Single- and double-lung transplantation. Problems and possible solutions

Early Gait Function After Lung Transplantation in Patients With and Without Pretransplant Extracorporeal Membrane Oxygenation Support

OBJECTIVE

We aimed to investigate the recovery of gait function, muscle strength, and the achievement of an independent gait after lung transplantation (LT) in patients with and without pretransplant extracorporeal membrane oxygenation (ECMO) support.

METHODS

We retrospectively reviewed the medical records of 33 inpatients who underwent bilateral LT and received physical therapy. We assessed the Functional Ambulatory Category (FAC) and Manual Muscle Test (MMT) scores at baseline, 1 month, and 3 months of rehabilitation and the time it took to achieve a FAC score of 3 within 3 months of LT surgery in ECMO and non-ECMO patients.

RESULTS

The FAC and MMT scores were generally improved during the first 3 months after LT. The number of patients who achieved a FAC score of 3 at 3 months did not significantly differ between the ECMO and non-ECMO groups (P = .193). At 1 month, significantly fewer patients had reached a FAC of 3 in the ECMO group than in the non-ECMO group (P = .042). There were no significant differences in the FAC (P = .398) and MMT scores (P = .079) at 3 months between the 2 groups.

CONCLUSIONS

Both groups' gait function and muscle strength were continuously restored 3 months after LT. At 1 month, the gait function was assessed by the FAC score, and the rate to achieve a FAC of 3 was higher in the non-ECMO group than in the ECMO group, but at 3 months, the difference was not significant between the 2 groups.

Revascularization of trachea in lung and tracheal transplantation

Ischemia is the primary risk factor for airway complications in double lung transplantation using tracheal anastomosis and in tracheal transplantation. Many treatment options as to revascularization for the trachea were herein described and reviewed. They include direct revascularization (using a conduit such as artery or vein), revascularization with tissue wrapping (using omentum, muscle, internal thoracic artery pedicle, pleura, or pericardial fat pad), and with drug administration (using corticosteroid hormone, prostaglandin, or angiogenic factor). As there are few organized reports including new information on revascularization for the trachea these days, this review article would help thoracic surgeons who get engaged transplantation.

Acute and chronic pleural complications in lung transplantation

BACKGROUND

Lung transplant recipients may have pleural complications. However, the influence of these complications on the prognosis is not well known.

METHODS

We analyzed pleural complications and clinical and radiologic data from 100 patients who underwent lung transplantation in a general hospital in a 9-year period. Pre-operative evaluation, surgical protocol, immunosuppressive regimen, and follow-up were carried out systematically. Chest computerized tomography (CT) was performed at 3 and 12 months after transplantation.

RESULTS

All patients had early post-operative pleural effusion ipsilateral to the graft, which required drainage for a mean of 19.3 days (range, 5-52 days). Thirty-four patients had 43 acute pleural complications: 15 hemothoraxes, 10 persistent air leaks, 8 pneumothoraxes, 7 transient air leaks, and 3 empyemas. Multivariate analysis showed hemothorax and persistent air leak were associated with increased post-operative mortality (p = 0.024, p = 0.011, respectively). Post-operative mortality was not associated with any pre-transplant variable. Chest CT findings at 3 months revealed > or =1 pleural alteration in 58 of 70 patients (83%): 34 post-operative residual ipsilateral pleural effusions; 36 pleural thickenings; and 3 residual pneumothoraxes, 1 with a coexisting bronchial dehiscence. Chest CT at 12 months showed pleural alterations in 50 of 58 patients (86%): pleural thickening in 48, calcification in 4, and residual pleural effusion in 4.

CONCLUSIONS

Pleural complications are common in lung transplant recipients. Hemothorax and persistent air leak are associated with increased post-operative mortality. Chest CT showed pleural alterations in most patients 12 months after transplantation.

Late postoperative pleural effusion following lung transplantation: characteristics and clinical implications

OBJECTIVE

Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14-45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX.

METHODS

Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined.

RESULTS

The median time for late pleural effusion appearance was 23 days (range, 14-34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100-1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients.

CONCLUSION

Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome.

Empyema complicating successful lung transplantation

OBJECTIVE

To assess the prevalence and etiology of empyema complicating successful lung transplantation.

DESIGN

Retrospective review.

SETTING

University medical center transplant service.

PATIENTS

All recipients (n = 392) of single-lung, double-lung, and heart-lung transplantation between May 1984 and April 1997.

RESULTS

Of the 392 transplant recipients, empyema was documented in 14 patients (3.6%) at a mean time (+/- SD) of 46 days after transplantation (range, 14 to 167 days). Of these 14 recipients with empyema, 4 recipients (28.6%) died of infectious complications related to empyema. Empyema was seen secondary to Gram-positive, Gram-negative, and saprophytic organisms; however, there was no predominance of a particular organism recovered from the empyemic fluid (chi2 = 0.53; p = 0.75). The development of empyema was not related to whether the transplant was performed secondary to a septic or nonseptic lung disorder (chi2 = 1.06; p = 0.67), nor was it related to the type of transplant procedure performed (ie, single-lung, double-lung, or heart-lung allografts; chi2 = 4.39; p = 0.30).

CONCLUSION

Empyema, a relatively uncommon complication of lung transplantation, is not related to the type of allograft received or to whether the recipient had a septic or a nonseptic lung disorder. If empyema does occur, the mortality associated with this infection is substantial.

Bronchoalveolar lavage in lung transplantation. State of the art

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) has become a crucial tool in the management of lung transplant recipients. Detection of pulmonary infectious pathogens by culture, cytology, and histology of BAL, protected brush specimens, and transbronchial biopsies (TBB) is highly effective. Morphologic and phenotypological analyses of BAL cells may be suggestive for certain complications after lung transplantation. For interpretation of BAL findings, the natural course of BAL cell morphology and phenotypology after lung transplantation must be considered. During the first 3 months after pulmonary transplantation, elevated total cell count in BAL and neutrophilic alveolitis are common, representing the cellular response to graft injury and interaction of immunocompetent cells of donor and recipient origin. With increasing time after transplantation the CD4/CD8 ratio decreases due to lowered percentages of CD4 cells in BAL. During bacterial pneumonias, the cellular profile of BAL is characterized by a marked granulocytic alveolitis. Lymphocytic alveolitis with a decreased CD4/CD8 ratio is suggestive of acute rejection, but is also found in viral pneumonias and obliterative bronchiolitis. In the case of a combined lymphocytosis and neutrophilia without any evidence of infection, obliterative bronchiolitis should be considered. Functional analyses of BAL cells can give additional information about the immunologic status of the graft, even before histologic changes become evident but have not been established in routine transplant monitoring. However, functional studies suggest an important role of activated, alloreactive and donor-specific T lymphocytes in the pathogenesis of acute and chronic lung rejection. Investigations of soluble components in BAL have given further insight into the immunologic processes after lung transplantation. In this overview, the characteristics of BAL after lung transplantation will be summarized, and its relevance for the detection of pulmonary complications will be discussed.

Pleural effusions following lung transplantation. Time course, characteristics, and clinical implications

The time course and characteristics of ipsilateral pleural effusion in nine consecutive single lung transplant recipients are described and compared with those of six patients who underwent other cardiothoracic operations. Ipsilateral pleural fluid occurs in all lung transplant recipients, beginning immediately following transplantation and continuing for up to 9 days. Pleural fluid immediately after lung transplantation is bloody, exudative, and neutrophil predominant, which is similar to the characteristics of pleural fluid following other cardiothoracic surgery. Pleural fluid cellularity, lactate dehydrogenase, and total protein content decrease rapidly over the first week in lung transplant recipients. The percentage of neutrophils decreases from 90 to 50% by day 7. Pleural fluid output in lung transplant recipients declines steadily during the first week and is minimal by day 9. Pleural fluid output declines more rapidly in patients who have undergone cardiothoracic surgery than in the lung transplant recipients. An early rise in pleural fluid output may reflect the development of posttransplant pulmonary edema. We conclude that it is unnecessary to analyze pleural fluid after lung transplantation if the pleural fluid output is decreasing and the clinical course is appropriate.

Pleural complications in lung transplant recipients

Pleural complications occurred in 30 (22%) of 138 patients after 53 single and 91 double lung transplants between September 1986 and February 1993. These were defined for the purpose of this study as pneumothorax persisting beyond the first 14 postoperative days, recurrent pneumothorax, or any other pleural process that necessitated diagnostic or therapeutic intervention. Overall, a higher pleural complication rate was seen in double lung transplantation (25 of 30) than in single lung transplantation (5 of 30) with no differences noted in the frequency among preoperative diagnostic groups (p > 0.05). Pneumothorax was the most frequent complication, affecting 14 of 30 patients, with 6 of 14 cases occurring after transbronchial biopsy. All pneumothoraces in single (n = 4) and double lung transplantation (n = 10) resolved spontaneously or with chest tube thoracostomy. One patient required placement of a Clagett window after open lung biopsy and another required thoracotomy and pleural abrasion after transbronchial biopsy. Parapneumonic effusion was observed in 4 of 30 double lung transplantations with spontaneous resolution in all cases. Empyema affected 7 of 30 patients and occurred exclusively in the double lung transplant group. Sepsis developed in three of the patients with this complication and they subsequently died. The risk of empyema was independent of preoperative diagnosis (p > 0.05). Of interest, all patients with cystic fibrosis (n = 3) with complicating empyema had Pseudomonas cepacia in the pleural fluid. Other miscellaneous complications included subpleural hematoma, chylothorax, and hemothorax. The latter two necessitated thoracic duct and bronchial artery ligation, respectively. In summary, a significant proportion of lung transplant recipients will have pleural space complications. The vast majority of these will resolve spontaneously or with conservative procedures. These complications were not related to preoperative diagnosis nor associated with a significant prolongation of hospital stay (p > 0.05). Empyema is the only pleural space complication associated with increased patient mortality and, as such, is an important clinical marker for those at risk for sepsis and death.

Routine immediate direct bronchial artery revascularization for single-lung transplantation

Ischemia of the donor airway remains a significant cause of morbidity after single-lung transplantation; serious manifestations may occur early (anastomotic dehiscence) or late (stricture). Direct, immediate revascularization of the donor bronchial arteries, using the recipient internal thoracic artery, was performed in 10 consecutive recipients of single-lung transplants for whom we procured the organs. Mean recipient age was 52.6 years (range, 43 to 59 years); 6 were male and 4 female. Recipient diagnoses were emphysema (6), obliterative bronchiolitis (2), pulmonary fibrosis (1), and primary pulmonary hypertension (1). Bronchial artery revascularization initially prolonged the ischemic time by only 15 to 20 minutes; this improved with experience. There was one early death and two late deaths in the series. Internal thoracic arteriography was performed 7 to 10 days postoperatively in all 9 surviving patients. There was excellent perfusion of the donor bronchial arteries in 7 of these 9 patients. Bronchoscopy was performed when clinically indicated. No patient had early or late airway healing complications at a median follow-up of 13 months (range, 6 to 16 months). We conclude that direct, immediate bronchial artery revascularization is feasible on a routine basis for single-lung transplantation, and airway healing has been excellent.

Airway complications in lung transplantation

This article reviews the literature on airway healing after lung transplantation. From a historical point of view, this has been the Achilles' heel of lung transplantation through two decades, from the first attempt at single-lung transplantation in 1963 to the clinical successes in the early 1980s. The overall incidence of lethal airway complications is estimated to be 2% to 3%, whereas that of late stricture is 7% to 14%. Comparison of experiences has been difficult without a universal classification; a new classification for airway and anastomotic complications and healing is proposed. Ischemia appears to be the most important factor influencing airway healing. Low-pressure collateral bronchial blood flow from the pulmonary artery may be affected by low cardiac output, reperfusion edema, or rejection; mucosal injury may be further increased by prolonged positive-pressure ventilation. Good bronchial healing appears to be possible without a protective wrap and with early use of steroids. The management of bronchial complications is challenging and requires endoscopic skills including knowledge of endobronchial laser photocoagulation and stent insertion techniques.

Airway complications after pulmonary transplantation

Airway healing was identified initially as one of the fundamental limitations of pulmonary transplantation. Recent experience suggests that this is no longer the case. A series of 67 pulmonary transplants (27 heart-lung, 31 single-lung, 9 double-lung) in 66 patients surviving more than 14 days was reviewed with reference to airway complications. There were 75 anastomoses at risk in two groups as defined by anastomotic location: 47 anastomoses in 38 patients in a bronchial group and 28 anastomoses in 28 patients in a tracheal group. A total of 10 airway complications developed (stenosis in 5 patients [4 bronchial group, 1 tracheal group] and dehiscence in 5 patients [1 bronchial group, 4 tracheal group]) causing two airway-related deaths (2 of 67) in the series. However, no significant correlation could be identified with either ischemic interval, suture technique, type of wrap, preoperative or postoperative steroid therapy, or date of first rejection episode. Airway complications are no longer a major limitation of pulmonary transplantation. Satisfactory airway healing can occur in both the presence of steroid therapy and the absence of an omental or pericardial wrap.

[Antibiotic prophylaxis in thoracic surgery, pulmonary endoscopy, thoracic injuries and lung transplantation]

Effectiveness of prophylactic antibiotics is at present time well documented for many surgical procedures. In lung surgery, numerous randomized double-blinded studies have demonstrated the effectiveness of 1st or 2nd generation cephalosporins, administered over a short period of time, not exceeding 24 h. In the opposite, thoracic injuries do not seem to require prophylactic antibiotics, except penetrating injuries of the chest, which could benefit from a single antibiotic injection. In case of lung transplantation, infectious complications result from many factors, among which immunosuppression plays an important role. A prolonged antibiotherapy is routinely used by many transplantation teams, despite the lack of studies proving the effectiveness of this practice.

Successful double-lung transplantation with direct bronchial artery revascularization

Double-lung transplantation with tracheal anastomosis has previously resulted in unacceptable ischemic complications of airway healing. Three patients underwent double-lung transplantation at our institution in 1986 and 1987, and 2 of these required later retransplantation because of airway complications. Recently, we began to perform direct revascularization of the bronchial arteries at their origin on the donor descending thoracic aorta, using recipient internal thoracic artery. Eight patients (2 male and 6 female patients; ages, 10-51 years) underwent nine double-lung transplantations with revascularization. The preoperative diagnoses in these patients were cystic fibrosis (2 patients), atrial septal defect and Eisenmenger's syndrome (1 patient), lymphagioleiomyomatosis (1 patient), bronchiectasis (1 patient), alpha 1-antitrypsin deficiency (1 patient), and primary pulmonary hypertension (2 patients); 1 underwent retransplantation because of pulmonary emboli. There have been no significant airway complications in any patient. Two patients died early postoperatively, 1 of early pulmonary dysfunction (at 1 day postoperatively) and 1 of subarachnoid hemorrhage (at 16 days postoperatively; tracheal healing was excellent in this patient). Follow-up in the remaining 6 patients ranged from 5 to 9 months. Internal thoracic artery angiography was performed on seven grafts, which documented patency of the internal thoracic artery in all seven and bronchial artery perfusion in six. Bronchoscopic examinations have demonstrated excellent airway healing in all six of these grafts, with no dehiscence, granulation, or narrowing of the trachea or distal bronchi. Ulceration of the tracheal anastomosis developed anteriorly in the remaining patient, which has resolved. We conclude that double-lung transplantation is an acceptable therapeutic approach when combined with bronchial artery revascularization, and early airway healing has been excellent.(ABSTRACT TRUNCATED AT 250 WORDS)

Infection in the transplanted and native lung after single lung transplantation

OBJECTIVE

To analyze a single-center experience with infectious complications of single lung transplantation (SLT) with special emphasis on risk factors for infection in the transplanted and native lung.

DESIGN

Consecutive case series.

SETTING

University teaching hospital.

PATIENTS

Fifteen consecutive SLT recipients (mean age, 43 years; 9 men and 6 women). Mean follow-up was 337 days.

RESULTS

Fifteen patients had 24 infectious episodes (1.6 per patient) of which 83 percent were life-threatening, 79 percent involved the lung, airway, or pleural space, and 79 percent occurred in the first 4 months after transplantation. Despite this high infectious morbidity, there were no infectious deaths. The most important infections were bacterial pneumonia (n = 10), cytomegalovirus (CMV) pneumonia (n = 5), and bronchial anastomotic infections (n = 3). Significant risk factors for bacterial pneumonia were a diagnosis of primary or secondary pulmonary hypertension (p < 0.05) and the presence of airway complications of stenosis or dehiscence (p < 0.05). No risk factors for overall lung infections were identified. The native lung was involved in 6 of 16 lung infections and was the exclusive site of infection in 4 cases. Underlying disease in the native lung may have predisposed to infection at that site by a mechanism of inadequate blood flow or impaired ventilation. Three bronchial anastomotic infections (Pseudomonas, Candida, Aspergillus) occurred, all with dehiscence of the anastomosis. These were highly morbid but resolved with antibiotics, stent placement, and surgical retention in two of the three cases. The five episodes of CMV pneumonia caused mild (four patients) or moderate (one patient) dysfunction and responded to antiviral agents without relapse.

CONCLUSION

The frequency, complexity, and morbidity of infections after SLT were great, but most infections were manageable and good outcomes were achieved. A pretransplant diagnosis of pulmonary hypertension or posttransplant occurrence of bronchial stenosis or dehiscence were associated with a higher rate of bacterial pneumonia. The underlying disease in the native lung may predispose to infection at that site.