1
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Grewal HS, Thaniyavarn T, Arcasoy SM, Goldberg HJ. Common Noninfectious Complications Following Lung Transplantation. Clin Chest Med 2023; 44:179-190. [PMID: 36774163 DOI: 10.1016/j.ccm.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
According to the Scientific Registry of Transplant Recipients, both transplant volume and survival among lung transplant recipients are improving over time. However, the outcomes of lung transplantation remain challenged by multiple thoracic and extrathoracic complications. With improving lung transplant survival, patients experience prolonged exposure to chronic immunosuppressive agents that can lead to multiple infectious and noninfectious complications. This article focuses on most common noninfectious complications with significant clinical impact.
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Affiliation(s)
- Harpreet Singh Grewal
- Lung Transplant Program, Columbia University, Irving Medical Center, 622 West 168th Street, PH 14E, Suite 104, New York, NY 10032, USA.
| | - Tany Thaniyavarn
- Lung Transplant Program, Brigham and Women's Hospital, 75 Francis Street, PBB Clinic 3, Boston, MA 02115, USA
| | - Selim M Arcasoy
- Lung Transplant Program, Columbia University, Irving Medical Center, 622 West 168th Street, PH 14E, Suite 104, New York, NY 10032, USA
| | - Hilary J Goldberg
- Lung Transplant Program, Brigham and Women's Hospital, 75 Francis Street, PBB Clinic 3, Boston, MA 02115, USA
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2
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Schumer EM, Saddoughi SA, Spencer PJ, Pochettino A, Daly RC, Villavicencio MA. Lung Transplantation Long-term Survival is Worse in Patients Who Have Undergone Previous Cardiac Surgery. Eur J Cardiothorac Surg 2022; 62:6677658. [PMID: 36029251 DOI: 10.1093/ejcts/ezac437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/13/2022] [Accepted: 08/26/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Approximately 10% of lung transplant recipients have had previous cardiothoracic surgery. We sought to determine if previous surgery affects outcomes after lung transplant at a national level. METHODS The United Network for Organ Sharing database was analyzed from 2005-2019 to include adult patients who underwent lung transplant who had previous cardiac surgery, and previous thoracic surgery. T-test and chi-squared analysis was used to compare perioperative outcomes. Long-term survival comparison was performed using the Kaplan-Meier method in an unadjusted and propensity matched analysis. RESULTS Out of 24,784 lung transplants, 691 (2.7%) had previous cardiac surgery and 1,321 (6.5%) had previous thoracic surgery. Operative mortality was worse in previous cardiac surgery 42(6.1%) versus no previous cardiac surgery 740(3.1%), p < 0.001, and in previous thoracic surgery 65(4.9%) versus no previous thoracic surgery 717(3.1%), p < 0.001. The previous thoracic surgery group had more primary graft failure and treated rejection during the first-year post-transplant. There was no difference in stroke, dialysis, intubation and extracorporeal membrane oxygenation at 72 hours. Long-term survival was significantly worse for lung transplant patients who had undergone previous cardiac surgery (median 3.8 vs 6.3 years, p < 0.001) due to an increase in cardiovascular deaths (p = 0.008) and malignancy (p = 0.043). However, there was no difference in previous thoracic surgery (median 6.6 vs 6.1 years, p = 0.337). CONCLUSIONS Previous cardiac surgery prior to lung transplant results in worse survival related to cardiovascular death and malignancies. Previous thoracic surgery worsens perioperative outcomes but does not affect long term survival.
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Affiliation(s)
- Erin M Schumer
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Sahar A Saddoughi
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Philip J Spencer
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Alberto Pochettino
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
| | - Richard C Daly
- Department of Cardiovascular Surgery, Mayo Clinic, 200 1 St. SW, Rochester, MD, 55905
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3
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Slama A, Ceulemans LJ, Hedderich C, Boehm PM, Van Slambrouck J, Schwarz S, Vandervelde CM, Kamler M, Jaksch P, Van Raemdonck D, Hoetzenecker K, Aigner C. Lung Volume Reduction Followed by Lung Transplantation in Emphysema-A Multicenter Matched Analysis. Transpl Int 2022; 35:10048. [PMID: 35497884 PMCID: PMC9047703 DOI: 10.3389/ti.2022.10048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/24/2022] [Indexed: 11/29/2022]
Abstract
Objective: The impact of previous lung volume reduction surgery (LVRS) or endoscopic lung volume reduction (ELVR) on lung transplantation (LuTX) remains unclear. This study assesses the risk of previous lung volume reduction on the outcome of a later LuTX. Methods: Patients suffering from emphysema who underwent bilateral LuTX were included in this multicenter analysis. Study groups were defined as: previous LVRS, previous ELVR, controls. Imbalances were corrected by coarsened exact matching for center, gender, age, diagnosis, and BMI. A comparative analysis of intraoperative characteristics, perioperative outcome and long-term survival was performed. Results: 615 patients were included (LVRS = 26; ELVR = 60). Compared to controls, LVRS patients had a higher rate of postoperative ECMO (15.4 vs. 3.9%; p = 0.006), whereas ELVR patients suffered more often from wound infections (8.9% vs. 2.5%; p = 0.018). Perioperative outcome, duration of ventilation, ICU stay, and hospital stay were comparable between groups. Bacterial colonization of the airway differed significantly between both LVR groups and controls in pre- and post-LuTX cultures. Survival was not impacted (1-/3-/5-year survival for LVRS: 92.3%/85.7%/77.1%; controls: 91.3%/82.4%/76.3%; p = 0.58 | ELVR: 93.1%/91%/91%; controls 91.2%/81.7%/75.3%; p = 0.17). Conclusion: Lung volume reduction does not impact short and long-time survival after bilateral LuTX. Due to differences in airway colonization after LVR, caution to prevent infectious complications is warranted.
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Affiliation(s)
- Alexis Slama
- Department of Thoracic Surgery and Thoracic Endoscopy, University Medicine Essen, Ruhrlandklinik, Essen, Germany.,West German Center for Lung Transplantation, University Medicine Essen, Essen, Germany
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Celia Hedderich
- Department of Thoracic Surgery and Thoracic Endoscopy, University Medicine Essen, Ruhrlandklinik, Essen, Germany
| | - Panja M Boehm
- Clinic of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Jan Van Slambrouck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | - Stefan Schwarz
- Clinic of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Markus Kamler
- West German Center for Lung Transplantation, University Medicine Essen, Essen, Germany
| | - Peter Jaksch
- Clinic of Thoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Department of Chronic Diseases and Metabolism, Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven, Leuven, Belgium
| | | | - Clemens Aigner
- Department of Thoracic Surgery and Thoracic Endoscopy, University Medicine Essen, Ruhrlandklinik, Essen, Germany.,West German Center for Lung Transplantation, University Medicine Essen, Essen, Germany
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4
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Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2021; 40:1349-1379. [PMID: 34419372 DOI: 10.1016/j.healun.2021.07.005] [Citation(s) in RCA: 290] [Impact Index Per Article: 96.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.
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5
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McCarthy DP, Taylor LJ, DeCamp MM. Analysis of Recent Literature on Lung Volume Reduction Surgery. Thorac Surg Clin 2021; 31:119-128. [PMID: 33926666 DOI: 10.1016/j.thorsurg.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Publication of the National Emphysema Treatment Trial (NETT) in 2003 established lung volume reduction surgery (LVRS) as a viable treatment of select patients with moderate to severe emphysema, and the only intervention since the availability of ambulatory supplemental oxygen to improve survival. Despite these findings, surgical treatment has been underused in part because of concern for high morbidity and mortality. This article reviews recent literature generated since the original NETT publication, focusing on physiologic implications of LVRS, recent data regarding the safety and durability of LVRS, and patient selection and extension of NETT criteria to other patient populations.
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Affiliation(s)
- Daniel P McCarthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792, USA
| | - Lauren J Taylor
- Division of Cardiothoracic Surgery, University of Colorado, Anschutz Medical Campus, 12631 East 17th Avenue, Room 5401, Mail Stop C-291, Aurora, CO 80045, USA
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin-Madison, 600 Highland Avenue, H4/340, Madison, WI 53792-0001, USA.
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6
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Krishnan A, Chidi A, Merlo CA, Shah PD, Ha J, Higgins RSD, Bush EL. Lung Volume Reduction Surgery Before Lung Transplantation: A Propensity-Matched Analysis. Ann Thorac Surg 2021; 113:491-497. [PMID: 33609545 DOI: 10.1016/j.athoracsur.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/25/2021] [Accepted: 02/08/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lung volume reduction surgery (LVRS) is treatment option for chronic obstructive pulmonary disease, the second most common indication for lung transplantation (LTx) in the United States. Lung volume reduction surgery before LTx is controversial. Single-institution studies report contradicting results, and the impact of undergoing LVRS before LTx on outcomes after LTx is unclear. METHODS We reviewed the United Network for Organ Sharing database for all adults (aged more than 18 years) who underwent first-time LTx for chronic obstructive pulmonary disease in the lung allocation score era. We used patient demographic and clinical characteristics and lung allocation score to propensity match patients who did and patients who did not undergo LVRS before LTx. The primary exposure was prior LVRS. The primary outcome was graft failure after LTx. Unadjusted Kaplan-Meier and adjusted Cox proportional hazards models were used to assess outcomes. RESULTS A total of 4905 patients with chronic obstructive pulmonary disease underwent LTx between May 2005 and March 2017. Of them, 107 patients (2.2%) underwent LVRS before LTx. Propensity matching generated 212 matches (106 LVRS+LTx, and 106 LTx only). Median survival was significantly longer in the LTx only cohort (6.5 vs 3.4 years, P = .034). Lung volume reduction surgery before lung transplantation was associated with significantly increased risk of graft failure after lung transplant (hazard ratio 1.72; 95% confidence interval, 1.13 to 2.60; P = .01). CONCLUSIONS In this national, propensity-matched analysis of LVRS before LTx, we show that LVRS is associated with a significantly increased risk of graft failure. Patients who undergo LVRS and remain in need of LTx should be carefully assessed and followed postoperatively.
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Affiliation(s)
- Aravind Krishnan
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alexis Chidi
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jinny Ha
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert S D Higgins
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Errol L Bush
- Division of Thoracic Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
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7
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Abstract
Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.
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Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, University Hospital, Raemistrasse, Zurich, Switzerland
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8
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Greer M, Welte T. Chronic Obstructive Pulmonary Disease and Lung Transplantation. Semin Respir Crit Care Med 2020; 41:862-873. [PMID: 32726838 DOI: 10.1055/s-0040-1714250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Lung transplantation (LTx) has been a viable option for patients with end-stage chronic obstructive pulmonary disease (COPD), with more than 20,000 procedures performed worldwide. Survival after LTx lags behind most other forms of solid-organ transplantation, with median survival for COPD recipients being a sobering 6.0 years. Given the limited supply of suitable donor organs, not all patients with end-stage COPD are candidates for LTx. We discuss appropriate criteria for accepting patients for LTx, as well as contraindications and exclusionary criteria. In the first year post-LTx, infection and graft failure are the leading causes of death. Beyond this chronic graft rejection-currently referred to as chronic lung allograft dysfunction-represents the leading cause of death at all time points, with infection and over time malignancy also limiting survival. Referral of COPD patients to a lung transplant center should be considered in the presence of progressing disease despite maximal medical therapy. As a rule of thumb, a forced expiratory volume in 1 second < 25% predicted in the absence of exacerbation, hypoxia (PaO2 < 60 mm Hg/8 kPa), and/or hypercapnia (PaCO2 > 50 mm Hg/6.6 kPa) and satisfactory general clinical condition should be considered the basic prerequisites for timely referral. We also discuss salient issues post-LTx and factors that impact posttransplant survival and morbidity such as infections, malignancy, renal insufficiency, and complications associated with long-term immunosuppression.
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Affiliation(s)
- Mark Greer
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), German Centre for Lung Research (DZL), Hannover, Germany
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9
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van der Mark SC, Hoek RAS, Hellemons ME. Developments in lung transplantation over the past decade. Eur Respir Rev 2020; 29:29/157/190132. [PMID: 32699023 PMCID: PMC9489139 DOI: 10.1183/16000617.0132-2019] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
With an improved median survival of 6.2 years, lung transplantation has become an increasingly acceptable treatment option for end-stage lung disease. Besides survival benefit, improvement of quality of life is achieved in the vast majority of patients. Many developments have taken place in the field of lung transplantation over the past decade. Broadened indication criteria and bridging techniques for patients awaiting lung transplantation have led to increased waiting lists and changes in allocation schemes worldwide. Moreover, the use of previously unacceptable donor lungs for lung transplantation has increased, with donations from donors after cardiac death, donors with increasing age and donors with positive smoking status extending the donor pool substantially. Use of ex vivo lung perfusion further increased the number of lungs suitable for lung transplantation. Nonetheless, the use of these previously unacceptable lungs did not have detrimental effects on survival and long-term graft outcomes, and has decreased waiting list mortality. To further improve long-term outcomes, strategies have been proposed to modify chronic lung allograft dysfunction progression and minimise toxic immunosuppressive effects. This review summarises the developments in clinical lung transplantation over the past decade. Many developments have taken place in lung transplantation over the last decade: indications have broadened, donor criteria expanded, allocations systems changed, and novel therapeutic interventions implemented, leading to improved long-term survivalhttp://bit.ly/2vnpwc1
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Affiliation(s)
- Sophie C van der Mark
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.,Authors contributed equally
| | - Rogier A S Hoek
- Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands.,Authors contributed equally
| | - Merel E Hellemons
- Dept of Pulmonary Medicine, Division of Interstitial Lung Disease, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands .,Dept of Pulmonary Medicine, Division of Lung Transplantation, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
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10
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Scatliffe KD, Mody M, Seethamraju H, Yanagida R. Bronchoscopic lung volume reduction for vanishing lung in a patient with systemic lupus erythematous. Prog Transplant 2020; 30:286-287. [PMID: 32602398 DOI: 10.1177/1526924820933831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kristen D Scatliffe
- Division of Pulmonary Medicine and Critical Care, 24055Newark Beth Israel Medical Center, NJ, USA
| | - Mohit Mody
- Division of Pulmonary Medicine and Critical Care, 24055Newark Beth Israel Medical Center, NJ, USA
| | - Harish Seethamraju
- Division of Pulmonary Medicine and Critical Care, 24055Newark Beth Israel Medical Center, NJ, USA
| | - Roh Yanagida
- Department of Cardiothoracic Surgery, 24055Newark Beth Israel Medical Center, NJ, USA
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11
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Vazquez Guillamet R. Chronic Obstructive Pulmonary Disease and the Optimal Timing of Lung Transplantation. MEDICINA-LITHUANIA 2019; 55:medicina55100646. [PMID: 31561607 PMCID: PMC6843760 DOI: 10.3390/medicina55100646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) accounts for the largest proportion of respiratory deaths worldwide and was historically the leading indication for lung transplantation. The success of lung transplantation procedures is measured as survival benefit, calculated as survival with transplantation minus predicted survival without transplantation. In chronic obstructive pulmonary disease, it is difficult to show a clear and consistent survival benefit. Increasing knowledge of the risk factors, phenotypical heterogeneity, systemic manifestations, and their management helps improve our ability to select candidates and list those that will benefit the most from the procedure.
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12
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Lung transplantation for chronic obstructive pulmonary disease: past, present, and future directions. Curr Opin Pulm Med 2019; 24:199-204. [PMID: 29227305 DOI: 10.1097/mcp.0000000000000452] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Lung transplantation offers an effective treatment modality for patients with end-stage chronic obstructive pulmonary disease (COPD). The exact determination of when to refer, list, and offer transplant as well as the preferred transplant procedure type remains unclear. Additionally, there are special considerations specific to patients with COPD being considered for lung transplantation, including the implications of single lung transplantation on lung cancer risk, native lung hyperinflation, and overall survival. RECENT FINDINGS The International Society for Heart and Lung Transplantation's most recent recommendations rely on an assessment of COPD severity based on BODE index. Despite the lack of evidence supporting a mortality benefit of bilateral over single lung transplantation for COPD patients, the majority of transplants performed in this population remain bilateral. Some of the concerns specific to single lung transplantation remain the possibility of de novo native lung cancer and the hemodynamic and physiologic implications of acute native lung hyperinflation. SUMMARY COPD remains the most common worldwide indication for lung transplantation. Ongoing study is still required to assess the overall survival benefit of lung transplantation and assess the overall quality of life impact on the COPD patient population.
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13
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Slama A, Taube C, Kamler M, Aigner C. Lung volume reduction followed by lung transplantation-considerations on selection criteria and outcome. J Thorac Dis 2018; 10:S3366-S3375. [PMID: 30450243 DOI: 10.21037/jtd.2018.06.164] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Lung transplantation (LuTX) and lung volume reduction (LVR), either surgical (LVRS: lung volume reduction surgery) or endoscopic (ELVR: endoscopic lung volume reduction), are established therapies in the treatment of end-stage chronic obstructive pulmonary disease (COPD) patients. Careful patient selection is crucial for each intervention. If these techniques are sequentially applied there is a paucity of available data and individual center experiences vary depending on details in selection criteria and operative technique. This review aims to summarize the published data with a focus on LuTX after LVRS. This review covers patient selection for LuTX and LVR, technical considerations, limitations and outcomes. Published literature was identified by systematic search on Medline and appropriate papers were reviewed. Seven case reports/series, 7 comparative observational studies and one multicenter database analysis incorporating a total of 284 patients with LuTX and LVR were evaluated. Prior LVR can significantly affect intraoperative and postoperative risks after subsequent LuTX. Careful patient selection and timing and the choice of appropriate techniques such as minimal invasive LVRS and using ECMO as extracorporeal support during LuTX if required can minimize those risks, ultimately leading to very good postoperative outcomes in terms of lung function and survival. LVRS has the potential to delay listing and to bridge patients to LuTX by improving their physical condition while on the waiting list. After single lung transplantation (SLuTX) contralateral LVRS can counteract the deleterious effects of native lung hyperinflation (NLH). LVR and LuTX are adjunct therapies in the treatment of end-stage COPD. The combination of both can safely be considered in selected patients.
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Affiliation(s)
- Alexis Slama
- Department of Thoracic Surgery, West German Center for Lung Transplantation, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Christian Taube
- Department of Pneumology, West German Center for Lung Transplantation, University Medicine Essen - Ruhrlandklinik, Essen, Germany
| | - Markus Kamler
- Department of Thoracic Transplantation, West German Center for Lung Transplantation, University Medicine Essen - University Clinic, Essen, Germany
| | - Clemens Aigner
- Department of Thoracic Surgery, West German Center for Lung Transplantation, University Medicine Essen - Ruhrlandklinik, Essen, Germany
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14
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Darwiche K, Aigner C. Clinical management of lung volume reduction in end stage emphysema patients. J Thorac Dis 2018; 10:S2732-S2737. [PMID: 30210825 DOI: 10.21037/jtd.2018.02.69] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Following the evaluation of surgical lung volume reduction (LVR) in the National Emphysema Treatment (NETT) trial, different endoscopic LVR procedures have been developed for severe emphysema. Among those, endobronchial valve placement is the best evaluated method. All these therapies aim at reducing hyperinflation and at improving respiratory mechanics. It has been shown that these procedures can improve quality of life, lung function and exercise capacity in a significant and clinically meaningful way in suitable patients. Optimal medical therapy, physical rehabilitation, smoking cessation and respiratory insufficiency assessments should been thoroughly evaluated by a multi-disciplinary team before considering any LVR procedure. Clinical experience is necessary to decide if a patient is an appropriate candidate for a surgical or an interventional LVR procedure, to choose the optimal treatment strategy and to provide a high-level of care after the intervention, particularly when complications such as pneumothorax or persistent air leak occur in this already severely ill patient population. High volume emphysema care centers, providing a broad spectrum of different LVR procedures and involving a multidisciplinary team in the diagnostic process, are best suited to provide an optimal outcome. The aim of this manuscript is to describe the structures and procedures required to achieve the best possible outcome even in patients with advanced stage of their emphysema disease, including patients who are candidates for lung transplantation.
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Affiliation(s)
- Kaid Darwiche
- Department of Pneumology, Division of Interventional Bronchology, University Medicine Essen-Ruhrlandklinik, Essen, Germany
| | - Clemens Aigner
- Department of Thoracic Surgery and Surgical Endoscopy, University Medicine Essen-Ruhrlandklinik, Essen, Germany
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15
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Makarov DV, Ciprut S, Walter D, Kelly M, Gold HT, Zhou XH, Sherman SE, Braithwaite RS, Gross C, Zeliadt S. Association Between Guideline-Discordant Prostate Cancer Imaging Rates and Health Care Service Among Veterans and Medicare Recipients. JAMA Netw Open 2018; 1:e181172. [PMID: 30646111 PMCID: PMC6324262 DOI: 10.1001/jamanetworkopen.2018.1172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/12/2018] [Indexed: 12/21/2022] Open
Abstract
Importance Prostate cancer imaging rates appear to vary by health care setting. With the recent extension of the Veterans Access, Choice, and Accountability Act, the government has provided funds for veterans to seek care outside the Veterans Health Administration (VA). It is important to understand the difference in imaging rates and subsequent differences in patterns of care in the VA vs a traditional fee-for-service setting such as Medicare. Objective To assess the association between prostate cancer imaging rates and a VA vs fee-for-service health care setting. Design, Setting, and Participants This cohort study included data for men who received a diagnosis of prostate cancer from January 1, 2004, through March 31, 2008, that were collected from the VA Central Cancer Registry, linked to administrate claims and Medicare utilization records, and the Surveillance, Epidemiology, and End Results Program database. Three distinct nationally representative cohorts were constructed (use of VA only, use of Medicare only, and dual use of VA and Medicare). Men older than 85 years at diagnosis and men without high-risk features but missing any tumor risk characteristic (prostate-specific antigen, Gleason grade, or clinical stage) were excluded. Analysis of the data was completed from March 2016 to February 2018. Exposures Patient utilization of different health care delivery systems. Main Outcomes and Measures Rates of prostate cancer imaging were analyzed by health care setting (Medicare only, VA and Medicare, and VA only) among patients with low-risk prostate cancer and patients with high-risk prostate cancer. Results Of 98 867 men with prostate cancer (77.4% white; mean [SD] age, 70.26 [7.48] years) in the study cohort, 57.3% were in the Medicare-only group, 14.5% in the VA and Medicare group, and 28.1% in the VA-only group. Among men with low-risk prostate cancer, the Medicare-only group had the highest rate of guideline-discordant imaging (52.5%), followed by the VA and Medicare group (50.9%) and the VA-only group (45.9%) (P < .001). Imaging rates for men with high-risk prostate cancer were not significantly different among the 3 groups. Multivariable analysis showed that individuals in the VA and Medicare group (risk ratio [RR], 0.87; 95% CI, 0.76-0.98) and VA-only group (RR, 0.79; 95% CI, 0.67-0.92) were less likely to receive guideline-discordant imaging than those in the Medicare-only group. Conclusions and Relevance The results of this study suggest that patients with prostate cancer who use Medicare rather than the VA for health care could experience more utilization of health care services without an improvement in the quality of care.
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Affiliation(s)
- Danil V. Makarov
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
- Robert F. Wagner Graduate School of Public Service, New York University, New York
- Cancer Institute, New York University School of Medicine, New York
| | - Shannon Ciprut
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
| | - Dawn Walter
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
| | - Matthew Kelly
- Department of Urology, New York University School of Medicine, New York
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
| | - Heather T. Gold
- Department of Population Health, New York University School of Medicine, New York
- Robert F. Wagner Graduate School of Public Service, New York University, New York
- Cancer Institute, New York University School of Medicine, New York
| | - Xiao-Hua Zhou
- Department of Biostatistics, University of Washington, Seattle
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington
| | - Scott E. Sherman
- Department of Population Health, New York University School of Medicine, New York
- VA New York Harbor Healthcare System, New York University School of Medicine, New York
- Cancer Institute, New York University School of Medicine, New York
| | | | - Cary Gross
- Cancer Outcomes Policy and Effectiveness Research Center, Yale University School of Medicine, New Haven, Connecticut
| | - Steven Zeliadt
- Health Services Research and Development, Department of Veterans Affairs Medical Center, Seattle, Washington
- Fred Hutchinson Cancer Research Center, Seattle, Washington
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Caviezel C, Schaffter N, Schneiter D, Franzen D, Inci I, Opitz I, Weder W. Outcome After Lung Volume Reduction Surgery in Patients With Severely Impaired Diffusion Capacity. Ann Thorac Surg 2018; 105:379-385. [DOI: 10.1016/j.athoracsur.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 08/09/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
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Inci I, Iskender I, Ehrsam J, Caviezel C, Hillinger S, Opitz I, Schneiter D, Weder W. Previous lung volume reduction surgery does not negatively affect survival after lung transplantation†. Eur J Cardiothorac Surg 2017; 53:596-602. [DOI: 10.1093/ejcts/ezx318] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 08/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ilker Iskender
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Jonas Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sven Hillinger
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Makarov DV, Hu EYC, Walter D, Braithwaite RS, Sherman S, Gold HT, Zhou XA, Gross CP, Zeliadt SB. Appropriateness of Prostate Cancer Imaging among Veterans in a Delivery System without Incentives for Overutilization. Health Serv Res 2016; 51:1021-51. [PMID: 26423687 PMCID: PMC4874832 DOI: 10.1111/1475-6773.12395] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine the frequency of appropriate and inappropriate prostate cancer imaging in an integrated health care system. DATA SOURCES/STUDY SETTING Veterans Health Administration Central Cancer Registry linked to VA electronic medical records and Medicare claims (2004-2008). STUDY DESIGN We performed a retrospective cohort study of VA patients diagnosed with prostate cancer (N = 45,084). Imaging (CT, MRI, bone scan, PET) use was assessed among patients with low-risk disease, for whom guidelines recommend against advanced imaging, and among high-risk patients for whom guidelines recommend it. PRINCIPAL FINDINGS We found high rates of inappropriate imaging among men with low-risk prostate cancer (41 percent) and suboptimal rates of appropriate imaging among men with high-risk disease (70 percent). Veterans utilizing Medicare-reimbursed care had higher rates of inappropriate imaging [OR: 1.09 (1.03-1.16)] but not higher rates of appropriate imaging. Veterans treated in middle [OR: 0.51 (0.47-0.56)] and higher [OR: 0.50 (0.46-0.55)] volume medical centers were less likely to undergo inappropriate imaging without compromising appropriate imaging. CONCLUSIONS Our results highlight the overutilization of imaging, even in an integrated health care system without financial incentives encouraging provision of health care services. Paradoxically, imaging remains underutilized among high-risk patients who could potentially benefit from it most.
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Affiliation(s)
- Danil V. Makarov
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of UrologyNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
- Robert F. Wagner Graduate School of Public ServiceNew York UniversityNew YorkNY
| | - Elaine Y. C. Hu
- VA Puget Sound Healthcare System and University of WashingtonSeattleWA
| | - Dawn Walter
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of UrologyNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - R. Scott Braithwaite
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - Scott Sherman
- VA New York Harbor Healthcare SystemNew York UniversityNew YorkNY
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | - Heather T. Gold
- Department of Population HealthNew York UniversityNew YorkNY
- Cancer InstituteNew York UniversityNew YorkNY
| | | | - Cary P. Gross
- Robert Wood Johnson Clinical Scholars Program and Department of Internal MedicineYale University School of MedicineNew HavenCT
| | - Steven B. Zeliadt
- VA Puget Sound Healthcare System and University of WashingtonSeattleWA
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Backhus LM, Mulligan MS, Ha R, Shriki JE, Mohammed TLH. Imaging in Lung Transplantation. Radiol Clin North Am 2016; 54:339-53. [DOI: 10.1016/j.rcl.2015.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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21
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Lane CR, Tonelli AR. Lung transplantation in chronic obstructive pulmonary disease: patient selection and special considerations. Int J Chron Obstruct Pulmon Dis 2015; 10:2137-46. [PMID: 26491282 PMCID: PMC4608618 DOI: 10.2147/copd.s78677] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity. Lung transplantation is one of the few treatments available for end-stage COPD with the potential to improve survival and quality of life. The selection of candidates and timing of listing present challenges, as COPD tends to progress fairly slowly, and survival after lung transplantation remains limited. Though the natural course of COPD is difficult to predict, the use of assessments of functional status and multivariable indices such as the BODE index can help identify which patients with COPD are at increased risk for mortality, and hence which are more likely to benefit from lung transplantation. Patients with COPD can undergo either single or bilateral lung transplantation. Although many studies suggest better long-term survival with bilateral lung transplant, especially in younger patients, this continues to be debated, and definitive recommendations about this cannot be made. Patients may be more susceptible to particular complications of transplant for COPD, including native lung hyperinflation, and development of lung cancer.
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Affiliation(s)
- C Randall Lane
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Fuehner T, Clajus C, Fuge J, Jonigk D, Welte T, Haverich A, Greer M, Gottlieb J. Lung transplantation after endoscopic lung volume reduction. Respiration 2015; 90:243-50. [PMID: 26138023 DOI: 10.1159/000434685] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Endoscopic lung volume reduction (ELVR) has become an established treatment option in selected patients with end-stage lung emphysema. ELVR, however, does not always prevent disease progression, and patients may inevitably be considered for lung transplantation. OBJECTIVES Currently, limited data exist regarding the impact of preceding ELVR on lung transplantation outcomes. METHODS A retrospective, single-center analysis of lung transplantation (LTx) waiting list candidates, who had previously undergone ELVR for emphysema between 2010 and 2014, was performed. Outcomes were compared to matched (1:2) controls who underwent LTx for emphysema without previous ELVR. The 12-month survival after LTx represented the primary end point. RESULTS In total 23/693 (3%) patients listed for LTx between January 2010 and May 2014 had undergone ELVR, of whom 20/23 (87%) proceeded to LTx (ELVR group). Forty matched non-ELVR emphysema patients acted as controls. Bronchiectasis on CT prior to LTx was more evident in ELVR patients [11/20 (55%) vs. 12/40 (30%); p = 0.04] as well as airway colonization after LTx [10/20 (50%) vs. 6/40 (15%); p = 0.004]. Among ELVR patients, the most prevalent colonizing organism was Stenotrophomonas maltophilia (4/10 patients, 40%). No significant differences were observed in LTx waiting list time, duration of LTx procedure, ventilatory support, ICU stay after LTx or time to hospital discharge. One ELVR patient (5%) died 189 days after LTx from pneumonia, compared to 1 non-ELVR patient (3%) who died after 269 days (p = 0.61). CONCLUSIONS Previous ELVR treatment was not associated with differing outcomes following LTx. Increased bacterial colonization rates were evident and warrant further investigation.
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Affiliation(s)
- Thomas Fuehner
- Department of Respiratory Medicine, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Kostron A, Horn-Tutic M, Franzen D, Kestenholz P, Schneiter D, Opitz I, Kohler M, Weder W. Repeated lung volume reduction surgery is successful in selected patients. Eur J Cardiothorac Surg 2014; 48:710-5. [PMID: 25548131 DOI: 10.1093/ejcts/ezu498] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 11/18/2014] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Lung volume reduction surgery (LVRS) improves dyspnoea, quality of life and may even prolong survival in carefully selected patients with end-stage emphysema. The benefit may be sustained for several years and vanishes with the natural progression of the disease. Data on repeated surgical treatment of emphysema are scarce. The aim of this study was to evaluate the safety, effects and outcomes of repeated LVRS (Re-LVRS) in patients no longer benefiting from their initial LVRS. METHODS Between June 2002 and December 2013, 22 patients (9 females) with advanced emphysema underwent Re-LVRS at a median of 60 months (25-196) after their initial LVRS. While initial LVRS was performed thoracoscopically as a bilateral procedure, Re-LVRS was performed unilaterally by a video-assisted thoracoscopic technique in 19 patients and, due to adhesions, by thoracotomy in 3 patients. Pulmonary function test (PFT) was performed at 3 and 12 months postoperatively. RESULTS Lung function at Re-LVRS was similar to that prior to the first LVRS. The 90-day mortality rate was 0%. The first patient died 15 months postoperatively. The median hospitalization time after Re-LVRS was significantly longer compared with the initial LVRS [14 days, interquartile range (IQR): 11-19, vs 9 days, IQR: 8-14; P = 0.017]. The most frequent complication was prolonged air leak with a median drainage time of 11 days (IQR: 6-13); reoperations due to persistent air leak were necessary in 7 patients (32%). Five patients (23%) had no complications. Lung function and Medical Research Council (MRC) score improved significantly for up to 12 months after Re-LVRS, with results similar to those after initial bilateral LVRS. The average increase in the forced expiratory volume in 1 s (FEV1) was 25% (a 7% increase over the predicted value or 0.18 l) at 3 months, and the mean reduction in hyperinflation, assessed by relative decrease in RV/TLC (residual volume/total lung capacity), was 12% at 3 months (a decrease of 8% in absolute ratios). The mean MRC breathlessness score decreased significantly after 3 months (from 3.7 to 2.2). CONCLUSIONS Re-LVRS can be performed successfully in carefully selected patients as a palliative treatment. It may be performed as a bridge to transplantation or in patients with newly diagnosed intrapulmonary nodules or during elective cardiac surgery. Morbidity is acceptable and outcomes may be satisfactory with significantly improved lung function and reduced dyspnoea for at least 12 months postoperatively.
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Affiliation(s)
- Arthur Kostron
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Michaela Horn-Tutic
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Daniel Franzen
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Peter Kestenholz
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland
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