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Gao Q, Kahan R, Gonzalez TJ, Zhang M, Alderete IS, DeLaura I, Kesseli SJ, Song M, Asokan A, Barbas AS, Hartwig MG. Gene delivery followed by ex vivo lung perfusion using an adeno-associated viral vector in a rodent lung transplant model. J Thorac Cardiovasc Surg 2024; 167:e131-e139. [PMID: 37678606 DOI: 10.1016/j.jtcvs.2023.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/14/2023] [Accepted: 08/30/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Ex vivo lung perfusion has emerged as a platform for organ preservation, evaluation, and restoration. Gene delivery using a clinically relevant adeno-associated vector during ex vivo lung perfusion may be useful in optimizing donor allografts while the graft is maintained physiologically active. We evaluated the feasibility of adeno-associated vector-mediated gene delivery during ex vivo lung perfusion in a rat transplant model. Additionally, we assessed off-target effects and explored different routes of delivery. METHODS Rat heart-lung blocks were procured and underwent 1-hour ex vivo lung perfusion. Before ex vivo lung perfusion, 4e11 viral genome luciferase encoding adeno-associated vector 9 was administered via the left bronchus (Br group, n = 4), via the left pulmonary artery (PA group, n = 3), or directly into the circuit (Circuit group, n = 3). Donor lungs in the Control group (n = 3) underwent ex vivo lung perfusion without adeno-associated vector 9. Only the left lung was transplanted. Animals underwent bioluminescence imaging weekly before being killed at 2 weeks. Tissues were collected for luciferase activity measurement. RESULTS All recipients tolerated the transplant well. At 2 weeks post-transplant, luciferase activity in the transplanted lung was significantly higher among animals in the Br group compared with the other 3 groups (Br: 1.1 × 106 RLU/g, PA: 8.3 × 104 RLU/g, Circuit: 3.8 × 103 RLU/g, Control: 2.5 × 103 RLU/g, P = .0003). No off-target transgene expression was observed. CONCLUSIONS In this work, we demonstrate that a clinically relevant adeno-associated vector 9 vector mediates gene transduction during ex vivo lung perfusion in rat lung grafts when administered via the airway and potentially the pulmonary artery. Our preliminary results suggest a higher transduction efficiency when adeno-associated vector 9 was delivered via the airway, and delivery during ex vivo lung perfusion reduces off-target effects after graft implant.
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Affiliation(s)
- Qimeng Gao
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Riley Kahan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Trevor J Gonzalez
- Department of Molecular Genetics and Microbiology, Duke University Medical Center, Durham, NC
| | - Min Zhang
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Isaac S Alderete
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Isabel DeLaura
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Samuel J Kesseli
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mingqing Song
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Aravind Asokan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Mathew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC.
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2
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Siddique A, Parekh KR, Huddleston SJ, Shults A, Locke JE, Keshavamurthy S, Schwartz G, Hartwig MG, Whitson BA. A call to action in thoracic transplant surgical training. J Heart Lung Transplant 2023; 42:1627-1631. [PMID: 37268052 DOI: 10.1016/j.healun.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 05/19/2023] [Accepted: 05/30/2023] [Indexed: 06/04/2023] Open
Abstract
Thoracic organ recovery and implantation is increasing in complexity. Simultaneously the logistic burden and associated cost is rising. An electronic survey distributed to the surgical directors of thoracic transplant programs in the United States indicated dissatisfaction amongst 72% of respondents with current procurement training and 85% of respondents favored a process for certification in thoracic organ transplantation. These responses highlight concerns for the current paradigm of training in thoracic transplantation. We discuss the implications of advancements in organ retrieval and implant for surgical training and propose that the thoracic transplant community might address the need through formalized training in procurement and certification in thoracic transplantation.
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Affiliation(s)
- A Siddique
- University of Nebraska Medical Center, Department of Surgery, Division of Cardiothoracic Surgery, Omaha, Nebraska.
| | - K R Parekh
- University of Iowa Hospitals and Clinics, Department of Cardiothoracic Surgery, Carver College of Medicine, Iowa City, Iowa
| | - S J Huddleston
- University of Minnesota, Department of Surgery, Division of Cardiothoracic Surgery
| | - A Shults
- American Society of Thoracic Surgeons, Arlington, Virginia
| | - J E Locke
- University of Alabama at Birmingham, Department of Surgery, Division of Transplantation, Birmingham, Alabama
| | - S Keshavamurthy
- University of Kentucky College of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Lexington, Kentucky
| | - G Schwartz
- Baylor University Medical Center, Department of Thoracic Surgery, Dallas, Texas
| | - M G Hartwig
- Duke University Health System, Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Durham, North Carolina
| | - B A Whitson
- The Ohio State University Wexner Medical Center, Department of Surgery, Division of Cardiac Surgery, Columbus, Ohio
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3
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Kesseli SJ, Halpern SE, Gloria JN, Abraham N, Zhang M, Hartwig MG, Barbas AS. Reply: Is hepatocyte necrosis a good marker of donor liver viability during machine perfusion? Hepatol Commun 2021; 6:437-438. [PMID: 34558863 PMCID: PMC8793984 DOI: 10.1002/hep4.1817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Samuel J Kesseli
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | | | | | - Nader Abraham
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Min Zhang
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Mathew G Hartwig
- Department of Surgery, Duke University Hospital, Durham, NC, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University Hospital, Durham, NC, USA
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4
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Kesseli SJ, Gloria JN, Abraham N, Halpern SE, Cywinska GN, Zhang M, Moris D, Schmitz R, Shaw BI, Fitch ZW, Song M, Guy CD, Hartwig MG, Knechtle S, Barbas AS. Point-of-Care Assessment of DCD Livers During Normothermic Machine Perfusion in a Nonhuman Primate Model. Hepatol Commun 2021; 5:1527-1542. [PMID: 34510831 PMCID: PMC8435285 DOI: 10.1002/hep4.1734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/14/2021] [Accepted: 03/31/2021] [Indexed: 02/04/2023] Open
Abstract
Normothermic machine perfusion (NMP) provides clinicians an opportunity to assess marginal livers before transplantation. However, objective criteria and point-of-care (POC) biomarkers to predict risk and guide decision making are lacking. In this investigation, we characterized trends in POC biomarkers during NMP and compared primate donation after circulatory death (DCD) livers with short and prolonged warm ischemic injury. Following asystole, livers were subjected to either 5 minutes (DCD-5min, n = 4) or 45 minutes (DCD-45min, n = 4) of warm ischemia time. Livers were flushed with heparinized UW solution, and preserved in cold storage before NMP. During flow-controlled NMP, circulating perfusate and tissue biopsies were collected at 0, 2, 4, 6, and 8 hours for analysis. DCD-45min livers had greater terminal portal vein pressure (8.5 vs. 13.3 mm Hg, P = 0.027) and terminal portal vein resistance (16.3 vs. 32.4 Wood units, P = 0.005). During perfusion, DCD-45min livers had equivalent terminal lactate clearance (93% vs. 96%, P = 0.344), greater terminal alanine aminotransferase (163 vs. 883 U/L, P = 0.002), and greater terminal perfusate gamma glutamyltransferase (GGT) (5.0 vs. 31.7 U/L, P = 0.002). DCD-45min livers had higher circulating levels of flavin mononucleotide (FMN) at hours 2 and 4 of perfusion (136 vs. 250 ng/mL, P = 0.029; and 158 vs. 293 ng/mL, P = 0.003; respectively). DCD-5min livers produced more bile and demonstrated progressive decline in bile lactate dehydrogenase, whereas DCD-45min livers did not. On blinded histologic evaluation, DCD-45min livers demonstrated greater injury and necrosis at late stages of perfusion, indicative of nonviability. Conclusion: Objective criteria are needed to define graft viability during NMP. Perfusate lactate clearance does not discriminate between viable and nonviable livers during NMP. Perfusate GGT and FMN may represent POC biomarkers predictive of liver injury during NMP.
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Affiliation(s)
| | | | - Nader Abraham
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | | | | | - Min Zhang
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Dimitrios Moris
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Robin Schmitz
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Brian I Shaw
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Zachary W Fitch
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Mingqing Song
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Cynthia D Guy
- Department of PathologyDuke University Medical CenterDurhamNCUSA
| | | | - Stuart Knechtle
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
| | - Andrew S Barbas
- Department of SurgeryDuke University Medical CenterDurhamNCUSA
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5
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Kesseli SJ, Halpern SE, Hartwig MG. Commentary: Bruised and battered, but not broken-use of lung allografts from donors with chest trauma. J Thorac Cardiovasc Surg 2020; 163:1735-1736. [PMID: 33419534 DOI: 10.1016/j.jtcvs.2020.11.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 11/18/2020] [Accepted: 11/19/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Samuel J Kesseli
- Department of Surgery, Duke University Medical Center, Durham, NC.
| | | | - Mathew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
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6
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Esposito VR, Yerokun BA, Mulvihill MS, Cox ML, Andrew BY, Yang CJ, Choi AY, Moore C, D’Amico TA, Tong BC, Hartwig MG. Resection of the irradiated esophagus: the impact of lymph node yield on survival. Dis Esophagus 2020; 33:5770817. [PMID: 32115648 PMCID: PMC7548436 DOI: 10.1093/dote/doaa007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 12/29/2019] [Accepted: 01/27/2020] [Indexed: 12/11/2022]
Abstract
There is debate surrounding the appropriate threshold for lymph node harvest during esophagectomy in patients with esophageal cancer, specifically for those receiving preoperative radiation. The purpose of this study was to determine the impact of lymph node yield on survival in patients receiving preoperative chemoradiation for esophageal cancer. The National Cancer Database (NCDB) was utilized to identify patients with esophageal cancer that received preoperative radiation. The cohort was divided into patients undergoing minimal (<9) or extensive (≥9) lymph node yield. Demographic, operative, and postoperative outcomes were compared between the groups. Kaplan-Meier analysis with the log rank test was used to compare survival between the yield groups. Cox proportional hazards model was used to determine the association between lymph node yield and survival. In total, 886 cases were included: 349 (39%) belonging to the minimal node group and 537 (61%) to the extensive group. Unadjusted 5-year survival was similar between the minimal and extensive groups, respectively (37.3% vs. 38.8%; P > 0.05). After adjustment using Cox regression, extensive lymph node yield was associated with survival (hazard ratio 0.80, confidence interval 0.66-0.98, P = 0.03). This study suggests that extensive lymph node yield is advantageous for patients with esophageal cancer undergoing esophagectomy following induction therapy. This most likely reflects improved diagnosis and staging with extensive yield.
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Affiliation(s)
- V R Esposito
- School of Medicine, Duke University, Durham, NC, USA
| | - B A Yerokun
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - M S Mulvihill
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - M L Cox
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - B Y Andrew
- School of Medicine, Duke University, Durham, NC, USA
| | - C J Yang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - A Y Choi
- School of Medicine, Duke University, Durham, NC, USA,Address correspondence to: Ashley Y. Choi, BA, Duke University Medical Center, Box 3863, Durham, NC 27710, USA. Tel: (410) 336-2490; Fax: (919) 613-5653.
| | - C Moore
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - T A D’Amico
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - B C Tong
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - M G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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7
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Barac YD, Klapper J, Pollack A, Poisson J, Welsby I, Hartwig MG, Bottiger B. Anticoagulation Strategies in the Perioperative Period for Lung Transplant. Ann Thorac Surg 2020; 110:e23-e25. [PMID: 31981503 DOI: 10.1016/j.athoracsur.2019.11.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 10/27/2019] [Accepted: 11/25/2019] [Indexed: 10/25/2022]
Abstract
Patients who are undergoing lung transplantation may require systemic anticoagulation in the perioperative period for various indications at the time of the procedure. Four-factor prothrombin complex concentrate has been approved in the United States to reverse the effects of warfarin for patients requiring urgent surgery. We describe a perioperative anticoagulation strategy with warfarin that is reversed before incision using 4-factor complex concentrate for off-pump lung transplant recipients.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Jacob Klapper
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Angela Pollack
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Jessica Poisson
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - M G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brandi Bottiger
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
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8
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Posner S, Zheng J, Wood RK, Shimpi RA, Hartwig MG, Chow SC, Leiman DA. Gastroesophageal reflux symptoms are not sufficient to guide esophageal function testing in lung transplant candidates. Dis Esophagus 2018; 31:4850448. [PMID: 29444329 DOI: 10.1093/dote/dox157] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/17/2017] [Indexed: 12/11/2022]
Abstract
Gastroesophageal reflux disease and esophageal dysmotility are prevalent in patients with advanced lung disease and are associated with graft dysfunction following lung transplantation. As a result, many transplant centers perform esophageal function testing as part of the wait-listing process but guidelines for testing in this population are lacking. The aim of this study is to describe whether symptoms of gastroesophageal reflux correlate with abnormal results on pH-metry and high-resolution manometry and can be used to identify those who require testing. We performed a retrospective cohort study of 226 lung transplant candidates referred for high-resolution manometry and pH-metry over a 12-month period in 2015. Demographic data, results of a standard symptom questionnaire and details of esophageal function testing were obtained. Associations between the presence of symptoms and test results were analyzed using Fisher's exact tests and multivariable logistic regression. The most common lung disease diagnosis was interstitial lung disease (N = 131, 58%). Abnormal pH-metry was seen in 116 (51%) patients and the presence of symptoms was significantly associated with an abnormal study (p < 0.01). Dysmotility was found in 98 (43%) patients, with major peristaltic or esophageal outflow disorders in 45 (20%) patients. Symptoms were not correlated with findings on esophageal high-resolution manometry. Fifteen of 25 (60%) asymptomatic patients had an abnormal manometry or pH-metry. These results demonstrate that in patients with advanced lung disease, symptoms of gastroesophageal reflux increase the likelihood of elevated acid exposure on pH-metry but were not associated with dysmotility. Given the proportion of asymptomatic patients with abnormal studies and associated post-transplant risks, a practice of universal high-resolution manometry and pH-metry testing in this population is justifiable.
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Affiliation(s)
- S Posner
- Department of Medicine, Duke University Medical Center
| | - J Zheng
- Department of Biostatistics and Bioinformatics, Duke University Medical Center
| | - R K Wood
- Division of Gastroenterology, Duke University Medical Center
| | - R A Shimpi
- Division of Gastroenterology, Duke University Medical Center
| | - M G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center
| | - S-C Chow
- Department of Biostatistics and Bioinformatics, Duke University Medical Center
| | - D A Leiman
- Division of Gastroenterology, Duke University Medical Center
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9
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Osho AA, Hirji SA, Castleberry AW, Mulvihill MS, Ganapathi AM, Speicher PJ, Yerokun B, Snyder LD, Davis RD, Hartwig MG. Long-term survival following kidney transplantation in previous lung transplant recipients-An analysis of the unos registry. Clin Transplant 2017; 31. [PMID: 28295652 DOI: 10.1111/ctr.12953] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Kidney transplantation has been advocated as a therapeutic option in lung recipients who develop end-stage renal disease (ESRD). This analysis outlines patterns of allograft survival following kidney transplantation in previous lung recipients (KAL). METHODS Data from the UNOS lung and kidney transplantation registries (1987-2013) were cross-linked to identify lung recipients who were subsequently listed for and/or underwent kidney transplantation. Time-dependent Cox models compared the survival rates in KAL patients with those waitlisted for renal transplantation who never received kidneys. Survival analyses compared outcomes between KAL patients and risk-matched recipients of primary, kidney-only transplantation with no history of lung transplantation (KTx). RESULTS A total of 270 lung recipients subsequently underwent kidney transplantation (KAL). Regression models demonstrated a lower risk of post-listing mortality for KAL patients compared with 346 lung recipients on the kidney waitlist who never received kidneys (P<.05). Comparisons between matched KAL and KTx patients demonstrated significantly increased risk of death and graft loss (P<.05), but not death-censored graft loss, for KAL patients (P = .86). CONCLUSIONS KAL patients enjoy a significant survival benefit compared with waitlisted lung recipients who do not receive kidneys. However, KAL patients do poorly compared with KTx patients. Decisions about KAL transplantation must be made on a case-by-case basis considering patient and donor factors.
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Affiliation(s)
- Asishana A Osho
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sameer A Hirji
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Asvin M Ganapathi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Paul J Speicher
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Babatunde Yerokun
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Laurie D Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D Davis
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mathew G Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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10
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Abstract
Evolution in technology has resulted in rapid increase in utilization of extracorporeal membrane oxygenation (ECMO) as a bridge to recovery and/or transplantation. Although there is limited evidence for the use of ECMO, recent improvements in ECMO technology, personnel training, ambulatory practices on ECMO and lung protective strategies have resulted in improved outcomes in patients bridged to lung transplantation. This review provides an insight into the current outcomes and best practices for utilization of ECMO in the pre- and post-lung transplantation period.
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Affiliation(s)
- Nirmal S Sharma
- Division of Pulmonary, Allergy & Critical Care Medicine, University of Alabama at Birmingham, Birmingham AL, USA
| | - Mathew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, NC, USA
| | - Don Hayes
- Departments of Pediatrics, Internal Medicine, and Surgery, The Ohio State University, OH, USA
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Hartwig MG, Ganapathi AM, Osho AA, Hirji SJ, Englum BR, Speicher PJ, Palmer SM, Davis RD, Snyder LD. Staging of Bilateral Lung Transplantation for High-Risk Patients With Interstitial Lung Disease: One Lung at a Time. Am J Transplant 2016; 16:3270-3277. [PMID: 27233085 PMCID: PMC5083210 DOI: 10.1111/ajt.13892] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 05/22/2016] [Accepted: 05/22/2016] [Indexed: 01/25/2023]
Abstract
The choice of a single or bilateral lung transplant for interstitial lung disease (ILD) is controversial, as surgical risk, long-term survival and organ allocation are competing factors. In an effort to balance risk and benefit, our center adopted a staged bilateral lung transplant approach for higher surgical risk ILD patients where the patient has a single lung transplant followed by a second single transplant at a later date. We sought to understand the surgical risk, organ allocation and early outcomes of these staged bilateral recipients as a group and in comparison to matched single and bilateral recipients. Our analysis demonstrates that staged bilateral lung transplant recipients (n = 12) have a higher lung allocation score (LAS), lower pulmonary function tests and a lower glomerular filtration rate prior to the first transplant compared to the second (p < 0.01). There was a shorter length of hospital stay for the second transplant (p = 0.02). The staged bilateral compared to the single and bilateral case-matched controls had comparable short-term survival (p = 0.20) and pulmonary function tests at 1 year. There was a higher incidence of renal injury in the conventional bilateral group compared to the single and staged bilateral groups. The staged bilateral procedure is a viable option in select ILD patients.
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Affiliation(s)
- MG Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - AM Ganapathi
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - AA Osho
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - SJ Hirji
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - BR Englum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - PJ Speicher
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - SM Palmer
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - RD Davis
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - LD Snyder
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
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12
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Li B, Hartwig MG, Appel JZ, Bush EL, Balsara KR, Holzknecht ZE, Collins BH, Howell DN, Parker W, Lin SS, Davis RD. Chronic aspiration of gastric fluid induces the development of obliterative bronchiolitis in rat lung transplants. Am J Transplant 2008. [PMID: 18557728 DOI: 10.111/j.1600-6143.2008.02298.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Long-term survival of a pulmonary allograft is currently hampered by obliterative bronchiolitis (OB), a form of chronic rejection that is unique to lung transplantation. While tracheobronchial aspiration from gastroesophageal reflux disease (GERD) has clinically been associated with OB, no experimental model exists to investigate this problem. Using a WKY-to-F344 rat orthotopic left lung transplant model, the effects of chronic aspiration on pulmonary allograft were evaluated. Recipients received cyclosporine with or without 8 weekly aspirations of gastric fluid into the allograft. Six (66.7%) of 9 allografts with aspiration demonstrated bronchioles with surrounding monocytic infiltrates, fibrosis and loss of normal lumen anatomy, consistent with the development of OB. In contrast, none of the allografts without aspiration (n = 10) demonstrated these findings (p = 0.002). Of the grafts examined grossly, 83% of the allografts with chronic aspiration but only 20% without aspiration appeared consolidated (p = 0.013). Aspiration was associated with increased levels of IL-1 alpha, IL-1 beta, IL-6, IL-10, TNF-alpha and TGF-beta in BAL and of IL-1 alpha, IL-4 and GM-CSF in serum. This study provides experimental evidence linking chronic aspiration to the development of OB and suggests that strategies aimed at preventing aspiration-related injuries might improve outcomes in clinical lung transplantation.
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Affiliation(s)
- B Li
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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