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Henry JP, Carlier F, Higny J, Benoit M, Xhaët O, Blommaert D, Telbis AM, Robaye B, Gabriel L, Guedes A, Michaux I, Demeure F, Luchian ML. Impact of Pre-Transplant Left Ventricular Diastolic Pressure on Primary Graft Dysfunction after Lung Transplantation: A Narrative Review. Diagnostics (Basel) 2024; 14:1340. [PMID: 39001230 PMCID: PMC11240543 DOI: 10.3390/diagnostics14131340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Lung transplantation (LT) constitutes the last therapeutic option for selected patients with end-stage respiratory disease. Primary graft dysfunction (PGD) is a form of severe lung injury, occurring in the first 72 h following LT and constitutes the most common cause of early death after LT. The presence of pulmonary hypertension (PH) has been reported to favor PGD development, with a negative impact on patients' outcomes while complicating medical management. Although several studies have suggested a potential association between pre-LT left ventricular diastolic dysfunction (LVDD) and PGD occurrence, the underlying mechanisms of such an association remain elusive. Importantly, the heterogeneity of the study protocols and the various inclusion criteria used to define the diastolic dysfunction in those patients prevents solid conclusions from being drawn. In this review, we aim at summarizing PGD mechanisms, risk factors, and diagnostic criteria, with a further focus on the interplay between LVDD and PGD development. Finally, we explore the predictive value of several diastolic dysfunction diagnostic parameters to predict PGD occurrence and severity.
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Affiliation(s)
- Jean Philippe Henry
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - François Carlier
- Department of Pneumology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium;
| | - Julien Higny
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Martin Benoit
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Olivier Xhaët
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Dominique Blommaert
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Alin-Mihail Telbis
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Benoit Robaye
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Laurence Gabriel
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Antoine Guedes
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Isabelle Michaux
- Department of Intensive Care, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium;
| | - Fabian Demeure
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Maria-Luiza Luchian
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
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Aggarwal R, Potel KN, Jackson S, Lemke NT, Kelly RF, Soule M, Diaz-Gutierrez I, Shumway SJ, Patil J, Hertz M, Nijjar PS, Huddleston SJ. Impact of lung transplantation on diastolic dysfunction in recipients with pretransplant pulmonary hypertension. J Thorac Cardiovasc Surg 2024; 167:1643-1653.e2. [PMID: 37741317 DOI: 10.1016/j.jtcvs.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/09/2023] [Accepted: 09/13/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVE Pulmonary hypertension can cause left ventricular diastolic dysfunction through ventricular interdependence. Moreover, diastolic dysfunction has been linked to adverse outcomes after lung transplant. The impact of lung transplant on diastolic dysfunction in recipients with pretransplant pulmonary hypertension is not defined. In this cohort, we aimed to assess the prevalence of diastolic dysfunction, the change in diastolic dysfunction after lung transplant, and the impact of diastolic dysfunction on lung transplant outcomes. METHODS In a large, single-center database from January 2011 to September 2021, single or bilateral lung transplant recipients with pulmonary hypertension (mean pulmonary artery pressure > 20 mm Hg) were retrospectively identified. Those without a pre- or post-transplant echocardiogram within 1 year were excluded. Diastolic dysfunction was diagnosed and graded according to the American Society of Echocardiography 2016 guideline on assessment of diastolic dysfunction (present, absent, indeterminate). McNemar's test was used to examine association between diastolic dysfunction pre- and post-transplant. Kaplan-Meier and Cox regression analysis were used to assess associations between pre-lung transplant diastolic dysfunction and post-lung transplant 1-year outcomes, including mortality, major adverse cardiac events, and bronchiolitis obliterans syndrome grade 1 or higher-free survival. RESULTS Of 476 primary lung transplant recipients, 205 with pulmonary hypertension formed the study cohort (mean age, 56.6 ± 11.9 years, men 61.5%, mean pulmonary artery pressure 30.5 ± 9.8 mm Hg, left ventricular ejection fraction < 55% 9 [4.3%]). Pretransplant, diastolic dysfunction was present in 93 patients (45.4%) (grade I = 8, II = 84, III = 1), absent in 16 patients (7.8%), and indeterminate in 89 patients (43.4%), and 7 patients (3.4%) had missing data. Post-transplant, diastolic dysfunction was present in 7 patients (3.4%) (grade I = 2, II = 5, III = 0), absent in 164 patients (80.0%), and indeterminate in 15 patients (7.3%), and 19 patients (9.3%) had missing data. For those with diastolic dysfunction grades in both time periods (n = 180), there was a significant decrease in diastolic dysfunction post-transplant (148/169 patients with resolved diastolic dysfunction; McNemar's test P < .001). Pretransplant diastolic dysfunction was not associated with major adverse cardiac events (hazard ratio [HR], 1.08, 95% CI, 0.72-1.62; P = .71), bronchiolitis obliterans syndrome-free survival (HR, 0.67, 95% CI, 0.39-1.56; P = .15), or mortality (HR, 0.70, 95% CI, 0.33-1.46; P = .34) at 1 year. CONCLUSIONS Diastolic dysfunction is highly prevalent in lung transplant candidates with normal left ventricular systolic function and pulmonary hypertension, and resolves in most patients after lung transplant regardless of patient characteristics. Pre-lung transplant diastolic dysfunction was not associated with adverse lung or cardiac outcomes after lung transplant. Collectively, these findings suggest that the presence of diastolic dysfunction in lung transplant recipients with pulmonary hypertension has no prognostic significance, and as such diastolic dysfunction and the associated clinical syndrome of heart failure with preserved ejection fraction should not be considered a relative contraindication to lung transplant in such patients.
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Affiliation(s)
- Rishav Aggarwal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Koray N Potel
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | - Scott Jackson
- Biostatistical Design and Analysis Center, Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minn
| | - Nicholas T Lemke
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Matthew Soule
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Ilitch Diaz-Gutierrez
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Sara J Shumway
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn
| | - Jagadish Patil
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minn
| | - Marshall Hertz
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minn
| | - Prabhjot S Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minn
| | - Stephen J Huddleston
- Division of Cardiothoracic Surgery, Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn.
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Date H. Living-donor lobar lung transplantation. J Heart Lung Transplant 2024; 43:162-168. [PMID: 37704161 DOI: 10.1016/j.healun.2023.09.006] [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: 06/03/2023] [Revised: 08/22/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023] Open
Abstract
Living-donor lobar lung transplantation (LDLLT) is indicated for critically ill patients who would not survive the waiting period in the case of severe brain-dead donor shortage. It is essential to confirm that potential donors are willing to donate without applying psychological pressure from others. In standard LDLLT, the right and left lower lobes donated by 2 healthy donors are implanted into the recipient under cardiopulmonary support. LDLLT can be applied to various lung diseases including restrictive, obstructive, infectious, and vascular lung diseases in both adult and pediatric patients if size matching is acceptable. Functional size matching by measuring donor pulmonary function and anatomical size matching by 3-dimensional computed tomography volumetry are very useful. When 2 donors with ideal size matching are not available, various transplant procedures, such as single lobe, segmental, recipient lobe-sparing, and inverted lobar transplants are valuable options. There seems to be immunological advantages in LDLLT as compared to cadaveric lung transplantation (CLT). Unilateral chronic allograft dysfunction is a unique manifestation after bilateral LDLLT, which may contribute to better prognosis. The growth of adult lung graft implanted into growing pediatric recipients is suggested by radiologic evaluation. Although only 2 lobes are implanted, postoperative pulmonary function is equivalent between LDLLT and CLT. The long-term outcome after LDLLT is similar to or better than that after CLT. The author has performed 164 LDLLTs resulting in 71.6% survival rate at 10 years. All living-donors returned to their previous life styles. Because of possible serious morbidity in donors, LDLLT should be applied only for critically ill patients.
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Affiliation(s)
- Hiroshi Date
- The Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan.
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Otto M, McGiffin D, Whitford H, Kure C, Snell G, Diehl A, Orosz J, Burrell AJC. Survival and left ventricular dysfunction post lung transplantation for pulmonary arterial hypertension. J Crit Care 2022; 72:154120. [PMID: 35914371 DOI: 10.1016/j.jcrc.2022.154120] [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: 03/24/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Bilateral lung transplantation for end-stage pulmonary arterial hypertension (PAH) is traditionally associated with higher early post-transplant mortality when compared with other indications. Changes in perioperative management, including the growing use of perioperative extracorporeal membrane oxygenation (ECMO) and an increased awareness of postoperative left ventricular dysfunction (LVD), have resulted in outcomes that are uncertain. MATERIALS AND METHODS We conducted a single-center, retrospective observational study at a lung transplantation center in Melbourne, Australia, from 2006 to 2019. ECMO use was categorized as preoperative, prophylactic, or rescue. Postoperative LVD was defined as a reduction in left ventricular function on echocardiography or using strict clinical criteria. RESULTS 50 patients underwent lung transplantation for PAH. 12-month survival was 48/50 (96%). ECMO was used in 26 (52%) patients, and the use of prophylactic VA-ECMO increased over the study period. Postoperative LVD was diagnosed in 21 (42%) patients. 12-month survival and left ventricular function was no different between LVD and non-LVD groups. CONCLUSIONS This study showed that high survival rates can be achieved following lung transplantation for PAH. We found that ECMO utilization was common, and indications have changed over time. LVD was common but did not impact 12-month survival.
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Affiliation(s)
- Madeleine Otto
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Helen Whitford
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Christina Kure
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Gregory Snell
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.
| | - Judit Orosz
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Aidan J C Burrell
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.
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Fujioka T, Akazawa Y, Ide H, Karur GR, Bannan B, Grosse-Wortmann L, Sun M, Hui W, Slorach C, Honjo O, Friedberg MK. Reversal of right ventricular pressure loading improves biventricular function independent of fibrosis in a rabbit model of pulmonary artery banding. J Physiol 2022; 600:3689-3703. [PMID: 35801377 DOI: 10.1113/jp283165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022] Open
Abstract
Right ventricular (RV) pressure loading leads to RV and left ventricular (LV) dysfunction through RV hypertrophy, dilatation and fibrosis. Relief of RV pressure load improves RV function. However, the impact and mechanisms on biventricular reverse-remodelling and function are only partially characterized. We evaluated the impact of RV pressure overload relief on biventricular remodelling and function in a rabbit model of reversible pulmonary artery banding (PAB). Rabbits were randomized to three groups: (1) Sham-operated controls (n = 7); (2) PAB (NDef, n = 7); (3) PAB followed by band deflation (Def, n = 5). Sham and NDef animals were sacrificed at 6 weeks after PAB surgery. Def animals underwent PAB deflation at 6 weeks and sacrifice at 9 weeks. Biventricular geometry, function, haemodynamics, hypertrophy and fibrosis were compared between groups using echocardiography, magnetic resonance imaging, high-fidelity pressure-tipped catheters and histology. RV pressure loading caused RV dilatation, systolic dysfunction, myocyte hypertrophy and LV compression which improved after PAB deflation. RV end-diastolic pressure (RVEDP) decreased after PAB deflation, although remaining elevated vs. Sham. LV end-diastolic pressure (LVEDP) was unchanged following PAB deflation. RV and LV collagen volumes in the NDef and Def group were increased vs. Sham, whereas RV and LV collagen volumes were similar between NDef and Def groups. RV myocyte hypertrophy (r = 0.75, P < 0.001) but not collagen volume was related to RVEDP. LV myocyte hypertrophy (r = 0.58, P = 0.016) and collagen volume (r = 0.56, P = 0.031) correlated with LVEDP. In conclusion, relief of RV pressure overload improves RV and LV geometry, hypertrophy and function independent of fibrosis. The long-term implications of persistent fibrosis and increased biventricular filling pressures, even after pressure load relief, need further study. KEY POINTS: Right ventricular (RV) pressure loading in a pulmonary artery banding rabbit model is associated with RV dilatation, left ventricular (LV) compression; biventricular myocyte hypertrophy, fibrosis and dysfunction. The mechanisms and impact of RV pressure load relief on biventricular remodelling and function has not been extensively studied. Relief of RV pressure overload improves biventricular geometry in conjunction with improved RV myocyte hypertrophy and function independent of reduced fibrosis. These findings raise questions as to the importance of fibrosis as a therapeutic target.
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Affiliation(s)
- Tao Fujioka
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Yohei Akazawa
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Haruki Ide
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Gauri Rani Karur
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Badr Bannan
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lars Grosse-Wortmann
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Mei Sun
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Wei Hui
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Cameron Slorach
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Division of Cardiology, The Labatt Family Heart Centre, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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New strategy to resume and taper epoprostenol after lung transplant for pulmonary hypertension. Gan To Kagaku Ryoho 2022; 70:372-377. [PMID: 34978021 DOI: 10.1007/s11748-021-01746-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/14/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The perioperative outcome of lung transplantation (LTx) for patients with severe pulmonary hypertension (PH) remains poor due to the occurrence of primary graft dysfunction (PGD) from left ventricular failure. We hypothesized that tapering pretransplant use of epoprostenol rather than abrupt discontinuation after transplantation might improve perioperative outcomes. METHODS We performed 23 LTxs for patients with severe PH who received epoprostenol therapy from 2008 until 2021. In the discontinued group (n = 6), epoprostenol was discontinued after the establishment of extracorporeal circulation. In the tapered group (n = 17), epoprostenol was discontinued and resumed after reperfusion, and then gradually tapered over the following 2 weeks. We assessed survival, bleeding, blood transfusion, re-opening of the chest, oxygenation, PGD score, extracorporeal membrane oxygenation (ECMO) requirement for recovery after transplantation, and duration of mechanical ventilation. RESULTS The PGD score was significantly lower in the tapered group than in the discontinued group at 0 h, 24 h, and 48 h after LTx. In addition, the discontinued group required longer mechanical ventilation than the tapered group. Delayed chest closure and post-transplant ECMO use for recovery occurred significantly more frequently in the discontinued group. CONCLUSIONS To resume and taper epoprostenol administration after reperfusion in patients with severe PH may be a valuable new strategy associated with better perioperative outcomes.
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Cain MT, Joyce D, Lahr BD, Day CN, Sandhu GS, Kushwaha S, Joyce LD. Do Right Heart Hemodynamic Improvements Persist After Pulmonary Thromboendarterectomy? Semin Thorac Cardiovasc Surg 2021; 34:80-89. [PMID: 33691188 DOI: 10.1053/j.semtcvs.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/04/2021] [Indexed: 11/11/2022]
Abstract
The survival benefits of pulmonary thromboendarterectomy (PTE) for the treatment of chronic thromboembolic pulmonary hypertension have been well described. However, the significance of right heart hemodynamic changes and their impact on survival remains poorly understood. We sought to characterize the effects of these changes. We conducted a single center, retrospective review of 159 patients who underwent PTE between 1993 and 2015. Echocardiographic and right heart catheterization data were compared longitudinally before and after PTE in order to establish the extent of hemodynamic response to surgery. Kaplan Meier estimates were used to characterize patient survival over time. Univariable and multivariable Cox proportional hazards regression models were used to assess factors associated with long-term mortality. Among the 159 patients studied, 74 (46.5%) were male with a median age of 55 (IQR: 42-66). One-, 5-, 10-, and 15-year survival was 91.0% (95% CI: 86.6-95.6), 79.6% (73.5-86.3), 66.5% (59.2-74.7), and 56.2% (48.1-65.8). Of the 9 candidate risk factors that were evaluated, only advanced age and increased cardiopulmonary bypass time were found to be significantly associated with increased risk of mortality. Pre- and postsurgical echocardiographic imaging data, when available, revealed a median reduction in right ventricular systolic pressure of 29.0 mm Hg (P < 0.0001) and improvement of tricuspid regurgitation (P < 0.0001), both of which appeared to be sustained across long-term follow-up. Improvements in right heart hemodynamics and tricuspid valvular regurgitation persist on long term surveillance following PTE. While patient selection is often driven by the distribution of disease, close postoperative follow up may improve outcomes.
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Affiliation(s)
- Michael T Cain
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brian D Lahr
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Courtney N Day
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet S Sandhu
- Mayo Clinic Department of Cardiovascular Medicine, Rochester, Minnesota
| | - Sudhir Kushwaha
- Mayo Clinic Department of Cardiovascular Medicine, Rochester, Minnesota
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Badu B, Cain MT, Durham LA, Joyce LD, Sundararajan S, Gaglianello N, Ishizawar D, Saltzberg M, Mohammed A, Joyce DL. A Dual-Lumen Percutaneous Cannula for Managing Refractory Right Ventricular Failure. ASAIO J 2020; 66:915-921. [PMID: 32740352 DOI: 10.1097/mat.0000000000001099] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A right ventricular assist device (RVAD) using a dual-lumen percutaneous cannula inserted through the right internal jugular vein (IJV) might improve weaning in patients with refractory right ventricular (RV) failure. However, the reported experience with this cannula is limited. We reviewed the records of all patients receiving RVAD support with this new dual-lumen cannula at our institution between April 2017 and February 2019. We recorded data on weaning, mortality, and device-specific complications. We compared outcomes among three subgroups based on the indications for RVAD support (postcardiotomy, cardiogenic shock, and primary respiratory failure) and against similar results in the literature. Mean (standard deviation [SD]) age of the 40 patients (29 men) was 53 (15.5) years. Indications for implantation were postcardiotomy support in 18 patients, cardiogenic shock in 12, and respiratory failure in 10. In all, 17 (94%) patients in the postcardiotomy group were weaned from RVAD support, five (42%) in the cardiogenic shock group, and seven (70%) in the respiratory failure group, overall higher than those reported in the literature (49% to 59%) for surgically placed RVADs. Whereas published in-hospital mortality rates range from 42% to 50% for surgically placed RVADs and from 41% to 50% for RVADs with percutaneous cannulas implanted through the right IJV, mortality was 11%, 58%, and 40% in our subgroups, respectively. There were no major device-related complications. This percutaneous dual-lumen cannula appears to be safe and effective for managing refractory RV failure, with improved weaning and mortality profile, and with limited device-specific adverse events.
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Affiliation(s)
- Bernice Badu
- From the Department of surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Cain
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sakthi Sundararajan
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nunzio Gaglianello
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Ishizawar
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mitchell Saltzberg
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Asim Mohammed
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Yoshinaga D, Baba S, Hirata T, Fukushima H, Hamaji M, Aoyama A, Chen-Yoshikawa TF, Yamagishi H, Date H, Heike T. Living-donor lung transplantation after surgical repair of transposition of the great arteries. Gen Thorac Cardiovasc Surg 2018; 67:640-643. [PMID: 30191531 DOI: 10.1007/s11748-018-1006-y] [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: 03/31/2018] [Accepted: 09/02/2018] [Indexed: 11/28/2022]
Abstract
Pediatric pulmonary hypertension after surgery for congenital heart disease is a significant complication. We present a case of living-donor lung transplantation for a 12-year-old girl with pulmonary hypertension after surgical repair of transposition of great arteries. Despite repairing the transposition of great arteries, her growth was severely restricted because of progressive pulmonary hypertension; thus, lung transplantation was discussed. Standard bilateral lobar transplantation seemed unfeasible due to oversized grafts, so we performed a single lobar transplantation. Unexpectedly, she developed complications and died 3 months postoperatively despite another emergent lobar transplantation. We discussed the challenges and potential solutions regarding lobar size mismatching.
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Affiliation(s)
- Daisuke Yoshinaga
- Department of Pediatrics, Graduate School of Medicine, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
| | - Shiro Baba
- Department of Pediatrics, Graduate School of Medicine, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan.
| | - Takuya Hirata
- Department of Pediatrics, Graduate School of Medicine, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
| | - Hiroyuki Fukushima
- Department of Pediatrics, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masatsugu Hamaji
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
| | - Akihiro Aoyama
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
| | - Toyofumi F Chen-Yoshikawa
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University Hospital, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
| | - Toshio Heike
- Department of Pediatrics, Graduate School of Medicine, Kyoto University Hospital, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Kyoto, 606-8507, Japan
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10
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Quezada-Loaiza C, de Pablo Gafas A, Pérez V, Alonso R, Juarros L, Real M, López E, Cortes M, Meneses J, González I, Díaz-Hellín Gude V, Subías P, Gámez P. Lung Transplantation in Pulmonary Hypertension: A Multidisciplinary Unit's Management Experience. Transplant Proc 2018; 50:1496-1503. [DOI: 10.1016/j.transproceed.2018.02.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/03/2018] [Accepted: 02/06/2018] [Indexed: 10/17/2022]
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11
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Postoperative left ventricular function in different types of pulmonary hypertension: a comparative study†. Interact Cardiovasc Thorac Surg 2018; 26:813-819. [DOI: 10.1093/icvts/ivx418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/02/2017] [Indexed: 11/14/2022] Open
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Avriel A, Klement AH, Johnson SR, de Perrot M, Granton J. Impact of Left Ventricular Diastolic Dysfunction on Lung Transplantation Outcome in Patients With Pulmonary Arterial Hypertension. Am J Transplant 2017; 17:2705-2711. [PMID: 28508451 DOI: 10.1111/ajt.14352] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 03/31/2017] [Accepted: 05/02/2017] [Indexed: 01/25/2023]
Abstract
Diastolic dysfunction may influence perioperative outcome, early graft function, and long-term survival. We compared the outcomes of double lung transplantation (DLTx) for patients with pulmonary arterial hypertension (PAH) with preoperative left ventricular (LV) diastolic dysfunction with the outcomes of patients without diastolic dysfunction. Of 116 consecutive patients with PAH (who underwent transplantation between January 1995 and December 2013), 44 met our inclusion and exclusion criteria. Fourteen (31.8%) patients with diastolic dysfunction pretransplantation had a higher body mass index (29 [IQR 21.5-32.6] vs 22.4 [IQR 19.9-25.3] kg/m2 ) and mean pulmonary arterial pressure (54.6 ± 10 mmHg vs 47 ± 11.3 mmHg) and right atrial pressure (16.5 ± 5.2 mmHg vs 10.6 ± 5.2 mmHg). The patients received extracorporeal life support more frequently (33% vs 7% [p = 0.02]), had worse APACHE II scores (21.7 ± 7.4 vs 15.3 ± 5.3 [p = 0.02]), and a trend toward worse ventilator-free days (2.5 [IQR 6.5-32.5] vs 17 [IQR 3-23] [p = 0.08]). There was no effect on development of primary graft dysfunction or intensive care unit/hospital survival. One-year survival was worse (hazard ratio [HR] 4.45, 95% confidence interval [CI] 1.3-22, p = 0.02). Diastolic dysfunction was the only variable that correlated with overall survival (HR 5.4, 95% CI 1.3-22, p = 0.02). Diastolic dysfunction leads to early postoperative morbidity and worse survival in patients with PAH after DLTx.
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Affiliation(s)
- A Avriel
- Pulmonology Institute, Department of Medicine, Soroka Medical Center, Faculty of Health Sciences Ben-Gurion University, Beer-Sheva, Israel
| | - A H Klement
- Meir Medical Center, Faculty of Health Sciences, Tel- Aviv University, Tel-Aviv, Israel
| | - S R Johnson
- Division of Rheumatology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - M de Perrot
- Multiorgan Transplant Program, University Health Network, and the Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - J Granton
- Multiorgan Transplant Program, University Health Network, and the Division of Respirology, University Health Network, Toronto, Ontario, Canada
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Sarashina T, Nakamura K, Akagi S, Oto T, Oe H, Ejiri K, Nakagawa K, Nishii N, Matsubara H, Kobayashi M, Morimatsu H, Miyoshi S, Ito H. Reverse Right Ventricular Remodeling After Lung Transplantation in Patients With Pulmonary Arterial Hypertension Under Combination Therapy of Targeted Medical Drugs. Circ J 2017; 81:383-390. [PMID: 28100891 DOI: 10.1253/circj.cj-16-0838] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Patients with pulmonary arterial hypertension (PAH) are currently treated with combination therapy of PAH-targeted drugs. Reverse right ventricular (RV) remodeling after lung transplantation (LTx) in patients with end-stage PAH despite combination therapy of PAH-targeted drugs has not been fully elucidated.Methods and Results:A total of 136 patients, including 32 with PAH, underwent LTx from 1998 to 2014. We enrolled 12 consecutive patients with PAH treated with combination therapy of PAH-targeted drugs who underwent LTx and retrospectively analyzed the temporal and serial changes in hemodynamics and echocardiography before LTx and at 3 and 12 months after LTx. Before LTx, the RV was markedly dilated with substantially reduced RV fractional area change (RVFAC). At 3 months after LTx, pulmonary artery pressure, pulmonary vascular resistance and RV stroke work index were significantly decreased, while left ventricular stroke work index was increased. RV size assessed by echocardiography also significantly decreased and RVFAC improved. At 12 months after LTx, RVFAC was further increased and RV wall thickness was decreased significantly. CONCLUSIONS Although severe RV dysfunction and dilation were observed in patients with end-stage PAH despite combination therapy of PAH-targeted drugs, RV function and morphology were improved after reduction of RV pressure load by LTx.
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Affiliation(s)
- Toshihiro Sarashina
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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14
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Left Ventricular Dysfunction After Lung Transplantation for Pulmonary Arterial Hypertension. Transplant Proc 2016; 47:2732-6. [PMID: 26680083 DOI: 10.1016/j.transproceed.2015.07.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/24/2015] [Accepted: 07/08/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lung transplantation (LT) is the final treatment option for patients with pulmonary arterial hypertension (PAH). Perioperative challenges after LT are unique and commonly include excessive bleeding, arrhythmias, and primary graft dysfunction. Transient left ventricular dysfunction (LVD) is a known postoperative complication, but not fully explored. We describe our experiences at a single institution. METHODS We reviewed our database for patients with PAH who underwent LT from July 2008 to July 2012. The data were analyzed for preoperative inotrope use, intravenous prostacyclin, cardiac catheterization, and imaging. Also measured were perioperative ischemic time, bypass time, primary graft dysfunction, ventilator days, length of stay, and mortality. LVD is defined as acute cardiopulmonary compromise (acute worsening of hypoxia with new bilateral infiltrates on imaging) with a drop in LV systolic function of 15% from baseline. We compared data between patients with LVD and without LVD. RESULTS Sixteen patients met the criteria, the majority of patients (10) with World Health Organization (WHO) group 1 PAH. Thirteen received intravenous prostacyclin therapy, and 6 required inotropes before surgery. Five patients (31%) developed LVD after transplantation. Average time to onset of LVD was 4.2 days. Preoperative vasopressors were required in 60% of those developing LVD. Patients with LVD had lower right and left ventricular ejection fraction with higher left ventricular end diastolic volume before surgery. All patients recovered from LVD within 4 months after LT. CONCLUSIONS LVD is a phenomenon observed mostly in patients with WHO group 1 PAH receiving LT. Prompt recognition and treatment of this condition reduced morbidity.
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15
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Kortchinsky T, Mussot S, Rezaiguia S, Artiguenave M, Fadel E, Stephan F. Extracorporeal life support in lung and heart-lung transplantation for pulmonary hypertension in adults. Clin Transplant 2016; 30:1152-8. [DOI: 10.1111/ctr.12805] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Talna Kortchinsky
- Cardiothoracic Intensive Care Unit; Centre Chirurgical Marie Lannelongue; Le Plessis Robinson France
| | - Sacha Mussot
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation; Centre Chirurgical Marie Lannelongue; Le Plessis Robinson France
| | - Saïda Rezaiguia
- Cardiothoracic Intensive Care Unit; Centre Chirurgical Marie Lannelongue; Le Plessis Robinson France
| | - Margaux Artiguenave
- Cardiothoracic Intensive Care Unit; Centre Chirurgical Marie Lannelongue; Le Plessis Robinson France
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation; Centre Chirurgical Marie Lannelongue; Le Plessis Robinson France
| | - François Stephan
- Cardiothoracic Intensive Care Unit; Centre Chirurgical Marie Lannelongue; Le Plessis Robinson France
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16
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Girgis RE, Khaghani A. A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure. Glob Cardiol Sci Pract 2016; 2016:e201605. [PMID: 29043255 PMCID: PMC5642749 DOI: 10.21542/gcsp.2016.5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 04/08/2016] [Indexed: 11/17/2022] Open
Abstract
Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.
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Affiliation(s)
- Reda E. Girgis
- Richard DeVos Heart and Lung Transplant Program, Spectrum Health,
| | - Asghar Khaghani
- Michigan State University, College of Human Medicine, Grand Rapids, MI, USA
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17
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Manders E, Rain S, Bogaard HJ, Handoko ML, Stienen GJM, Vonk-Noordegraaf A, Ottenheijm CAC, de Man FS. The striated muscles in pulmonary arterial hypertension: adaptations beyond the right ventricle. Eur Respir J 2015; 46:832-42. [PMID: 26113677 DOI: 10.1183/13993003.02052-2014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 05/19/2015] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a fatal lung disease characterised by progressive remodelling of the small pulmonary vessels. The daily-life activities of patients with PAH are severely limited by exertional fatigue and dyspnoea. Typically, these symptoms have been explained by right heart failure. However, an increasing number of studies reveal that the impact of the PAH reaches further than the pulmonary circulation. Striated muscles other than the right ventricle are affected in PAH, such as the left ventricle, the diaphragm and peripheral skeletal muscles. Alterations in these striated muscles are associated with exercise intolerance and reduced quality of life. In this Back to Basics article on striated muscle function in PAH, we provide insight into the pathophysiological mechanisms causing muscle dysfunction in PAH and discuss potential new therapeutic strategies to restore muscle dysfunction.
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Affiliation(s)
- Emmy Manders
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands Dept of Physiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Silvia Rain
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - M Louis Handoko
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands Dept of Cardiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Ger J M Stienen
- Dept of Physiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands Dept of Physics and Astronomy, VU University, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Coen A C Ottenheijm
- Dept of Physiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Frances S de Man
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
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18
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Talati M, Hemnes A. Fatty acid metabolism in pulmonary arterial hypertension: role in right ventricular dysfunction and hypertrophy. Pulm Circ 2015; 5:269-78. [PMID: 26064451 DOI: 10.1086/681227] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 12/30/2014] [Indexed: 12/21/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a complex, multifactorial disease in which an increase in pulmonary vascular resistance leads to increased afterload on the right ventricle (RV), causing right heart failure and death. Our understanding of the pathophysiology of RV dysfunction in PAH is limited but is constantly improving. Increasing evidence suggests that in PAH RV dysfunction is associated with various components of metabolic syndrome, such as insulin resistance, hyperglycemia, and dyslipidemia. The relationship between RV dysfunction and fatty acid/glucose metabolites is multifaceted, and in PAH it is characterized by a shift in utilization of energy sources toward increased glucose utilization and reduced fatty acid consumption. RV dysfunction may be caused by maladaptive fatty acid metabolism resulting from an increase in fatty acid uptake by fatty acid transporter molecule CD36 and an imbalance between glucose and fatty acid oxidation in mitochondria. This leads to lipid accumulation in the form of triglycerides, diacylglycerol, and ceramides in the cytoplasm, hallmarks of lipotoxicity. Current interventions in animal models focus on improving RV dysfunction through altering fatty acid oxidation rates and limiting lipid accumulation, but more specific and effective therapies may be available in the coming years based on current research. In conclusion, a deeper understanding of the complex mechanisms of the metabolic remodeling of the RV will aid in the development of targeted treatments for RV failure in PAH.
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Affiliation(s)
- Megha Talati
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anna Hemnes
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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19
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Manders E, Bogaard HJ, Handoko ML, van de Veerdonk MC, Keogh A, Westerhof N, Stienen GJM, Dos Remedios CG, Humbert M, Dorfmüller P, Fadel E, Guignabert C, van der Velden J, Vonk-Noordegraaf A, de Man FS, Ottenheijm CAC. Contractile dysfunction of left ventricular cardiomyocytes in patients with pulmonary arterial hypertension. J Am Coll Cardiol 2014; 64:28-37. [PMID: 24998125 DOI: 10.1016/j.jacc.2014.04.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND After lung transplantation, increased left ventricular (LV) filling can lead to LV failure, increasing the risk of post-operative complications and mortality. LV dysfunction in pulmonary arterial hypertension (PAH) is characterized by a reduced LV ejection fraction and impaired diastolic function. OBJECTIVES The pathophysiology of LV dysfunction in PAH is incompletely understood. This study sought to assess the contribution of atrophy and contractility of cardiomyocytes to LV dysfunction in PAH patients. METHODS LV function was assessed by cardiac magnetic resonance imaging. In addition, LV biopsies were obtained in 9 PAH patients and 10 donors. The cross-sectional area (CSA) and force-generating capacity of isolated single cardiomyocytes was investigated. RESULTS Magnetic resonance imaging analysis revealed a significant reduction in LV ejection fraction in PAH patients, indicating a reduction in LV contractility. The CSA of LV cardiomyocytes of PAH patients was significantly reduced (~30%), indicating LV cardiomyocyte atrophy. The maximal force-generating capacity, normalized to cardiomyocyte CSA, was significantly reduced (~25%). Also, a reduction in the number of available myosin-based cross-bridges was found to cause the contractile weakness of cardiomyocytes. This finding was supported by protein analyses, which showed an ~30% reduction in the myosin/actin ratio in cardiomyocytes from PAH patients. Finally, the phosphorylation level of sarcomeric proteins was reduced in PAH patients, which was accompanied by increased calcium sensitivity of force generation. CONCLUSIONS The contractile function and the CSA of LV cardiomyocytes is substantially reduced in PAH patients. We propose that these changes contribute to the reduced in vivo contractility of the LV in PAH patients.
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Affiliation(s)
- Emmy Manders
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands; Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Harm-Jan Bogaard
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - M Louis Handoko
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands; Cardiology Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Marielle C van de Veerdonk
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - Anne Keogh
- Heart Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Nico Westerhof
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands; Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Ger J M Stienen
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands; Department of Physics and Astronomy, VU University, Amsterdam, the Netherlands
| | | | - Marc Humbert
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Département Hospitalo-Universitaire, Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Peter Dorfmüller
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France; Service d'Anatomie Pathologique, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Elie Fadel
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France; Service de Chirurgie Thoracique, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Christophe Guignabert
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Jolanda van der Velden
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands; ICIN Netherlands Heart Institute, Utrecht, the Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - Frances S de Man
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands.
| | - Coen A C Ottenheijm
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands.
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Esper SA. Role of Transesophageal Echocardiography in Perioperative Patient Management of Lung Transplantation Surgery. ACTA ACUST UNITED AC 2013. [DOI: 10.5005/jp-journals-10034-1008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ABSTRACT
Lung transplantation is the only option for patients with end-stage lung disease. Chronic obstructive lung disease, idiopathic pulmonary fibrosis, cystic fibrosis and primary pulmonary hypertension are few common indications for lung transplantation. Patients with end-stage lung disease may have pre-existing cardiovascular compromise related to pulmonary hypertension and other cardiovascular lesions, such as coronary artery disease or valvular heart disease. Preoperative evaluation and optimization of hemodynamics is expected to improve outcomes from lung transplantation. Intraoperative hemodynamic instability is common during lung transplantation and requires highest level of cardiovascular monitoring. After transplantation, vascular anastomosis should be evaluated for flow patterns to rule out obstruction from stenosis or thrombosis. Postoperative complications are common and include bleeding, cardiac failure and hypoxemia from right to left shunt. Primary graft dysfunction may necessitate mechanical cardiorespiratory support. Transesophageal echocardiography plays a central role in preoperative evaluation, intraoperative hemodynamic management, evaluation of pulmonary vascular anastomosis, diagnosis of postoperative complications and also in the critical care management of mechanical cardiorespiratory support.
How to cite this article
Subramaniam K, Esper SA. Role of Transesophageal Echocardiography in Perioperative Patient Management of Lung Transplantation Surgery. J Perioper Echocardiogr 2013;1(2):48-56.
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Abstract
Right ventricular (RV) function is a strong independent predictor of outcome in a number of distinct cardiopulmonary diseases. The RV has a remarkable ability to sustain damage and recover function which may be related to unique anatomic, physiologic, and genetic factors that differentiate it from the left ventricle. This capacity has been described in patients with RV myocardial infarction, pulmonary arterial hypertension, and chronic thromboembolic disease as well as post-lung transplant and post-left ventricular assist device implantation. Various echocardiographic and magnetic resonance imaging parameters of RV function contribute to the clinical assessment and predict outcomes in these patients; however, limitations remain with these techniques. Early diagnosis of RV function and better insight into the mechanisms of RV recovery could improve patient outcomes. Further refinement of established and emerging imaging techniques is necessary to aid subclinical diagnosis and inform treatment decisions.
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Affiliation(s)
- Evan L Brittain
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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Tonelli AR, Timofte I, Minai OA, Baz M, Akindipe O. Pulmonary hypertension before first and second lung transplantation. Clin Transplant 2012; 26:672-8. [PMID: 22320224 DOI: 10.1111/j.1399-0012.2011.01588.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary hypertension (PH) is frequently encountered in patients with advanced lung disease before the first and second lung transplantation. We sought to determine whether there is any relationship between pulmonary hemodynamics obtained before first and second lung transplantation. We also assessed whether PH has prognostic implications in lung transplant patients going for second transplantation. METHODS We included consecutive adult (16-yr-old or older) patients who underwent lung re-transplantation, between 1997 and 2009, and had right heart catheterization before their first and second lung transplantation. RESULTS Eighteen patients were included in the study. Age at first transplantation was 50.4 (SD 10.4) yr, and bronchiolitis obliterans syndrome (BOS) in the transplanted lung was the only indication for re-transplantation. PH was observed in 39% of the patients before the first lung transplant and in 56% of the subjects before re-transplantation (p = 0.91). Pre-capillary PH was present in 28% (n = 5) and 33% (n = 6) of the patients before first and second lung transplantation, respectively. None of the hemodynamic variables obtained before the first transplant predicted the development of PH before re-transplantation. PH before re-transplantation did not predict survival or development of BOS after re-transplantation. CONCLUSIONS PH before initial lung transplantation did not predict the development of PH before the second transplantation. In our cohort, PH before second lung transplantation did not predict outcomes after re-transplantation.
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Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, OH 44195, USA.
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Shigemura N, Sareyyupoglu B, Bhama J, Bonde P, Thacker J, Bermudez C, Gries C, Crespo M, Johnson B, Pilewski J, Toyoda Y. Combining tricuspid valve repair with double lung transplantation in patients with severe pulmonary hypertension, tricuspid regurgitation, and right ventricular dysfunction. Chest 2011; 140:1033-1039. [PMID: 21700686 DOI: 10.1378/chest.10-2929] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Concomitant tricuspid valve repair (TVR) and double lung transplantation (DLTx) has been a surgical option at our institution since 2004 in an attempt to improve the outcome of DLTx for end-stage pulmonary hypertension, severe tricuspid regurgitation, and right ventricle (RV) dysfunction. This study is a review of that single institutional experience. METHODS Consecutive cases of concomitant TVR and DLTx performed between 2004 and 2009 (TVR group, n = 20) were retrospectively compared with cases of DLTx alone for severe pulmonary hypertension without TVR (non-TVR group, n = 58). RESULTS There was one in-hospital death in the TVR group. The 90-day and 1- and 3-year survival rates for the TVR group were 90%, 75%, and 65%, respectively, which were not significantly different from those for the non-TVR group. The TVR group required less inotropic support and less prolonged mechanical ventilation in the ICU. Follow-up echocardiography demonstrated immediate elimination of both volume and pressure overload in the RV and tricuspid regurgitation in the TVR group. Notably, there was a significantly lower incidence of primary graft dysfunction following transplantation in the TVR group (P < .05). Pulmonary functional improvement shown by an FEV(1) increase after 6 months was also significantly better in the TVR group (40% vs 20%, P < .05). CONCLUSIONS Combined TVR and DLTx procedures were successfully performed without an increase in morbidity or mortality and contributed to decreased primary graft dysfunction. In our experience, this combined operative approach achieves clinical outcomes equal or superior to the outcomes seen in DLTx patients without RV dysfunction and severe tricuspid regurgitation.
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Affiliation(s)
- Norihisa Shigemura
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Basar Sareyyupoglu
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jay Bhama
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Pramod Bonde
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jnanesh Thacker
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Christian Bermudez
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Cynthia Gries
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Maria Crespo
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bruce Johnson
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Joseph Pilewski
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Yoshiya Toyoda
- Division of Cardiothoracic Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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