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Hyzny EJ, Chan EG, Malik SM, Morrell M, Furukawa M, Ryan JP, Sanchez PG. Risk Factors and Outcomes of Postoperative Hepatic Dysfunction After Lung Transplantation. Ann Thorac Surg 2023; 116:1277-1284. [PMID: 37000464 DOI: 10.1016/j.athoracsur.2022.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/18/2022] [Accepted: 08/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hepatic dysfunction is a morbid complication of lung transplantation. Little is known about risk factors for postoperative hepatic dysfunction or its impact on survival after lung transplantation. METHODS This retrospective analysis of 1406 adult lung transplant recipients was performed at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania between January 1, 2007 and December 1, 2019. Patients were excluded for redo lung transplantation, concomitant cardiac surgery, or concurrent solid organ transplantation. Postoperative liver dysfunction was classified as either ischemic liver injury or nonischemic dysfunction (transaminitis, hyperbilirubinemia). RESULTS Among the 1155 primary lung transplant recipients included, postoperative hepatic dysfunction developed in 96 (8.3%) after lung transplantation. A history of liver disease was the greatest predictor of postoperative hepatic dysfunction (odds ratio, 6.19; CI, 2.13-17.4; P < .001). Patients with postoperative hepatic dysfunction had a greater need for intraoperative blood products (ischemic, 12 U [range, 6-21 U]; nonischemic, 10 U [range, 4-28 U]; vs none, 4 U [range, 1-12 U]; P < .001) and an increased need for postoperative circulatory support (ischemic, 16 [76%]; nonischemic, 25 [33%]; none, 117 [11%]; P < .001). Both ischemic liver injury and nonischemic dysfunction were associated with diminished 1-, 3-, and 5-year term survival (ischemic, 27.5%, 16.5%, and 0%, respectively; nonischemic, 60%, 49.6%, and 46.9%, respectively; none, 87.3%, 72.3%, and 59.5%, respectively; P < .001). CONCLUSIONS Hepatic dysfunction after lung transplantation is associated with significant morbidity and mortality. A history of liver disease was the best positive predictor for postoperative dysfunction. Additional studies are necessary to identify the best treatment algorithm to avoid hepatic dysfunction more effectively in the postoperative setting after lung transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shahid M Malik
- Division of Gastroenterology Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Morrell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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2
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Noda K, Furukawa M, Chan EG, Sanchez PG. Expanding Donor Options for Lung Transplant: Extended Criteria, Donation After Circulatory Death, ABO Incompatibility, and Evolution of Ex Vivo Lung Perfusion. Transplantation 2023; 107:1440-1451. [PMID: 36584375 DOI: 10.1097/tp.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Only using brain-dead donors with standard criteria, the existing donor shortage has never improved in lung transplantation. Currently, clinical efforts have sought the means to use cohorts of untapped donors, such as extended criteria donors, donation after circulatory death, and donors that are ABO blood group incompatible, and establish the evidence for their potential contribution to the lung transplant needs. Also, technical maturation for using those lungs may eliminate immediate concerns about the early posttransplant course, such as primary graft dysfunction or hyperacute rejection. In addition, recent clinical and preclinical advances in ex vivo lung perfusion techniques have allowed the safer use of lungs from high-risk donors and graft modification to match grafts to recipients and may improve posttransplant outcomes. This review summarizes recent trends and accomplishments and future applications for expanding the donor pool in lung transplantation.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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3
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Sef AV, Yin Ling CN, Aw TC, Romano R, Crescenzi O, Manikavasagar V, Simon A, de Waal EEC, Thakuria L, Reed AK, Marczin N. Postoperative vasoplegia in lung transplantation: incidence and relation to outcome. Br J Anaesth 2023; 130:666-676. [PMID: 37127440 DOI: 10.1016/j.bja.2023.01.027] [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: 03/15/2022] [Revised: 01/07/2023] [Accepted: 01/31/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The incidence and clinical importance of vasoplegia after lung transplantation remains poorly studied. We describe the incidence of vasoplegia and its association with complications after lung transplantation. METHODS Perioperative data of 279 lung transplant recipients operated on from 2015 to 2020 were retrospectively analysed. RESULTS Vasoplegia occurred in 41.6% of patients after lung transplantation (mild, 31.0%; moderate, 55.2%; severe, 13.8%). Compared with non-vasoplegic patients, vasoplegic patients had a higher incidence of any acute kidney injury, defined by Kidney Disease Improving Global Outcomes (KDIGO) criteria (78.5% vs 65%, P=0.015), renal replacement therapy (47.4% vs 24.5%, P<0.001), and delayed chest closure (18.4% vs 9.2%, P=0.025); were ventilated longer (70 [32-368] vs 34 [19-105] h, P<0.001); and stayed longer in the ICU (12.9 [5-30] vs 6.8 [3-20] days, P<0.001). Mortality at 30 days and 1 yr was higher in patients with vasoplegia (11.2% vs 5.5% and 20.7% vs 11.7%, P=0.039, respectively). Severe vasoplegia represented a predictor of longer-term mortality (hazard ratio=1.65, P=0.008). Underlying infectious disease, increased BMI, higher preoperative pulmonary artery systolic pressure and bilirubin levels, lower glomerular filtration rate, and increased fresh frozen plasma transfusion were predictors of vasoplegia severity. Neutrophilia, leucocytosis, and increased C-reactive protein were associated with vasoplegia, but release of the neutrophil activation markers myeloperoxidase and heparin-binding protein was similar between groups. CONCLUSIONS Influenced by preoperative status as well as procedural factors and inflammatory response, vasoplegia is a common and critical condition after lung transplantation with worse short-term outcomes and long-term survival.
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Affiliation(s)
- Alessandra V Sef
- Department of Anesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Clarissa N Yin Ling
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tuan C Aw
- Department of Anaesthesia, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Rosalba Romano
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Anaesthesia and Intensive Care, Cardarelli Hospital, Naples, Italy
| | - Oliviero Crescenzi
- Department of Anesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Venughanan Manikavasagar
- Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Andre Simon
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Eric E C de Waal
- Department of Anesthesiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Louit Thakuria
- Department of Cardiothoracic Transplantation and Mechanical Support, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Anna K Reed
- Department of Cardiothoracic Transplantation and Mechanical Support, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nandor Marczin
- Department of Anesthesia and Critical Care, Harefield Hospital, Royal Brompton & Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK; Division of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK; Department of Anaesthesia and Intensive Care, Semmelweis University Budapest, Hungary.
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4
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Ehrsam JP, Schuurmans MM, Laager M, Opitz I, Inci I. Recipient Comorbidities for Prediction of Primary Graft Dysfunction, Chronic Allograft Dysfunction and Survival After Lung Transplantation. Transpl Int 2022; 35:10451. [PMID: 35845547 PMCID: PMC9276940 DOI: 10.3389/ti.2022.10451] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/13/2022] [Indexed: 11/21/2022]
Abstract
Since candidates with comorbidities are increasingly referred for lung transplantation, knowledge about comorbidities and their cumulative effect on outcomes is scarce. We retrospectively collected pretransplant comorbidities of all 513 adult recipients transplanted at our center between 1992–2019. Multiple logistic- and Cox regression models, adjusted for donor-, pre- and peri-operative variables, were used to detect independent risk factors for primary graft dysfunction grade-3 at 72 h (PGD3-T72), onset of chronic allograft dysfunction grade-3 (CLAD-3) and survival. An increasing comorbidity burden measured by Charleston-Deyo-Index was a multivariable risk for survival and PGD3-T72, but not for CLAD-3. Among comorbidities, congestive right heart failure or a mean pulmonary artery pressure >25 mmHg were independent risk factors for PGD3-T72 and survival, and a borderline risk for CLAD-3. Left heart failure, chronic atrial fibrillation, arterial hypertension, moderate liver disease, peptic ulcer disease, gastroesophageal reflux, diabetes with end organ damage, moderate to severe renal disease, osteoporosis, and diverticulosis were also independent risk factors for survival. For PGD3-T72, a BMI>30 kg/m2 was an additional independent risk. Epilepsy and a smoking history of the recipient of >20packyears are additional independent risk factors for CLAD-3. The comorbidity profile should therefore be closely considered for further clinical decision making in candidate selection.
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Affiliation(s)
- Jonas Peter Ehrsam
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Macé M. Schuurmans
- Division of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Mirjam Laager
- Department of Biostatistics, University of Basel, Basel, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
- *Correspondence: Ilhan Inci,
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5
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Anesthetic Management During Lung Transplantation - What's New in 2021? Thorac Surg Clin 2022; 32:175-184. [PMID: 35512936 DOI: 10.1016/j.thorsurg.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As outcomes of lung transplantation (LTx) are improving transplant centers are pushing boundaries. There has been a steady increase in the medical complexity of lung transplant candidates. Many transplant centers are listing older patients with comorbidities, and there has been a steady rise in the number of candidates supported with extracorporeal membrane oxygenation (ECMO) as a bridge to transplantation. There has been a growing appreciation of the importance intraoperative management of potentially modifiable risk factors has on postoperative outcomes. Evidence suggests that LTx even in high-risk patients requiring perioperative ECMO can offer excellent results. This article outlines the current state-of-the-art intraoperative management of LTx.
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6
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Chan EG, Hyzny EJ, Ryan JP, Morrell MR, Pilewski J, Sanchez PG. Outcomes following lung re-transplantation in patients with cystic fibrosis. J Cyst Fibros 2021; 21:482-488. [PMID: 34949557 DOI: 10.1016/j.jcf.2021.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/10/2021] [Accepted: 12/05/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE We examined cystic fibrosis (CF) patients and compared their clinical status at the time of primary versus double lung re-transplantation (re-DLTx) in order to better understand lung retransplant practice patterns. METHODS We performed a retrospective analysis of the UNOS Database identifying CF patients ≥18 years old undergoing re-DLTx (5/4/2005 and 12/4/2020). Baseline and clinical variables at the primary and re-DLTx were compared utilizing the paired student t-test. Graft survival was defined as time from surgery to retransplant and analyzed using Kaplan-Meier estimates. RESULTS 277 CF patients who underwent re-DLTx experienced a significantly worse 5-year survival when compared to the primary DLTx cohort (47.9% vs 58.8%, p = 0.00012). The following differences were observed comparing CF re-DLTx group to their primary DLTx: higher LAS score at the time of listing (50.66 vs 42.15, p < 0.001) and transplant (62.19 vs 48.20, p < 0.001), and increase LAS from the time of listing to transplant (+12.22 vs +7.23, p = 0.002). While serum albumin and total bilirubin were similar, CF patients had a higher creatinine (1.05 vs 0.74, p < 0.001), dialysis (4.4% vs 0.6%, p < 0.001), ECMO bridge to transplant rates (7.6% vs 4.0%, p < 0.001), and higher oxygen requirements (5.95 vs 3.93, p < 0.001) at the time of listing for a re-DLTx. CONCLUSION Compared to their initial transplant, CF patients experience significant clinical decline in renal, cardiac, and pulmonary function at the time of lung retransplantation. This may indicate that an earlier evaluation and rehabilitation process may be necessary to identify patients earlier for lung retransplantation prior significant clinical decline.
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Affiliation(s)
- Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew R Morrell
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph Pilewski
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
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7
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Black RJ, Novakovic D, Plit M, Miles A, MacDonald P, Madill C. Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis. J Heart Lung Transplant 2021; 40:1483-1494. [PMID: 34836605 DOI: 10.1016/j.healun.2021.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/29/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022] Open
Abstract
Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life.
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Affiliation(s)
- Rebecca J Black
- Speech Pathology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Australia.
| | - Daniel Novakovic
- Faculty of Medicine and Health, The University of Sydney, Australia
| | | | | | - Peter MacDonald
- Faculty of Medicine and Health, The University of Sydney, Australia
| | - Catherine Madill
- Faculty of Medicine and Health, The University of Sydney, Australia
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8
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Marczin N, de Waal EEC, Hopkins PMA, Mulligan MS, Simon A, Shaw AD, Van Raemdonck D, Neyrinck A, Gries CJ, Algotsson L, Szegedi L, von Dossow V. International consensus recommendations for anesthetic and intensive care management of lung transplantation. An EACTAIC, SCA, ISHLT, ESOT, ESTS, and AST approved document. J Heart Lung Transplant 2021; 40:1327-1348. [PMID: 34732281 DOI: 10.1016/j.healun.2021.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nandor Marczin
- Harefield Hospital Royal Brompton and Harefield Hospitals, Imperial College London, London, United Kingdom, Semmelweis University, Budapest, Hungary.
| | | | | | | | - Andre Simon
- Harefield Hospital RBHT, London, United Kingdom
| | | | | | | | | | | | - Laszlo Szegedi
- Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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9
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Manickavel S, Sinha N. A pandemic of acute respiratory distress syndrome-role of lung transplant in coronavirus disease-2019-associated respiratory failure. Indian J Thorac Cardiovasc Surg 2021; 37:359-365. [PMID: 34483505 PMCID: PMC8408360 DOI: 10.1007/s12055-021-01233-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/08/2023] Open
Abstract
Lung transplantation may be appropriate, and may offer benefit only to a carefully selected subset of morbidly ill patients afflicted by coronavirus disease-2019. Identifying the appropriate recipient for the allocation of scarce resources, by safely navigating through the challenges that are unique to lung transplantation for coronavirus disease-2019-associated acute respiratory distress syndrome, demands a conscientious and meticulous approach. Categorizing the respiratory failure in coronavirus disease-2019 may facilitate the process of evaluation for the purpose of transplant. The progress in rescue transplants over the past two decades has greatly improved our ability to successfully perform high-risk lung transplantation.
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Affiliation(s)
| | - Neeraj Sinha
- University of Miami Miller School of Medicine, Miami, FL 33101 USA
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10
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Hyzny EJ, Chan EG, Morrell M, Harano T, Sanchez PG. A review of liver dysfunction in the lung transplant patient. Clin Transplant 2021; 35:e14344. [PMID: 33960530 DOI: 10.1111/ctr.14344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Morrell
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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11
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Lazzaro R, Patton B. Commentary: Keepin' it real-the future is now. JTCVS Tech 2020; 3:404-405. [PMID: 34317946 PMCID: PMC8302903 DOI: 10.1016/j.xjtc.2020.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Richard Lazzaro
- Address for reprints: Richard Lazzaro, MD, FACS, Department of Cardiothoracic Surgery, Lenox Hill Hospital, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 130 E 77th St, New York, NY 10075.
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12
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Nolley E, Fleck J, Kavalieratos D, Dew MA, Dilling D, Colman R, Crespo MM, Goldberg H, Hays S, Hachem R, Lease E, Lee J, Reynolds J, Morrell M, Schenker Y. Lung Transplant Pulmonologists' Views of Specialty Palliative Care for Lung Transplant Recipients. J Palliat Med 2020; 23:619-626. [PMID: 31895634 PMCID: PMC7232634 DOI: 10.1089/jpm.2019.0222] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Lung transplant recipients with serious illness may benefit from but rarely receive specialty palliative care (SPC) services. Transplant pulmonologists' views of SPC may be key to understanding SPC utilization but have not been well characterized. Objectives: (1) To understand how transplant pulmonologists view SPC and decide to refer transplant recipients and (2) to identify unique aspects of lung transplantation that may influence referral decisions. Design: We conducted semistructured interviews with transplant pulmonologists at nine geographically diverse high-volume North American transplant centers with SPC services. A multidisciplinary team analyzed interview transcripts using constant comparative methods to inductively develop and refine a coding framework related to SPC views and referral decisions. Results: We interviewed 38 transplant pulmonologists; most (36/38) had referred lung transplant recipients to SPC. Participants described SPC as a medical specialty that aims to improve quality of life and distinguished SPC from hospice care, which was considered end-of-life care. Participants who viewed transplant as a temporary solution (n = 17/38, 45%) described earlier utilization of SPC alongside disease-directed therapies, whereas those who viewed transplant as survival-focused (n = 21/38, 55%) described utilization of SPC after disease-directed therapies were exhausted. Concerns about one-year survival metrics and use of addicting medications for symptom palliation were barriers to referral. Conclusions: Transplant pulmonologists' SPC referral practices may be related to their views of lung transplantation. Optimizing use of SPC in lung transplantation will require improving communication between transplant pulmonology and SPC to ensure a collaborative effort toward patient-centered goals while addressing unique barriers to SPC referral.
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Affiliation(s)
- Eric Nolley
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica Fleck
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel Dilling
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Loyola, Chicago, Illinois, USA
| | - Rebecca Colman
- Division of Respirology and Division of Palliative Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Maria M. Crespo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hiliary Goldberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Steven Hays
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Ramsey Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St Louis, St. Louis, Missouri, USA
| | - Erika Lease
- Department of Medicine, Division of Pulmonary Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James Lee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Matthew Morrell
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Jorge A, Sanchez PG, Hayanga JWA, Pilewski JM, Morrell M, Tuft M, Ryan J, D'Cunha J. Routine deep vein thrombosis screening after lung transplantation: Incidence and risk factors. J Thorac Cardiovasc Surg 2019; 159:1142-1150. [PMID: 31839224 DOI: 10.1016/j.jtcvs.2019.08.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Deep vein thrombosis (DVT) remains a common complication following lung transplantation despite universal routine DVT screening. Moreover, many of the previously reported risk factors are incompletely defined. We sought to explore the influence of DVT screening and to more definitively assess predisposing risk factors. METHODS A single-institution, retrospective, cohort study of 1141 patients undergoing lung transplantation from January 1, 2005, to December 31, 2014, was performed evaluating for the rate of DVT. Patients were given prophylactic subcutaneous heparin postoperatively. DVT events were noted if they occurred before 90 days after transplant. We compared DVT rates before and after 2008 when universal screening was implemented. We also evaluated the timing of DVT event and location (above the knee vs below the knee). DVTs were treated with standard anticoagulation therapy or an inferior cava filter when patients were unable to tolerate anticoagulation treatment. Univariable and multivariable models were used to identify risk factors for occurrence. A propensity match was performed to match groups across the eras, and a Cox regression was performed to identify differences in 1-year survival trajectory between cohorts. RESULTS The rates of DVT before and after routine screening were 8.8% (36 DVT out of 412 transplants) and 17.3% (126 out of 729 transplants), respectively. These 2 rates were significantly different (P < .01); moreover, the observed DVT incidence per year was not significantly different across the 6 years after universal DVT screening was implemented (P > .90 for all comparisons). Observed DVT incidence at day 0 and day 14 were 3.8% and 3.8%, respectively, for the cohort before DVT protocols were established. Observed DVT incidence for the cohort after protocols were established at the same time points was 8.7% and 3.7%, respectively. Univariable analysis revealed that significant factors associated with a DVT include hypercholesterolemia (odds ratio [OR], 6.90; 95% confidence interval [CI], 1.82-26.13; P < .01), the number of days in the intensive care unit (OR, 1.03; 95% CI, 1.00-1.01; P < .01), and the length of stay in the hospital (OR, 1.01; 95% CI, 1.01-1.02; P < .01), whereas having quit smoking (vs never smoked) was associated with a decrease in DVT development (OR, 0.50; 95% CI, 0.33-0.75; P < .01). Multivariable analysis revealed 2 significant variables: hypercholesterolemia (OR, 8.13; 95% CI, 1.22-54.37; P = .03) and length of stay (OR, 1.03; 95% CI, 1.01-1.05; P < .01). There was a trend for better 1-year survival in the post-2008 era (Exp[β], 1.49; P = .09). CONCLUSIONS The rate of DVT diagnosis significantly increased after universal DVT screening was implemented. Furthermore, those patients undergoing lung transplantation with extended length of stay and hypercholesterolemia were prone to increased rates of DVT. There was a trend toward better 1-year survival in DVT-screened patients, suggesting DVT screening may result in beneficial outcomes.
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Affiliation(s)
- Ahmed Jorge
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pablo G Sanchez
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Mathew Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Marie Tuft
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pa
| | - John Ryan
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, Mayo Clinic Arizona, Phoenix, Ariz.
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Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease. J Thorac Cardiovasc Surg 2018; 155:2762-2771.e1. [DOI: 10.1016/j.jtcvs.2018.02.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 01/26/2018] [Accepted: 02/05/2018] [Indexed: 01/17/2023]
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15
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Antonoff MB. How much does early fundoplication for lung transplant recipients with gastroesophageal reflux disease truly help? Challenges in escaping the perils of retrospective review. J Thorac Cardiovasc Surg 2018; 155:2772-2773. [DOI: 10.1016/j.jtcvs.2018.02.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Hess NR, Esper SA, Awori Hayanga JW, Tuft M, Morrell M, D'Cunha J. Patent foramen ovale repair at the time of double lung transplantation: Necessary or not? Clin Transplant 2018; 32:e13201. [PMID: 29349838 DOI: 10.1111/ctr.13201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Patient foramen ovale (PFO) is a common and often incidental intraoperative finding during lung transplantation (LTx). We sought to characterize the potential outcomes related to the decision making of whether the PFO was repaired or left unrepaired. METHODS We retrospectively evaluated bilateral LTx recipients between 2005 and 2015 from our prospective database. Incidence of postoperative stoke, 90-day mortality, and overall survival was compared between the PFO-positive and PFO-negative groups, and secondly compared between repaired PFO (rPFO) and non-repaired PFO (nrPFO) groups. RESULTS A total of 831 LTx recipients were analyzed: 185 PFO-positive (140 nrPFO, 45 rPFO) and 646 PFO-negative. Study groups were similar with regard to age and comorbidity. The presence of PFO was not associated with a difference in postoperative stroke (P = .89) or 90-day mortality (P = .64). In patients with PFO, intraoperative repair resulted in a lower, but non-significant rate of stroke (0% vs 5%; P = .20) and no difference in mortality (P = .26). As expected, PFO and PFO repair were both associated with a higher incidence of cardiopulmonary bypass utilization, but no difference in pump-related complications. CONCLUSIONS The protective effect of PFO repair remains unclear. However, it is not associated with an increased incidence of stroke or postoperative mortality following LTx.
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Affiliation(s)
- Nicholas R Hess
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Stephen A Esper
- Department of Anesthesia, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Marie Tuft
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew Morrell
- Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan D'Cunha
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Baumann B, Byers S, Wasserman-Wincko T, Smith L, Hathaway B, Bhama J, Shigemura N, Hayanga JA, D'Cunha J, Johnson JT. Postoperative Swallowing Assessment After Lung Transplantation. Ann Thorac Surg 2017; 104:308-312. [DOI: 10.1016/j.athoracsur.2017.01.080] [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: 08/25/2016] [Revised: 01/17/2017] [Accepted: 01/18/2017] [Indexed: 11/25/2022]
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Abstract
Overall, there is a lack of randomized controlled trials examining the correlation between fluid volume delivery and outcomes in postoperative lung transplant patients. However, using thoracic surgery patients as a guide, the evidence suggests that hypervolemia correlates with pulmonary edema and should be avoided in lung transplant patients. However, it is recognized that patients with hemodynamic instability may require volume for attenuation of this situation, but it can likely be mitigated with the use of inotropic medication to maintain adequate perfusion and avoid the development of edema.
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Gamez J, Salvado M, Martinez-de La Ossa A, Deu M, Romero L, Roman A, Sacanell J, Laborda C, Rochera I, Nadal M, Carmona F, Santamarina E, Raguer N, Canela M, Solé J. Influence of early neurological complications on clinical outcome following lung transplant. PLoS One 2017; 12:e0174092. [PMID: 28301586 PMCID: PMC5354450 DOI: 10.1371/journal.pone.0174092] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 03/05/2017] [Indexed: 01/19/2023] Open
Abstract
Background Neurological complications after lung transplantation are common. The full spectrum of neurological complications and their impact on clinical outcomes has not been extensively studied. Methods We investigated the neurological incidence of complications, categorized according to whether they affected the central, peripheral or autonomic nervous systems, in a series of 109 patients undergoing lung transplantation at our center between January 1 2013 and December 31 2014. Results Fifty-one patients (46.8%) presented at least one neurological complication. Critical illness polyneuropathy-myopathy (31 cases) and phrenic nerve injury (26 cases) were the two most prevalent complications. These two neuromuscular complications lengthened hospital stays by a median period of 35.5 and 32.5 days respectively. However, neurological complications did not affect patients’ survival. Conclusions The real incidence of neurological complications among lung transplant recipients is probably underestimated. They usually appear in the first two months after surgery. Despite not affecting mortality, they do affect the mean length of hospital stay, and especially the time spent in the Intensive Care Unit. We found no risk factor for neurological complications except for long operating times, ischemic time and need for transfusion. It is necessary to develop programs for the prevention and early recognition of these complications, and the prevention of their precipitant and risk factors.
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Affiliation(s)
- Josep Gamez
- Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
- * E-mail:
| | - Maria Salvado
- Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Alejandro Martinez-de La Ossa
- Department of Neurophysiology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Maria Deu
- Department of Thoracic Surgery, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Laura Romero
- Department of Thoracic Surgery, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Antonio Roman
- Department of Pulmonology, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Judith Sacanell
- Critical Care Department, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Cesar Laborda
- Critical Care Department, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Isabel Rochera
- Department of Anesthesiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Miriam Nadal
- Department of Anesthesiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Francesc Carmona
- Department of Statistics, University of Barcelona, Barcelona, Spain
| | - Estevo Santamarina
- Neurology Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Nuria Raguer
- Department of Neurophysiology, Vall d'Hebron University Hospital, Autonomous University of Barcelona, Barcelona, Spain
| | - Merce Canela
- Department of Thoracic Surgery, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Joan Solé
- Department of Thoracic Surgery, Lung Transplant Unit, Vall d'Hebron University Hospital, Barcelona, Spain
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Subramaniam K, Nazarnia S. Noteworthy Literature Published in 2016 for Thoracic Organ Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2017; 21:45-57. [DOI: 10.1177/1089253216688537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This article is first in the series to review the published literature on perioperative issues in patients undergoing thoracic solid organ transplantations. We present recent literature from 2016 on preoperative considerations, organ preservation, intraoperative anesthesia management, surgical techniques, postoperative complications, and the impact of perioperative management on short- and long-term outcomes that are pertinent to thoracic transplantation anesthesiologists.
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Choi J, Hergenroeder AL, Burke L, Dabbs AD, Morrell M, Saptono A, Parmanto B. Delivering an in-Home Exercise Program via Telerehabilitation: A Pilot Study of Lung Transplant Go (LTGO). Int J Telerehabil 2016; 8:15-26. [PMID: 28775798 PMCID: PMC5536726 DOI: 10.5195/ijt.2016.6201] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We evaluated the feasibility, safety, system usability, and intervention acceptability of Lung Transplant Go (LTGO), an 8-week in-home exercise intervention for lung transplant recipients using a telerehabilitation platform, and described changes in physical function and physical activity from baseline to post-intervention. The intervention was delivered to lung transplant recipients in their home via the Versatile and Integrated System for TeleRehabilitation (VISYTER). The intervention focused on aerobic and strengthening exercises tailored to baseline physical function. Participants improved walk distance (6-minute walk distance), balance (Berg Balance Scale), lower body strength (30-second chair stand test) and steps walked (SenseWear Armband®). No adverse events were reported. Participants rated the program highly positively in regard to the technology and intervention. The telerehabilitation exercise program was feasible, safe, and acceptable. Our findings provide preliminary support for the LTGO intervention to improve physical function and promote physical activity in lung transplant recipients.
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Affiliation(s)
- Jiyeon Choi
- DEPARTMENT OF ACUTE & TERTIARY CARE, SCHOOL OF NURSING, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
| | - Andrea L Hergenroeder
- DEPARTMENT OF PHYSICAL THERAPY, SCHOOL OF HEALTH AND REHABILITATION SCIENCE, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
| | - Lora Burke
- DEPARTMENT OF HEALTH & COMMUNITY SYSTEMS, SCHOOL OF NURSING, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
| | - Annette Devito Dabbs
- DEPARTMENT OF ACUTE & TERTIARY CARE, SCHOOL OF NURSING, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
| | - Matthew Morrell
- DIVISION OF PULMONARY ALLERGY AND CRITICAL CARE MEDICINE, DEPARTMENT OF MEDICINE, UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE & SCHOOL OF NURSING, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
| | - Andi Saptono
- DEPARTMENT OF HEALTH INFORMATION MANAGEMENT, SCHOOL OF HEALTH AND REHABILITATION SCIENCE, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
| | - Bambang Parmanto
- DEPARTMENT OF HEALTH INFORMATION MANAGEMENT, SCHOOL OF HEALTH AND REHABILITATION SCIENCE, UNIVERSITY OF PITTSBURGH, PITTSBURGH, PENNSYLVANIA, USA
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Kinaschuk K, Nagendran J. Improving long-term survival by preventing early complications after lung transplantation: Can we prevent ripples by keeping pebbles out of the water? J Thorac Cardiovasc Surg 2016; 151:1181-2. [PMID: 26832212 DOI: 10.1016/j.jtcvs.2015.12.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Katie Kinaschuk
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Alberta Health Services, University of Alberta, Edmonton, Alberta, Canada
| | - Jayan Nagendran
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Mazankowski Alberta Heart Institute, Alberta Health Services, University of Alberta, Edmonton, Alberta, Canada; Alberta Transplant Institute, University of Alberta, Edmonton, Alberta, Canada; Canadian National Transplant Research Program, Edmonton, Alberta, Canada.
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