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Henry JP, Carlier F, Higny J, Benoit M, Xhaët O, Blommaert D, Telbis AM, Robaye B, Gabriel L, Guedes A, Michaux I, Demeure F, Luchian ML. Impact of Pre-Transplant Left Ventricular Diastolic Pressure on Primary Graft Dysfunction after Lung Transplantation: A Narrative Review. Diagnostics (Basel) 2024; 14:1340. [PMID: 39001230 PMCID: PMC11240543 DOI: 10.3390/diagnostics14131340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Lung transplantation (LT) constitutes the last therapeutic option for selected patients with end-stage respiratory disease. Primary graft dysfunction (PGD) is a form of severe lung injury, occurring in the first 72 h following LT and constitutes the most common cause of early death after LT. The presence of pulmonary hypertension (PH) has been reported to favor PGD development, with a negative impact on patients' outcomes while complicating medical management. Although several studies have suggested a potential association between pre-LT left ventricular diastolic dysfunction (LVDD) and PGD occurrence, the underlying mechanisms of such an association remain elusive. Importantly, the heterogeneity of the study protocols and the various inclusion criteria used to define the diastolic dysfunction in those patients prevents solid conclusions from being drawn. In this review, we aim at summarizing PGD mechanisms, risk factors, and diagnostic criteria, with a further focus on the interplay between LVDD and PGD development. Finally, we explore the predictive value of several diastolic dysfunction diagnostic parameters to predict PGD occurrence and severity.
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Affiliation(s)
- Jean Philippe Henry
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - François Carlier
- Department of Pneumology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium;
| | - Julien Higny
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Martin Benoit
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Olivier Xhaët
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Dominique Blommaert
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Alin-Mihail Telbis
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Benoit Robaye
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Laurence Gabriel
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Antoine Guedes
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Isabelle Michaux
- Department of Intensive Care, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium;
| | - Fabian Demeure
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
| | - Maria-Luiza Luchian
- Department of Cardiology, Université Catholique de Louvain, CHU UCL Namur, 5530 Yvoir, Belgium; (J.H.); (M.B.); (O.X.); (D.B.); (A.-M.T.); (B.R.); (L.G.); (A.G.); (F.D.); (M.-L.L.)
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Xuan C, Gu J, Xu Z, Chen J, Xu H. A novel nomogram for predicting prolonged mechanical ventilation in lung transplantation patients using extracorporeal membrane oxygenation. Sci Rep 2024; 14:11692. [PMID: 38778128 PMCID: PMC11111670 DOI: 10.1038/s41598-024-62601-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 05/20/2024] [Indexed: 05/25/2024] Open
Abstract
Prolonged mechanical ventilation (PMV) is commonly associated with increased post-operative complications and mortality. Nevertheless, the predictive factors of PMV after lung transplantation (LTx) using extracorporeal membrane oxygenation (ECMO) as a bridge remain unclear. The present study aimed to develop a novel nomogram for PMV prediction in patients using ECMO as a bridge to LTx. A total of 173 patients who used ECMO as a bridge following LTx from January 2022 to June 2023 were divided into the training (122) and validation sets (52). A mechanical ventilation density plot of patients after LTx was then performed. The training set was divided in two groups, namely PMV (95) and non-prolonged ventilation (NPMV) (27). For the survival analysis, the effect of PMV was assessed using the log-rank test. Univariate and multivariate logistic regression analyses were performed to assess factors associated with PMV. A risk nomogram was established based on the multivariate analysis, and model performance was further assessed in terms of calibration, discrimination, and clinical usefulness. Internal validation was additionally conducted. The difference in survival curves in PMV and NPMV groups was statistically significant (P < 0.001). The multivariate analysis and risk factors in the nomogram revealed four factors to be significantly associated with PMV, namely the body mass index (BMI), operation time, lactic acid at T0 (Lac), and driving pressure (DP) at T0. These four factors were used to develop a nomogram, with an area under the curve (AUC) of 0.852 and good calibration. After internal validation, AUC was 0.789 with good calibration. Furthermore, goodness-of-fit test and decision-curve analysis (DCA) indicated satisfactory performance in the training and internal validation sets. The proposed nomogram can reliably and accurately predict the risk of patients to develop PMV after LTx using ECMO as a bridge. Four modifiable factors including BMI, operation time, Lac, and DP were optimized, which may guide preventative measures and improve prognosis.
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Affiliation(s)
- Chenhao Xuan
- The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, Jiangsu, China
| | - Jingxiao Gu
- The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, Jiangsu, China
| | - Zhongping Xu
- The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, Jiangsu, China
| | - Jingyu Chen
- Wuxi Lung Transplant Center, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, 214023, Jiangsu, China
| | - Hongyang Xu
- The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, 214023, Jiangsu, China.
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Girgis RE, Manandhar‐Shrestha NK, Krishnan S, Murphy ET, Loyaga‐Rendon R. Predictors of early mortality after lung transplantation for idiopathic pulmonary arterial hypertension. Pulm Circ 2024; 14:e12371. [PMID: 38646412 PMCID: PMC11027072 DOI: 10.1002/pul2.12371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 04/23/2024] Open
Abstract
Lung transplantation remains an important therapeutic option for idiopathic pulmonary arterial hypertension (IPAH), yet short-term survival is the poorest among the major diagnostic categories. We sought to develop a prediction model for 90-day mortality using the United Network for Organ Sharing database for adults with IPAH transplanted between 2005 and 2021. Variables with a p value ≤ 0.1 on univariate testing were included in multivariable analysis to derive the best subset model. The cohort comprised 693 subjects, of whom 71 died (10.2%) within 90 days of transplant. Significant independent predictors of early mortality were: extracorporeal circulatory support and/or mechanical ventilation at transplant (OR: 3; CI: 1.4-5), pulmonary artery diastolic pressure (OR: 1.3 per 10 mmHg; CI: 1.07-1.56), forced expiratory volume in the first second percent predicted (OR: 0.8 per 10%; CI: 0.7-0.94), recipient total bilirubin >2 mg/dL (OR: 3; CI: 1.4-7.2) and ischemic time >6 h (OR: 1.7, CI: 1.01-2.86). The predictive model was able to distinguish 25% of the cohort with a mortality of ≥20% from 49% with a mortality of ≤5%. We conclude that recipient variables associated with increasing severity of pulmonary vascular disease, including pretransplant advanced life support, and prolonged ischemic time are important risk factors for 90-day mortality after lung transplant for IPAH.
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Affiliation(s)
- Reda E. Girgis
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Nabin K. Manandhar‐Shrestha
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Sheila Krishnan
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Edward T. Murphy
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
| | - Renzo Loyaga‐Rendon
- Richard Devos Heart and Lung Transplant ProgramCorewell Health and Michigan State University College of Human MedicineGrand RapidsMichiganUSA
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Diamond JM, Anderson MR, Cantu E, Clausen ES, Shashaty MGS, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Lama VN, Patel MG, Singer JP, Hachem RR, Michelson AP, Hsu J, Russell Localio A, Christie JD. Development and validation of primary graft dysfunction predictive algorithm for lung transplant candidates. J Heart Lung Transplant 2024; 43:633-641. [PMID: 38065239 PMCID: PMC10947904 DOI: 10.1016/j.healun.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 11/05/2023] [Accepted: 11/30/2023] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Accurate prediction of PGD risk could inform donor approaches and perioperative care planning. We sought to develop a clinically useful, generalizable PGD prediction model to aid in transplant decision-making. METHODS We derived a predictive model in a prospective cohort study of subjects from 2012 to 2018, followed by a single-center external validation. We used regularized (lasso) logistic regression to evaluate the predictive ability of clinically available PGD predictors and developed a user interface for clinical application. Using decision curve analysis, we quantified the net benefit of the model across a range of PGD risk thresholds and assessed model calibration and discrimination. RESULTS The PGD predictive model included distance from donor hospital to recipient transplant center, recipient age, predicted total lung capacity, lung allocation score (LAS), body mass index, pulmonary artery mean pressure, sex, and indication for transplant; donor age, sex, mechanism of death, and donor smoking status; and interaction terms for LAS and donor distance. The interface allows for real-time assessment of PGD risk for any donor/recipient combination. The model offers decision-making net benefit in the PGD risk range of 10% to 75% in the derivation centers and 2% to 10% in the validation cohort, a range incorporating the incidence in that cohort. CONCLUSION We developed a clinically useful PGD predictive algorithm across a range of PGD risk thresholds to support transplant decision-making, posttransplant care, and enrich samples for PGD treatment trials.
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Affiliation(s)
- Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Michaela R Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael G S Shashaty
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria M Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian A Bermudez
- Division of Cardiovascular Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | - Scott M Palmer
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Laurie D Snyder
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Ghundeep S Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Mrunal G Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary and Critical Care Allergy and Sleep Medicine, University of California, San Francisco, San Francisco, California
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Washington University, St. Louis, Missouri
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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5
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Bottiger B, Klapper J, Fessler J, Shaz BH, Levy JH. Examining Bleeding Risk, Transfusion-related Complications, and Strategies to Reduce Transfusions in Lung Transplantation. Anesthesiology 2024; 140:808-816. [PMID: 38345894 DOI: 10.1097/aln.0000000000004829] [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: 03/13/2024]
Abstract
Blood product transfusions for bleeding management in lung transplantation affect recipient outcomes. Interventions are needed to reduce perioperative bleeding risk and optimize outcomes.
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Affiliation(s)
- Brandi Bottiger
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, North Carolina
| | - Jacob Klapper
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Julien Fessler
- Department of Anesthesiology, Hôpital Foch, Suresnes, France
| | - Beth H Shaz
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Jerrold H Levy
- Department of Anesthesiology, Cardiothoracic Anesthesiology Division, Duke University Medical Center, Durham, North Carolina
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Michelson AP, Oh I, Gupta A, Puri V, Kreisel D, Gelman AE, Nava R, Witt CA, Byers DE, Halverson L, Vazquez-Guillamet R, Payne PRO, Hachem RR. Developing machine learning models to predict primary graft dysfunction after lung transplantation. Am J Transplant 2024; 24:458-467. [PMID: 37468109 DOI: 10.1016/j.ajt.2023.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 06/21/2023] [Accepted: 07/04/2023] [Indexed: 07/21/2023]
Abstract
Primary graft dysfunction (PGD) is the leading cause of morbidity and mortality in the first 30 days after lung transplantation. Risk factors for the development of PGD include donor and recipient characteristics, but how multiple variables interact to impact the development of PGD and how clinicians should consider these in making decisions about donor acceptance remain unclear. This was a single-center retrospective cohort study to develop and evaluate machine learning pipelines to predict the development of PGD grade 3 within the first 72 hours of transplantation using donor and recipient variables that are known at the time of donor offer acceptance. Among 576 bilateral lung recipients, 173 (30%) developed PGD grade 3. The cohort underwent a 75% to 25% train-test split, and lasso regression was used to identify 11 variables for model development. A K-nearest neighbor's model showing the best calibration and performance with relatively small confidence intervals was selected as the final predictive model with an area under the receiver operating characteristics curve of 0.65. Machine learning models can predict the risk for development of PGD grade 3 based on data available at the time of donor offer acceptance. This may improve donor-recipient matching and donor utilization in the future.
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Affiliation(s)
- Andrew P Michelson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA; Institute for Informatics, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Inez Oh
- Institute for Informatics, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Aditi Gupta
- Institute for Informatics, Washington University School of Medicine, Saint Louis, Missouri, USA; Division of Biostatistics, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Andrew E Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Chad A Witt
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Derek E Byers
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Laura Halverson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Rodrigo Vazquez-Guillamet
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Philip R O Payne
- Institute for Informatics, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ramsey R Hachem
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA.
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Cerier E, Manerikar A, Kandula V, Toyoda T, Thomae B, Yagi Y, Patino DMA, Lung K, Garza-Castillon R, Bharat A, Kurihara C. Postreperfusion Pulmonary Artery Pressure Indicates Primary Graft Dysfunction After Lung Transplant. Ann Thorac Surg 2024; 117:206-212. [PMID: 36521520 PMCID: PMC10258214 DOI: 10.1016/j.athoracsur.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 11/10/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Primary graft dysfunction is a risk factor of early mortality after lung transplant. Models identifying patients at high risk for primary graft dysfunction are limited. We hypothesize high postreperfusion systolic pulmonary artery pressure is a clinical marker for primary graft dysfunction. METHODS This is a retrospective review of 158 consecutive lung transplants performed at a single academic center from January 2020 through July 2022. Only bilateral lung transplants were included and patients with pretransplant extracorporeal life support were excluded. RESULTS Primary graft dysfunction occurred in 42.3% (n = 30). Patients with primary graft dysfunction had higher postreperfusion systolic pulmonary artery pressure (41 ± 9.1 mm Hg) than those without (31.5 ± 8.8 mm Hg) (P < .001). Logistic regression showed postreperfusion systolic pulmonary artery pressure is a predictor for primary graft dysfunction (odds ratio 1.14, 95% CI 1.06-1.24, P < .001). Postreperfusion systolic pulmonary artery pressure of 37 mm Hg was optimal for predicting primary graft dysfunction by Youden index. The receiver operating characteristic curve of postreperfusion systolic pulmonary artery pressure at 37 mm Hg (sensitivity 0.77, specificity 0.78, area under the curve 0.81), was superior to the prereperfusion pressure curve at 36 mm Hg (sensitivity 0.77, specificity 0.39, area under the curve 0.57) (P < .01). CONCLUSIONS Elevated postreperfusion systolic pulmonary artery pressure after lung transplant is predictive of primary graft dysfunction. Postreperfusion systolic pulmonary artery pressure is more indicative of primary graft dysfunction than prereperfusion systolic pulmonary artery pressure. Using postreperfusion systolic pulmonary artery pressure as a positive signal of primary graft dysfunction allows earlier intervention, which could improve outcomes.
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Affiliation(s)
- Emily Cerier
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adwaiy Manerikar
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Viswajit Kandula
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Takahide Toyoda
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin Thomae
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yuriko Yagi
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Diego Mauricio Avella Patino
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Kalvin Lung
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rafael Garza-Castillon
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit Bharat
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Chitaru Kurihara
- Division of Thoracic Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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8
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Diamond JM, Cantu E, Calfee CS, Anderson MR, Clausen ES, Shashaty MGS, Courtwright AM, Kalman L, Oyster M, Crespo MM, Bermudez CA, Benvenuto L, Palmer SM, Snyder LD, Hartwig MG, Todd JL, Wille K, Hage C, McDyer JF, Merlo CA, Shah PD, Orens JB, Dhillon GS, Weinacker AB, Lama VN, Patel MG, Singer JP, Hsu J, Localio AR, Christie JD. The Impact of Donor Smoking on Primary Graft Dysfunction and Mortality after Lung Transplantation. Am J Respir Crit Care Med 2024; 209:91-100. [PMID: 37734031 PMCID: PMC10870879 DOI: 10.1164/rccm.202303-0358oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 09/21/2023] [Indexed: 09/23/2023] Open
Abstract
Rationale: Primary graft dysfunction (PGD) is the leading cause of early morbidity and mortality after lung transplantation. Prior studies implicated proxy-defined donor smoking as a risk factor for PGD and mortality. Objectives: We aimed to more accurately assess the impact of donor smoke exposure on PGD and mortality using quantitative smoke exposure biomarkers. Methods: We performed a multicenter prospective cohort study of lung transplant recipients enrolled in the Lung Transplant Outcomes Group cohort between 2012 and 2018. PGD was defined as grade 3 at 48 or 72 hours after lung reperfusion. Donor smoking was defined using accepted thresholds of urinary biomarkers of nicotine exposure (cotinine) and tobacco-specific nitrosamine (4-[methylnitrosamino]-1-[3-pyridyl]-1-butanol [NNAL]) in addition to clinical history. The donor smoking-PGD association was assessed using logistic regression, and survival analysis was performed using inverse probability of exposure weighting according to smoking category. Measurements and Main Results: Active donor smoking prevalence varied by definition, with 34-43% based on urinary cotinine, 28% by urinary NNAL, and 37% by clinical documentation. The standardized risk of PGD associated with active donor smoking was higher across all definitions, with an absolute risk increase of 11.5% (95% confidence interval [CI], 3.8% to 19.2%) by urinary cotinine, 5.7% (95% CI, -3.4% to 14.9%) by urinary NNAL, and 6.5% (95% CI, -2.8% to 15.8%) defined clinically. Donor smoking was not associated with differential post-lung transplant survival using any definition. Conclusions: Donor smoking associates with a modest increase in PGD risk but not with increased recipient mortality. Use of lungs from smokers is likely safe and may increase lung donor availability. Clinical trial registered with www.clinicaltrials.gov (NCT00552357).
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Affiliation(s)
- Joshua M. Diamond
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Carolyn S. Calfee
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Michaela R. Anderson
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Emily S. Clausen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | | | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | - Maria M. Crespo
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
| | | | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University School of Medicine, New York, New York
| | | | | | - Matthew G. Hartwig
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jamie L. Todd
- Division of Pulmonary and Critical Care Medicine and
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chadi Hage
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F. McDyer
- Division of Pulmonary, Allergy, and Critical Care, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christian A. Merlo
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Pali D. Shah
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Jonathan B. Orens
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University Medical Center, Baltimore, Maryland
| | - Gundeep S. Dhillon
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Ann B. Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University Medical Center, Palo Alto, California
| | - Vibha N. Lama
- Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, Michigan; and
| | - Mrunal G. Patel
- Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P. Singer
- Department of Medicine and Anesthesia, University of California, San Francisco, San Francisco, California
| | - Jesse Hsu
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Division of Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D. Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine
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9
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Weatherald J, Varughese RA, Liu J, Humbert M. Management of Pulmonary Arterial Hypertension. Semin Respir Crit Care Med 2023; 44:746-761. [PMID: 37369218 DOI: 10.1055/s-0043-1770118] [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: 06/29/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a rare pulmonary vascular disease characterized by progressive pulmonary arterial remodeling, increased pulmonary vascular resistance, right ventricular dysfunction, and reduced survival. Effective therapies have been developed that target three pathobiologic pathways in PAH: nitric oxide, endothelin-1, and prostacyclin. Approved therapies for PAH include phosphodiesterase type-5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, prostacyclin analogs, and prostacyclin receptor agonists. Management of PAH in the modern era incorporates multidimensional risk assessment to guide the use of these medications. For patients with PAH and without significant comorbidities, current guidelines recommend two oral medications (phosphodiesterase type-5 inhibitor and endothelin receptor antagonist) for low- and intermediate-risk patients, with triple therapy including a parenteral prostacyclin to be considered in those at high or intermediate-high risk. Combination therapy may be poorly tolerated and less effective in patients with PAH and cardiopulmonary comorbidities. Thus, a single-agent approach with individualized decisions to add-on other PAH therapies is recommended in older patients and those with significant comorbid conditions. Management of PAH is best performed in multidisciplinary teams located in experienced centers. Other core pillars of PAH management include supportive and adjunctive treatments including oxygen, diuretics, rehabilitation, and anticoagulation in certain patients. Patients with PAH who progress despite optimal treatment or who are refractory to best medical care should be referred for lung transplantation, if eligible. Despite considerable progress, PAH is often fatal and new therapies that reverse the disease and improve outcomes are desperately needed.
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Affiliation(s)
- Jason Weatherald
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Rhea A Varughese
- Division of Pulmonary Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Jonathan Liu
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, Canada
| | - Marc Humbert
- Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Assistance Publique Hôpitaux de Paris, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- Hôpital Marie Lannelongue, Le Plessis Robinson, INSERM UMR_S 999, France
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10
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Sunder T, Ramesh Thangaraj P, Kumar Kuppusamy M, Balasubramanian Sriraman K, Selvi and
Srinivasan Yaswanth Kumar C. Lung Transplantation for Pulmonary Artery Hypertension. NEW INSIGHTS ON PULMONARY HYPERTENSION [WORKING TITLE] 2023. [DOI: 10.5772/intechopen.1002961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
This manuscript discusses the role of lung transplantation in patients with pulmonary hypertension. The indications and timing for referral to a transplant unit and timing for wait-listing for lung transplantation are discussed. The type of transplantation—isolated (single or double) lung transplantation and situations when combined heart and double lung transplantation is indicated—will be elaborated. Escalation of medical therapy with the need and timing for bridging therapies such as extracorporeal membrane oxygenation until an appropriate organ becomes available will be discussed. Challenges in the postoperative period, specific to lung transplantation for pulmonary artery hypertension, will be reviewed. The outcomes following lung transplantation will also be considered in greater detail.
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11
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Kolaitis NA. Lung Transplantation for Pulmonary Arterial Hypertension. Chest 2023; 164:992-1006. [PMID: 37150504 DOI: 10.1016/j.chest.2023.04.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 04/26/2023] [Accepted: 04/28/2023] [Indexed: 05/09/2023] Open
Abstract
TOPIC IMPORTANCE Even though patients with pulmonary arterial hypertension have multiple therapeutic options, the disease can be refractory despite appropriate management. In patients with end-stage pulmonary arterial hypertension, lung transplantation has the potential both to extend survival and improve health-related quality of life. Pulmonary arterial hypertension is the only major diagnostic indication for transplantation that is not a parenchymal pulmonary process, and thus the care of these patients is unique. REVIEW FINDINGS This review focuses on the complexities of lung transplantation for patients with pulmonary arterial hypertension, presents the updated referral and listing criteria, and discusses the inequities in the organ allocation process that impact this disease group and the strategies to optimize outcomes for patients with pulmonary arterial hypertension who require lung transplantation. SUMMARY Lung transplantation is an effective and lifesaving therapy for patients with end-stage lung disease. Sadly, patients with pulmonary arterial hypertension face many challenges as it relates to transplantation including higher perioperative risks, inequities in the allocation system, and less favorable long-term outcomes. This review covers the complexities of transplantation in patients with pulmonary vascular disease.
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Affiliation(s)
- Nicholas A Kolaitis
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA.
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12
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Qin J, Hu C, Cao X, Gao J, Chen Y, Yan M, Chen J. Development and validation of a nomogram model to predict primary graft dysfunction in patients after lung transplantation based on the clinical factors. Clin Transplant 2023; 37:e15039. [PMID: 37256785 DOI: 10.1111/ctr.15039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Primary graft dysfunction (PGD), a significant complication that can affect patients' prognosis and quality of life, develops within 72 h post lung transplantation (LTx). Early detection and prevention of PGD should be given special consideration. The purpose of this study was to create a clinical prediction model to forecast the occurrence of PGD. METHODS We collected information on 622 LTx patients from Wuxi People's Hospital from 2016 to 2020 and used the data to construct the prediction model. Information on 224 patients from 2021 to June 2022 was used for external validation. We used LASSO regression for variable screening. A nomogram was developed for model presentation. Distinctness, fit, and calibration were used to evaluate the performance of the model. RESULTS Subjects with respiratory failure, who received fresh frozen plasma, donor age, donor gender, donor mechanism of death, donor smoking, donor ventilator use time, and donor PaO 2/FiO 2 ratio were independent predictor variables for the occurrence of PGD. The area under the curve of the nomogram was .779. The Hosmer-Lemeshow test showed a good model fit (P = .158). The calibration curve of the nomogram is fairly close to the ideal diagonal. Moreover, the decision curve analysis revealed a positive net benefit of the model. External validation also confirmed the reliability of the model. CONCLUSIONS The nomogram of PGD based on clinical risk factors in postoperative LTx patients was established with high reliability. It provides clinicians and nurses with a new and effective tool for early prediction of PGD and early intervention.
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Affiliation(s)
- Jianan Qin
- School of Nursing, Fudan University, Shanghai, China
- Operation Department, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Chunxiao Hu
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Xiaodong Cao
- Department of Nursing, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Jian Gao
- Department of Nutrition, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuan Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
| | - Meiqiong Yan
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jingyu Chen
- Wuxi Lung Transplant Center, Wuxi People's Hospital Affiliated to Nanjing Medical University, Wuxi, China
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13
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Girgis RE, Hadley RJ, Murphy ET. Pulmonary, circulatory and renal considerations in the early postoperative management of the lung transplant recipient. Glob Cardiol Sci Pract 2023; 2023:e202318. [PMID: 37575284 PMCID: PMC10422876 DOI: 10.21542/gcsp.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/15/2023] [Indexed: 08/15/2023] Open
Abstract
Lung transplantation volumes and survival rates continue to increase worldwide. Primary graft dysfunction (PGD) and acute kidney injury (AKI) are common early postoperative complications that significantly affect short-term mortality and long-term outcomes. These conditions share overlapping risk factors and are driven, in part, by circulatory derangements. The prevalence of severe PGD is up to 20% and is the leading cause of early death. Patients with pulmonary hypertension are at a higher risk. Prevention and management are based on principles learned from acute lung injury of other causes. Targeting the lowest effective cardiac filling pressure will reduce alveolar edema formation in the setting of increased pulmonary capillary permeability. AKI is reported in up to one-half of lung transplant recipients and is strongly associated with one-year mortality as well as long-term chronic kidney disease. Optimization of renal perfusion is critical to reduce the incidence and severity of AKI. In this review, we highlight key early post-transplant pulmonary, circulatory, and renal perturbations and our center's management approach.
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Affiliation(s)
- Reda E. Girgis
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
| | - Ryan J. Hadley
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
| | - Edward T. Murphy
- Richard DeVos Lung Transplant Program, Corewell Health West, Michigan State University, College of Human Medicine, Grand Rapids, Michigan, USA
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14
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Subramaniam K, Loor G, Chan EG, Bottiger BA, Ius F, Hartwig MG, Daoud D, Zhang Q, Wei Q, Villavicencio-Theoduloz MA, Osho AA, Chandrashekaran S, Noguchi Machuca T, Van Raemdonck D, Neyrinck A, Toyoda Y, Kashem MA, Huddleston S, Ryssel NR, Sanchez PG. Intraoperative Red Blood Cell Transfusion and Primary Graft Dysfunction After Lung Transplantation. Transplantation 2023; 107:1573-1579. [PMID: 36959119 DOI: 10.1097/tp.0000000000004545] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
BACKGROUND In this international, multicenter study of patients undergoing lung transplantation (LT), we explored the association between the amount of intraoperative packed red blood cell (PRBC) transfusion and occurrence of primary graft dysfunction (PGD) and associated outcomes. METHODS The Extracorporeal Life Support in LT Registry includes data on LT recipients from 9 high-volume (>40 transplants/y) transplant centers (2 from Europe, 7 from the United States). Adult patients who underwent bilateral orthotopic lung transplant from January 2016 to January 2020 were included. The primary outcome of interest was the occurrence of grade 3 PGD in the first 72 h after LT. RESULTS We included 729 patients who underwent bilateral orthotopic lung transplant between January 2016 and November 2020. LT recipient population tertiles based on the amount of intraoperative PRBC transfusion (0, 1-4, and >4 units) were significantly different in terms of diagnosis, age, gender, body mass index, mean pulmonary artery pressure, lung allocation score, hemoglobin, prior chest surgery, preoperative hospitalization, and extracorporeal membrane oxygenation requirement. Inverse probability treatment weighting logistic regression showed that intraoperative PRBC transfusion of >4 units was significantly ( P < 0.001) associated with grade 3 PGD within 72 h (odds ratio [95% confidence interval], 2.2 [1.6-3.1]). Inverse probability treatment weighting analysis excluding patients with extracorporeal membrane oxygenation support produced similar findings (odds ratio [95% confidence interval], 2.4 [1.7-3.4], P < 0.001). CONCLUSIONS In this multicenter, international registry study of LT patients, intraoperative transfusion of >4 units of PRBCs was associated with an increased risk of grade 3 PGD within 72 h. Efforts to improve post-LT outcomes should include perioperative blood conservation measures.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Baylor College of Medicine, Houston, TX
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Fabio Ius
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Daoud Daoud
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qianzi Zhang
- Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Qi Wei
- Department of Statistics, Phastar Inc, Durham, NC
| | | | - Asishana A Osho
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Satish Chandrashekaran
- Department of Pulmonary and Critical Care, McKelvey Lung Transplant Center, Emory University Hospital, Atlanta, GA
| | | | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Division of Anesthesiology and Algology, University Hospitals Leuven, Leuven, Belgium
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University, Philadelphia, PA
| | - Mohammed A Kashem
- Division of Cardiovascular Surgery, Temple University, Philadelphia, PA
| | - Stephen Huddleston
- Division of Cardiothoracic Surgery, University of Minnesota Medical School, Minneapolis, MI
| | - Naomi R Ryssel
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA
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15
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Melnyk V, Xu W, Ryan JP, Karim HT, Chan EG, Mahajan A, Subramaniam K. Utilization of machine learning to model the effect of blood product transfusion on short-term lung transplant outcomes. Clin Transplant 2023:e14961. [PMID: 36912861 DOI: 10.1111/ctr.14961] [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: 03/06/2022] [Revised: 11/29/2022] [Accepted: 03/01/2023] [Indexed: 03/14/2023]
Abstract
The objective of this study was to identify the relationship between blood product transfusion and short-term morbidity and mortality following lung transplantation utilizing machine learning. Preoperative recipient characterstics, procedural variables, perioperative blood product transfusions, and donor charactersitics were included in the model. The primary composite outcome was occurrence on any of the following six endpoints: mortality during index hospitalization; primary graft dysfunction at 72 h post-transplant or the need for postoperative circulatory support; neurological complications (seizure, stroke, or major encephalopathy); perioperative acute coronary syndrome or cardiac arrest; and renal dysfunction requiring renal replacement therapy. The cohort included 369 patients, with the composite outcome occurring in 125 cases (33.9%). Elastic net regression analysis identified 11 significant predictors of composite morbidity: higher packed red blood cell, platelet, cryoprecipitate and plasma volume from the critical period, preoperative functional dependence, any preoperative blood transfusion, VV ECMO bridge to transplant, and antifibrinolytic therapy were associated with higher risk of morbidity. Preoperative steroids, taller height, and primary chest closure were protective against composite morbidity.
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Affiliation(s)
- Vladyslav Melnyk
- Department of Anesthesiology, University of Alberta - Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Wen Xu
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Lung Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Helmet T Karim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Lung Transplantation, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aman Mahajan
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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16
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Natalini JG, Clausen ES. Critical Care Management of the Lung Transplant Recipient. Clin Chest Med 2023; 44:105-119. [PMID: 36774158 DOI: 10.1016/j.ccm.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Lung transplantation is often the only treatment option for patients with severe irreversible lung disease. Improvements in donor and recipient selection, organ allocation, surgical techniques, and immunosuppression have all contributed to better survival outcomes after lung transplantation. Nonetheless, lung transplant recipients still experience frequent complications, often necessitating treatment in an intensive care setting. In addition, the use of extracorporeal life support as a means of bridging critically ill patients to lung transplantation has become more widespread. This review focuses on the critical care aspects of lung transplantation, both before and after surgery.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, 530 First Avenue, HCC 4A, New York, NY 10016, USA.
| | - Emily S Clausen
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9036 Gates Building, Philadelphia, PA 19104, USA
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17
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Narula T, Martin AK, Asif AA, Fritz AV, Li Z, Erasmus DB, Alvarez F, Thomas M. Outcomes of Lung Transplantation in Patients With Combined Pulmonary Fibrosis and Emphysema: A Single-Center Experience. Transplant Proc 2023; 55:449-455. [PMID: 36849338 DOI: 10.1016/j.transproceed.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/24/2022] [Accepted: 01/24/2023] [Indexed: 02/27/2023]
Abstract
BACKGROUND Combined pulmonary fibrosis and emphysema (CPFE) is a distinct clinical entity that can progress to end-stage lung disease. Patients with CPFE may develop pulmonary hypertension and face a predicted 1-year mortality of 60%. Lung transplantation is the only curative therapeutic option for CPFE. This report describes our experience after lung transplantation in patients with CPFE. METHODS This retrospective, single-center study describes short- and long-term outcomes for adult patients who underwent lung transplant for CPFE. RESULTS The study included 19 patients with explant pathology-proven diagnosis of CPFE. The patients were transplanted between July 2005 and December 2018. Sixteen recipients (84%) had pulmonary hypertension before transplant. Of the 19 patients, 7 (37%) had primary graft dysfunction at 72 hours post-transplant. 1-, 3-, and 5-year freedom from bronchiolitis obliterans syndrome was 100%, 91% (95% CI, 75%-100%), and 82% (95% CI, 62%-100%), respectively. One-, 3-, and 5-year survival was 94% (95% CI, 84%-100%), 82% (95% CI, 65%-100%), and 74% (95% CI, 54%-100%), respectively. CONCLUSION Our experience demonstrates the safety and feasibility of lung transplant for patients with CPFE. Significant morbidity and mortality without lung transplant coupled with favorable post-transplant outcomes merit prioritization of CPFE in the Lung Allocation Score algorithm for lung transplant candidacy.
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Affiliation(s)
- Tathagat Narula
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida.
| | - Archer K Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Abuzar A Asif
- Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois
| | - Ashley V Fritz
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | - Zhuo Li
- Department of Biostatistics, Mayo Clinic, Jacksonville, Florida
| | - David B Erasmus
- Division of Allergy, Pulmonary, and Critical Care Medicine and The Vanderbilt Lung Institute
| | | | - Mathew Thomas
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida
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18
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Otto M, McGiffin D, Whitford H, Kure C, Snell G, Diehl A, Orosz J, Burrell AJC. Survival and left ventricular dysfunction post lung transplantation for pulmonary arterial hypertension. J Crit Care 2022; 72:154120. [PMID: 35914371 DOI: 10.1016/j.jcrc.2022.154120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/17/2022] [Accepted: 07/17/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Bilateral lung transplantation for end-stage pulmonary arterial hypertension (PAH) is traditionally associated with higher early post-transplant mortality when compared with other indications. Changes in perioperative management, including the growing use of perioperative extracorporeal membrane oxygenation (ECMO) and an increased awareness of postoperative left ventricular dysfunction (LVD), have resulted in outcomes that are uncertain. MATERIALS AND METHODS We conducted a single-center, retrospective observational study at a lung transplantation center in Melbourne, Australia, from 2006 to 2019. ECMO use was categorized as preoperative, prophylactic, or rescue. Postoperative LVD was defined as a reduction in left ventricular function on echocardiography or using strict clinical criteria. RESULTS 50 patients underwent lung transplantation for PAH. 12-month survival was 48/50 (96%). ECMO was used in 26 (52%) patients, and the use of prophylactic VA-ECMO increased over the study period. Postoperative LVD was diagnosed in 21 (42%) patients. 12-month survival and left ventricular function was no different between LVD and non-LVD groups. CONCLUSIONS This study showed that high survival rates can be achieved following lung transplantation for PAH. We found that ECMO utilization was common, and indications have changed over time. LVD was common but did not impact 12-month survival.
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Affiliation(s)
- Madeleine Otto
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - David McGiffin
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Helen Whitford
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Christina Kure
- Department of Cardiothoracic Surgery and Transplantation, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Gregory Snell
- Lung Transplant Service, Department of Respiratory Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Arne Diehl
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.
| | - Judit Orosz
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia.
| | - Aidan J C Burrell
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, 55 Commercial Road, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, Australia.
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19
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Perez AA, Shah RJ. Critical Care of the Lung Transplant Patient. Clin Chest Med 2022; 43:457-470. [PMID: 36116814 DOI: 10.1016/j.ccm.2022.04.007] [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: 11/03/2022]
Abstract
Lung transplantation is a therapeutic option for end-stage lung disease that improves survival and quality of life. Prelung transplant admission to the intensive care unit (ICU) for bridge to transplant with mechanical ventilation and extracorporeal membrane oxygenation (ECMO) is common. Primary graft dysfunction is an important immediate complication of lung transplantation with short- and long-term morbidity and mortality. Later transplant-related causes of respiratory failure necessitating ICU admission include acute cellular rejection, atypical infections, and chronic lung allograft dysfunction. Lung transplantation for COVID-19-related ARDS is increasingly common..
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Affiliation(s)
- Alyssa A Perez
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, 400 Parnassus Street, 5th Floor, San Francisco, CA 94143, USA.
| | - Rupal J Shah
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, 400 Parnassus Street, 5th Floor, San Francisco, CA 94143, USA
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20
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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21
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New strategy to resume and taper epoprostenol after lung transplant for pulmonary hypertension. Gan To Kagaku Ryoho 2022; 70:372-377. [PMID: 34978021 DOI: 10.1007/s11748-021-01746-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/14/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The perioperative outcome of lung transplantation (LTx) for patients with severe pulmonary hypertension (PH) remains poor due to the occurrence of primary graft dysfunction (PGD) from left ventricular failure. We hypothesized that tapering pretransplant use of epoprostenol rather than abrupt discontinuation after transplantation might improve perioperative outcomes. METHODS We performed 23 LTxs for patients with severe PH who received epoprostenol therapy from 2008 until 2021. In the discontinued group (n = 6), epoprostenol was discontinued after the establishment of extracorporeal circulation. In the tapered group (n = 17), epoprostenol was discontinued and resumed after reperfusion, and then gradually tapered over the following 2 weeks. We assessed survival, bleeding, blood transfusion, re-opening of the chest, oxygenation, PGD score, extracorporeal membrane oxygenation (ECMO) requirement for recovery after transplantation, and duration of mechanical ventilation. RESULTS The PGD score was significantly lower in the tapered group than in the discontinued group at 0 h, 24 h, and 48 h after LTx. In addition, the discontinued group required longer mechanical ventilation than the tapered group. Delayed chest closure and post-transplant ECMO use for recovery occurred significantly more frequently in the discontinued group. CONCLUSIONS To resume and taper epoprostenol administration after reperfusion in patients with severe PH may be a valuable new strategy associated with better perioperative outcomes.
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22
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Abstract
Patients with advanced lung disease can develop pulmonary hypertension and succumb to right ventricular failure/cor pulmonale. Patients with pulmonary hypertension owing to chronic lung disease, or World Health Organization group 3 pulmonary hypertension, are more limited and carry a high risk of mortality. Adjunctive therapies remain the cornerstones of treatment. Recent evidence suggests that inhaled pulmonary vasodilator therapy can be helpful in patients with pulmonary hypertension owing to interstitial lung disease. Lung transplantation may be the only life-saving option in select patients, whereas palliative care and hospice should be sought for those who are not candidates as the disease progresses.
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Affiliation(s)
- Kareem Ahmad
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA.
| | - Vikramjit Khangoora
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Steven D Nathan
- Transplant Department, Advanced Lung Disease and Lung Transplant, Inova Fairfax Medical Center, 3300 Gallows Road, Falls Church, VA 22042, USA
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23
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Gazengel P, Hascoët S, Amsallem M, Savale L, Montani D, Mercier O, Humbert M, Fadel E, Le Pavec J. Double-lung transplantation followed by delayed percutaneous repair for atrial septal defect-associated pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02388-2021. [PMID: 34737221 DOI: 10.1183/13993003.02388-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/15/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Pierre Gazengel
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Sébastien Hascoët
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Service de cardiopathie congénitale de l'enfant et de l'adulte, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Myriam Amsallem
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Service de cardiologie, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Laurent Savale
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - David Montani
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Olaf Mercier
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marc Humbert
- Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France.,Assistance Publique - Hôpitaux de Paris (AP-HP), Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France.,Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Jérôme Le Pavec
- Service de Chirurgie Thoracique, Vasculaire et Transplantation Cardio-pulmonaire, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France .,Université Paris-Saclay, Faculty of Medicine, Le Kremlin-Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
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24
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Klapper JA, Hicks AC, Ledbetter L, Poisson J, Hartwig MG, Hashmi N, Welsby I, Bottiger BA. Blood product transfusion and lung transplant outcomes: A systematic review. Clin Transplant 2021; 35:e14404. [PMID: 34176163 DOI: 10.1111/ctr.14404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 12/01/2022]
Abstract
The perioperative transfusion of blood products has long been linked to development of acute lung injury and associated with mortality across both medical and surgical patient populations.1,2 The need for blood product transfusion during and after lung transplantation is common and, in many instances, unavoidable. However, this practice may potentially be modifiable.3 In this systematic review, we explore and summarize what is known regarding the impact of blood product transfusion on outcomes following lung transplantation, highlighting the most recent work in this area. Overall, the majority of the literature consists of single center retrospective analyses or the work of multicenter working groups referencing the same database. In the end, there are a number of remaining questions regarding blood product transfusion and their downstream effects on graft function and survival.
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Affiliation(s)
- Jacob A Klapper
- Division of Cardiothoracic Surgery, Duke University, Durham, North California, USA
| | - Anne C Hicks
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Leila Ledbetter
- Duke University, Medical Center Library, Durham, North California, USA
| | - Jessica Poisson
- Department of Pathology, Duke University, Durham, North California, USA
| | - Matthew G Hartwig
- Division of Cardiothoracic Surgery, Duke University, Durham, North California, USA
| | - Nazish Hashmi
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
| | - Brandi A Bottiger
- Division of Cardiothoracic Anesthesiology, Duke University, Durham, North California, USA
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25
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Li C, Patel K, Tu Z, Yang X, Kulik L, Alawieh A, Allen P, Cheng Q, Wallace C, Kilkenny J, Kwon J, Gibney B, Cantu E, Sharma A, Pipkin M, Machuca T, Emtiazjoo A, Goddard M, Holers VM, Nadig S, Christie J, Tomlinson S, Atkinson C. A novel injury site-natural antibody targeted complement inhibitor protects against lung transplant injury. Am J Transplant 2021; 21:2067-2078. [PMID: 33210808 PMCID: PMC8246004 DOI: 10.1111/ajt.16404] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/27/2020] [Accepted: 10/27/2020] [Indexed: 01/25/2023]
Abstract
Complement is known to play a role in ischemia and reperfusion injury (IRI). A general paradigm is that complement is activated by self-reactive natural IgM antibodies (nAbs), after they engage postischemic neoepitopes. However, a role for nAbs in lung transplantation (LTx) has not been explored. Using mouse models of LTx, we investigated the role of two postischemic neoepitopes, modified annexin IV (B4) and a subset of phospholipids (C2), in LTx. Antibody deficient Rag1-/- recipient mice were protected from LTx IRI. Reconstitution with either B4 or C2nAb restored IRI, with C2 significantly more effective than B4 nAb. Based on these information, we developed/characterized a novel complement inhibitor composed of single-chain antibody (scFv) derived from the C2 nAb linked to Crry (C2scFv-Crry), a murine inhibitor of C3 activation. Using an allogeneic LTx, in which recipients contain a full nAb repertoire, C2scFv-Crry targeted to the LTx, inhibited IRI, and delayed acute rejection. Finally, we demonstrate the expression of the C2 neoepitope in human donor lungs, highlighting the translational potential of this approach.
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Affiliation(s)
- Changhai Li
- The Hepatic Surgery Centre at Tongji Hospital, Tongji Medical College, HUST, Wuhan, China
- Hubei Province for the Clinical Medicine Research Center of Hepatic Surgery, Key Laboratory of Organ Transplantation, Ministry of Education and Ministry of Public Health, Wuhan, China
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Kunal Patel
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Zhenxiao Tu
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Hepatic and Vascular Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofeng Yang
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Liudmila Kulik
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, Colorado, USA
| | - Ali Alawieh
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Patterson Allen
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Qi Cheng
- The Hepatic Surgery Centre at Tongji Hospital, Tongji Medical College, HUST, Wuhan, China
- Hubei Province for the Clinical Medicine Research Center of Hepatic Surgery, Key Laboratory of Organ Transplantation, Ministry of Education and Ministry of Public Health, Wuhan, China
| | - Caroline Wallace
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Jane Kilkenny
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Jennie Kwon
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Barry Gibney
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
| | - Ashish Sharma
- Department of Surgery, University of Florida, Gainesville, Florida, USA
| | - Mauricio Pipkin
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Tiago Machuca
- Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA
| | - Amir Emtiazjoo
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Martin Goddard
- Pathology Department, Papworth Hospital, NHS Trust, Papworth Everard, Cambridge, UK
| | - V Michael Holers
- Department of Medicine and Immunology, University of Colorado Denver, Aurora, Colorado, USA
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Satish Nadig
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jason Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephen Tomlinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, University of Florida, Gainesville, Florida, USA
- Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
| | - Carl Atkinson
- Department of Microbiology and Immunology, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- Department of Surgery, Lee Patterson Allen Transplant Immunobiology Laboratory, Medical University of South Carolina, Microbiology and Immunology, Charleston, South Carolina, USA
- South Carolina Investigators in Transplantation, Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
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26
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Abstract
PURPOSE OF REVIEW Primary graft dysfunction (PGD) is a devastating complication in the acute postoperative lung transplant period, associated with high short-term mortality and chronic rejection. We review its definition, pathophysiology, risk factors, prevention, treatment strategies, and future research directions. RECENT FINDINGS New analyses suggest donation after circulatory death and donation after brain death donors have similar PGD rates, whereas donors >55 years are not associated with increased PGD risk. Recipient pretransplant diastolic dysfunction and overweight or obese recipients with predominant abdominal subcutaneous adipose tissue have increased PGD risk. Newly identified recipient biomarkers and donor and recipient genes increase PGD risk, but their clinical utility remains unclear. Mixed data still exists regarding cold ischemic time and PGD risk, and increased PGD risk with cardiopulmonary bypass remains confounded by transfusions. Portable ex vivo lung perfusion (EVLP) may prevent PGD, but its use is limited to a handful of centers. Although updates to current PGD treatment are lacking, future therapies are promising with targeted therapy and the use of EVLP to pharmacologically recondition donor lungs. SUMMARY There is significant progress in defining PGD and identifying its several risk factors, but effective prevention and treatment strategies are needed.
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27
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Stokes JW, Gannon WD, Bacchetta M. Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant. Semin Respir Crit Care Med 2021; 42:380-391. [PMID: 34030201 DOI: 10.1055/s-0041-1728795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a cardiopulmonary technology capable of supporting cardiac and respiratory function in the presence of end-stage lung disease. Initial experiences using ECMO as a bridge to lung transplant (ECMO-BTLT) were characterized by high rates of ECMO-associated complications and poor posttransplant outcomes. More recently, ECMO-BTLT has garnered success in preserving patients' physiologic condition and candidacy prior to lung transplant due to technological advances and improved management. Despite recent growth, clinical practice surrounding use of ECMO-BTLT remains variable, with little data to inform optimal patient selection and management. Although many questions remain, the use of ECMO-BTLT has shown promising outcomes suggesting that ECMO-BTLT can be an effective strategy to ensure that complex and rapidly decompensating patients with end-stage lung disease can be safely transplanted with good outcomes. Further studies are needed to refine and inform practice patterns, management, and lung allocation in this high-risk and fragile patient population.
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Affiliation(s)
- John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Whitney D Gannon
- Departments of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
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28
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Natalini JG, Diamond JM. Primary Graft Dysfunction. Semin Respir Crit Care Med 2021; 42:368-379. [PMID: 34030200 DOI: 10.1055/s-0041-1728794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
Primary graft dysfunction (PGD) is a form of acute lung injury after transplantation characterized by hypoxemia and the development of alveolar infiltrates on chest radiograph that occurs within 72 hours of reperfusion. PGD is among the most common early complications following lung transplantation and significantly contributes to increased short-term morbidity and mortality. In addition, severe PGD has been associated with higher 90-day and 1-year mortality rates compared with absent or less severe PGD and is a significant risk factor for the subsequent development of chronic lung allograft dysfunction. The International Society for Heart and Lung Transplantation released updated consensus guidelines in 2017, defining grade 3 PGD, the most severe form, by the presence of alveolar infiltrates and a ratio of PaO2:FiO2 less than 200. Multiple donor-related, recipient-related, and perioperative risk factors for PGD have been identified, many of which are potentially modifiable. Consistently identified risk factors include donor tobacco and alcohol use; increased recipient body mass index; recipient history of pulmonary hypertension, sarcoidosis, or pulmonary fibrosis; single lung transplantation; and use of cardiopulmonary bypass, among others. Several cellular pathways have been implicated in the pathogenesis of PGD, thus presenting several possible therapeutic targets for preventing and treating PGD. Notably, use of ex vivo lung perfusion (EVLP) has become more widespread and offers a potential platform to safely investigate novel PGD treatments while expanding the lung donor pool. Even in the presence of significantly prolonged ischemic times, EVLP has not been associated with an increased risk for PGD.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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29
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Natalini JG, Diamond JM, Porteous MK, Lederer DJ, Wille KM, Weinacker AB, Orens JB, Shah PD, Lama VN, McDyer JF, Snyder LD, Hage CA, Singer JP, Ware LB, Cantu E, Oyster M, Kalman L, Christie JD, Kawut SM, Bernstein EJ. Risk of primary graft dysfunction following lung transplantation in selected adults with connective tissue disease-associated interstitial lung disease. J Heart Lung Transplant 2021; 40:351-358. [PMID: 33637413 DOI: 10.1016/j.healun.2021.01.1391] [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: 09/22/2020] [Revised: 12/23/2020] [Accepted: 01/19/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Previous studies have reported similarities in long-term outcomes following lung transplantation for connective tissue disease-associated interstitial lung disease (CTD-ILD) and idiopathic pulmonary fibrosis (IPF). However, it is unknown whether CTD-ILD patients are at increased risk of primary graft dysfunction (PGD), delays in extubation, or longer index hospitalizations following transplant compared to IPF patients. METHODS We performed a multicenter retrospective cohort study of CTD-ILD and IPF patients enrolled in the Lung Transplant Outcomes Group registry who underwent lung transplantation between 2012 and 2018. We utilized mixed effects logistic regression and stratified Cox proportional hazards regression to determine whether CTD-ILD was independently associated with increased risk for grade 3 PGD or delays in post-transplant extubation and hospital discharge compared to IPF. RESULTS A total of 32.7% (33/101) of patients with CTD-ILD and 28.9% (145/501) of patients with IPF developed grade 3 PGD 48-72 hours after transplant. There were no significant differences in odds of grade 3 PGD among patients with CTD-ILD compared to those with IPF (adjusted OR 1.12, 95% CI 0.64-1.97, p = 0.69), nor was CTD-ILD independently associated with a longer post-transplant time to extubation (adjusted HR for first extubation 0.87, 95% CI 0.66-1.13, p = 0.30). However, CTD-ILD was independently associated with a longer post-transplant hospital length of stay (median 23 days [IQR 14-35 days] vs17 days [IQR 12-28 days], adjusted HR for hospital discharge 0.68, 95% CI 0.51-0.90, p = 0.008). CONCLUSION Patients with CTD-ILD experienced significantly longer postoperative hospitalizations compared to IPF patients without an increased risk of grade 3 PGD.
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Affiliation(s)
- Jake G Natalini
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Diamond
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary K Porteous
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Keith M Wille
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama
| | - Ann B Weinacker
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jonathan B Orens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pali D Shah
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vibha N Lama
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - John F McDyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laurie D Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Chadi A Hage
- Division of Pulmonary Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jonathan P Singer
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, California
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Edward Cantu
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Oyster
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven M Kawut
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.
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30
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Weingarten N, Schraufnagel D, Plitt G, Zaki A, Ayyat KS, Elgharably H. Comparison of mechanical cardiopulmonary support strategies during lung transplantation. Expert Rev Med Devices 2020; 17:1075-1093. [PMID: 33090042 DOI: 10.1080/17434440.2020.1841630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lung transplantation outcomes are influenced by the intraoperative mechanical cardiopulmonary support strategy used. This surgery was historically done either on cardiopulmonary bypass (CPB) or off pump. Recently, there has been increased interest in intraoperative support with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO). However, there is a lack of consensus on the relative risks, benefits and indications for each intraoperative support strategy. AREAS COVERED This review includes information from cohort studies, case-control studies, and case series that compare morbidity and/or mortality of two or more intraoperative cardiopulmonary support strategies during lung transplantation. EXPERT OPINION The optimal strategy for intraoperative cardiopulmonary support during lung transplantation remains an area of debate. Current data suggest that off pump is associated with better outcomes and could be considered whenever feasible. ECMO is generally associated with preferable outcomes to CPB, but the data supporting this association is not robust. Interestingly, whether CPB is unplanned or prolonged might influence outcomes more than the use of CPB itself. These observations can help guide surgical teams in their approach for intraoperative mechanical support strategy during lung transplantation and should serve as the basis for further investigations.
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Affiliation(s)
- Noah Weingarten
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Dean Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Gilman Plitt
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Kamal S Ayyat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
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31
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Syrett AJ, Huang A. Transfusion and Primary Graft Dysfunction After Lung Transplantation: All About the Ratio? J Cardiothorac Vasc Anesth 2020; 34:3033-3035. [PMID: 32782190 DOI: 10.1053/j.jvca.2020.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew J Syrett
- Department of Anesthesia and Pain Management, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada
| | - Alexander Huang
- Department of Anesthesia and Pain Management, University Health Network-Toronto General Hospital, Toronto, Ontario, Canada.
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32
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Saito M, Chen-Yoshikawa TF, Takahashi M, Kayawake H, Yokoyama Y, Kurokawa R, Hirano SI, Date H. Protective effects of a hydrogen-rich solution during cold ischemia in rat lung transplantation. J Thorac Cardiovasc Surg 2019; 159:2110-2118. [PMID: 31780065 DOI: 10.1016/j.jtcvs.2019.09.175] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/09/2019] [Accepted: 09/09/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Molecular hydrogen can reduce the oxidative stress of ischemia-reperfusion injury in various organs for transplantation and potentially improve survival rates in recipients. This study aimed to evaluate the protective effects of a hydrogen-rich preservation solution against ischemia-reperfusion injury after cold ischemia in rat lung transplantation. METHODS Lewis rats were divided into a nontransplant group (n = 3), minimum-ischemia group (n = 3), cold ischemia group (n = 6), and cold ischemia with hydrogen-rich (more than 1.0 ppm) preservation solution group (n = 6). The rats in the nontransplant group underwent simple thoracotomy, and the rats in the remaining 3 groups underwent orthotopic left lung transplantation. The ischemic time was <30 minutes in the minimum-ischemia group and 6 hours in the cold ischemia groups. After 2-hour reperfusion, we evaluated arterial blood gas levels, pulmonary function, lung wet-to-dry weight ratio, and histologic features of the lung tissue. The expression of proinflammatory cytokines was measured using quantitative polymerase chain reaction assays, and 8-hydroxydeoxyguanosine levels were evaluated using enzyme-linked immunosorbent assays. RESULTS When compared with the nontransplant and minimum-ischemia groups, the cold ischemia group had lower dynamic compliance, lower oxygenation levels, and higher wet-to-dry weight ratios. However, these variables were significantly improved in the cold ischemia with hydrogen-rich preservation solution group. This group also had fewer signs of perivascular edema, lower interleukin-1β messenger RNA expression, and lower 8-hydroxydeoxyguanosine levels than the cold ischemia group. CONCLUSIONS The use of a hydrogen-rich preservation solution attenuates ischemia-reperfusion injury in rat lungs during cold ischemia through antioxidant and anti-inflammatory effects.
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Affiliation(s)
- Masao Saito
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Mamoru Takahashi
- Department of Thoracic Surgery, Kyoto Katsura Hospital, Kyoto, Japan
| | - Hidenao Kayawake
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yuhei Yokoyama
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | | | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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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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Abstract
Lung transplantation is a valuable therapeutic option for many patients with severe lung disease who have exhausted other medical or surgical therapies. However, since lungs are not a manufacturable organ like artificial heart valves or left ventricular assist devices, and since they are a limited resource compared to number of patients requiring the organs, the Department of Health and Human Services set the Final Rule of organ allocation in 1998. This led to development and implementation of Lung Allocation Score (LAS) in 2005. The score broadly divides lung diseases into 4 diagnostic criteria with a coefficient factor given to each category. The score is based on the prognostic factors of each patient to determine the risk of mortality without a transplant combined with the probability of patient survival post-transplant. Most of the guidelines for "Indications for referral and listing in lung transplant" is based on consensus opinion as there is limited amount of robust data and trials about this topic. The International Society for Heart and Lung Transplant (ISHLT) has published three editions for candidate selection and listing. In this article, we have attempted to highlight the guidelines and incorporated other disease specific prognostic factors that are not captured in the LAS. Ultimately, there are other factors like geographic location, height, blood group, preformed antibodies, transplant center experience, past wait times and transplant rate, availability of organs, etc., which also play a role especially when considering listing a patient for lung transplant. We also highlighted a representative disease in each category and most criteria for that disease will apply to other diseases in that category. Finally, this article does not delve into the history and reasoning behind each guideline but is meant to provide a general overview of indications and contraindications applicable in the field of adult lung transplantation.
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Affiliation(s)
- Omar Shweish
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Goutham Dronavalli
- Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX, USA
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Pena JJ, Bottiger BA, Miltiades AN. Perioperative Management of Bleeding and Transfusion for Lung Transplantation. Semin Cardiothorac Vasc Anesth 2019; 24:74-83. [DOI: 10.1177/1089253219869030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Perioperative allogeneic blood product transfusion is common in lung transplantation and has various implications on the short- and long-term outcomes of lung recipients. This review summarizes the effect of transfusion on outcomes including primary graft dysfunction, chronic lung allograft dysfunction, and all-cause mortality. We outline known risk factors for increased transfusion requirement in lung transplantation and present current evidence regarding the effect of hemostatic agents including antifibrinolytics, recombinant factor VII, and prothrombin complex concentrates. Finally, we highlight the roles of point-of-care coagulation testing and goal-directed transfusion strategies in reducing transfusion requirements in lung transplantation.
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Loor G, Warnecke G, Villavicencio MA, Smith MA, Kukreja J, Ardehali A, Hartwig M, Daneshmand MA, Hertz MI, Huddleston S, Haverich A, Madsen JC, Van Raemdonck D. Portable normothermic ex-vivo lung perfusion, ventilation, and functional assessment with the Organ Care System on donor lung use for transplantation from extended-criteria donors (EXPAND): a single-arm, pivotal trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:975-984. [PMID: 31378427 DOI: 10.1016/s2213-2600(19)30200-0] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/21/2019] [Accepted: 05/30/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Donor lung use for transplantation is the lowest among solid organ tranplants because of several complex and multifactorial reasons; one area that could have a substantial role is the limited capabilities of cold ischaemic storage. The aim of the EXPAND trial was to evaluate the efficacy of normothermic portable Organ Care System (OCS) Lung perfusion and ventilation on donor lung use from extended-criteria donors and donors after circulatory death, which are rarely used. METHODS In this single-arm, pivotal trial done in eight institutions across the USA, Germany, and Belgium, lungs from extended-criteria donors were included if fulfilling one or more of the following criteria: a ratio of partial pressure of arterial oxygen (PaO2) to fractional concentration of oxygen inspired air (FiO2) in the donor lung of 300 mm Hg or less; expected ischaemic time longer than 6 h; donor age 55 years or older; or lungs from donors after circulatory death that were recruited and assessed using OCS Lung. Lungs were transplanted if they showed stability of OCS Lung variables, PaO2:FiO2 was more than 300 mm Hg, and they were accepted by the transplanting surgeon. Patients were adult bilateral lung transplant recipients. The primary efficacy endpoint was a composite of patient survival at day 30 post-transplant and absence of The International Society for Heart & Lung Tranplantation primary-graft dysfunction grade 3 (PGD3) within 72 h post-transplantation, with a prespecified objective performance goal of 65%. The primary analysis population was all transplanted recipients. This trial is registered with ClinicalTrials.gov, number NCT01963780, and is now complete. FINDINGS Between Jan 23, 2014, and Oct 23, 2016, 93 lung pairs were perfused, ventilated, and assessed on the OCS Lung. 12 lungs did not meet OCS transplantation criteria so 81 lungs were suitable for transplantation. Two lungs were excluded for logistical reasons, hence 79 (87%) of eligible lungs were transplanted. The primary endpoint was achieved in 43 (54%) of 79 patients and did not meet the objective performance goal. 35 (44%) of 79 patients had PGD3 within the initial 72 h. 78 (99%) of 79 patients had survived at 30 days post-transplant. The mean number of lung graft-related serious adverse events (respiratory failure and major pulmonary-related infection) was 0·3 events per patient (SD 0·5). INTERPRETATION Despite missing the objective primary endpoint, the portable OCS Lung resulted in 87% donor lung use for transplantation with excellent clinical outcomes. Many lungs declined by other transplant centres were successfully transplanted using this new technology, which implies its use has the potential to increase the number of lung transplants performed worldwide. Whether similar outcomes could be obtained if these lungs were preserved on ice is unknown and remains an area for future research. FUNDING TransMedics Inc.
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Affiliation(s)
- Gabriel Loor
- Department of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN, USA; Baylor College of Medicine, Baylor St Luke's Medical Center, Houston, TX, USA.
| | - Gregor Warnecke
- Department of Cardiac, Thoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mauricio A Villavicencio
- Massachusetts General Transplant Center and Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael A Smith
- Department of General Thoracic Surgery, St Joseph's Medical Center, Phoenix, AZ, USA
| | - Jasleen Kukreja
- Department of Thoracic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Abbas Ardehali
- Department of Surgery, Division of Cardiothoracic Surgery, Ronald Reagan University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | - Matthew Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mani A Daneshmand
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marshall I Hertz
- Department of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Stephen Huddleston
- Department of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Axel Haverich
- Department of Cardiac, Thoracic, Transplantation, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Joren C Madsen
- Massachusetts General Transplant Center and Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Dirk Van Raemdonck
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Pulmonary Hypertension and Primary Graft Dysfunction in Lung Transplant Recipients: We Still Have a Long Way to Go. Ann Am Thorac Soc 2019; 14:1504-1505. [PMID: 28961030 DOI: 10.1513/annalsats.201706-480ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Martin AK, Renew JR, Jayaraman AL, Murray AW, Fritz AV, Ramakrishna H. Analysis of Outcomes in Lung Transplantation. J Cardiothorac Vasc Anesth 2019; 33:1455-1466. [DOI: 10.1053/j.jvca.2018.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Indexed: 01/04/2023]
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Rosenheck J, Pietras C, Cantu E. Early Graft Dysfunction after Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2018; 7:176-187. [PMID: 31548919 PMCID: PMC6756771 DOI: 10.1007/s13665-018-0213-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Primary graft dysfunction is an acute lung injury syndrome occurring immediately following lung transplantation. This review aims to provide an overview of the current understanding of PGD, including epidemiology, immunology, clinical outcomes and management. RECENT FINDINGS Identification of donor and recipient factors allowing accurate prediction of PGD has been actively pursued. Improved understanding of the immunology underlying PGD has spurred interest in identifying relevant biomarkers. Work in PGD prediction, severity stratification and targeted therapies continue to make progress. Donor expansion strategies continue to be pursued with ex vivo lung perfusion playing a prominent role. While care of PGD remains supportive, ECMO has established a prominent role in the early aggressive management of severe PGD. SUMMARY A consensus definition of PGD has allowed marked advances in research and clinical care of affected patients. Future research will lead to reliable predictive tools, and targeted therapeutics of this important syndrome.
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Affiliation(s)
- Justin Rosenheck
- Pulmonary, Allergy, and Critical Care Division, University
of Pennsylvania Perelman School of Medicine
| | - Colleen Pietras
- Department of Surgery, University of Pennsylvania Perelman
School of Medicine
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania Perelman
School of Medicine
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40
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Bartolome S, Hoeper MM, Klepetko W. Advanced pulmonary arterial hypertension: mechanical support and lung transplantation. Eur Respir Rev 2017; 26:26/146/170089. [PMID: 29263172 PMCID: PMC9488526 DOI: 10.1183/16000617.0089-2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/22/2017] [Indexed: 11/23/2022] Open
Abstract
The development of targeted therapies has transformed the outlook for patients with pulmonary arterial hypertension (PAH); however, some patients fail to achieve an adequate clinical response despite receiving maximal treatment. For these patients, lung transplantation remains an important therapeutic option, and recommendations for transplantation are included in the current European Society of Cardiology/European Respiratory Society guidelines for the diagnosis and treatment of pulmonary hypertension. Although lung transplantation is not without risk, overall long-term survival rates are good and substantial improvements in quality of life have been reported for lung transplant recipients. In this review, we describe the important considerations prior to, during and after transplantation, including the role of mechanical support, in patients with advanced PAH. Lung transplantation and mechanical support play key therapeutic roles in patients with advanced PAHhttp://ow.ly/mqfG30gMcMd
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Affiliation(s)
- Sonja Bartolome
- Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research, Hannover, Germany
| | - Walter Klepetko
- Dept of Thoracic Surgery, Medical University Vienna/Vienna General Hospital, Vienna, Austria
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