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Deitz RL, Clifford S, Ryan JP, Chan EG, Coster JN, Furukawa M, Hage CA, Sanchez PG. Performance status at the time of lung retransplant predicts long-term function. Clin Transplant 2024; 38:e15310. [PMID: 38591128 DOI: 10.1111/ctr.15310] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/05/2024] [Accepted: 03/22/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Lung retransplantation is offered to select patients with chronic allograft dysfunction. Given the increased risk of morbidity and mortality conferred by retransplantation, post-transplant function should be considered in the decision of who and when to list. The aim of this study is to identify predictors of post-operative disability in patients undergoing lung retransplantation. METHODS Data were collected from the UNOS national dataset and included all patients who underwent lung retransplant from May 2005-March 2023. Pre- and post-operative function was reported by the Karnofsky Performance Status (KPS) and patients were stratified based on their needs. Cumulative link mixed effects models identified associations between pre-transplant variables and post-transplant function. RESULTS A total of 1275 lung retransplant patients were included. After adjusting for between-group differences, pre-operative functional status was predictive of post-transplant function; patients requiring Total Assistance ( n = 740) were 74% more likely than No/Some Assistance patients (n = 535) to require more assistance in follow-up (OR 1.74, 95% CI 1.13-2.68, p = .012). Estimated one year survival of Total Assistance patients is lower than No/Some Assistance Recipients (72% vs. 82%, CI 69%-75%; 79%-86%) but similar to overall re-transplant survival (76%, CI 74%-79%). CONCLUSION Both survival and regain of function in patients requiring Total Assistance prior to retransplant may be higher than previously reported. Pre-operative functional status is predictive of post-operative function and should weigh in the selection, timing and post-operative care of patients considered for lung retransplantation.
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Affiliation(s)
- Rachel L Deitz
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Sarah Clifford
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Department of Cardiothoracic Surgery, Division of Lung Transplant and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Jenalee N Coster
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Department of Cardiothoracic Surgery, Division of Lung Transplant and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Department of Cardiothoracic Surgery, Division of Lung Transplant and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Chadi A Hage
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Department of Cardiothoracic Surgery, Division of Lung Transplant and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, USA
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Chen T, Chan EG, Huang B, Bertolaccini L, Fernando HC, Tasoudis PT, Motas N, Pennathur A, Fang W, Zhang J. Outcomes following minimally invasive approaches vs. open extended lobectomy for non-small cell lung cancer: a propensity-matched analysis of the National Cancer Database. Transl Lung Cancer Res 2024; 13:334-344. [PMID: 38496690 PMCID: PMC10938095 DOI: 10.21037/tlcr-24-37] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/18/2024] [Indexed: 03/19/2024]
Abstract
Background Traditional thoracotomy, an invasive surgical procedure, has been the standard approach for extended lobectomy in treating non-small cell lung cancer (NSCLC). However, minimally invasive surgery (MIS) has gained traction with advancements in surgical techniques. Despite this, the outcomes of extended lobectomy via a minimally invasive approach remain largely uncharted. Using the comprehensive National Cancer Database (NCDB), our research aimed to clarify the safety, feasibility, and efficacy of minimally invasive extended lobectomy in patients diagnosed with NSCLC. Methods Our study encompassed a selection of patients with NSCLC who underwent extended lobectomy (defined as lobectomy or bilobectomy with chest wall, diaphragm or pericardial resection) between 2010 and 2014. Through propensity score matching (PSM), we ensured a balanced comparison between patients who underwent MIS and those who opted for the traditional open extended lobectomy. Both univariate and multivariate analyses were employed to discern whether the surgical approach had any significant impact on the prognosis of patients undergoing this specific procedure. Results Before PSM, our dataset included 3,934 patients. After 1:2 PSM, the MIS group included 683 cases, while the open group included 1,317 cases. One notable finding was the reduced average postoperative hospital stay for the MIS group at 7.15 days compared to the open group at 8.40 days (P<0.001). Furthermore, the 5-year survival rate was similar, with the MIS group at 53.1% and the open group at 51.3% (P=0.683). Conclusions The results of our study suggest that MIS for extended lobectomy not only is safe and feasible but also is oncologically effective. However, it is imperative to note that these encouraging findings necessitate further validation through prospective studies to ascertain the full scope of benefits and potential risks associated with MIS.
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Affiliation(s)
- Tangbing Chen
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ernest G. Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Binhao Huang
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Hiran C. Fernando
- Department of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Panagiotis T. Tasoudis
- Division of Cardiothoracic Surgery, Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Natalia Motas
- Department of Thoracic Surgery, Institute of Oncology Bucharest, Bucharest, Romania
- Clinic of Thoracic Surgery, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Department of Thoracic Surgery, Memorial Hospital, Bucharest, Romania
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Zhang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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3
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Donohue JK, Chan EG, Clifford S, Ryan JP, Furukawa M, Haidar G, Bertani A, Hage CA, Sanchez PG. Lung transplantation in HIV seropositive recipients: An analysis of the UNOS registry. Clin Transplant 2024; 38:e15246. [PMID: 38289885 DOI: 10.1111/ctr.15246] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/29/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Experience with lung transplantation (LT) in patients with human immunodeficiency virus (HIV) is limited. Many studies have demonstrated the success of kidney and liver transplantation in HIV-seropositive (HIV+) patients. Our objective was to conduct a national registry analysis comparing LT outcomes in HIV+ to HIV-seronegative (HIV-) recipients. METHODS The United Network for Organ Sharing database was queried to identify LTs performed in adult HIV+ patients between 2016 and 2023. Patients with unknown HIV status, multiorgan transplants, and redo transplants were excluded. The primary endpoints were mortality and graft rejection. Survival time was analyzed using Kaplan-Meier analysis. RESULTS The study included 17 487 patients, 67 of whom were HIV+. HIV+ recipients were younger (59 vs. 62 years, p = .02), had higher pulmonary arterial pressure (28 vs. 25 mm Hg, p = .04), and higher lung allocation scores (47 vs. 41, p = .01) relative to HIV- recipients. There were no differences in graft/recipient survival time between groups. HIV+ recipients had higher rates of post-transplant dialysis (18% vs. 8.4%, p = .01), but otherwise had similar post-transplant outcomes to HIV-recipients. CONCLUSIONS This national registry analysis suggests LT outcomes in HIV+ patients are not inferior to outcomes in HIV- patients and that well-selected HIV+ recipients can achieve comparable patient and graft survival rates relative to HIV- recipients.
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Affiliation(s)
- Jack K Donohue
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Clifford
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ghady Haidar
- Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alessandro Bertani
- Division of Thoracic Surgery and Lung Transplantation, Thoracic Center, IRCCS ISMETT - UPMC, Palermo, Italy
| | - Chadi A Hage
- Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Hyzny EJ, Chan EG, Malik SM, Morrell M, Furukawa M, Ryan JP, Sanchez PG. Risk Factors and Outcomes of Postoperative Hepatic Dysfunction After Lung Transplantation. Ann Thorac Surg 2023; 116:1277-1284. [PMID: 37000464 DOI: 10.1016/j.athoracsur.2022.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/18/2022] [Accepted: 08/27/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hepatic dysfunction is a morbid complication of lung transplantation. Little is known about risk factors for postoperative hepatic dysfunction or its impact on survival after lung transplantation. METHODS This retrospective analysis of 1406 adult lung transplant recipients was performed at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania between January 1, 2007 and December 1, 2019. Patients were excluded for redo lung transplantation, concomitant cardiac surgery, or concurrent solid organ transplantation. Postoperative liver dysfunction was classified as either ischemic liver injury or nonischemic dysfunction (transaminitis, hyperbilirubinemia). RESULTS Among the 1155 primary lung transplant recipients included, postoperative hepatic dysfunction developed in 96 (8.3%) after lung transplantation. A history of liver disease was the greatest predictor of postoperative hepatic dysfunction (odds ratio, 6.19; CI, 2.13-17.4; P < .001). Patients with postoperative hepatic dysfunction had a greater need for intraoperative blood products (ischemic, 12 U [range, 6-21 U]; nonischemic, 10 U [range, 4-28 U]; vs none, 4 U [range, 1-12 U]; P < .001) and an increased need for postoperative circulatory support (ischemic, 16 [76%]; nonischemic, 25 [33%]; none, 117 [11%]; P < .001). Both ischemic liver injury and nonischemic dysfunction were associated with diminished 1-, 3-, and 5-year term survival (ischemic, 27.5%, 16.5%, and 0%, respectively; nonischemic, 60%, 49.6%, and 46.9%, respectively; none, 87.3%, 72.3%, and 59.5%, respectively; P < .001). CONCLUSIONS Hepatic dysfunction after lung transplantation is associated with significant morbidity and mortality. A history of liver disease was the best positive predictor for postoperative dysfunction. Additional studies are necessary to identify the best treatment algorithm to avoid hepatic dysfunction more effectively in the postoperative setting after lung transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shahid M Malik
- Division of Gastroenterology Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Morrell
- Division of Pulmonary and Critical Care, Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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5
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Donohue JK, Hyzny EJ, Clifford S, Chan EG, Coster JN, Furukawa M, Sanchez PG. Immediate Postoperative COVID-19 Infection after Lung Transplantation: A Systematic Review and Case Series. J Clin Med 2023; 12:7028. [PMID: 38002643 PMCID: PMC10671990 DOI: 10.3390/jcm12227028] [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: 09/15/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND With new variants challenging the effectiveness of preventive measures, we are beginning to recognize the reality that COVID-19 will continue to pose an endemic threat. The manifestations of COVID-19 in lung transplant recipients during index admission are poorly understood with very few cases reported in recent lung transplant recipients. Optimal management of immunosuppression and antiviral therapy in recent transplant recipients is challenging. METHODS We performed a retrospective analysis identifying lung transplant recipients at our institution who contracted COVID-19 in the immediate postoperative period (within index admission). In addition, we performed a systematic review from January 2020 to August 2023 identifying all publications on the PUBMED database regarding COVID-19 infection in lung transplant recipients during index admission. RESULTS We report four cases of COVID-19 pneumonia in lung transplant recipients in the immediate postoperative period and we describe the clinical course, treatment options, and immunosuppression changes to manage this unique clinical problem. All patients made a full recovery and were eventually discharged home. Within our review of the literature, the most prevalent presenting symptoms were cough, dyspnea, and fatigue. Six (75%) patients decreased or held their antimetabolite. The two most common treatments were monoclonal antibodies (38%) and remdesivir (63%). CONCLUSION Although previous literature demonstrates that COVID-19 can be deadly in recent lung transplant recipients, rapid treatment with anti-viral therapy/immunotherapy, deescalating immunosuppression, and treatment of respiratory decompensation with Decadron was effective in our patients.
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Affiliation(s)
| | | | | | | | | | | | - Pablo G. Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop Street Suite C-900, Pittsburgh, PA 15213, USA; (J.K.D.); (S.C.); (E.G.C.); (J.N.C.)
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Chan EG, Pan G, Clifford S, Hyzny EJ, Furukawa M, Coster JN, Ryan JP, Gomez H, Sanchez PG. Postoperative Acute Kidney Injury and Long-Term Outcomes After Lung Transplantation. Ann Thorac Surg 2023; 116:1056-1062. [PMID: 37414386 DOI: 10.1016/j.athoracsur.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 01/09/2023] [Revised: 05/17/2023] [Accepted: 06/19/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND This study sought to characterize perioperative risk factors of acute kidney injury (AKI) and report outcomes associated with its development in the immediate postoperative setting after lung transplantation. METHODS Study investigator performed a retrospective analysis of all adult patients undergoing primary lung transplantation at a single institution from January 1, 2011 to December 31, 2021 AKI was defined using Kidney Disease: Improving Global Outcomes (KDIGO) criteria after lung transplantation and was stratified on the basis of whether patients required renal replacement therapy (RRT; AKI-no RRT vs AKI-RRT). RESULTS Of the 754 patients included, 369 (48.9%) any AKI developed in the postoperative period (252 AKI-no RRT vs 117 AKI-RRT). Risk factors for postoperative AKI included higher preoperative creatinine levels (odds ratio [OR], 5.15; P < .001), lower preoperative estimated glomerular filtration rate (OR, 0.99; P < 0.018), delayed chest closure (OR, 2.72; P < .001), and higher volumes of postoperative blood products (OR, 1.09; P < .001) in the multivariable analysis. On univariate analysis, both AKI groups were also associated with higher rates of pneumonia (P < .001), reintubation (P < .001), mortality on index admission (P < 0.001), longer ventilator duration (P < .001), longer intensive care unit length of stay (P < .001), and longer hospital length of stay (P < .001), with the highest rates in the AKI-RRT group. In a multivariable survival analysis, postoperative AKI-no RRT (hazard ratio [HR], 1.50; P = .006) and AKI-RRT (HR, 2.70; P < .001) were associated with significantly worse survival independent of severe grade 3 primary graft dysfunction at 72 hours (HR, 1.45; P = .038). CONCLUSIONS The development of postoperative AKI was associated with numerous preoperative and intraoperative factors. Postoperative AKI remained significantly associated with poorer posttransplantation survival. Severe cases of AKI necessitating RRT portended the worst survival after lung transplantation.
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Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gilbert Pan
- Boston University School of Medicine, Boston, Massachusetts
| | - Sarah Clifford
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric J Hyzny
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jenalee N Coster
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hernando Gomez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Hyzny EJ, Chan EG, Hage C, Rachakonda V, Sanchez PG, Malik SM. A novel scoring system to predict survival in cirrhotic patients undergoing isolated lung transplantation: The PENS-CEPT score. Clin Transplant 2023; 37:e15130. [PMID: 37698469 DOI: 10.1111/ctr.15130] [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] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/23/2023] [Accepted: 09/04/2023] [Indexed: 09/13/2023]
Abstract
Cirrhosis is usually regarded as a contraindication to isolated lung transplantation (ILT). We sought to determine which patients with cirrhosis could safely undergo ILT. Based on a retrospective analysis of patients with cirrhosis who underwent ILT at our center between 2007 and 2020, we developed an exclusionary algorithm (PENS-CEPT: Pittsburgh ExclusioN Score in Cirrhotics Evaluated for Pulmonary Transplant) to help determine which patients can undergo ILT with minimal incurred risk from their underlying liver disease. The score utilizes a combination of readily available clinical data and the presence (or absence) of spontaneous portosystemic shunts on preoperative cross-sectional imaging. Sixteen patients underwent ILT with a diagnosis of cirrhosis: nine with cystic fibrosis. On univariate analysis, only our model was able to predict 1 year survival. Of the nine patients that would have been approved using our model, there was only one short term death. Of the seven patients that would have been rejected by the model, all but one died within the first year with six dying of complications from liver failure. We are proposing a simple score utilizing routine clinical parameters and pre-operative imaging to determine the safety of ILT in cirrhotic patients. Further studies are required to validate this scoring system with the goal of safely increasing the opportunity for cirrhotic patients who would otherwise be rejected for ILT.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Chadi Hage
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Vikrant Rachakonda
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine Veteran's Association Northern California Healthcare System, Sacramento, California, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shahid M Malik
- Division of Gastroenterology, Hepatology & Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Furukawa M, Chan EG, Ryan JP, Coster JN, Sanchez PG. Impact of gastro-jejunostomy tube in lung transplant patients: a propensity-matched analysis. Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad149. [PMID: 37656927 PMCID: PMC10918761 DOI: 10.1093/icvts/ivad149] [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] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/21/2023] [Accepted: 08/31/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVES During the postoperative phase of lung transplantation, the surgical creation of a gastro-jejunostomy (GJ) may be deemed necessary for patients with severe oesophageal dysmotility, prolonged oral intake difficulties stemming from use of a ventilator or marked malnutrition. We explored the effects of postoperative GJ tube on survival and bronchiolitis obliterans syndrome in lung transplant recipients. METHODS We retrospectively reviewed all lung transplants performed at our institution between 2011 and 2022. Propensity score matching was performed to match patients who required a GJ tube with control patients on a 1:1 ratio. The preoperative, operative and postoperative outcomes of the patients were evaluated. RESULTS After propensity score matching, 193 patients with GJ were compared to 193 patients without GJ. Patients with GJ had significantly higher rates of delayed chest closure (P = 0.007), and postoperative dialysis (P = 0.016), longer intensive care unit stays (P < 0.001), longer ventilator duration (P < 0.001), higher rates of pneumonia (P = 0.035) and higher rates of being treated for acute cellular rejection within 1 year of transplant (P = 0.008). Overall survival and freedom from bronchiolitis obliterans syndrome were not found to be significantly different between the matched groups (P = 0.09 and P = 0.3). CONCLUSIONS GJ tube placement during the postoperative phase of lung transplantation did not compromise patient survival or freedom from bronchiolitis obliterans syndrome although the results reflect more difficult and complicated cases. This study indicates that the GJ tube may be a useful option for enteral feeding.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jenalee N Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Iyanna N, Chan EG, Ryan JP, Furukawa M, Coster JN, Hage CA, Sanchez PG. Lung Transplantation Outcomes in Recipients Aged 70 Years or Older and the Impact of Center Volume. J Clin Med 2023; 12:5372. [PMID: 37629414 PMCID: PMC10455483 DOI: 10.3390/jcm12165372] [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: 07/05/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE To evaluate trends and outcomes of lung transplants (LTx) in recipients ≥ 70 years. METHODS We performed a retrospective analysis of the UNOS database identifying all patients undergoing LTx (May 2005-December 2022). Baseline characteristics and postoperative outcomes were compared by age (<70 years, ≥70 years) and center volume. Kaplan-Meier analyses were performed with pairwise comparisons between subgroups. RESULTS 34,957 patients underwent LTx, of which 3236 (9.3%) were ≥70 years. The rate of LTx in recipients ≥ 70 has increased over time, particularly in low-volume centers (LVCs); consequently, high-volume centers (HVCs) and LVCs perform similar rates of LTx for recipients ≥ 70. Recipients ≥ 70 had higher rates of receiving from donor after circulatory death lungs and of extended donor criteria. Recipients ≥ 70 were more likely to die of cardiovascular diseases or malignancy, while recipients < 70 of chronic primary graft failure. Survival time was shorter for recipients ≥ 70 compared to recipients < 70 old (hazard ratio (HR): 1.36, 95% confidence interval (CI): 1.28-1.44, p < 0.001). HVCs were associated with a survival advantage in recipients < 70 (HR: 0.91, 95% CI: 0.88-0.94, p < 0.001); however, in recipients ≥ 70, survival was similar between HVCs and LVCs (HR: 1.11, 95% CI: 0.99-1.25, p < 0.08). HVCs were more likely to perform a bilateral LTx (BLT) for obstructive lung diseases compared to LVCs, but there was no difference in BLT and single LTx likelihood for restrictive lung diseases. CONCLUSIONS Careful consideration is needed for recipient ≥ 70 selection, donor assessment, and post-transplant care to improve outcomes. Further research should explore strategies that advance perioperative care in centers with low long-term survival for recipients ≥ 70.
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Affiliation(s)
- Nidhi Iyanna
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA;
| | - Ernest G. Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.G.C.); (J.P.R.); (M.F.); (J.N.C.)
| | - John P. Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.G.C.); (J.P.R.); (M.F.); (J.N.C.)
| | - Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.G.C.); (J.P.R.); (M.F.); (J.N.C.)
| | - Jenalee N. Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.G.C.); (J.P.R.); (M.F.); (J.N.C.)
| | - Chadi A. Hage
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA;
| | - Pablo G. Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA; (E.G.C.); (J.P.R.); (M.F.); (J.N.C.)
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10
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Deitz RL, Emerel L, Chan EG, Ryan JP, Hyzny E, Furukawa M, Sanchez PG. Waitlist Mortality and Extracorporeal Membrane Oxygenation Bridge to Lung Transplant. Ann Thorac Surg 2023; 116:156-162. [PMID: 37004804 PMCID: PMC10587849 DOI: 10.1016/j.athoracsur.2023.02.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 01/13/2023] [Accepted: 02/28/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Use of extracorporeal membrane oxygenation (ECMO) as bridge to lung transplant has increased. However, little is known about patients placed on ECMO who die while on the waiting list. Using a national lung transplant data set, we investigated variables associated with waitlist mortality of patients bridged to lung transplant. METHODS All patients supported on ECMO at time of listing were identified using the United Network for Organ Sharing database. Univariable analyses were performed using bias-reduced logistic regression. Cause-specific hazard models were used to determine the effect of variables of interest on hazard of outcomes. RESULTS From April 2016 to December 2021, 634 patients met inclusion criteria. Of these, 445 (70%) were successfully bridged to transplant, 148 (23%) died on the waitlist, and 41 (6.5%) were removed for other reasons. Univariable analysis found associations between waitlist mortality and blood group, age, body mass index, serum creatinine, lung allocation score, days on waitlist, United Network for Organ Sharing region, and being listed at a lower-volume center. Cause-specific hazard models demonstrated that patients at high-volume centers were 24% more likely to survive to transplant and 44% less likely to die on the waitlist. Among patients who were successfully bridged to transplant, there was no difference in survival between low- and high-volume centers. CONCLUSIONS ECMO is an appropriate strategy to bridge selected high-risk patients to lung transplant. Of those placed on ECMO with intent to transplant, about one quarter may not survive to transplantation. High-risk patients requiring advanced support strategies may be more likely to survive to transplant when bridged at a high-volume center.
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Affiliation(s)
- Rachel L Deitz
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Leonid Emerel
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Lung Transplantation and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric Hyzny
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Lung Transplantation and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Lung Transplantation and Lung Failure, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Noda K, Furukawa M, Chan EG, Sanchez PG. Expanding Donor Options for Lung Transplant: Extended Criteria, Donation After Circulatory Death, ABO Incompatibility, and Evolution of Ex Vivo Lung Perfusion. Transplantation 2023; 107:1440-1451. [PMID: 36584375 DOI: 10.1097/tp.0000000000004480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Only using brain-dead donors with standard criteria, the existing donor shortage has never improved in lung transplantation. Currently, clinical efforts have sought the means to use cohorts of untapped donors, such as extended criteria donors, donation after circulatory death, and donors that are ABO blood group incompatible, and establish the evidence for their potential contribution to the lung transplant needs. Also, technical maturation for using those lungs may eliminate immediate concerns about the early posttransplant course, such as primary graft dysfunction or hyperacute rejection. In addition, recent clinical and preclinical advances in ex vivo lung perfusion techniques have allowed the safer use of lungs from high-risk donors and graft modification to match grafts to recipients and may improve posttransplant outcomes. This review summarizes recent trends and accomplishments and future applications for expanding the donor pool in lung transplantation.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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12
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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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Coster JN, Chan EG, Furukawa M, Pilewski JM, Nguyen MHT, Sanchez PG. Sequential redo-bilateral lung transplantation in recipient with prior heart-lung transplantation with tracheal anastomosis. JTCVS Tech 2023; 19:160-163. [PMID: 37324355 PMCID: PMC10268495 DOI: 10.1016/j.xjtc.2023.03.017] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Jenalee N. Coster
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ernest G. Chan
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Masashi Furukawa
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph M. Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Minh Hong T. Nguyen
- Division of Infectious Disease, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pablo G. Sanchez
- Division of Lung Transplantation and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Chan EG, Hyzny EJ, Furukawa M, Ryan JP, Subramaniam K, Morrell MR, Pilewski J, Luketich JD, Sanchez PG. Intraoperative Support for Primary Bilateral Lung Transplantation: A Propensity-Matched Analysis. Ann Thorac Surg 2023; 115:743-749. [PMID: 35780817 DOI: 10.1016/j.athoracsur.2022.06.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 12/19/2021] [Revised: 04/19/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Single-center studies support benefits of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a method of intraoperative support. Propensity-matched data from a large cohort, however, are currently lacking. Therefore, our goal was to compare outcomes of intraoperative VA-ECMO and cardiopulmonary bypass (CPB) during bilateral lung transplantation (LTx) with a propensity analysis. METHODS We performed a retrospective analysis of 795 consecutive primary adult LTx patients (June 1, 2011-December 26, 2020) using no intraoperative support (n = 210), VA-ECMO (n = 150), or CPB (n = 197). Exclusion criteria included LTx on venovenous-ECMO, single/redo LTx, ex vivo lung perfusion, and concomitant solid-organ transplantation or cardiac procedure. Propensity analysis was performed comparing patients who underwent intraoperative CPB or VA-ECMO. RESULTS The propensity CPB group required more blood products at 72 hours (P = .02) and longer intensive care unit length of stay (P < .001) and ventilator dependence days (P < .001). There were no differences in cerebrovascular accident (P = 1), reintubation (P = .4), dialysis (P = .068), in-hospital mortality (P = .33), and 1-year (P = .67) and 3-year (P = .32) survival. The CPB group had a higher incidence of grade 3 primary graft dysfunction at 72 hours (P < .001). Neither support strategy was a predictor of 1- and 3-year mortality in our multivariable model (VA-ECMO, P = .72 and P = .57; CPB, P = .45 and P = .91, respectively). CONCLUSIONS Intraoperative VA-ECMO during lung transplantation was associated with fewer postoperative blood transfusions, shorter length of mechanical ventilation, and lower incidence of a grade 3 primary graft dysfunction at 72 hours. Although there were some differences in the postoperative course between the VA-ECMO and CPB groups, support type was not associated with differences in survival.
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Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eric J Hyzny
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew R Morrell
- Division of Pulmonary and Critical Care, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Joseph Pilewski
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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16
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Furukawa M, Noda K, Chan EG, Ryan JP, Coster JN, Sanchez PG. Lung transplantation from donation after circulatory death, evolution, and current status in the United States. Clin Transplant 2023; 37:e14884. [PMID: 36542414 DOI: 10.1111/ctr.14884] [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: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The number of lung transplants from donors after circulatory death has increased over the last decade. This study aimed to describe the evolution and outcomes following lung transplantation donation after circulatory death (DCD) and report the practices and outcomes of ex vivo lung perfusion (EVLP) in this donor population. METHODS This was a retrospective study using a prospectively collected national registry. The United Network for Organ Sharing (UNOS) database was queried to identify adult patients who underwent lung transplantation between May 1, 2005, and December 31, 2021. Kaplan-Meier analysis and Weibull regression were used to compare survival in four cohorts (donation after brain death [DBD] with or without EVLP, and DCD with or without EVLP). The primary outcome of interest was patient survival. RESULTS Of the 21 356 recipients who underwent lung transplantation, 20 380 (95.4%) were from brain death donors and 976 (4.6%) from donors after circulatory death. Kaplan-Meier analysis showed no difference in the survival time between the two groups. In a multivariable analysis that controlled for baseline differences in donor and recipient characteristics, recipients who received lungs from cardiac death donors after EVLP had 28% shorter survival time relative to donor lungs after brain death without EVLP (hazard ratio [HR] 1.53, 95% confidence interval [CI] 1.10-2.15, p = .01). CONCLUSIONS The early survival differences observed after lung transplants from donors after circulatory death in lungs evaluated with EVLP deserves further investigation.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kentaro Noda
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Jenalee N Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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17
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Noda K, Chan EG, Furukawa M, Ryan JP, Clifford S, Luketich JD, Sanchez PG. Single-center experience of ex vivo lung perfusion and subsequent lung transplantation. Clin Transplant 2023; 37:e14901. [PMID: 36588340 DOI: 10.1111/ctr.14901] [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: 09/30/2022] [Revised: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND The safety of lung transplantation using ex vivo lung perfusion (EVLP) has been confirmed in multiple clinical studies; however, limited evidence is currently available regarding the potential effects of EVLP on posttransplant graft complications and survival with mid- to long-term follow-up. In this study, we reviewed our institutional data to better understand the impact of EVLP. METHODS Lungs placed on EVLP from 2014 through 2020 and transplant outcomes were retrospectively analyzed. Data were compared between lungs transplanted and declined after EVLP, between patients with severe primary graft dysfunction (PGD3) and no PGD3 after EVLP, and between matched patients with lungs transplanted with and without EVLP. RESULTS In total, 98 EVLP cases were performed. Changes in metabolic indicators during EVLP were correlated with graft quality and transplantability, but not changes in physiological parameters. Among 58 transplanted lungs after EVLP, PGD3 at 72 h occurred in 36.9% and was associated with preservation time, mechanical support prior to transplant, and intraoperative transfusion volume. Compared with patients without EVLP, patients who received lungs screened with EVLP had a higher incidence of PGD3 and longer ICU and hospital stays. Lung grafts placed on EVLP exhibited a significantly higher chance of developing airway anastomotic ischemic injury by 30 days posttransplant. Acute and chronic graft rejection, pulmonary function, and posttransplant survival were not different between patients with lungs screened on EVLP versus lungs with no EVLP. CONCLUSION EVLP use is associated with an increase of early posttransplant adverse events, but graft functional outcomes and patient survival are preserved.
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Affiliation(s)
- Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Masashi Furukawa
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John P Ryan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sarah Clifford
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - James D Luketich
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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18
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Coster JN, Noda K, Ryan JP, Chan EG, Furukawa M, Luketich JD, Sanchez PG. Effects of Intraoperative Support Strategies on Endothelial Injury and Clinical Lung Transplant Outcomes. Semin Thorac Cardiovasc Surg 2023:S1043-0679(23)00001-1. [PMID: 36716942 DOI: 10.1053/j.semtcvs.2022.09.016] [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: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 01/29/2023]
Abstract
In lung transplantation, postoperative outcomes favor intraoperative use of extracorporeal membrane oxygenation (ECMO) over cardiopulmonary bypass (CBP). We investigated the effect of intraoperative support strategies on endothelial injury biomarkers and short-term posttransplant outcomes. Adults undergoing bilateral lung transplantation with No-Support, venoarterial (V-A) ECMO, or CPB were included. Plasma samples pre- and post-transplant were collected for Luminex assay to measure endothelial injury biomarkers including syndecan-1 (SYN-1), intercellular adhesion molecule-1 (ICAM-1), and matrix metalloprotease-9. Fifty five patients were included for analysis. The plasma level of SYN-1 at arrival in the intensive care unit was significantly higher with CPB compared to V-A ECMO and No-Support (P < 0.01). The rate of primary graft dysfunction grade 3 (PGD3) at 72 hours was 60.0% in CPB, 40.1% in V-A ECMO, and 15% in No-Support (P = 0.01). Postoperative plasma levels of SYN-1 and ICAM-1 were significantly higher in recipients who developed PGD3 at 72 hours. SYN-1 levels were also significantly higher in patients who developed acute kidney injury and hepatic dysfunction after transplant. Postoperative, SYN-1 upon intensive care arrival was found to be a significant predictive biomarker of PGD3, acute kidney injury, and hepatic dysfunction following lung transplantation. CPB is associated with higher plasma concentrations of SYN-1, a marker of endothelial glycocalyx degradation, upon arrival to the intensive care unit. Higher levels of SYN-1 are predictive of end-organ dysfunction following lung transplantation. Our data suggests that intraoperative strategies aimed at modulating endothelial injury will help improve lung transplantation outcomes.
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Affiliation(s)
- Jenalee N Coster
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Kentaro Noda
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John P Ryan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Masashi Furukawa
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - James D Luketich
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.
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19
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Furukawa M, Chan EG, Ryan JP, Hyzny EJ, Sacha LM, Coster JN, Pilewski JM, Lendermon EA, Kilaru SD, McDyer JF, Sanchez PG. Induction Strategies in Lung Transplantation: Alemtuzumab vs. Basiliximab a Single-Center Experience. Front Immunol 2022; 13:864545. [PMID: 35720296 PMCID: PMC9199390 DOI: 10.3389/fimmu.2022.864545] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background Induction therapy is used in about 80% of lung transplant centers and is increasing globally. Currently, there are no standards or guidelines for the use of induction therapy. At our institution, we have two induction strategies, basiliximab, and alemtuzumab. The goal of this manuscript is to share our experience and practice since this is an area of controversy. Methods We retrospectively reviewed 807 lung transplants performed at our institution between 2011 and 2020. Indications for the use of the basiliximab protocol were as follows: patients over the age of 70 years, history of cancer, hepatitis C virus or human immunodeficiency virus infection history, and cytomegalovirus or Epstein-Barr virus (donor positive/ recipient negative). In the absence of these clinical factors, the alemtuzumab protocol was used. Results 453 patients underwent alemtuzumab induction and 354 patients underwent basiliximab. There were significant differences in delayed chest closure (24.7% alemtuzumab vs 31.4% basiliximab, p = 0.037), grade 3 primary graft dysfunction observed within 72 hours (19.9% alemtuzumab vs 29.9% basiliximab, p = 0.002), postoperative hepatic dysfunction (8.8% alemtuzumab vs 14.7% basiliximab, p = 0.009), acute cellular rejection in first year (39.1% alemtuzumab vs 53.4% basiliximab, p < 0.001). The overall survival rate of the patients with alemtuzumab induction was significantly higher than those of the patients with basiliximab induction (5 years survival rate: 64.1% alemtuzumab vs 52.3%, basiliximab, p < 0.001). Multivariate Cox regression analysis confirmed lower 5-year survival for basiliximab induction (HR = 1.41, p = 0.02), recipient cytomegalovirus positive (HR = 1.49, p = 0.01), postoperative hepatic dysfunction (HR = 2.20, p < 0.001), and acute kidney injury requiring renal replacement therapy (HR = 2.27, p < 0.001). Conclusions In this single center retrospective review, there was a significant difference in survival rates between induction strategies. This outcome may be attributable to differences in recipient characteristics between the groups. However, the Alemtuzumab group experienced less episodes of acute cellular rejection within the first year.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lauren M Sacha
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jenalee N Coster
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Joseph M Pilewski
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Elizabeth A Lendermon
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Silpa D Kilaru
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John F McDyer
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Furukawa M, Chan EG, Sanchez PG. Bridge to second double lung transplant with an extracorporeal carbon dioxide removal system in situs inversus patient. J Card Surg 2022; 37:2191-2193. [PMID: 35411562 DOI: 10.1111/jocs.16493] [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: 01/05/2022] [Revised: 02/24/2022] [Accepted: 03/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Extracorporeal life support use in redo-lung transplant is limited due to poor outcomes. Extracorporeal circulation with a single duo-lumen cannula provides the advantage of more comfortable mobilization particularly in patients in which we expect a longer bridge to transplant. CASE A 29-year-old female with Kartagener syndrome and complete situs inversus underwent a double lung transplant for end stage lung disease. Within one year after transplant the patient had primarily hypercapnic respiratory failure with radiographic signs of chronic lung allograft dysfunction. To optimize her nutritional status and muscle strength before re-do lung transplantation, we decided to bridge her with an extracorporeal carbon dioxide removal system due to anatomical difficulty. She was listed and underwent an uneventful re-do double lung transplant with cardiopulmonary support. CONCLUSIONS We report a first case with the use of extracorporeal carbon dioxide removal system as a bridge to re-do lung transplant in complete situs inversus patient.
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Affiliation(s)
- Masashi Furukawa
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, Division of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Neto DM, Chan EG, Sanchez PG. Double lung transplantation in patients with lung atelectasis and complete mediastinal shift. Clin Case Rep 2022; 10:e05515. [PMID: 35990927 PMCID: PMC9385115 DOI: 10.1002/ccr3.5515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 11/14/2022] Open
Abstract
Mediastinal shift and chest wall retraction limit the indication of a double lung transplant in patients with complete destruction of lung parenchyma. We report outcomes as well as preoperative and operative management in two patients with significant lung volume reduction and mediastinal shift due to bronchiectasis of the right lung.
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Affiliation(s)
- Daniel M. Neto
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA
| | - Ernest G. Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA
| | - Pablo G. Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA
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Furukawa M, Chan EG, Morrell MR, Ryan JP, Rivosecchi RM, Iasella CJ, Lendermon EA, Pilewski JM, Sanchez PG. Risk factors of bronchial dehiscence after primary lung transplantation. J Card Surg 2022; 37:950-957. [PMID: 35133655 DOI: 10.1111/jocs.16291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 09/07/2021] [Revised: 10/15/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although the incidence of bronchial dehiscence following lung transplantation has decreased significantly due to improvements in perioperative managements and surgical techniques, it remains a devastating postoperative complication associated with high morbidity and mortality. METHODS We retrospectively reviewed 811 lung transplantation performed at our institution between January 2011 and December 2020. Bronchial dehiscence was confirmed with flexible bronchoscopy, computed tomography (CT) scan, or clinical findings grade using International Society for Heart and Lung Transplantation recommendations. RESULTS Bronchial dehiscence was diagnosed in 38 patients (4.7%). The overall survival rates of the patients with bronchial dehiscence were significantly worse than those of the patients without bronchial dehiscence (p = .003). Multivariate analysis identified use of our basiliximab induction protocol (odds ratio = 3.03, p = .008) as an independent predictive factor of postoperative airway dehiscence in our multivariable model, along with total ventilator duration (odds ratio = 1.02, p = .002). CONCLUSIONS Based on our analysis, patients that underwent our basiliximab induction protocol for lung transplantation experienced a higher rate of postoperative bronchial dehiscence when compared with patients who receive alemtuzumab induction. We believe this may be associated with a higher steroid exposure in this population. Additional studies are necessary to further characterize the relationship between different induction protocols and bronchial dehiscence following transplantation.
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Affiliation(s)
- Masashi Furukawa
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew R Morrell
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Utah
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ryan M Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carlo J Iasella
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Lendermon
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joseph M Pilewski
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Chan EG, Hyzny EJ, Ryan JP, Morrell MR, Pilewski J, Sanchez PG. Outcomes following lung re-transplantation in patients with cystic fibrosis. J Cyst Fibros 2021; 21:482-488. [PMID: 34949557 DOI: 10.1016/j.jcf.2021.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/10/2021] [Accepted: 12/05/2021] [Indexed: 01/09/2023]
Abstract
PURPOSE We examined cystic fibrosis (CF) patients and compared their clinical status at the time of primary versus double lung re-transplantation (re-DLTx) in order to better understand lung retransplant practice patterns. METHODS We performed a retrospective analysis of the UNOS Database identifying CF patients ≥18 years old undergoing re-DLTx (5/4/2005 and 12/4/2020). Baseline and clinical variables at the primary and re-DLTx were compared utilizing the paired student t-test. Graft survival was defined as time from surgery to retransplant and analyzed using Kaplan-Meier estimates. RESULTS 277 CF patients who underwent re-DLTx experienced a significantly worse 5-year survival when compared to the primary DLTx cohort (47.9% vs 58.8%, p = 0.00012). The following differences were observed comparing CF re-DLTx group to their primary DLTx: higher LAS score at the time of listing (50.66 vs 42.15, p < 0.001) and transplant (62.19 vs 48.20, p < 0.001), and increase LAS from the time of listing to transplant (+12.22 vs +7.23, p = 0.002). While serum albumin and total bilirubin were similar, CF patients had a higher creatinine (1.05 vs 0.74, p < 0.001), dialysis (4.4% vs 0.6%, p < 0.001), ECMO bridge to transplant rates (7.6% vs 4.0%, p < 0.001), and higher oxygen requirements (5.95 vs 3.93, p < 0.001) at the time of listing for a re-DLTx. CONCLUSION Compared to their initial transplant, CF patients experience significant clinical decline in renal, cardiac, and pulmonary function at the time of lung retransplantation. This may indicate that an earlier evaluation and rehabilitation process may be necessary to identify patients earlier for lung retransplantation prior significant clinical decline.
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Affiliation(s)
- Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew R Morrell
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, PA, United States
| | - Joseph Pilewski
- Department of Medicine, Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh, Pittsburgh, PA, United States
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.
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Huang B, Chan EG, Pennathur A, Luketich JD, Zhang J. The ideal approach for treatment of cT1N+ and cT2Nany esophageal cancer.: a NCDB analysis. BMC Cancer 2021; 21:1334. [PMID: 34911468 PMCID: PMC8672500 DOI: 10.1186/s12885-021-08896-0] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
Background Neoadjuvant therapy followed by surgery is recommended for locally advanced esophageal cancer. With the inaccuracies of clinical staging particularly for cT1N+ and cT2Nany tumors, some have proposed consideration of surgery followed by adjuvant treatment. Our objective is to evaluate the efficacy of neoadjuvant therapy vs surgery followed by adjuvant therapy, and to identify the ideal sequence of treatment in patients with cT1N+ and cT2Nany tumors. Methods We performed an analysis utilizing the National Cancer Database (2006-2015) identifying all patients with cT1N+ and cT2Nany esophageal cancer undergoing esophagectomy. The treatment was stratified as: neoadjuvant therapy (NT), adjuvant therapy (AT) and combination therapy of neoadjuvant and adjuvant (CT) groups and outcomes were analyzed. Results We identified 2795 patients with 81.9% (n=2289) receiving NT, 10.2% (n=285) AT, and 7.9% (n=221) CT. There were no significant differences noted in survival among AT, NT, and CT group in cT1N+(P=0.376), cT2N-(P=0.436), cT2N+(P=0.261) esophageal cancer by multivariate analysis using Cox regression model. This relationship held true in both squamous cell carcinoma and adenocarcinoma. Conclusion In clinical T1N+, T2Nany patients, there was no evident superiority of NT over AT. Surgery followed by adjuvant therapy can be considered to be an alternative option in these patients. Further prospective studies are needed to validate these findings. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08896-0.
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Affiliation(s)
- Binhao Huang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China.,Department of Gastric Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C800, Pittsburgh, PA, 15213, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C800, Pittsburgh, PA, 15213, USA
| | - Arjun Pennathur
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C800, Pittsburgh, PA, 15213, USA.
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C800, Pittsburgh, PA, 15213, USA
| | - Jie Zhang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China. .,Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, Suite C800, Pittsburgh, PA, 15213, USA.
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25
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Alder JK, Sutton RM, Iasella CJ, Nouraie M, Koshy R, Hannan SJ, Chan EG, Chen X, Zhang Y, Brown M, Popescu I, Veatch M, Saul M, Berndt A, Methé BA, Morris A, Pilewski JM, Sanchez PG, Morrell MR, Shapiro SD, Lindell KO, Gibson KF, Kass DJ, McDyer JF. Lung transplantation for idiopathic pulmonary fibrosis enriches for individuals with telomere-mediated disease. J Heart Lung Transplant 2021; 41:654-663. [PMID: 34933798 PMCID: PMC9038609 DOI: 10.1016/j.healun.2021.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 11/03/2021] [Accepted: 11/09/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is the most common indication for lung transplantation in North America and variants in telomere-maintenance genes are the most common identifiable cause of IPF. We reasoned that younger IPF patients are more likely to undergo lung transplantation and we hypothesized that lung transplant recipients would be enriched for individuals with telomere-mediated disease due to the earlier onset and more severe disease in these patients. METHODS Individuals with IPF who underwent lung transplantation or were evaluated in an interstitial lung disease specialty clinic who did not undergo lung transplantation were examined. Genetic evaluation was completed via whole genome sequencing (WGS) of 426 individuals and targeted sequencing for 5 individuals. Rare variants in genes previously associated with IPF were classified using the American College of Medical Genetics guidelines. Telomere length from WGS data was measured using TelSeq software. Patient characteristics were collected via medical record review. RESULTS Of 431 individuals, 149 underwent lung transplantation for IPF. The median age of diagnosis of transplanted vs non-transplanted individuals was significantly younger (60 years vs 70 years, respectively, p<0.0001). IPF lung transplant recipients (IPF-LTRs) were twice as likely to have telomere-related rare variants compared to non-transplanted individuals (24% vs 12%, respectively, p=0.0013). IPF-LTRs had shorter telomeres than non-transplanted IPF patients (p=0.0028) and >85% had telomeres below the age-adjusted mean. Post-transplant survival and CLAD were similar amongst IPF-LTRs with rare variants in telomere-maintenance genes compared to those without, as well as in those with short telomeres versus longer telomeres. CONCLUSIONS There is an enrichment for telomere-maintenance gene variants and short telomeres among IPF-LTRs. However, transplant outcomes of survival and CLAD do not differ by gene variants or telomere length within IPF-LTRs. Our findings support individual with telomere-mediated disease should not be excluded from lung transplantation and focusing research efforts on therapies directed toward individuals with short-telomere mediated disease.
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Affiliation(s)
- Jonathan K Alder
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Rachel M Sutton
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Carlo J Iasella
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mehdi Nouraie
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ritchie Koshy
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Stefanie J Hannan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xiaoping Chen
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yingze Zhang
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Brown
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Iulia Popescu
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melinda Veatch
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa Saul
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Annerose Berndt
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara A Methé
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alison Morris
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew R Morrell
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Steven D Shapiro
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathleen O Lindell
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; College of Nursing, Medical University of South Carolina, Charleston, South Carolina
| | - Kevin F Gibson
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel J Kass
- The Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John F McDyer
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Ekeke CN, Chan EG, Fabian T, Villa-Sanchez M, Luketich JD. Recommendations for Surveillance and Management of Recurrent Esophageal Cancer Following Endoscopic Therapies. Surg Clin North Am 2021; 101:415-426. [PMID: 34048762 DOI: 10.1016/j.suc.2021.03.004] [Citation(s) in RCA: 2] [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] [Indexed: 02/08/2023]
Abstract
With advancing endoscopic technology and screening protocols for Barrett disease, more patients are being diagnosed with early-stage esophageal cancer. These early-stage patients may be amendable to endoscopic therapies, such as endomucosal resection and ablation. These therapies may minimize morbidity, but the elevated risk of recurrence cannot be overlooked. This article reports outcomes and recommendations for surveillance and management of recurrent esophageal cancer following endoscopic therapies.
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Affiliation(s)
- Chigozirim N Ekeke
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - Thomas Fabian
- Department of Surgery, Section of Thoracic Surgery, Albany Medical Center, 43 New Scotland Avenue, MC-50, R-113, Albany, NY 12208, USA
| | - Manuel Villa-Sanchez
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C816, Pittsburgh, PA 15213, USA.
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Hyzny EJ, Chan EG, Morrell M, Harano T, Sanchez PG. A review of liver dysfunction in the lung transplant patient. Clin Transplant 2021; 35:e14344. [PMID: 33960530 DOI: 10.1111/ctr.14344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/09/2021] [Accepted: 04/26/2021] [Indexed: 12/11/2022]
Abstract
Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.
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Affiliation(s)
- Eric J Hyzny
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Morrell
- Pulmonary, Allergy, and Critical Care Medicine Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Chan EG, Harano T, Morrell MR, Sanchez PG. Lung transplantation protocols during the COVID-19 pandemic: a single center experience. J Thorac Dis 2021; 13:2081-2086. [PMID: 34012558 PMCID: PMC8107516 DOI: 10.21037/jtd-20-3289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew R Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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29
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Harano T, Chan EG, Furukawa M, Reck dos Santos P, Morrell MR, Sappington PL, Sanchez PG. Oxygenated right ventricular assist device with a percutaneous dual-lumen cannula as a bridge to lung transplantation. J Thorac Dis 2021; 14:832-840. [PMID: 35572883 PMCID: PMC9096291 DOI: 10.21037/jtd-21-1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 02/18/2022] [Indexed: 11/24/2022]
Abstract
Background Oxygenated right ventricular assist device (oxyRVAD) placement has become more streamlined with the introduction of the dual-lumen pulmonary artery cannula. Peripherally cannulated oxyRVAD may provide oxygenation support with right heart support as an alternative to venoarterial extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. Methods A single-institution, retrospective analysis was performed on patients placed on oxyRVAD with a dual-lumen pulmonary artery cannula with the intention of bridging to lung transplantation in 2019. Results Four patients with idiopathic pulmonary fibrosis were placed on oxyRVAD as a bridge to transplantation. Two patients were extubated and ambulated while waiting for a lung offer, and two patients required conversion to venoarteriovenous ECMO (VAV ECMO) from oxyRVAD. The median waiting time for extracorporeal life support (ECLS) was 42 h. All patients underwent double lung transplantation. Two patients stayed on oxyRVAD, and one patient was placed on venovenous ECMO (VV ECMO) after transplantation. Primary graft dysfunction score at 72 h after transplantation was grade 1 in three patients and grade 3 in one patient. Conclusions Peripherally cannulated oxyRVAD with percutaneous dual-lumen venous cannula could be an ambulatory bridge for lung transplantation. It is unknown whether oxyRVAD is feasible as a long-term bridge to lung transplantation.
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Affiliation(s)
- Takashi Harano
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ernest G. Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pedro Reck dos Santos
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew R. Morrell
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Pablo G. Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chan EG, Chan PG, Harano T, Ryan JP, Morrell MR, Sanchez PG. Trends in Lung Transplantation Practices Across the United States During the COVID-19 Pandemic. Transplantation 2021; 105:187-192. [PMID: 33141810 DOI: 10.1097/tp.0000000000003522] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The purpose of this study is to examine the effects of the coronavirus disease 2019 (COVID-19) pandemic on adult lung transplants and report practice changes in the United States. METHODS A retrospective analysis of a public dataset from the United Network for Organ Sharing was performed regarding adult lung transplantation (January 19, 2020-June 30, 2020). Data were stratified into 3 periods: pre-COVID-19 (January 19, 2020-March 14, 2020), first COVID-19 era (March 15, 2020-May 8, 2020), and second COVID-19 era (May 9, 2020-June 30, 2020). Weekly changes in waitlist inactivations (COVID-19 precautions or not), waitlist additions, transplant volume, and donor recovery were examined across eras and changes across era were correlated. RESULTS During the first COVID-19 era, 301 patients were added to the waitlist, representing a 40% decrease when compared to the prior 8-week period. This was followed by a significant increase in listing during the second COVID-19 era (t = 2.16, P = 0.032). Waitlist inactivations decreased in the second COVID-19 era from the first COVID-19 era (t = 3.60, P < 0.001). There was no difference in waitlist inactivations between the pre-COVID era and the second COVID-19 era (P = 0.10). Weekly volume was not associated with trends in COVID-19 cases across any era, but was negatively associated with waitlist inactivations due to COVID-19 precautions entering the first COVID-19 era (r = -0.73, P = 0.04) and second COVID-19 era (r = -0.89, P = 0.003). CONCLUSIONS Due to the COVID-19 pandemic, the United States experienced a decrease in lung transplant volume. While overall volume has returned to normal, additional studies are needed to identify areas of improvement to better prepare for future pandemics.
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Affiliation(s)
- Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John P Ryan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Matthew R Morrell
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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Chan EG, Luketich JD, Sanchez PG. Commentary: Recovery following COVID-19 infection: Are we truly ready for what is to come? ACTA ACUST UNITED AC 2020; 5:169-170. [PMID: 34173555 PMCID: PMC7771313 DOI: 10.1016/j.xjon.2020.12.016] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 12/18/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
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Harano T, Ryan JP, Chan EG, Noda K, Morrell MR, Luketich JD, Sanchez PG. Lung transplantation for the treatment of irreversible acute respiratory distress syndrome. Clin Transplant 2020; 35:e14182. [PMID: 33280169 PMCID: PMC7883278 DOI: 10.1111/ctr.14182] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/21/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite advances in critical care for acute respiratory distress syndrome (ARDS), some survivors in the acute phase are unable to wean from extracorporeal membrane oxygenation (ECMO) or mechanical ventilation. To date, little is known regarding whether lung transplantation confers a survival benefit for irreversible ARDS. METHODS This retrospective study was conducted using the United Network for Organ Sharing database (May 2005-December 2018). Patients with restrictive lung disease were divided into two groups: patients with and without ARDS. Propensity score matching identified recipients without ARDS for the control group. RESULTS A total of 63 patients with ARDS were waitlisted for lung transplantation, while 39 received a lung transplant after a median waitlist duration of 8 days. Seventy-eight patients were matched as controls. In the ARDS group, the median age was 30 years, and the median lung allocation score was 88.4. Among the 39 recipients, 30 (76.9%) received ECMO support prior to transplantation. Lung transplantation for ARDS and restrictive lung disease showed similar 90-day (87.2% vs. 88.5%, p = .80), 1-year (82.1% vs. 85.9%, p = .52), and 3-year (69.2% vs. 65.4%, p = .94) survival rates. CONCLUSIONS Lung transplantation provides acceptable outcomes in selected patients with irreversible ARDS.
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Affiliation(s)
- Takashi Harano
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John P Ryan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kentaro Noda
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew R Morrell
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chan EG, Luketich JD, Sarkaria IS. Commentary: The cervical esophagogastric anastomosis: Augmenting training through simulation. J Thorac Cardiovasc Surg 2020; 160:1610-1611. [PMID: 33069422 DOI: 10.1016/j.jtcvs.2020.03.119] [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: 03/30/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
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Chan EG, Schuchert MJ. Commentary: Is it always greener on the other side? JTCVS Tech 2020; 3:325-326. [PMID: 34317917 PMCID: PMC8302922 DOI: 10.1016/j.xjtc.2020.04.028] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/16/2020] [Accepted: 04/22/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Ernest G. Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Matthew J. Schuchert
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, Pittsburgh, Pa
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Chan EG, Chan PG, Harano T, Sanchez PG. Transition of femoral-jugular to dual-stage left subclavian without discontinuation of extracorporeal membrane oxygenation. J Card Surg 2020; 35:2794-2797. [PMID: 32720393 DOI: 10.1111/jocs.14881] [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] [Indexed: 11/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technology that has allowed further cardiopulmonary support in the setting of respiratory failure refractory to mechanical ventilation. While it has evolved since its first description, one area of improvement continues to be its implementation. With advancements in cannulation techniques, in recent years, there has been a plethora of new cannulas that has been introduced in the market. For urgent venous-venous cannulation, the right internal jugular vein along with either femoral veins remain the most utilized strategy due to minimal need for imaging support. This allows for safe bedside cannulation. However, as the number of days of ECMO support continue to increase, transitioning to a cannulation strategy that is easier to ambulate with and more comfortable is preferred. Therefore, we describe a method for transitioning from right jugular-femoral cannulation to left subclavian placement of the Crescent Dual-Lumen catheter without interrupting ECMO support.
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Affiliation(s)
- Ernest G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Patrick G Chan
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Takashi Harano
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abstract
The ethical concerns of refusing lifesaving treatments after receiving an already limited resource such as a solid organ transplantation in a Jehovah's Witness patient have been discussed in the literature. Many of these studies have concluded that with a multidisciplinary approach, solid organ transplantation is possible in the setting of Jehovah's Witness patients. To date, there are no reported cases of bilateral sequential lung transplantation in the literature. We report two successful cases of bilateral sequential lung transplantation in Jehovah's Witness patients with excellent long-term follow-up.
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Affiliation(s)
- Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew R Morrell
- Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Pulmonology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Christie IG, Chan EG, Ryan JP, Harano T, Morrell M, Luketich JD, Sanchez PG. National Trends in Extended Criteria Donor Utilization and Outcomes for Lung Transplantation. Ann Thorac Surg 2020; 111:421-426. [PMID: 32663473 DOI: 10.1016/j.athoracsur.2020.05.087] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 02/04/2020] [Revised: 04/15/2020] [Accepted: 05/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Extended criteria donor (ECD) for lung transplantation (LTx) have been implemented due to the donor organ shortage. The impact on recipient survival is under investigation. We report trends in the use of extended criteria lungs in the modern era and its association with survival outcomes using a large national database. METHODS We performed a retrospective analysis of all adult LTx from May 2005 to December 2018 using the United Network for Organ Sharing database. ECD were defined by 2 or more variances from standard criteria: age ≥ 55 years, pO2 ≤ 300, pack years ≥ 20, diabetes, purulent bronchoscopy, blood infection, or abnormal chest radiographs. Transplant centers were dichotomized based on volume. Recipient survival was analyzed using lung allocation score as a covariate. RESULTS Of 24,888 LTx, 80% had extended criteria; 42% had 2 or more extensions and were deemed ECD in this analysis. Both LTx volume (2005: 1352; 2018: 2495) and use of ECD (2005: 27% ECD, 2018: 50% ECD) have increased over the study period. Survival of LTx recipients has steadily increased (2005: 82% 1-year survival in 2005; 2017: 90% 1-year survival). High-volume centers (>47 annual LTx) utilized ECD in 46% of transplants compared with 40% ECD among other centers. Recipients of ECD and standard criteria organs had no difference in 1-year survival. CONCLUSIONS Donor supply limits the number of LTx performed. Extension of donor criteria has occurred alongside increased overall LTx volume. Use of ECD did not compromise 30-day, 90-day, nor 1-year survival. Further studies are warranted to define long-term outcomes.
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Affiliation(s)
- Ian G Christie
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania
| | - John P Ryan
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania
| | - Takashi Harano
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania
| | - Matthew Morrell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania
| | - James D Luketich
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania
| | - Pablo G Sanchez
- Division of Lung Transplant and Lung Failure, Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center; Pittsburgh, Pennsylvania.
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Chan EG, Schuchert MJ. Commentary: Bronchial artery aneurysms: Embolization or bust? JTCVS Tech 2020; 3:57-58. [PMID: 34317812 PMCID: PMC8303064 DOI: 10.1016/j.xjtc.2020.06.041] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/19/2020] [Accepted: 06/27/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Matthew J Schuchert
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Pittsburgh, Pa
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Ekeke CN, Chan EG, Luketich JD, Dhupar R. Delayed Chylothorax during Treatment of Follicular Lymphoma with a Malignant Pleural Effusion. Case Rep Surg 2020; 2020:2893942. [PMID: 32158584 PMCID: PMC7061108 DOI: 10.1155/2020/2893942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 02/07/2020] [Indexed: 11/17/2022] Open
Abstract
Chylothorax occurs following dysfunction or disruption of the lymphatic drainage along the thoracic duct. Malignant and traumatic causes account for the majority of these occurrences, with lymphoma accounting for 11-37% of chylothoraces. The clinical course of chylothorax may include dehydration, malnutrition, immunosuppression, electrolyte disturbances, infection, and ultimately death. Management of chylothorax is patient-specific and is based on etiology and surgeon experience. Initially, most chyle leaks are managed with nonoperative strategies, such as gut rest, hyperalimentation, and pleural drainage, and, at times, medium-chained fatty acid diet or octreotide, with hopes to decrease chyle production (Zabeck et al. (2011)). High-output chyle leaks following iatrogenic injury or trauma are commonly managed with thoracic duct ligation. Lymphangiography with or without thoracic duct embolization has become increasingly popular and efficacious with the possible benefit of less morbidity (Cope et al. (2002)). We report a case of a 61-year-old male with delayed chylothorax while having an indwelling pleural catheter for malignant pleural effusion during treatment of follicular lymphoma. Percutaneous thoracic duct embolization was attempted but was unsuccessful. Chemotherapy, fluid management, and nutritional support allowed this to resolve over the course of ninety days from diagnosis. We describe the patient's clinical course and highlight nonoperative management of delayed chylothorax in the setting of follicular lymphoma treatment.
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Affiliation(s)
- Chigozirim N. Ekeke
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ernest G. Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - James D. Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rajeev Dhupar
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Surgical Services Division, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Hayanga JWA, Chan EG, Musgrove K, Leung A, Shigemura N, Hayanga HK. Extracorporeal Membrane Oxygenation in the Perioperative Care of the Lung Transplant Patient. Semin Cardiothorac Vasc Anesth 2020; 24:45-53. [PMID: 31893982 DOI: 10.1177/1089253219896123] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lung transplantation (LT) is definitive therapy for end-stage lung disease. Donor allocation based on medical urgency has led to an increased trend in the transplantation of sicker and older patients. Mechanical ventilation (MV) formerly was the only method of bridging high-acuity patients to LT. When the physiological demands of ventilatory support exceeds the capability of MV, extracorporeal membrane oxygenation (ECMO) may become necessary. Recent improvements in ECMO technology and component design have led to a resurgence of interest in its use before, during, and after LT. Survival with ECMO as a bridge to LT has improved over time, now with many centers reporting little or no difference in outcomes, and some even reporting better outcomes, as compared with MV. Extracorporeal life support may also be used intraoperatively. In many studies to date, ECMO or cardiopulmonary bypass (CPB) has been reserved for patients who became hemodynamically unstable during the procedure or patients who could not tolerate single-lung ventilation. Both methods of support are fraught with potential complications. However, multiple studies comparing ECMO with CPB have shown that intraoperative use of ECMO resulted in improved outcomes and overall survival as well as lower rates of bleeding complications. In order to further reduce complications associated with ECMO, planned intraoperative ECMO use is occasionally reserved for high-risk patients who might otherwise require CPB. Future studies will need to improve patient selection to fully take advantage of the use of ECMO in LT while minimizing its costs.
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Affiliation(s)
| | - Ernest G Chan
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Patrick G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pablo G Sanchez
- Department of Cardiothoracic Surgery, Division of Lung Transplantation, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chan PG, Chan EG, Seese L, Sultan I, Kilic A, Gleason TG, Chu D. Safety and Feasibility of a Nonpledgeted Suture Technique for Heart Valve Replacement. JAMA Surg 2019; 154:260-261. [PMID: 30476964 DOI: 10.1001/jamasurg.2018.4243] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Patrick G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laura Seese
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Thomas G Gleason
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Chan PG, Schaheen LW, Chan EG, Cook CC, Luketich JD, D’Cunha J. Technology-Enhanced Simulation Improves Trainee Readiness Transitioning to Cardiothoracic Training. Journal of Surgical Education 2018; 75:1395-1402. [DOI: 10.1016/j.jsurg.2018.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Chan PG, Seese L, Chan EG, Gleason TG, Chu D. Trileaflet aortic valve reconstruction using glutaraldehyde fixed autologous pericardium. J Vis Surg 2018. [DOI: 10.21037/jovs.2018.06.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Chan EG, D'Cunha J. Redefining our cardiothoracic surgical intensive care units: Change is good. J Thorac Cardiovasc Surg 2016; 152:643-4. [PMID: 27423852 DOI: 10.1016/j.jtcvs.2016.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 05/01/2016] [Accepted: 05/02/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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D'Angelo AM, Chan EG, Hayanga JWA, Odell DD, Pilewski J, Crespo M, Morrell M, Shigemura N, Luketich J, Bermudez C, Althouse AD, D'Cunha J. Atrial arrhythmias after lung transplantation: Incidence and risk factors in 652 lung transplant recipients. J Thorac Cardiovasc Surg 2016; 152:901-9. [PMID: 27234020 DOI: 10.1016/j.jtcvs.2016.04.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 06/12/2015] [Revised: 03/25/2016] [Accepted: 04/23/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Atrial arrhythmia (AA) after lung transplantation (LTx) is a potentially morbid event often associated with increased length of hospital stay. Predictors of postsurgical AA, however, are incompletely understood. We characterized the incidence and predisposing risk factors for AA in patients undergoing LTx. METHODS A retrospective analysis of prospectively collected data was conducted to identify LTx recipients between January 2008 and October 2013. Patients were divided into 2 groups on the basis of postoperative AA development. Univariable and multivariable analyses were performed to define differences between groups and identify factors associated with AA. Survival differences were assessed by the use of competing risks methodology. RESULTS A total of 198 of 652 (30.4%) patients developed AA at a median onset of 5 days after transplant. Increasing age (hazard ratio [HR] 1.03 per additional year, P < .001) and previous coronary artery bypass grafting (HR 2.77, P = .002) were found to be independent risk factors. Counterintuitively, patients with a medical history of AA before LTx had a lower incidence of postoperative AA. Preoperative beta-blocker usage was not a significant predictor of postoperative AA. Postoperative AA was a significant predictor of long-term mortality (HR 1.63, P = .007) when we adjusted for other risk factors. CONCLUSIONS AA is a common occurrence after LTx, occurring with greatest frequency in the first postoperative week, and results in a significant reduction in long-term survival. Increasing age and before coronary artery bypass grafting were identified as independent risk factors for AA development. Better understanding of these risk factors may improve identification of patients at heightened risk after transplantation.
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Affiliation(s)
- Alex M D'Angelo
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - J W Awori Hayanga
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - David D Odell
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Joseph Pilewski
- Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Maria Crespo
- Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Matthew Morrell
- Department of Pulmonary Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Norihisa Shigemura
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - James Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Christian Bermudez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Andrew D Althouse
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Chan EG, Bianco V, Richards T, Hayanga JA, Morrell M, Shigemura N, Crespo M, Pilewski J, Luketich J, D'Cunha J. The ripple effect of a complication in lung transplantation: Evidence for increased long-term survival risk. J Thorac Cardiovasc Surg 2016; 151:1171-9. [DOI: 10.1016/j.jtcvs.2015.11.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 11/06/2015] [Accepted: 11/25/2015] [Indexed: 01/31/2023]
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Chan EG, Landreneau JR, Schuchert MJ, Odell DD, Gu S, Pu J, Luketich JD, Landreneau RJ. Preoperative (3-dimensional) computed tomography lung reconstruction before anatomic segmentectomy or lobectomy for stage I non-small cell lung cancer. J Thorac Cardiovasc Surg 2015; 150:523-8. [PMID: 26319461 DOI: 10.1016/j.jtcvs.2015.06.051] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [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: 07/03/2014] [Revised: 04/17/2015] [Accepted: 06/06/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Accurate cancer localization and negative resection margins are necessary for successful segmentectomy. In this study, we evaluate a newly developed software package that permits automated segmentation of the pulmonary parenchyma, allowing 3-dimensional assessment of tumor size, location, and estimates of surgical margins. METHODS A pilot study using a newly developed 3-dimensional computed tomography analytic software package was performed to retrospectively evaluate preoperative computed tomography images of patients who underwent segmentectomy (n = 36) or lobectomy (n = 15) for stage 1 non-small cell lung cancer. The software accomplishes an automated reconstruction of anatomic pulmonary segments of the lung based on bronchial arborization. Estimates of anticipated surgical margins and pulmonary segmental volume were made on the basis of 3-dimensional reconstruction. RESULTS Autosegmentation was achieved in 72.7% (32/44) of preoperative computed tomography images with slice thicknesses of 3 mm or less. Reasons for segmentation failure included local severe emphysema or pneumonitis, and lower computed tomography resolution. Tumor segmental localization was achieved in all autosegmented studies. The 3-dimensional computed tomography analysis provided a positive predictive value of 87% in predicting a marginal clearance greater than 1 cm and a 75% positive predictive value in predicting a margin to tumor diameter ratio greater than 1 in relation to the surgical pathology assessment. CONCLUSIONS This preoperative 3-dimensional computed tomography analysis of segmental anatomy can confirm the tumor location within an anatomic segment and aid in predicting surgical margins. This 3-dimensional computed tomography information may assist in the preoperative assessment regarding the suitability of segmentectomy for peripheral lung cancers.
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Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - James R Landreneau
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Matthew J Schuchert
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
| | - David D Odell
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Suicheng Gu
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jiantao Pu
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - James D Luketich
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Rodney J Landreneau
- Department of Cardiothoracic Surgery, Allegheny Health Network, Pittsburgh, Pa
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Chan EG, D'Cunha J. Anatomic segmentectomy for non-small cell lung cancer: can we believe the hype? Transl Lung Cancer Res 2015. [PMID: 26207208 DOI: 10.3978/j.issn.2218-6751.2015.02.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Chan EG, D'Cunha J. Growing evidence for a weighty problem. J Thorac Cardiovasc Surg 2015; 149:1192-3. [PMID: 25748594 DOI: 10.1016/j.jtcvs.2015.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 01/21/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Ernest G Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Jonathan D'Cunha
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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