (BLTx) is an established treatment for end-stage pulmonary hypertension (PH). Ventilator weaning failure and death are more common as in BLTx for other indications. We hypothesized that left ventricular (LV) dysfunction is the main cause of early postoperative morbidity or mortality and investigated a weaning strategy using awake venoarterial extracorporeal membrane oxygenation (ECMO). METHODS In 23 BLTx for severe PH, ECMO used during BLTx was continued for a minimum of 5 days (BLTx-ECMO group). Echocardiography, left atrial (LA) and Swan-Ganz catheters were used for monitoring. Early extubation after transplantation was attempted under continued ECMO. RESULTS Preoperatively, all patients had severely reduced cardiac index (mean, 2.1 L/min/m2). On postoperative day 2, reduction of ECMO flow resulted in increasing LA and decreasing systemic blood pressures. On the day of ECMO explantation (median, postoperative day 8), LV diameter had increased; LA and blood pressures remained stable. Survival rates at 3 and 12 months were 100% and 96%, respectively. Data were compared to two historic control groups of BLTx without ECMO (BLTx ventilation) or combined heart-lung transplantation for severe PH. CONCLUSION Early after BLTx for severe PH, the LV may be unable to handle normalized LV preload. This can be effectively bridged with awake venoarterial ECMO.
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Wenzel D, Knies R, Matthey M, Klein AM, Welschoff J, Stolle V, Sasse P, Röll W, Breuer J, Fleischmann BK. β
2
-Adrenoceptor Antagonist ICI 118,551 Decreases Pulmonary Vascular Tone in Mice via a G
i/o
Protein/Nitric Oxide-Coupled Pathway. Hypertension 2009; 54:157-63. [DOI: 10.1161/hypertensionaha.109.130468] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniela Wenzel
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Ralf Knies
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Michaela Matthey
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Alexandra M. Klein
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Julia Welschoff
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Vanessa Stolle
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Philipp Sasse
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Wilhelm Röll
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Johannes Breuer
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
| | - Bernd K. Fleischmann
- From the Institute of Physiology I (D.W., M.M., A.M.K., J.W., P.S., W.R., B.K.F.) and Departments of Pediatric Cardiology (R.K., V.S., J.B.) and Cardiac Surgery (A.M.K., W.R.), University of Bonn, Bonn, Germany
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Barr ML, Kawut SM, Whelan TP, Girgis R, Böttcher H, Sonett J, Vigneswaran W, Follette DM, Corris PA. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction Part IV: Recipient-Related Risk Factors and Markers. J Heart Lung Transplant 2005; 24:1468-82. [PMID: 16210118 DOI: 10.1016/j.healun.2005.02.019] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Revised: 02/07/2005] [Accepted: 02/17/2005] [Indexed: 12/27/2022] Open
Affiliation(s)
- Mark L Barr
- University of Southern California, Los Angeles, California 90033, USA.
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