1
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Operating room extubation: A predictive factor for 1-year survival after double-lung transplantation. J Heart Lung Transplant 2021; 40:334-342. [PMID: 33632637 DOI: 10.1016/j.healun.2021.01.1965] [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: 08/06/2020] [Revised: 01/24/2021] [Accepted: 01/30/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Operating room (OR) extubation has been reported after lung transplantation (LT) in small cohorts. This study aimed to evaluate the prognosis of OR-extubated patients. The secondary objectives were to evaluate the safety of this approach and to identify its predictive factors. METHODS This retrospective single-center cohort study included patients undergoing double lung transplantation (DLT) from January 2012 to June 2019. Patients undergoing multiorgan transplantation, repeat transplantation, or cardiopulmonary bypass during the study period were excluded. OR-extubated patients were compared with intensive care unit (ICU)-extubated patients. RESULTS Among the 450 patients included in the analysis, 161 (35.8%) were extubated in the OR, and 4 were reintubated within 24 hours. Predictive factors for OR extubation were chronic obstructive pulmonary disease (COPD)/emphysema (p = .002) and cystic fibrosis (p = .005), recipient body mass index (p = .048), and the PaO2/FiO2 ratio 10 minutes after second graft implantation (p < .001). OR-extubated patients had a lower prevalence of grade 3 primary graft dysfunction at day 3 (p < .001). Eight (5.0%) patients died within the first year after OR extubation, and 49 (13.5%) patients died after ICU extubation (log-rank test; p = .005). After adjustment for OR extubation predictive factors, the multivariate Cox regression model showed that OR extubation was associated with greater one-year survival (adjusted hazard ratio = 0.40 [0.16-0.91], p = .028). CONCLUSIONS OR extubation was associated with a favorable prognosis after DLT, but the association should not be interpreted as causality. This fast-track protocol was made possible by a team committed to developing a comprehensive strategy to enhance recovery.
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Wilkey BJ, Abrams BA. Mitigation of Primary Graft Dysfunction in Lung Transplantation: Current Understanding and Hopes for the Future. Semin Cardiothorac Vasc Anesth 2019; 24:54-66. [DOI: 10.1177/1089253219881980] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury that develops within the first 72 hours after lung transplantation. The overall incidence of PGD is estimated to be around 30%, and the 30-day mortality for grade 3 PGD around 36%. PGD is also associated with the development of bronchiolitis obliterans syndrome, a specific form of chronic lung allograft dysfunction. In this article, we will discuss perioperative strategies for PGD prevention as well as possible future avenues for prevention and treatment.
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3
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Schwarz S, Muckenhuber M, Benazzo A, Beer L, Gittler F, Prosch H, Röhrich S, Milos R, Schweiger T, Jaksch P, Klepetko W, Hoetzenecker K. Interobserver variability impairs radiologic grading of primary graft dysfunction after lung transplantation. J Thorac Cardiovasc Surg 2019; 158:955-962.e1. [DOI: 10.1016/j.jtcvs.2019.02.134] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 11/28/2022]
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4
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Cantu E, Diamond JM, Suzuki Y, Lasky J, Schaufler C, Lim B, Shah R, Porteous M, Lederer DJ, Kawut SM, Palmer SM, Snyder LD, Hartwig MG, Lama VN, Bhorade S, Bermudez C, Crespo M, McDyer J, Wille K, Orens J, Shah PD, Weinacker A, Weill D, Wilkes D, Roe D, Hage C, Ware LB, Bellamy SL, Christie JD. Quantitative Evidence for Revising the Definition of Primary Graft Dysfunction after Lung Transplant. Am J Respir Crit Care Med 2019; 197:235-243. [PMID: 28872353 DOI: 10.1164/rccm.201706-1140oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Primary graft dysfunction (PGD) is a form of acute lung injury that occurs after lung transplantation. The definition of PGD was standardized in 2005. Since that time, clinical practice has evolved, and this definition is increasingly used as a primary endpoint for clinical trials; therefore, validation is warranted. OBJECTIVES We sought to determine whether refinements to the 2005 consensus definition could further improve construct validity. METHODS Data from the Lung Transplant Outcomes Group multicenter cohort were used to compare variations on the PGD definition, including alternate oxygenation thresholds, inclusion of additional severity groups, and effects of procedure type and mechanical ventilation. Convergent and divergent validity were compared for mortality prediction and concurrent lung injury biomarker discrimination. MEASUREMENTS AND MAIN RESULTS A total of 1,179 subjects from 10 centers were enrolled from 2007 to 2012. Median length of follow-up was 4 years (interquartile range = 2.4-5.9). No mortality differences were noted between no PGD (grade 0) and mild PGD (grade 1). Significantly better mortality discrimination was evident for all definitions using later time points (48, 72, or 48-72 hours; P < 0.001). Biomarker divergent discrimination was superior when collapsing grades 0 and 1. Additional severity grades, use of mechanical ventilation, and transplant procedure type had minimal or no effect on mortality or biomarker discrimination. CONCLUSIONS The PGD consensus definition can be simplified by combining lower PGD grades. Construct validity of grading was present regardless of transplant procedure type or use of mechanical ventilation. Additional severity categories had minimal impact on mortality or biomarker discrimination.
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Affiliation(s)
| | - Joshua M Diamond
- 2 Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | - Brian Lim
- 1 Division of Cardiovascular Surgery and
| | - Rupal Shah
- 2 Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Mary Porteous
- 2 Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David J Lederer
- 3 Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Steven M Kawut
- 2 Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.,4 Center for Clinical Epidemiology and Biostatistics and.,5 Penn Cardiovascular Institute, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Scott M Palmer
- 6 Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Laurie D Snyder
- 6 Division of Pulmonary, Allergy, and Critical Care Medicine and
| | - Matthew G Hartwig
- 7 Division of Cardiothoracic Surgery, Duke University, Durham, North Carolina
| | - Vibha N Lama
- 8 Division of Pulmonary, Allergy, and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sangeeta Bhorade
- 9 Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
| | | | - Maria Crespo
- 2 Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - John McDyer
- 10 Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Keith Wille
- 11 Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jonathan Orens
- 12 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Johns Hopkins University Hospital, Baltimore, Maryland
| | - Pali D Shah
- 12 Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Johns Hopkins University Hospital, Baltimore, Maryland
| | - Ann Weinacker
- 13 Division of Pulmonary and Critical Care Medicine, Stanford University, Palo Alto, California
| | - David Weill
- 14 Institute for Advanced Organ Disease and Transplantation, University of South Florida, Tampa, Florida
| | - David Wilkes
- 15 Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - David Roe
- 15 Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chadi Hage
- 15 Division of Pulmonary, Allergy, Critical Care, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lorraine B Ware
- 16 Department of Medicine and.,17 Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, Tennessee; and
| | - Scarlett L Bellamy
- 18 Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
| | - Jason D Christie
- 2 Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.,4 Center for Clinical Epidemiology and Biostatistics and
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5
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Fessler J, Thes J, Pirracchio R, Godement M, Sage E, Roux A, Parquin F, Cerf C, Fischler M, Le Guen M. Prognostic value of the PaO
2
/FiO
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ratio determined at the end‐surgery stage of a double‐lung transplantation. Clin Transplant 2019; 33:e13484. [DOI: 10.1111/ctr.13484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 01/02/2019] [Accepted: 01/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Julien Fessler
- Department of Anesthesiology Hôpital Foch Suresnes France
- Université Versailles‐Saint‐Quentin‐en‐Yvelines Versailles France
| | - Jacques Thes
- Cardiothoracic Intensive Care Unit Centre Chirurgical Marie Lannelongue Le Plessis Robinson France
| | - Romain Pirracchio
- Department of Anesthesiology and Intensive Care Medicine Hôpital Européen Georges Pompidou Paris France
- Department of Biostatistics and of Medical Informatics Inserm U1153, ECSTRA, Hôpital Saint Louis, Université Paris Diderot, Sorbonne Paris Cité Paris France
| | - Mathieu Godement
- Department of Anesthesiology and Intensive Care Medicine Hôpital Bichat Paris France
- Université Paris Diderot Paris France
| | - Edouard Sage
- Université Versailles‐Saint‐Quentin‐en‐Yvelines Versailles France
- Department of Thoracic Surgery Hôpital Foch Suresnes France
| | - Antoine Roux
- Université Versailles‐Saint‐Quentin‐en‐Yvelines Versailles France
- Department of Pneumology Hôpital Foch Suresnes France
| | - François Parquin
- Université Versailles‐Saint‐Quentin‐en‐Yvelines Versailles France
- Department of Thoracic Surgery Hôpital Foch Suresnes France
| | - Charles Cerf
- Department of Intensive Care Medicine Hôpital Foch Suresnes France
| | - Marc Fischler
- Department of Anesthesiology Hôpital Foch Suresnes France
- Université Versailles‐Saint‐Quentin‐en‐Yvelines Versailles France
| | - Morgan Le Guen
- Department of Anesthesiology Hôpital Foch Suresnes France
- Université Versailles‐Saint‐Quentin‐en‐Yvelines Versailles France
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6
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Panwar R, Capellier G, Schmutz N, Davies A, Cooper DJ, Bailey M, Baguley D, Pilcher DV, Bellomo R. Current Oxygenation Practice in Ventilated Patients—An Observational Cohort Study. Anaesth Intensive Care 2019; 41:505-14. [DOI: 10.1177/0310057x1304100412] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- R. Panwar
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, John Hunter Hospital, Newcastle, New South Wales
| | - G. Capellier
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- University Hospital Besançon and University of Franche-Comté, France
| | - N. Schmutz
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - A. Davies
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - D. J. Cooper
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, The Alfred Hospital; and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University
| | - M. Bailey
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University
| | - D. Baguley
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Fremantle Hospital, Perth, Western Australia
| | - D. V. Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, The Alfred Hospital; and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University
| | - R. Bellomo
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, The Austin Hospital; and Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University
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7
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Geube M, Anandamurthy B, Yared JP. Perioperative Management of the Lung Graft Following Lung Transplantation. Crit Care Clin 2018; 35:27-43. [PMID: 30447779 DOI: 10.1016/j.ccc.2018.08.007] [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] [Indexed: 02/08/2023]
Abstract
Perioperative management of patients undergoing lung transplantation is one of the most complex in cardiothoracic surgery. Certain perioperative interventions, such as mechanical ventilation, fluid management and blood transfusions, use of extracorporeal mechanical support, and pain management, may have significant impact on the lung graft function and clinical outcome. This article provides a review of perioperative interventions that have been shown to impact the perioperative course after lung transplantation.
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Affiliation(s)
- Mariya Geube
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Clinic, 9500 Euclid Avenue, J4-331, Cleveland, OH 44195, USA.
| | - Balaram Anandamurthy
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland Clinic, 9500 Euclid Avenue, J4-331, Cleveland, OH 44195, USA
| | - Jean-Pierre Yared
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, 9500 Euclid Avenue, J4-331, Cleveland, OH 44195, USA
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8
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Diamond JM, Arcasoy S, Kennedy CC, Eberlein M, Singer JP, Patterson GM, Edelman JD, Dhillon G, Pena T, Kawut SM, Lee JC, Girgis R, Dark J, Thabut G. Report of the International Society for Heart and Lung Transplantation Working Group on Primary Lung Graft Dysfunction, part II: Epidemiology, risk factors, and outcomes—A 2016 Consensus Group statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2017; 36:1104-1113. [DOI: 10.1016/j.healun.2017.07.020] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 11/28/2022] Open
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9
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Raphael J, Collins SR, Wang XQ, Scalzo DC, Singla P, Lau CL, Kozower BD, Durieux ME, Blank RS. Perioperative statin use is associated with decreased incidence of primary graft dysfunction after lung transplantation. J Heart Lung Transplant 2017; 36:948-956. [DOI: 10.1016/j.healun.2017.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/21/2017] [Accepted: 05/03/2017] [Indexed: 12/28/2022] Open
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10
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Increased Extravascular Lung Water and Plasma Biomarkers of Acute Lung Injury Precede Oxygenation Impairment in Primary Graft Dysfunction After Lung Transplantation. Transplantation 2017; 101:112-121. [PMID: 27495752 DOI: 10.1097/tp.0000000000001434] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND After lung transplantation (LT), early prediction of grade 3 pulmonary graft dysfunction (PGD) remains a research gap for clinicians. We hypothesized that it could be improved using extravascular lung water (EVLWi) and plasma biomarkers of acute lung injury. METHODS After institutional review board approval and informed consent, consecutive LT recipients were included. Transpulmonary thermodilution-based EVLWi, plasma concentrations of epithelial (soluble receptor for advanced glycation endproducts [sRAGE]) and endothelial biomarkers (soluble intercellular adhesion molecule-1 and endocan [full-length and cleaved p14 fragment]) were obtained before and after LT (0 [H0], 6, 12, 24, 48 and 72 hours after pulmonary artery unclamping). Grade 3 PGD was defined according to the International Society for Lung and Heart Transplantation definition, combining arterial oxygen partial pressure (PaO2)/inspired fraction of oxygen (FiO2) ratio and chest X-rays. Association of clinical risk factors, EVLWi and biomarkers with grade 3 PGD was analyzed under the Bayesian paradigm, using logistic model and areas under the receiver operating characteristic curves (AUCs). RESULTS In 47 LT recipients, 10 developed grade 3 PGD, which was obvious at H6 in 8 cases. Clinical risk factors, soluble intercellular adhesion molecule-1 and endocan (both forms) were not associated with grade 3 PGD. Significant predictors of grade 3 PGD included (1) EVLWi (optimal cutoff, 13.7 mL/kg; AUC, 0.74; 95% confidence interval [CI], 0.48-0.99), (2) PaO2/FiO2 ratio (optimal cutoff, 236; AUC, 0.68; 95% CI, 0.52-0.84), and (3) sRAGE (optimal cutoff, 11 760 pg/mL; AUC, 0.66; 95% CI, 0.41-0.91) measured at H0. CONCLUSIONS Immediate postreperfusion increases in EVLWi and sRAGE along with impaired PaO2/FiO2 ratios were early predictors of grade 3 PGD at or beyond 6 hours and may trigger early therapeutic interventions.
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11
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Riera J, Senna A, Cubero M, Roman A, Rello J. Primary Graft Dysfunction and Mortality Following Lung Transplantation: A Role for Proadrenomedullin Plasma Levels. Am J Transplant 2016; 16:634-9. [PMID: 26461449 DOI: 10.1111/ajt.13478] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 01/25/2023]
Abstract
Primary graft dysfunction (PGD) after lung transplantation (LT) is a heterogeneous syndrome that comprises clinical presentations with diverse grades of severity. Proadrenomedullin (proADM) levels may be associated with PGD and may enhance its relationship with outcomes. We prospectively included 100 LT recipients. Plasma levels of proADM were measured at 24, 48 and 72 h after admission to the intensive care unit (ICU). We assessed their relationship with PGD grade and ICU mortality. Fifty patients (50%) presented grade 3 PGD at ICU admission. Twenty-two patients (22%) developed grade 3 PGD at 72 h, the only grade associated with higher mortality (odds ratio 6.84, 95% confidence interval [CI] 1.47-38.44). ProADM levels measured at 24 h (3.25 vs. 1.61 nmol/L; p = 0.016) and 72 h (2.17 vs. 1.35 nmol/L; p = 0.011) were higher in these patients than the rest of the population. When we added the individual predictive utility of grade 3 PGD at 72 h for ICU mortality (area under the curve [AUC] 0.72, 95% CI 0.53-0.90) to that of ProADM at 72 h, the predictive value of the model improved (AUC 0.81, 95% CI 0.65-0.97). Higher levels of proADM measured following LT are associated with grade 3 PGD at 72 h. ProADM enhances the association of this entity with mortality.
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Affiliation(s)
- J Riera
- Critical Care Department, Vall d'Hebron University Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institut, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - A Senna
- Vall d'Hebron Research Institut, Barcelona, Spain
| | - M Cubero
- Vall d'Hebron Research Institut, Barcelona, Spain
| | - A Roman
- Vall d'Hebron Research Institut, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Department of Pulmonology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - J Rello
- Critical Care Department, Vall d'Hebron University Hospital, Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,Vall d'Hebron Research Institut, Barcelona, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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12
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Nayyar D, Man HSJ, Granton J, Lilly LB, Gupta S. Proposed management algorithm for severe hypoxemia after liver transplantation in the hepatopulmonary syndrome. Am J Transplant 2015; 15:903-13. [PMID: 25649047 PMCID: PMC5132094 DOI: 10.1111/ajt.13177] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/08/2014] [Accepted: 12/19/2014] [Indexed: 01/25/2023]
Abstract
The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, intrapulmonary vascular dilatation, and abnormal gas exchange, and is found in 10-32% of patients with liver disease. Liver transplantation is the only known cure for HPS, but patients can develop severe posttransplant hypoxemia, defined as a need for 100% inspired oxygen to maintain a saturation of ≥85%. This complication is seen in 6-21% of patients and carries a 45% mortality. Its management requires the application of specific strategies targeting the underlying physiologic abnormalities in HPS, but awareness of these strategies and knowledge on their optimal use is limited. We reviewed existing literature to identify strategies that can be used for this complication, and developed a clinical management algorithm based on best evidence and expert opinion. Evidence was limited to case reports and case series, and we determined which treatments to include in the algorithm and their recommended sequence based on their relative likelihood of success, invasiveness, and risk. Recommended therapies include: Trendelenburg positioning, inhaled epoprostenol or nitric oxide, methylene blue, embolization of abnormal pulmonary vessels, and extracorporeal life support. Availability and use of this pragmatic algorithm may improve management of this complication, and will benefit from prospective validation.
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Affiliation(s)
- D. Nayyar
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoCanada
| | - H. S. J. Man
- Department of MedicineUniversity of TorontoTorontoCanada,Division of RespirologyDepartment of MedicineUniversity Health NetworkTorontoCanada
| | - J. Granton
- Department of MedicineUniversity of TorontoTorontoCanada,Division of RespirologyDepartment of MedicineUniversity Health NetworkTorontoCanada
| | - L. B. Lilly
- Department of MedicineUniversity of TorontoTorontoCanada,Division of Gastroenterology and MultiOrgan Transplant ProgramUniversity Health NetworkTorontoCanada
| | - S. Gupta
- Li Ka Shing Knowledge Institute of St. Michael's HospitalTorontoCanada,Department of MedicineUniversity of TorontoTorontoCanada,Division of RespirologyDepartment of MedicineSt. Michael's HospitalTorontoCanada
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13
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Farooki AM, Bazick-Cuschieri H, Gordon EK, Lee JC, Cantu EC, Augoustides JG. CASE 7--2014 Rescue therapy with early extracorporeal membrane oxygenation for primary graft dysfunction after bilateral lung transplantation. J Cardiothorac Vasc Anesth 2014; 28:1126-32. [PMID: 23999325 PMCID: PMC3969394 DOI: 10.1053/j.jvca.2013.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Indexed: 01/24/2023]
Affiliation(s)
- Ali M Farooki
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
| | | | - Emily K Gordon
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
| | | | - Edward C Cantu
- Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.AMF was a cardiac anesthesia fellow
| | - John G Augoustides
- Departments of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section
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14
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Abstract
Primary graft dysfunction (PGD) is a syndrome encompassing a spectrum of mild to severe lung injury that occurs within the first 72 hours after lung transplantation. PGD is characterized by pulmonary edema with diffuse alveolar damage that manifests clinically as progressive hypoxemia with radiographic pulmonary infiltrates. In recent years, new knowledge has been generated on risks and mechanisms of PGD. Following ischemia and reperfusion, inflammatory and immunological injury-repair responses appear to be key controlling mechanisms. In addition, PGD has a significant impact on short- and long-term outcomes; therefore, the choice of donor organ is impacted by this potential adverse consequence. Improved methods of reducing PGD risk and efforts to safely expand the pool are being developed. Ex vivo lung perfusion is a strategy that may improve risk assessment and become a promising platform to implement treatment interventions to prevent PGD. This review details recent updates in the epidemiology, pathophysiology, molecular and genetic biomarkers, and state-of-the-art technical developments affecting PGD.
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Affiliation(s)
- Yoshikazu Suzuki
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jason D Christie
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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15
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Bastarache JA, Diamond JM, Kawut SM, Lederer DJ, Ware LB, Christie JD. Postoperative estradiol levels associate with development of primary graft dysfunction in lung transplantation patients. ACTA ACUST UNITED AC 2012; 9:154-65. [PMID: 22361838 DOI: 10.1016/j.genm.2012.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/04/2012] [Accepted: 01/18/2012] [Indexed: 01/11/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD) frequently complicates lung transplantation in the immediate postoperative period. Both female gender and estradiol modulate the body's response to injury and can influence the rate of alveolar fluid clearance. OBJECTIVE We hypothesized that female gender and higher estradiol levels would be associated with a lower risk of PGD after lung transplantation. METHODS We measured plasma estradiol levels preoperatively, 6 hours postoperatively, and 24 hours postoperatively in a cohort of 111 lung transplant recipients at 2 institutions. RESULTS Mean age was 57 years (12.5) and 52% were female. Median postoperative estradiol level was 63.9 pg/mL (interquartile range, 28.8-154.3 pg/mL) in male and 65.1 pg/mL (interquartile range, 28.4-217.2 pg/mL) in female patients. Contrary to our hypothesis, higher estradiol levels at 24 hours were associated with an increased risk of PGD at 72 hours in male patients (P = 0.001). This association was preserved when accounting for other factors known to be associated with PGD. However, there was no relationship between gender and risk of PGD or between estradiol levels and PGD in females. CONCLUSION These findings suggest that there might be different biologic effects of estrogens in males and females, and highlight the importance of considering gender differences in future studies of PGD.
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Affiliation(s)
- Julie A Bastarache
- Division of Allergy, Pulmonary and Critical Care, Vanderbilt University School of Medicine, Nashville, TN 37232-2650, USA.
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16
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Abstract
Primary graft dysfunction (PGD) is the most important cause of early morbidity and mortality following lung transplantation. PGD affects up to 25% of all lung transplant procedures and currently has no proven preventive therapy. Lung transplant recipients who recover from PGD may have impaired long-term function and an increased risk of bronchiolitis obliterans syndrome. This article aims to provide a state-of-the-art review of PGD epidemiology, outcomes, and risk factors, and to summarize current efforts at biomarker development and novel strategies for prevention and treatment.
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Affiliation(s)
- James C Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA.
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Felten ML, Sinaceur M, Treilhaud M, Roze H, Mornex JF, Pottecher J, Journois D, Fischler M. Factors associated with early graft dysfunction in cystic fibrosis patients receiving primary bilateral lung transplantation. Eur J Cardiothorac Surg 2011; 41:686-90. [DOI: 10.1093/ejcts/ezr019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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González-Castro A, Díaz-Regañón G, Fernández-Miret B, Suberviola-Cañas B, Llorca J, Miñambres E. Validación externa de la escala Risk Quantification of Early Outcome After Lung Transplantation. Med Intensiva 2010; 34:446-52. [DOI: 10.1016/j.medin.2010.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 02/10/2010] [Accepted: 02/13/2010] [Indexed: 10/19/2022]
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Christie JD, Bellamy S, Ware LB, Lederer D, Hadjiliadis D, Lee J, Robinson N, Localio AR, Wille K, Lama V, Palmer S, Orens J, Weinacker A, Crespo M, Demissie E, Kimmel SE, Kawut SM. Construct validity of the definition of primary graft dysfunction after lung transplantation. J Heart Lung Transplant 2010; 29:1231-9. [PMID: 20655249 DOI: 10.1016/j.healun.2010.05.013] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Revised: 05/07/2010] [Accepted: 05/09/2010] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This study tested the discriminant validity of International Society for Heart and Lung Transplantation (ISHLT) primary graft dysfunction (PGD) grades with lung injury biomarker profiles and survival. METHODS The study samples consisted of a multicenter prospective cohort study for the biomarker analysis and a cohort study of 450 patients for the mortality analyses. PGD was defined according to ISHLT consensus at 24, 48, and 72 hours after transplantation. We compared the changes in plasma markers of acute lung injury between PGD grades using longitudinal data models. To test predictive validity, we compared differences in the 30-day mortality and long-term survival according to PGD grade. RESULTS PGD Grade 3 demonstrated greater differences between plasma intercellular adhesion molecule 1 (ICAM-1), protein C, and plasminogen activator inhibitor type 1 (PAI-1) levels than did PGD Grades 0 to 2 at 24, 48, and 72 hours after lung transplantation (p < 0.05 for each). Grade 3 had the highest 30-day (test for trend p < 0.001) and overall mortality (log rank p < 0.001), with PGD Grades 1 and 2 demonstrating intermediate risks of mortality. The ability to discriminate both 30-day and overall mortality improved as the time of grading moved away from the time of transplantation (test for trend p < 0.001). CONCLUSIONS The ISHLT grading system has good discriminant validity, based on plasma markers of lung injury and mortality. Grade 3 PGD was associated with the most severely altered plasma biomarker profile and the worst outcomes, regardless of the time point of grading. PGD grade at 48 and 72 hours discriminated mortality better than PGD grade at 24 hours.
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Affiliation(s)
- Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, 423 Guardian Drive, Philadelphia, PA 19104, USA.
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Dumonceaux M, Knoop C, Rondelet B, Estenne M. Complications de la transplantation pulmonaire : complications péri-opératoires, rejet aigu et chronique. Rev Mal Respir 2009; 26:639-53. [DOI: 10.1016/s0761-8425(09)74694-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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McCue JD, Mooney J, Quail J, Arrington A, Herrington C, Dahlberg PS. Ninety-day Mortality and Major Complications Are Not Affected by Use of Lung Allocation Score. J Heart Lung Transplant 2008; 27:192-6. [DOI: 10.1016/j.healun.2007.11.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2007] [Revised: 10/31/2007] [Accepted: 11/02/2007] [Indexed: 10/22/2022] Open
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