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Stącel T, Sybila P, Mędrala A, Ochman M, Nęcki M, Pasek P, Kegler K, Przybyłowski P, Hrapkowicz T, Borowik D, Urlik M. Lung Transplantation in Patients With Systemic Scleroderma-Description of the First Consecutive Cases in Poland: Case Series Report and a Short Literature Review. Transplant Proc 2024; 56:868-876. [PMID: 38702265 DOI: 10.1016/j.transproceed.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
Pulmonary complications of systemic scleroderma (SSc), such as interstitial lung disease and pulmonary hypertension (PH), are responsible for up to 60% of deaths among patients. For many years, most centers considered SSc a contraindication to lung transplantation (LTx); however, recent publications show that appropriately selected SSc candidates for LTx give results comparable to patients with idiopathic PH or idiopathic pulmonary fibrosis. This paper presents the cases of a 60-year-old male patient (patient 1) and a 42-year-old female patient (patient 2) diagnosed with SSc in 2019 and 2013, respectively. In both patients, interstitial-fibrotic changes in the lungs leading to respiratory failure were confirmed by high-resolution computed tomography as well as pulmonary hypertension (WHO group 3), which was also diagnosed during right heart catheterization. In both cases, despite pharmacotherapy, pulmonary fibrosis progressed, leading to severe respiratory failure. The patients were referred for LTx qualification. LTx was possible to consider in patients due to the lack of significant changes in other internal organs. Double LTx was successfully performed in both patients (patient 1-July 19, 2022; patient 2-September 14, 2022). They were discharged from the hospital in good condition on the 22nd and 20th postoperative day, respectively. LTx is a last-chance therapy that saves lives among patients with extreme respiratory failure in the course of SSc. It prolongs and improves the quality of life. The selection of appropriate patients is key to the success of the procedure.
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Affiliation(s)
- Tomasz Stącel
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Paweł Sybila
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland.
| | - Agata Mędrala
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Marek Ochman
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Mirosław Nęcki
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Pasek
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Kamil Kegler
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Hrapkowicz
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Dawid Borowik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac Anaesthesia and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Urlik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
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2
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Hu X, Ding N, Songchen W, Wang R, Chen J, Zhong A, Nan J, Zuo Y, Huang H, Tian D. Lung Transplantation for Pulmonary Arterial Hypertension: Optimized Referral and Listing Based on an Evolving Disease Concept. J Cardiovasc Dev Dis 2023; 10:350. [PMID: 37623363 PMCID: PMC10455552 DOI: 10.3390/jcdd10080350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/31/2023] [Accepted: 08/13/2023] [Indexed: 08/26/2023] Open
Abstract
Pulmonary hypertension (PH) was once a devastating and fatal disease entity, the outlook of which has been significantly improved by the continued progress of medical treatment algorithms. However, some patients still ultimately fail to achieve an adequate clinical response despite receiving maximal medical treatment. Historically, lung transplantation (LTx) has been the only effective therapeutic option that could lead to satisfactory outcomes and save these advanced patients' lives. However, patients with PH tend to have the highest mortality rates on the transplant waiting list; especially after comprehensive medical treatment, they continue to deteriorate very rapidly, eventually missing optimal transplantation windows. Balancing optimized medical treatment with the appropriate timing of referral and listing has been highly controversial in LTx for patients with PH. The 2021 consensus document for the selection of lung transplant candidates from the International Society for Heart and Lung Transplantation (ISHLT) updated the specific recommendations for the LTx referral and listing time for patients with PH based on objective risk stratification. Herein, we review the evolving PH-related concepts and highlight the optimization of LTx referral and listing for patients with PH, as well as their management on the waiting list.
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Affiliation(s)
- Xiaokun Hu
- Outpatient Department, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Ningying Ding
- Anesthesia Operation Center of West China Hospital/West China School of Nursing, Sichuan University, Chengdu 610041, China;
| | - Wanqiu Songchen
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Ruifeng Wang
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Jing Chen
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Ailing Zhong
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Jinzhu Nan
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Yujie Zuo
- Heart and Lung Transplantation Research Laboratory, North Sichuan Medical College, Nanchong 637000, China; (W.S.); (R.W.); (J.C.); (A.Z.); (J.N.); (Y.Z.)
| | - Heng Huang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
- Lung Transplant Research Laboratory, Institute of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Dong Tian
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
- Lung Transplant Research Laboratory, Institute of Thoracic Oncology, West China Hospital, Sichuan University, Chengdu 610041, China
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3
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Managing pulmonary arterial hypertension: how to select and facilitate successful transplantation. Curr Opin Organ Transplant 2022; 27:169-176. [PMID: 35649107 DOI: 10.1097/mot.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite improvements in available medical therapies, pulmonary arterial hypertension (PAH) remains a progressive, ultimately fatal disorder. Lung transplantation is a viable treatment option for PAH patients with advanced disease. RECENT FINDINGS Recent guidelines from the International Society of Heart and Lung Transplantation (ISHLT) have updated recommendations regarding time of referral and listing for lung transplantation in PAH. The new guidelines emphasize earlier referral for transplant evaluation to ensure adequate time for proper evaluation and listing. They also incorporate objective risk stratification criteria to assist in decision-making regarding timing of referral and listing. With regards to the transplant procedure, bilateral lung transplantation has largely supplanted heart-lung transplantation as the procedure of choice for transplantation for advanced PAH. Exceptions to this include patients with PAH because of congenital heart disease and those with concurrent LV dysfunction. Use of mechanical support via venoarterial ECMO initiated before transplantation and continued into the early postoperative period is emerging as a standard of care and may help to reduce early posttransplant mortality in this population. There has been increased recognition of the importance of WHO Group 3 pulmonary hypertension. Many of the lessons learned from PAH may be applied when transplanting patients with severe WHO Group 3 pulmonary hypertension. SUMMARY Patients with PAH present unique challenges with regards to transplantation that require a therapeutic approach distinct from other lung disorders. Lung transplantations for PAH are high-risk endeavors best performed at centers with expertise in management of both PAH and extracorporeal support.
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Takahashi T, Terada Y, Pasque MK, Liu J, Byers DE, Witt CA, Nava RG, Puri V, Kozower BD, Meyers BF, Kreisel D, Patterson GA, Hachem RR. Clinical features and outcomes of combined pulmonary fibrosis and emphysema after lung transplantation. Chest 2021; 160:1743-1750. [PMID: 34186034 DOI: 10.1016/j.chest.2021.06.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/09/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Combined pulmonary fibrosis and emphysema (CPFE) is recognized as a characteristic syndrome of smoking-related interstitial lung disease that has a worse prognosis than idiopathic pulmonary fibrosis (IPF). However, outcomes after lung transplantation for CPFE have not been reported. The aim of this study is to describe the clinical features and outcomes of CPFE after lung transplantation. RESEARCH QUESTION What are the clinical features and outcomes of CPFE after lung transplantation? STUDY DESIGN AND METHODS This is a single-center retrospective cohort study of patients with CPFE and IPF who underwent lung transplantation at our center between January 2011 and December 2016. We defined CPFE as ≥ 10% emphysema in the upper lung fields combined with fibrosis on high-resolution computed tomography scan. We characterized the clinical features of patients with CPFE and compared their outcomes after lung transplantation to those with IPF. RESULTS 27 of 172 (16%) patients with IPF met criteria for CPFE. Severe pulmonary hypertension was present in 16 of 27 (59%) patients with CPFE. On logistic regression analysis, CPFE was significantly associated with primary graft dysfunction (PGD) grade 3 (odds ratio: 3.14, 95% confidence interval [CI]: 1.18-8.37, p=0.02). On competing risk regression analysis, CPFE was associated with acute cellular rejection (ACR) grade ≥ A2, and chronic lung allograft dysfunction (CLAD) (hazard ratio [HR]: 1.89, 95% CI: 1.10-3.25, p=0.02, HR: 1.96, 95% CI: 1.02-3.77, p=0.04, respectively). 5-year survival was 79.0% for the CPFE group and 75.4% for the IPF group, respectively (log rank p = 0.684). INTERPRETATION After transplant, patients with CPFE were more likely to develop PGD, ACR, and CLAD compared to those with IPF. However, survival was not significantly different between the 2 groups.
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Affiliation(s)
- Tsuyoshi Takahashi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yuriko Terada
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael K Pasque
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Derek E Byers
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Chad A Witt
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ruben G Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Bryan F Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - G Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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Olsen JE, Auråen H, Durheim MT, Fiane AE, Holm AM. Predictors of long intensive care need after lung transplantation. Clin Transplant 2020; 35:e14152. [PMID: 33185913 DOI: 10.1111/ctr.14152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND While expected need for intensive care after lung transplantation (LTx) does not normally affect organ allocation, it would be useful to estimate whether intensive care capacity is limited. The aim of this study was to assess factors available before LTx to identify predictors of prolonged intensive care unit (ICU) length of stay (LOS) after LTx. METHODS All bilateral LTx recipients excluding re-transplantation and multi-organ transplantation at Oslo University Hospital from 2000 to 2013 were included (n = 277). Predictive factors for ICU LOS were identified using pre- and perioperative variables. RESULTS Univariate analyses showed that recipients with pulmonary arterial hypertension, young age, female gender, low body height, low pretransplant actual total lung capacity (aTLC), and recipients who received an oversized donor lung were at risk for long ICU LOS. Patients with emphysema had lower risk of long ICU LOS. In multivariate analyses, a lower aTLC (p < .001) and a higher mean pulmonary artery pressure (mPAP) (p = .004) predicted prolonged ICU LOS. CONCLUSIONS We found that small recipient lung volume and high mPAP were predictors for prolonged ICU LOS. Our observations may be useful in planning use of resources in LTx, particularly in times of limited intensive care resources.
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Affiliation(s)
- Jul Eirik Olsen
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Henrik Auråen
- Department of Gastroenterological Surgery, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Michael T Durheim
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Respiratory Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Arnt E Fiane
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Are M Holm
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Respiratory Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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6
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Stącel T, Urlik M, Nęcki M, Antończyk R, Latos M, Wajda-Pokrontka M, Tatoj Z, Zawadzki F, Przybyłowski P, Zembala M, Ochman M. Secondary Pulmonary Hypertension Among Patients Qualified for Lung Transplantation: Single-Center Study. Transplant Proc 2020; 52:2101-2109. [DOI: 10.1016/j.transproceed.2020.02.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 02/13/2020] [Indexed: 11/17/2022]
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7
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Bartolome S, Hoeper MM, Klepetko W. Advanced pulmonary arterial hypertension: mechanical support and lung transplantation. Eur Respir Rev 2017; 26:26/146/170089. [PMID: 29263172 PMCID: PMC9488526 DOI: 10.1183/16000617.0089-2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/22/2017] [Indexed: 11/23/2022] Open
Abstract
The development of targeted therapies has transformed the outlook for patients with pulmonary arterial hypertension (PAH); however, some patients fail to achieve an adequate clinical response despite receiving maximal treatment. For these patients, lung transplantation remains an important therapeutic option, and recommendations for transplantation are included in the current European Society of Cardiology/European Respiratory Society guidelines for the diagnosis and treatment of pulmonary hypertension. Although lung transplantation is not without risk, overall long-term survival rates are good and substantial improvements in quality of life have been reported for lung transplant recipients. In this review, we describe the important considerations prior to, during and after transplantation, including the role of mechanical support, in patients with advanced PAH. Lung transplantation and mechanical support play key therapeutic roles in patients with advanced PAHhttp://ow.ly/mqfG30gMcMd
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Affiliation(s)
- Sonja Bartolome
- Pulmonary and Critical Care Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research, Hannover, Germany
| | - Walter Klepetko
- Dept of Thoracic Surgery, Medical University Vienna/Vienna General Hospital, Vienna, Austria
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8
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Hipertensión pulmonar y trasplante. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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9
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Alkukhun L, Wang XF, Ahmed MK, Baumgartner M, Budev MM, Dweik RA, Tonelli AR. Non-invasive screening for pulmonary hypertension in idiopathic pulmonary fibrosis. Respir Med 2016; 117:65-72. [PMID: 27492515 PMCID: PMC4976395 DOI: 10.1016/j.rmed.2016.06.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 06/01/2016] [Accepted: 06/01/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common complication of idiopathic pulmonary fibrosis (IPF) that is associated with poor prognosis. Noninvasive screening for PH in IPF patients is challenging and a combination of several noninvasive determinations can improve discrimination. METHODS We included 235 IPF patients who underwent right heart catheterization (RHC) as part of the lung transplant evaluation. We measured electrocardiographic (ECG) and echocardiographic variables as well as the pulmonary artery (PA) and ascending aorta (AA) diameters on chest CT. We recorded results of arterial blood gases (ABG), pulmonary function (PFT) and 6-min walk tests (6MWT). RESULTS Several variables were predictors of PH in IPF patients in univariable models including a lower arterial oxygenation and 6MWT distance; worse right ventricular (RV) function, rightward deviation of the QRS axis and a higher FVC/DLCOc ratio, PA/AA diameter ratio, and estimated RV systolic pressure. In multivariable analysis, a worse RV function and higher PA/AA ratio remained predictors of PH (c-index 0.75 (0.65-0.84)). Similarly, a worse RV function, a higher PA/AA ratio and a rightward QRS axis deviation were independent predictors of precapillary PH (c-index 0.86 (0.76-0.92)). A combination of PA/AA diameter ratio <1.1, a QRS axis <90° and normal RV function showed a negative predictive value of 85% for precapillary PH. CONCLUSIONS There are significant differences in ECG, echocardiographic, chest CT, PFT and ABG parameters between IPF patients with and without PH. However, these noninvasive tests alone or combination have limited discrimination ability for PH screening in IPF.
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Affiliation(s)
- Laith Alkukhun
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA.
| | - Xiao-Feng Wang
- Respiratory Institute Biostatistics Core, Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
| | - Mostafa K Ahmed
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Chest Diseases, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | | | - Marie M Budev
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Raed A Dweik
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Adriano R Tonelli
- Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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10
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Manders E, Rain S, Bogaard HJ, Handoko ML, Stienen GJM, Vonk-Noordegraaf A, Ottenheijm CAC, de Man FS. The striated muscles in pulmonary arterial hypertension: adaptations beyond the right ventricle. Eur Respir J 2015; 46:832-42. [PMID: 26113677 DOI: 10.1183/13993003.02052-2014] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 05/19/2015] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a fatal lung disease characterised by progressive remodelling of the small pulmonary vessels. The daily-life activities of patients with PAH are severely limited by exertional fatigue and dyspnoea. Typically, these symptoms have been explained by right heart failure. However, an increasing number of studies reveal that the impact of the PAH reaches further than the pulmonary circulation. Striated muscles other than the right ventricle are affected in PAH, such as the left ventricle, the diaphragm and peripheral skeletal muscles. Alterations in these striated muscles are associated with exercise intolerance and reduced quality of life. In this Back to Basics article on striated muscle function in PAH, we provide insight into the pathophysiological mechanisms causing muscle dysfunction in PAH and discuss potential new therapeutic strategies to restore muscle dysfunction.
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Affiliation(s)
- Emmy Manders
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands Dept of Physiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Silvia Rain
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Harm-Jan Bogaard
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - M Louis Handoko
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands Dept of Cardiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Ger J M Stienen
- Dept of Physiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands Dept of Physics and Astronomy, VU University, Amsterdam, The Netherlands
| | - Anton Vonk-Noordegraaf
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Coen A C Ottenheijm
- Dept of Physiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
| | - Frances S de Man
- Dept of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, The Netherlands
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11
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Manders E, Bogaard HJ, Handoko ML, van de Veerdonk MC, Keogh A, Westerhof N, Stienen GJM, Dos Remedios CG, Humbert M, Dorfmüller P, Fadel E, Guignabert C, van der Velden J, Vonk-Noordegraaf A, de Man FS, Ottenheijm CAC. Contractile dysfunction of left ventricular cardiomyocytes in patients with pulmonary arterial hypertension. J Am Coll Cardiol 2014; 64:28-37. [PMID: 24998125 DOI: 10.1016/j.jacc.2014.04.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND After lung transplantation, increased left ventricular (LV) filling can lead to LV failure, increasing the risk of post-operative complications and mortality. LV dysfunction in pulmonary arterial hypertension (PAH) is characterized by a reduced LV ejection fraction and impaired diastolic function. OBJECTIVES The pathophysiology of LV dysfunction in PAH is incompletely understood. This study sought to assess the contribution of atrophy and contractility of cardiomyocytes to LV dysfunction in PAH patients. METHODS LV function was assessed by cardiac magnetic resonance imaging. In addition, LV biopsies were obtained in 9 PAH patients and 10 donors. The cross-sectional area (CSA) and force-generating capacity of isolated single cardiomyocytes was investigated. RESULTS Magnetic resonance imaging analysis revealed a significant reduction in LV ejection fraction in PAH patients, indicating a reduction in LV contractility. The CSA of LV cardiomyocytes of PAH patients was significantly reduced (~30%), indicating LV cardiomyocyte atrophy. The maximal force-generating capacity, normalized to cardiomyocyte CSA, was significantly reduced (~25%). Also, a reduction in the number of available myosin-based cross-bridges was found to cause the contractile weakness of cardiomyocytes. This finding was supported by protein analyses, which showed an ~30% reduction in the myosin/actin ratio in cardiomyocytes from PAH patients. Finally, the phosphorylation level of sarcomeric proteins was reduced in PAH patients, which was accompanied by increased calcium sensitivity of force generation. CONCLUSIONS The contractile function and the CSA of LV cardiomyocytes is substantially reduced in PAH patients. We propose that these changes contribute to the reduced in vivo contractility of the LV in PAH patients.
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Affiliation(s)
- Emmy Manders
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands; Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Harm-Jan Bogaard
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - M Louis Handoko
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands; Cardiology Institute for Cardiovascular Research, VU University Medical Center, Amsterdam, the Netherlands
| | - Marielle C van de Veerdonk
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - Anne Keogh
- Heart Transplant Unit, St. Vincent's Hospital, Sydney, Australia
| | - Nico Westerhof
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands; Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands
| | - Ger J M Stienen
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands; Department of Physics and Astronomy, VU University, Amsterdam, the Netherlands
| | | | - Marc Humbert
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Département Hospitalo-Universitaire, Thorax Innovation (DHU TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Peter Dorfmüller
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France; Service d'Anatomie Pathologique, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Elie Fadel
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France; Service de Chirurgie Thoracique, Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Christophe Guignabert
- University of Paris-Sud, Faculté de Médecine, Le Kremlin-Bicêtre, France; Inserm U999, Laboratoire d'Excellence en Recherche sur le Médicament et l'Innovation Thérapeutique (LabEx LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis-Robinson, France
| | - Jolanda van der Velden
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands; ICIN Netherlands Heart Institute, Utrecht, the Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands
| | - Frances S de Man
- Department of Pulmonology, Vrije Universiteit (VU) University Medical Center, Amsterdam, the Netherlands.
| | - Coen A C Ottenheijm
- Department of Physiology, VU University Medical Center, Amsterdam, the Netherlands.
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13
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Preoperative cardiac variables of diastolic dysfunction and clinical outcomes in lung transplant recipients. J Transplant 2013; 2013:391620. [PMID: 24163757 PMCID: PMC3791796 DOI: 10.1155/2013/391620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 06/26/2013] [Accepted: 06/28/2013] [Indexed: 12/31/2022] Open
Abstract
Background. Orthotopic lung transplantation is now widely performed in patients with advanced lung disease. Patients with moderate or severe ventricular systolic dysfunction are typically excluded from lung transplantation; however, there is a paucity of data regarding the prognostic significance of abnormal left ventricular diastolic function and elevated pretransplant pulmonary pressures. Methods. We reviewed the characteristics of 111 patients who underwent bilateral and unilateral lung transplants from 200 to 2009 in order to evaluate the prognostic significance of preoperative markers of diastolic function, including invasively measured pulmonary capillary wedge pressure (PCWP) and echocardiographic variables of diastolic dysfunction including mitral A > E and A′ > E′. Results. Out of 111 patients, 62 were male (56%) and average age was 54.0 ± 10.5 years. Traditional echocardiographic Doppler variables of abnormal diastolic function, including A′ > E′ and A > E, did not predict adverse events (P = 0.49). Mildly elevated pretransplant PCWP (16–20 mmHg) and moderately/severely elevated PCWP (>20 mmHg) were not associated with adverse clinical events after transplant (P = 0.30). Additionally, all clinical endpoints did not show any statistical significance between the two groups. Conclusions. Pre-lung transplant invasive and echocardiographic findings of elevated pulmonary pressures and abnormal left ventricular diastolic function are not predictive of adverse posttransplant clinical events.
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Wrobel JP, Thompson BR, Snell GI, Williams TJ. Preoperative Echocardiographic-Defined Moderate–Severe Pulmonary Hypertension Predicts Prolonged Duration of Mechanical Ventilation Following Lung Transplantation for Patients with COPD. Lung 2012; 190:635-43. [DOI: 10.1007/s00408-012-9423-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 09/20/2012] [Indexed: 11/28/2022]
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Abstract
Pulmonary hypertension (PH) is a serious and progressive disorder that results in right ventricular dysfunction that lead to subsequent right heart failure and death. When untreated the median survival for these patients is 2.8 years. Over the past decade advances in disease specific medical therapy considerably changed the natural history. This is reflected in a threefold decrease in the number of patients undergoing lung transplantation for PH which used to be main stay of treatment. Despite the successful development of medical therapy lung transplant still remains the gold standard for patients who fail medical therapy. Referral for lung transplant is recommended when patients have a less than 2-3 years of predicted survival or in NYHA class III or IV. Both single and bilateral lung transplants have been successfully performed for PH but outcome analyses and survival comparisons generally favor a bilateral lung transplant.
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Affiliation(s)
- Jason Long
- Department of Surgery, Section of Cardiac and Thoracic Surgery, University of Chicago Medical Center, Chicago, Illinois
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16
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Abstract
Although medical therapies for pulmonary arterial hypertension have greatly improved, it remains a chronic and fatal disease. For patients who are refractory to medical therapy, lung transplantation is an important treatment option. This review discusses issues pertaining to indications for transplant, preparation for transplant and listing, operative issues, and outcomes for patients with pulmonary arterial hypertension.
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Affiliation(s)
- M Patricia George
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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17
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Pitsiou G, Papakosta D, Bouros D. Pulmonary hypertension in idiopathic pulmonary fibrosis: a review. ACTA ACUST UNITED AC 2011; 82:294-304. [PMID: 21677422 DOI: 10.1159/000327918] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 03/29/2011] [Indexed: 01/16/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a progressive diffuse parenchymal disease with a poor prognosis. Pulmonary hypertension (PH) often complicates the course of IPF and may even be found in patients with preserved lung function. Possible pathogenetic mechanisms of PH in IPF include vascular destruction, pulmonary hypoxic vasoconstriction and vascular remodeling due to overexpression of cytokines and growth factors. PH in IPF patients is associated with decreased exercise capacity and a worse prognosis. Due to its prognostic significance, it seems important to investigate for PH in these patients. As the symptoms of PH in IPF are nonspecific, the development of PH in a patient with known IPF can be easily overlooked. Noninvasive methods provide clues for the diagnosis, but their sensitivity is limited. Doppler echocardiography is a useful tool for the detection of PH which also provides additional information regarding associated cardiac abnormalities. However, right heart catheterization remains the gold standard diagnostic test. Therapeutic options for PH in IPF are limited. Long-term oxygen administration for the correction of hypoxemia should be recommended. The availability of new pharmacological agents in the treatment of PH has raised the possibility of therapy in patients with IPF and associated PH. Whether these PH-targeted therapies may be of benefit in this patient group, in terms of improving functional outcomes and survival, remains uncertain.
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Affiliation(s)
- Georgia Pitsiou
- Department of Pneumonology, Aristotle University of Thessaloniki, G. Papanikolaou Hospital, Thessaloniki, Greece
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18
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Fang A, Studer S, Kawut SM, Ahya VN, Lee J, Wille K, Lama V, Ware L, Orens J, Weinacker A, Palmer SM, Crespo M, Lederer DJ, Deutschman CS, Kohl BA, Bellamy S, Demissie E, Christie JD. Elevated pulmonary artery pressure is a risk factor for primary graft dysfunction following lung transplantation for idiopathic pulmonary fibrosis. Chest 2010; 139:782-787. [PMID: 20864607 DOI: 10.1378/chest.09-2806] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is often associated with elevations in pulmonary artery pressures. Although primary pulmonary arterial hypertension (PAH) has been associated with primary graft dysfunction (PGD), the role of secondary PAH in mediating PGD risk in patients with IPF is incompletely understood. The purpose of this study was to evaluate the relationship between mean pulmonary artery pressure (mPAP) and PGD among patients with IPF. METHODS We performed a multicenter prospective cohort study of 126 lung transplant procedures performed for IPF between March 2002 and August 2007. The primary outcome was grade 3 PGD at 72 h after lung transplant. The mPAP was measured as the initial reading following insertion of the right-sided heart catheter during lung transplant. Multivariable logistic regression was used to adjust for confounding variables. RESULTS The mPAP for patients with PGD was 38.5 ± 16.3 mm Hg vs 29.6 ± 11.5 mm Hg for patients without PGD (mean difference, 8.9 mm Hg [95% CI, 3.6-14.2]; P = .001). The increase in odds of PGD associated with each 10-mm Hg increase in mPAP was 1.64 (95% CI, 1.18-2.26; P = .003). In multivariable models, this relationship was independent of confounding by other clinical variables, although the use of cardiopulmonary bypass partially attenuated the relationship. CONCLUSIONS Higher mPAP in patients with IPF is associated with the development of PGD.
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Affiliation(s)
- Adam Fang
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh PA
| | - Sean Studer
- Division of Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, Newark, NJ
| | - Steven M Kawut
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia PA; Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia PA
| | - Vivek N Ahya
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia PA
| | - James Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia PA
| | - Keith Wille
- Division of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham AL
| | - Vibha Lama
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Michigan, Nashville TN
| | - Lorraine Ware
- Division of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University, Nashville TN
| | - Jonathan Orens
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Johns Hopkins University Hospital, Baltimore MD
| | - Ann Weinacker
- Division of Pulmonary and Critical Care Medicine, Stanford University, Durham NC
| | - Scott M Palmer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University, Durham NC
| | - Maria Crespo
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh, Pittsburgh PA
| | - David J Lederer
- Division of Pulmonary and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Clifford S Deutschman
- Department of Anesthesia and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Benjamin A Kohl
- Department of Anesthesia and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Scarlett Bellamy
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia PA
| | - Ejigayehu Demissie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia PA; Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia PA
| | - Jason D Christie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia PA; Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia PA.
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Neurohr C, Huppmann P, Thum D, Leuschner W, von Wulffen W, Meis T, Leuchte H, Baumgartner R, Zimmermann G, Hatz R, Czerner S, Frey L, Ueberfuhr P, Bittmann I, Behr J. Potential functional and survival benefit of double over single lung transplantation for selected patients with idiopathic pulmonary fibrosis. Transpl Int 2010; 23:887-96. [PMID: 20230541 DOI: 10.1111/j.1432-2277.2010.01071.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a frequent indication for lung transplantation (LTX) with pulmonary hypertension (PH) negatively affecting outcome. The optimal procedure type remains a debated topic. The aim of this study was to evaluate the impact of pretransplant PH in IPF patients. Single LTX (SLTX, n = 46) was the standard procedure type. Double LTX (DLTX, n = 30) was only performed in cases of relevant PH or additional suppurative lung disease. There was no significant difference for pretransplant clinical parameters. Preoperative mean pulmonary arterial pressure was significantly higher in DLTX recipients (22.7 +/- 0.8 mmHg vs. 35.9 +/- 1.8 mmHg, P < 0.001). After transplantation, 6-min-walk distance and BEST-FEV(1) were significantly higher for DLTX patients (6-MWD: 410 +/- 25 m vs. 498 +/- 23 m, P = 0.02; BEST-FEV(1): 71.2 +/- 3.0 (% pred) vs. 86.2 +/- 4.2 (% pred), P = 0.004). Double LTX recipients demonstrated a significantly better 1-year-, overall- and Bronchiolitis obliterans Syndrome (BOS)-free survival (P < 0.05). Cox regression analysis confirmed SLTX to be a significant predictor for death and BOS. Single LTX offers acceptable survival rates for IPF patients. Double LTX provides a significant benefit in selected recipients. Our data warrant further trials of SLTX versus DLTX stratifying for potential confounders including PH.
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Affiliation(s)
- Claus Neurohr
- Division of Pulmonary Diseases, Department of Internal Medicine I, Klinikum Grosshadern, Ludwig-Maximilians University, Munich, Germany.
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20
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Abstract
Significant advances in the treatment of pulmonary arterial hypertension have occurred in the last several years. The decision to refer a patient for transplantation requires a dynamic approach. Candidate selection and timing of referral to transplant centers is critical for success, particularly with current allocation protocols that do not take into account the severity of illness. Though long-term success is tempered by chronic allograft dysfunction and infection, considerable improvements in outcomes have established lung transplantation for pulmonary arterial hypertension as an efficacious and life-prolonging treatment. However, transplantation should be reserved for patients who have failed the best available medical therapy. Ideally, transplantation occurs when the clinically deteriorating patient has enough reserve to survive long enough to be transplanted but is not debilitated enough to jeopardize the graft. There is significant uncertainty with regard to this ideal.
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Affiliation(s)
- Edward Cantu
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - R. Duane Davis
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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21
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Philippe B, Dromer C, Mornex JF, Velly JF, Stern M. Quand le pneumologue doit-il envisager la greffe pulmonaire pour un de ses patients ? Rev Mal Respir 2009; 26:423-35; quiz 480, 483. [DOI: 10.1016/s0761-8425(09)74047-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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22
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Guth S, Prüfer D, Kramm T, Mayer E. Length of pressure-controlled reperfusion is critical for reducing ischaemia-reperfusion injury in an isolated rabbit lung model. J Cardiothorac Surg 2007; 2:54. [PMID: 18067666 PMCID: PMC2228300 DOI: 10.1186/1749-8090-2-54] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2007] [Accepted: 12/07/2007] [Indexed: 11/30/2022] Open
Abstract
Background Ischaemia-reperfusion injury is still a major problem after lung transplantation. Several reports describe the benefits of controlled graft reperfusion. In this study the role of length of the initial pressure-controlled reperfusion (PCR) was evaluated in a model of isolated, buffer-perfused rabbit lungs. Methods Heart-lung blocks of 25 New Zealand white rabbits were used. After measurement of baseline values (haemodynamics and gas exchange) the lungs were exposed to 120 minutes of hypoxic warm ischaemia followed by repeated measurements during reperfusion. Group A was immediately reperfused using a flow of 100 ml/min whereas groups B, C and D were initially reperfused with a maximum pressure of 5 mmHg for 5, 15 or 30 minutes, respectively. The control group had no period of ischaemia or PCR. Results Uncontrolled reperfusion (group A) caused a significant pulmonary injury with increased pulmonary artery pressures (PAP) and pulmonary vascular resistance and a decrease in oxygen partial pressure (PO2), tidal volume and in lung compliance. All groups with PCR had a significantly higher PO2 for 5 to 90 min after start of reperfusion. At 120 min there was also a significant difference between group B (264 ± 91 mmHg) compared to groups C and D (436 ± 87 mmHg; 562 ± 20 mmHg, p < 0.01). All PCR groups showed a significant decrease of PAP compared to group A. Conclusion Uncontrolled reperfusion results in a severe lung injury with rapid oedema formation. PCR preserves pulmonary haemodynamics and gas exchange after ischaemia and might allows for recovery of the impaired endothelial function. 30 minutes of PCR provide superior results compared to 5 or 15 minutes of PCR.
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Affiliation(s)
- Stefan Guth
- Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg - University, Langenbeckstr, 1, 55131 Mainz, Germany.
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23
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Patel NM, Lederer DJ, Borczuk AC, Kawut SM. Pulmonary hypertension in idiopathic pulmonary fibrosis. Chest 2007; 132:998-1006. [PMID: 17873194 DOI: 10.1378/chest.06-3087] [Citation(s) in RCA: 182] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is an untreatable diffuse parenchymal lung disease with a median survival of < 3 years. Pulmonary hypertension (PH) is frequently seen in patients with IPF and is commonly attributed to hypoxic vasoconstriction and capillary destruction. Pathology findings include endothelial proliferation and medial hypertrophy that exceed those expected in the setting of hypoxia. Noninvasive evaluation has limited sensitivity and specificity for the diagnosis of PH in IPF; therefore, right-heart catheterization remains the "gold standard" diagnostic test. PH in patients with IPF is associated with decreased exercise capacity and worse survival. Given the grave consequences of this condition, treatment of PH could improve functional outcomes and survival. However, possible treatments such as long-term supplemental oxygen and targeted vascular therapy are either unstudied or remain unproven.
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Affiliation(s)
- Nina M Patel
- Department of Medicine, Division of Pulmonary, Allergy & Critical Care, Columbia University, 622 W 168th St, PH 8 East, Room 101, New York, NY 10032, USA.
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24
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Ryu JH, Krowka MJ, Pellikka PA, Swanson KL, McGoon MD. Pulmonary hypertension in patients with interstitial lung diseases. Mayo Clin Proc 2007; 82:342-50. [PMID: 17352370 DOI: 10.4065/82.3.342] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pulmonary hypertension (PH) in patients with interstitial lung diseases (ILDs) is not well recognized and can occur in the absence of advanced pulmonary dysfunction or hypoxemia. To address this topic, we identified relevant studies in the English language by searching the MEDLINE database (1966 to November 2006) and by individually reviewing the references of identified articles. Connective tissue disease-related ILD, sarcoidosis, idiopathic pulmonary fibrosis, and pulmonary Langerhans cell histiocytosis are the ILDs most commonly associated with PH. Pulmonary hypertension is an underrecognized complication in patients with ILDs and can adversely affect symptoms, functional capacity, and survival. Pulmonary hypertension can arise in patients with ILDs through various mechanisms, Including pulmonary vasoconstriction and vascular remodeling, vascular destruction associated with progressive parenchymal fibrosis, vascular inflammation, perivascular fibrosis, and thrombotic angiopathy. Diagnosis of PH in these patients requires a high index of suspicion because the clinical presentation tends to be nonspecific, particularly in the presence of an underlying parenchymal lung disease. Doppler echocardiography is an essential tool in the evaluation of suspected PH and allows ready recognition of cardiac causes. Right heart catheterization is needed to confirm the presence of PH, assess its severity, and guide therapy. Management of PH in patients with ILDs is guided by identification of the underlying mechanism and the clinical context. An increasing number of available pharmacologic agents in the treatment of PH allow possible treatment of PH in some patients with ILDs. Whether specific treatment of PH in these patients favorably alters functional capacity or outcome needs to be determined.
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Affiliation(s)
- Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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25
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Fitton TP, Kosowski TR, Barreiro CJ, Chan V, Patel ND, Borja MC, Orens JB, Conte JV. Impact of secondary pulmonary hypertension on lung transplant outcome. J Heart Lung Transplant 2006; 24:1254-9. [PMID: 16143242 DOI: 10.1016/j.healun.2004.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Revised: 08/06/2004] [Accepted: 08/15/2004] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Secondary pulmonary hypertension (SPH), defined as a mean pulmonary artery pressure (PAM) greater than 25 mm Hg, complicates end-stage lung diseases of varying etiology. Although previous studies have suggested that SPH does not adversely affect outcome, no study has assessed the impact of the degree of SPH. METHODS A retrospective review of the lung transplant database was used to identify patients who underwent either single-lung (SLT) or bilateral lung transplantation (BLT) complicated by SPH. SPH patients were stratified into low SPH (PAM = 30-40 mm Hg) and high SPH (PAM > or = 40 mm Hg). Each group was further sub-categorized into SLT or BLT. Patients with a heart-lung transplant or primary pulmonary hypertension were excluded. Recipients without pulmonary hypertension transplanted over the same time were used as controls. Data are reported as controls vs low SPH vs high SPH. RESULTS One hundred-four patients received lung transplants between August 1998 and March 2003. There were 45 patients (18 men and 27 women) with SPH. Of these, 28 patients had low SPH, and 17 patients had high SPH. Forty-two patients (18 men and 24 women) without PH were the controls. There were no significant differences between groups except pre-operative oxygen dependence (81% vs 100% vs 94%, respectively) and use of CPB (28.6% vs 57.1% vs 64.7%, respectively). PAO2-PaO2 gradients and PaO2/FIO2 ratios were significantly worse in the high SPH group (116.2 vs 132.9 vs 186.3; p < 0.006) and (277.8 vs 234.3 vs 214.4; p < 0.026) respectively. There was no statistical difference in length of mechanical ventilation or duration of intensive care unit stay between groups. PAMs were significantly different pre-operatively (22.2 +/- 0.8 vs 34.0 +/- 0.6 vs 47.8 +/- 2.0; p < 0.001) and post-operatively (20.9 +/- 1.1 vs 23.7 +/- 1.3 vs 24.8 +/- 2.1; p < 0.001). There were no operative deaths. There were 3 early deaths in the control group, 1 in the low SPH group, and 3 in the high SPH group, none were related to pulmonary hypertension. Actuarial survival at 12, 24, and 48 months was not significantly different among the groups nor between SLT or BLT with SPH. CONCLUSION Although SPH increases the risk of reperfusion injury; survival is equivalent with mild or moderate pulmonary hypertension. Either SLT or BLT may be used in patients with SPH without compromising outcome. This has the added benefit of expanding the donor pool.
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Affiliation(s)
- Torin P Fitton
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland 21287-4618, USA
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26
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Whelan TPM, Dunitz JM, Kelly RF, Edwards LB, Herrington CS, Hertz MI, Dahlberg PS. Effect of preoperative pulmonary artery pressure on early survival after lung transplantation for idiopathic pulmonary fibrosis. J Heart Lung Transplant 2006; 24:1269-74. [PMID: 16143244 DOI: 10.1016/j.healun.2004.10.014] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2004] [Revised: 10/11/2004] [Accepted: 10/11/2004] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is the second largest indication for lung transplantation worldwide. Average 90-day mortality rates for this procedure are 22%. It is unclear what factors predispose patients with IPF to this increased early posttransplant mortality. Pulmonary hypertension may increase the risk of development of early posttransplant complications through several mechanisms. We examined the effect of secondary pulmonary hypertension on 90-day mortality after lung transplantation for IPF. METHODS An International Society for Heart and Lung Transplant Registry cohort study of 830 patients with IPF transplanted from January 1995 to June 2002 was undertaken. Risk factors were assessed individually and adjusted for confounding by a multivariable logistic regression model. RESULTS In the univariate analysis, pulmonary hypertension and bilateral-lung transplantation were significant risk factors for increased 90-day mortality. Multivariate analysis confirmed that mean pulmonary artery pressure and bilateral procedure remain independent risk factors after adjustment for potential confounders. Recipient age, ischemia time, cytomegalovirus status mismatch, and donor age were not independent risk factors for early mortality. CONCLUSIONS Bilateral-lung transplantation carries a greater risk of early mortality than single-lung transplantation for IPF. Increasing pulmonary artery pressure is a risk factor for death after single-lung transplantation in IPF. Mean pulmonary artery pressure should be included in the overall risk assessment of patients with IPF evaluated for lung transplantation.
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Affiliation(s)
- T P M Whelan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, Minnesota, USA.
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27
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Pilcher DV, Snell GI, Scheinkestel CD, Bailey MJ, Williams TJ. High Donor Age, Low Donor Oxygenation, and High Recipient Inotrope Requirements Predict Early Graft Dysfunction in Lung Transplant Recipients. J Heart Lung Transplant 2005; 24:1814-20. [PMID: 16297787 DOI: 10.1016/j.healun.2005.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2004] [Revised: 03/20/2005] [Accepted: 04/04/2005] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Early dysfunction in lung transplants is characterized by poor oxygenation, which may then lead to prolonged mechanical ventilation. This may be due to a combination of donor, recipient, and management factors. Our aim was to determine the incidence and severity of hypoxia and graft dysfunction and which factors were directly associated with poor oxygenation within the first 24 hours after lung transplantation. METHODS A retrospective study of all 128 lung transplants between 1999 and 2002 was undertaken. Multiple linear regression analysis was performed to determine which donor, recipient, operative, and intensive care unit (ICU) parameters were associated with the worst recorded arterial blood gas partial pressure of oxygen (PAO2)/fraction of inspired oxygen (FIO2) ratio in the initial 24 hours after operation. RESULTS Eighty-three percent of the patients (104 of 128) had a PAO2/FIO2 ratio below 300 within the first 24 hours post-transplantation, and 60% (77 of 128) had a PAO2/FIO2 ratio below 200. A high donor age (p = 0.004), low donor PAO2 (p = 0.007), and high post-operative inotrope requirements (p = 0.02) were correlated with a low PAO2/FIO2 ratio. Recipient diagnosis, ischemic time, use of cardiopulmonary bypass, fluid balance in the ICU, and cardiac index were not related. There was no difference in the long-term outcomes of patients with high or low PAO2/FIO2 ratios. CONCLUSIONS A low PAO2/FIO2 ratio is a common finding in the first 24 hours after lung transplantation. Donor factors such as age and PAO2, and the need for increasing inotrope requirements in ICU predict early graft dysfunction and hypoxia.
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Affiliation(s)
- David V Pilcher
- Department of Intensive Care Medicine, The Alfred Hospital, Prahran, Victoria, Australia.
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28
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Barr ML, Kawut SM, Whelan TP, Girgis R, Böttcher H, Sonett J, Vigneswaran W, Follette DM, Corris PA. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction Part IV: Recipient-Related Risk Factors and Markers. J Heart Lung Transplant 2005; 24:1468-82. [PMID: 16210118 DOI: 10.1016/j.healun.2005.02.019] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Revised: 02/07/2005] [Accepted: 02/17/2005] [Indexed: 12/27/2022] Open
Affiliation(s)
- Mark L Barr
- University of Southern California, Los Angeles, California 90033, USA.
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29
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Pilcher DV, Scheinkestel CD, Snell GI, Davey-Quinn A, Bailey MJ, Williams TJ. High central venous pressure is associated with prolonged mechanical ventilation and increased mortality after lung transplantation. J Thorac Cardiovasc Surg 2005; 129:912-8. [PMID: 15821663 DOI: 10.1016/j.jtcvs.2004.07.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Poor oxygenation might occur in transplanted lungs as a result of reperfusion injury and lack of lymphatic drainage. Low central venous and pulmonary capillary wedge pressures are advocated to reduce pulmonary edema and maximize oxygenation but might adversely affect cardiac index, circulation, and renal function. METHODS Histories, intensive care unit charts, and donor data on 118 lung transplantations performed between 1999 and 2002 were retrospectively assessed. Multiple logistic regression analysis was performed on donor, recipient, operative, and intensive care unit parameters to determine the relationship of filling pressure (central venous and pulmonary capillary wedge pressures) to prolonged mechanical ventilation and outcome. The mean central venous pressure was used to divide patients into high and low central venous pressure groups, which were then compared to determine differences in outcome and complication rates. RESULTS A high central venous pressure was found to be associated with prolonged mechanical ventilation (odds ratio, 1.57; 95% confidence interval, 1.13-2.20; P = .008). After removing the effect of poor myocardial function by excluding patients with low cardiac index (< 2.2 L x min -1 x m(-2) ) and high inotrope requirement (> 10 microg/min), central venous pressure remained associated with prolonged mechanical ventilation (odds ratio, 2.31; 95% confidence interval, 1.31-4.07; P = .004). Duration of ventilation (P < .001), intensive care unit mortality (P = .02), hospital mortality (P = .09), and 2-month mortality (P = .02) were higher in patients with central venous pressures of greater than 7 mm Hg. There was no evidence of complications caused by hypovolemia in the low (< or = 7 mm Hg) central venous pressure group, who had lower inotrope requirements (P = .02) and lower creatinine levels (P = .013). Conclusions A high central venous pressure was associated with adverse outcomes after lung transplantation.
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Affiliation(s)
- D V Pilcher
- Department of Intensive Care Medicine, The Alfred Hospital, Prahran, Australia
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Doyle RL, McCrory D, Channick RN, Simonneau G, Conte J. Surgical Treatments/Interventions for Pulmonary Arterial Hypertension. Chest 2004; 126:63S-71S. [PMID: 15249495 DOI: 10.1378/chest.126.1_suppl.63s] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
While considerable advances have been achieved in the medical treatment of pulmonary arterial hypertension (PAH) over the past decade, surgical and interventional approaches continue to have important roles in those patients for whom medical therapy is unavailable or has been unsuccessful. These techniques include pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension, thoracic transplantation, and atrial septostomy. This chapter will provide evidence-based recommendations for the selection and timing of surgical and interventional treatments of PAH for physicians involved in the care of these complex patients.
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Affiliation(s)
- Ramona L Doyle
- Pulmonary and Critical Care Medicine, H3147 Stanford University School of Medicine, Palo Alto, CA 94305, USA.
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31
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Ceriana P, Braschi A, Navalesi P. Detection of severe intraoperative hypoxemia after single-lung transplantation for primary pulmonary hypertension. J Cardiothorac Vasc Anesth 2004; 18:204-6. [PMID: 15073714 DOI: 10.1053/j.jvca.2004.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Piero Ceriana
- Pulmonary Rehabilitation and Respiratory Intensive Care Unit, IRCCS S Maugeri Foundation, University of Pavia, Pavia, Italy.
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Cantu E, Davis RD. Lung Transplantation: Timing, Perioperative Considerations and Postoperative Outcome. ACTA ACUST UNITED AC 2004. [DOI: 10.21693/1933-088x-3.1.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Edward Cantu
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
- Dr. Cantu was supported by a grant from the National Institutes of Health (1F32 HL 71457-01)
| | - R. Duane Davis
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Abstract
Although much has been accomplished in HTx and LTx in the past few decades, much remains to be conquered. It is an ever-changing, always fascinating field. Though science and technology know no limits, the primary limitation of HTx and LTx continues to be the availability of donor organs. One can only hope that further advances in educating the public will help close the large gap between the list of those waiting and the organs available for transplantation.
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Affiliation(s)
- Behnam M Goudarzi
- Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY 10467, USA.
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Abstract
STUDY OBJECTIVES To characterize patients who acquired postoperative respiratory failure after lung transplantation (LT), and to identify risks associated with postoperative respiratory failure and poor surgical outcome. STUDY DESIGN Retrospective clinical analysis in a tertiary care transplantation center. METHODS We reviewed the records of 80 consecutive patients who underwent LT from April 1994 to May 1999, analyzing their records for a number of preoperative and perioperative variables and complications. RESULTS Forty-four patients (55%) acquired postoperative respiratory failure and had a mortality rate of 45%. No difference was noted between patients with respiratory failure and those without in terms of age (mean +/- SD, 56 +/- 9 years vs 53 +/- 11 years), gender, baseline pretransplant arterial blood gas analysis (PaCO(2), 46 +/- 9 mm Hg vs 44 +/- 10 mm Hg), and cardiopulmonary exercise testing (maximum oxygen uptake, 0.76 +/- 0.44 L/min/m(2) vs 0.82 +/- 0.20 L/min/m(2)). Ischemic reperfusion lung injury (IRLI) [55%] and perioperative cardiovascular/hemorrhagic events (36%) were the major contributors to the development of respiratory failure. Preoperative pulmonary hypertension, right ventricular (RV) dysfunction, ischemic times, and need for bilateral LT and cardiopulmonary bypass (CPB) were higher in patients with respiratory failure (p < 0.05) compared to recipients without respiratory failure. However, the presence of preoperative moderate-to-severe RV dysfunction was the only independent factor (odds ratio, 21.9; 95% confidence interval, 1.6 to 309.0). CONCLUSION Respiratory failure after LT is common and is associated with high morbidity and mortality. Respiratory failure often occurred in patients with operative technical complications, cardiovascular events, and postoperative IRLI, which were observed most in patients requiring CPB because of RV dysfunction.
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Affiliation(s)
- Wissam M Chatila
- Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, 3401 N Broad St, Philadelphia, PA 19140, USA.
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35
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Fiser SM, Tribble CG, Kaza AK, Long SM, Kern JA, Cassada DC, Linden J, Rieger J, Laubach VE, Matisoff A, Kron IL. Adenosine A2A receptor activation decreases reperfusion injury associated with high-flow reperfusion. J Thorac Cardiovasc Surg 2002; 124:973-8. [PMID: 12407381 DOI: 10.1067/mtc.2002.124886] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION High pulmonary artery flow rates can result in severe reperfusion injury after lung transplantation. Our hypothesis was that selective activation of the adenosine A(2A) receptor with a highly specific analog (ATL-146e) would inhibit leukocyte activation and decrease reperfusion injury after high-flow reperfusion. METHODS Using our isolated, ventilated, blood-perfused rabbit lung model, all groups (n = 8 per group) underwent lung harvest, 4 hours of cold storage, and blood reperfusion for 30 minutes. Measurements of pulmonary artery pressure (in millimeters of mercury), arterial oxygenation (in millimeters of mercury), myeloperoxidase, peak inspiratory pressure, and wet/dry weight ratio were obtained. Groups 1 (high flow) and 2 (high flow ATL-146e) underwent reperfusion at 120 mL/min for 30 minutes. Groups 3 (controlled high flow) and 4 (controlled high flow ATL-146e) underwent controlled reperfusion with an initial reperfusion of 60 mL/min for the first 5 minutes, followed by a rate of 120 mL/min for 25 minutes. During reperfusion, groups 2 and 4 received ATL-146e at 4 microg. kg(-1). min(-1). RESULTS ATL-146e significantly improved lung physiologic measurements under both high-flow (group 1 vs group 2) and controlled high-flow (group 3 vs group 4) conditions after 30 minutes. CONCLUSIONS The adenosine A(2A) receptor analogue ATL-146e significantly decreases the severity of reperfusion injury in the setting of both high-flow and controlled high-flow reperfusion.
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Affiliation(s)
- Steven M Fiser
- Department of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, VA 22908, USA.
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Franke UFW, Wahlers T, Wittwer T, Franke T, Niedermeyer J, Harringer W, Haverich A. Heart-lung transplantation is the method of choice in the treatment of patients with end-stage pulmonary hypertension. Transplant Proc 2002; 34:2181-2. [PMID: 12270357 DOI: 10.1016/s0041-1345(02)03195-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- U F W Franke
- Department of Cardiothoracic and Vascular Surgery, Friedrich-Schiller-University, Jena, Germany.
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37
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Fiser SM, Kron IL, Long SM, Kaza AK, Kern JA, Cassada DC, Laubach VE, Tribble CG. Controlled perfusion decreases reperfusion injury after high-flow reperfusion. J Heart Lung Transplant 2002; 21:687-91. [PMID: 12057703 DOI: 10.1016/s1053-2498(01)00774-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Some investigators have suggested that high pulmonary artery flow rates increase the risk of severe reperfusion injury after lung transplantation. We hypothesized that controlling the initial flow rate and pulmonary artery pressure would decrease the severity of lung dysfunction in the setting of high-flow reperfusion. METHODS Using our isolated, ventilated, blood-perfused rabbit lung model, all groups underwent lung harvest, 4-hour storage (4 degrees C), and blood reperfusion. We measured pulmonary artery pressure, peak inspiratory pressure, arterial oxygenation, and wet-to-dry weight ratio. Group 1 (control, n = 8) underwent reperfusion at 60 ml/min for 30 minutes. Group 2 (high flow, n = 8) underwent reperfusion at 120 ml/min for 30 minutes. Group 3 (controlled flow, n = 8) underwent initial reperfusion at 60 ml/min for 5 minutes, followed by reperfusion at 120 ml/min for 25 minutes. RESULTS Group 1 had significantly improved pulmonary artery pressure, peak inspiratory pressure, arterial oxygenation, and wet-to-dry weight ratio measurements compared with groups 2 and 3 after 30 minutes of reperfusion. However, Group 3 had improved pulmonary artery pressure, peak inspiratory pressure, arterial oxygenation, and wet-to-dry weight ratio measurements compared with Group 2. CONCLUSIONS High-flow reperfusion results in severe reperfusion injury after lung transplantation. Controlled reperfusion using a low initial flow rate decreases the severity of reperfusion injury associated with high-flow rates.
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Affiliation(s)
- Steven M Fiser
- Department of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908, USA.
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Conte JV, Borja MJ, Patel CB, Yang SC, Jhaveri RM, Orens JB. Lung transplantation for primary and secondary pulmonary hypertension. Ann Thorac Surg 2001; 72:1673-9; discussion 1679-80. [PMID: 11722064 DOI: 10.1016/s0003-4975(01)03081-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Single lung transplantation (SLT) and bilateral lung transplantation (BLT) are routinely performed in patients with primary pulmonary hypertension (PPH) and secondary pulmonary hypertension (SPH). It is unclear which procedure is preferable. We reviewed our experience with lung transplants for PPH and SPH to determine if any advantage exists with SLT or BLT for either PPH or SPH. METHODS We reviewed the outcomes of all lung transplants performed for PPH or SPH for 4.5 years (July 1995 to January 2000). Survival was reported by the Kaplan-Meier method, and log rank analysis was used to determine significance. Statistical analyses of clinical data were performed using analysis of variance and chi2 analysis. RESULTS A total of 57 recipients met criteria for pulmonary hypertension with a mean pulmonary artery pressure of greater than or equal to 30 mm Hg. There were 15 patients with PPH and 40 patients with SPH. There were 6 patients who had SLTs and 9 patients who had BLTs in the PPH group; and there were 9 patients who had SLTs and 21 patients who had BLTs in the SPH group. We found a survival advantage for PPH patients who underwent BLTs at all time points up to 4 years (100% vs 67%; p < or = 0.02). There was no clear advantage to SLTs or BLTs for SPH. At 4 years there was a trend toward improved survival with SLTs (91% vs 75%) in SPH patients with a mean pulmonary artery pressure less than or equal to 40 mm Hg (p < or = 0.11) with equivalent survival (80%) in patients with a mean pulmonary artery pressure greater than or equal to 40 mm Hg. There was also a trend toward improved survival in patients with a mean pulmonary artery pressure greater than or equal to 40 mm Hg (PPH and SPH) with BLTs (88% vs 62%; p = 0.19). The incidence of rejection, infection, and other complications was comparable between SLTs and BLTs in each group. CONCLUSIONS We believe that BLT is the procedure of choice for PPH. The procedure of choice is less clear for SPH. Patients with SPH and a mean pulmonary artery pressure greater than 40 mm Hg may benefit from a BLT and those with a mean pulmonary artery pressure less than or equal to 40 mm Hg may do better with an SLT; however, no clear advantage is seen.
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Affiliation(s)
- J V Conte
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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39
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Abstract
Interstitial lung disease is a heterogeneous group of illnesses, some of which may progress to a fibrosing stage and cause respiratory failure. For selected candidates, lung transplantation is the ultimate therapeutic option. We review data on lung transplantation for various interstitial lung diseases. We address indications, procedures, and outcomes for patients undergoing transplantation. Unique issues affecting morbidity, mortality, and recurrence of disease are discussed. We review the literature of transplantation for specific interstitial lung diseases and the outcomes of transplantation for interstitial lung diseases. Candidates with idiopathic pulmonary fibrosis experience high mortality on the waiting list, but derive significant survival benefit from lung transplantation. Recurrence is reported for several interstitial lung diseases after lung transplantation. Survival with lung transplantation for interstitial lung diseases is comparable with that attained in recipients with other indications. Lung transplantation is a well-tolerated, effective therapy for respiratory failure in interstitial lung disease.
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Affiliation(s)
- R Sulica
- Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
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40
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Fiser SM, Kron IL, McLendon Long S, Kaza AK, Kern JA, Tribble CG. Early intervention after severe oxygenation index elevation improves survival following lung transplantation. J Heart Lung Transplant 2001; 20:631-6. [PMID: 11404168 DOI: 10.1016/s1053-2498(01)00249-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Reperfusion injury and technical problems following lung transplantation may result in life-threatening pulmonary dysfunction that requires intervention with either extracorporeal membrane oxygenation or reoperation. Early intervention in these patients could prevent complications associated with delayed or emergent intervention and may improve survival. The oxygenation index [(mean airway pressure x percent of inspired oxygen)/partial pressure of arterial oxygen] provides a rapid assessment of pulmonary function in the critical phase of reperfusion. Our hypothesis was that the oxygenation index could be used as an early predictor for severe respiratory failure requiring acute intervention. METHODS Analysis of 136 consecutive lung transplant operations revealed 18 patients (reperfusion injury in 16 and technical complications in 2) with an oxygen index of > or = 30. Of those patients with reperfusion injury, 9 had fibrotic lung disease, 4 had obstructive lung disease, and 3 had primary pulmonary hypertension. RESULTS Patients undergoing transplantation for fibrotic lung diseases were more likely to develop severe reperfusion injury (oxygenation index > or = 30) compared to patients with obstructive lung diseases (9 of 42 or 21% vs 4 or 80 or 5%, p = 0.005). The 5 patients with early intervention (< or = 2 hours) after an oxygenation index elevation above 30 had significantly improved survival compared to the 13 with no or late intervention (80% vs 15% survival, p = 0.02). CONCLUSION Oxygenation index elevation > or = 30 following lung transplantation is an early predictor of severe respiratory failure requiring acute intervention. Early intervention in these patients improves survival.
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Affiliation(s)
- S M Fiser
- Department of Thoracic and Cardiovascular Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia 22908, USA
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McAdams HP, Erasmus JJ, Palmer SM. Complications (excluding hyperinflation) involving the native lung after single-lung transplantation: incidence, radiologic features, and clinical importance. Radiology 2001; 218:233-41. [PMID: 11152808 DOI: 10.1148/radiology.218.1.r01ja45233] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the incidence, importance, and radiologic features of native lung complications after single-lung transplantation. MATERIALS AND METHODS Seventeen (15%) of 111 single-lung transplant recipients developed native lung complications (excluding hyperinflation) 0-58 months (mean, 17 months) after transplantation. Complaints at presentation, culture or histopathologic results, diagnostic or therapeutic procedures, and outcome were recorded. Chest radiographs (n = 17) and computed tomographic (CT) scans (n = 8) obtained at time of diagnosis were reviewed. Serial radiographs were assessed for disease progression or improvement. RESULTS The most common complications were infection (n = 10), caused by bacteria (n = 4), fungi (n = 4), or mycobacteria (n = 2), typically manifested as lobar or segmental opacities on chest radiographs or CT scans. Lung cancer manifested as a solitary well-circumscribed nodule (n = 1), multiple nodules (n = 1), or a hilar mass (n = 1). Five (29%) of 17 patients died of native lung complications. Seven patients underwent mediastinoscopy (n = 3), lobectomy (n = 2), thoracoscopic wedge resection (n = 2), tube thoracostomy (n = 2), or pneumonectomy (n = 1) for diagnosis or treatment. CONCLUSION Native lung complications occurred in 17 (15%) single-lung transplant recipients, were most commonly due to infection or lung cancer, and caused serious morbidity or mortality in 12 (71%) of 17 patients affected.
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Affiliation(s)
- H P McAdams
- Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA.
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Franke U, Wiebe K, Harringer W, Franke T, Wittwer T, Wahlers T, Haverich A. Ten years experience with lung and heart-lung transplantation in primary and secondary pulmonary hypertension. Eur J Cardiothorac Surg 2000; 18:447-52. [PMID: 11024383 DOI: 10.1016/s1010-7940(00)00525-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Patients with primary pulmonary hypertension (PPHT) have a worse natural outcome compared with those with secondary pulmonary hypertension in Eisenmenger's syndrome (ES) and chronic pulmonary embolism (CPE). Lung transplantation (SLTx, DLTx, HLTx) still remains the only therapeutical option for patients with this type of endstage lung disease. METHODS From 1988 to 1998, 63 patients underwent lung transplantation for PPHT (n=29, 9 m, 20 f, 2 SLTx, 14 DLTx, 13 HLTx), ES (n=29, 13 m, 16 f, 2 SLTx, 3 DLTx, 24 HLTx) or CPE (n=5, 2 m, 3 f, 1 SLTx, 2 DLTx, 2 HLTx). Groups were comparable for NYHA functional class, preoperative pulmonary arterial pressure, recipient and donor age, ischemic time, necessity and duration of cardiopulmonary bypass and cross-match. RESULTS The 1-, 3- and 5-year survival was 52, 40 and 35% for the PPHT-group, 83, 78 and 74% for the ES-group and 80, 60 and 60% for the CPE-group, respectively (P=0.026, P=0.033, P=0.082 for 1-, 3- and 5-year survival). Patients following DLTx showed a lower 1-year survival rate as compared with patients after HLTx both in PPHT patients (36 vs. 62%, P=0.091) and in ES patients (67 vs. 83%, P=0.213). The incidence of bronchiolitis obliterans syndrome was 29% at 1 year and 45% at 3 years for the PPHT-group vs. 17 and 65% for the ES-group (n. s. in between groups). Excluding postoperative ventilation time (PPHT-group: 26.8+/-24.0 days vs. ES-group: 16.1+/-30.8 days, P=0. 011) and a higher incidence of infectious causes of death (PPHT-group n=8 vs. ES-group n=1, P=0.017) groups were comparable with regard to their postoperative courses. CONCLUSIONS It is concluded, that predominantly the underlying primary disease influences graft survival after lung transplantation in patients with pulmonary hypertension compared with all other patient and procedure dependent factors. Lung transplantation in patients with PPHT requires further investigations to achieve results comparable with other indications.
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Affiliation(s)
- U Franke
- Department of Thoracic and Cardiovascular Surgery, Friedrich-Schiller-University, D-07740, Jena, Germany.
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King RC, Binns OA, Rodriguez F, Kanithanon RC, Daniel TM, Spotnitz WD, Tribble CG, Kron IL. Reperfusion injury significantly impacts clinical outcome after pulmonary transplantation. Ann Thorac Surg 2000; 69:1681-5. [PMID: 10892906 DOI: 10.1016/s0003-4975(00)01425-9] [Citation(s) in RCA: 237] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Reperfusion injury after pulmonary transplantation can contribute significantly to postoperative pulmonary dysfunction. We hypothesized that posttransplantation reperfusion injury would result in an increase in both in-hospital mortality and morbidity. We also hypothesized that the incidence of reperfusion injury would be dependent upon the cause of recipient lung disease and the interval of donor allograft ischemia. METHODS We performed a retrospective study of all lung transplant recipients at our institution from June 1990 until June 1998. One hundred patients received 120 organs during this time period. We compared two groups of patients in this study: those experiencing a significant reperfusion injury (22%) and those who did not (78%). RESULTS In-hospital mortality was significantly greater in patients experiencing reperfusion injury (40.9% versus 11.7%, p < 0.02). Posttransplantation reperfusion injury also resulted in prolonged ventilation (393.5 versus 56.8 hours, p < 0.001) and an increased length of stay in both the intensive care unit (22.2 versus 10.5 days, p < 0.01) and in the hospital (48.8 versus 25.6 days, p < 0.03). The incidence of reperfusion injury could not be attributed to length of donor organ ischemia (221.5 versus 252.9 minutes, p < 0.20). The clinical impact of reperfusion injury was significantly greater in patients undergoing transplantation for preexisting pulmonary hypertension (6/14) than those with chronic obstructive pulmonary disease or emphysema alone (6/54) (42.9% versus 11.1%, p < 0.012). CONCLUSIONS Clinically significant pulmonary reperfusion injury increased in-hospital mortality and morbidity resulting in prolonged ventilation, length of stay in the intensive care unit, and cost of hospitalization. The incidence of reperfusion injury was not dependent upon the duration of donor organ ischemia but increased with the presence of preoperative pulmonary hypertension. These findings suggest that recipient pathophysiology and donor allograft quality may play important roles in determining the incidence of reperfusion injury.
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Affiliation(s)
- R C King
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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44
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Huerd SS, Hodges TN, Grover FL, Mault JR, Mitchell MB, Campbell DN, Aziz S, Chetham P, Torres F, Zamora MR. Secondary pulmonary hypertension does not adversely affect outcome after single lung transplantation. J Thorac Cardiovasc Surg 2000; 119:458-65. [PMID: 10694604 DOI: 10.1016/s0022-5223(00)70124-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Primary and secondary pulmonary hypertension have been associated with poor outcomes after single lung transplantation. Some groups advocate double lung transplantation and the routine use of cardiopulmonary bypass during transplantation in this population. However, the optimal procedure for these patients remains controversial. The goal of our study was to determine the safety of single lung transplantation without cardiopulmonary bypass in patients with secondary pulmonary hypertension. METHODS We retrospectively reviewed 76 consecutive patients with pulmonary parenchymal disease who underwent single lung transplantation from 1992 to 1998. Recipients were stratified according to preoperative mean pulmonary artery pressure. Secondary pulmonary hypertension was defined as parenchymal lung disease with a preoperative mean pulmonary artery pressure of 30 mm Hg or more. Patients with primary pulmonary hypertension or Eisenmenger's syndrome were excluded from analysis. RESULTS Eighteen of 76 patients had secondary pulmonary hypertension. No patient with secondary pulmonary hypertension required cardiopulmonary bypass, whereas 1 patient without pulmonary hypertension required bypass. After the operation, no significant differences were seen in lung injury as measured by chest radiograph score and PaO(2)/FIO(2) ratio, the requirement for inhaled nitric oxide, the length of mechanical ventilation, the intensive care unit or hospital length of stay, and 30-day survival. There were no differences in the forced expiratory volume in 1 second or 6-minute walk at 1 year, or the incidence of rejection, infection, or bronchiolitis obliterans syndrome greater than grade 2. Survival at 1, 2, and 4 years after transplantation was 86%, 79%, and 65%, respectively, in the low pulmonary artery pressure group and 81%, 81%, and 61%, respectively, in the group with secondary pulmonary hypertension (P >.2). CONCLUSION We found that patients with pulmonary parenchymal disease and concomitant secondary pulmonary hypertension had successful outcomes as measured by early and late allograft function and appear to have acceptable long-term survival after single lung transplantation. Our results do not support the routine use of cardiopulmonary bypass or double lung transplantation for patients with this disorder.
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Affiliation(s)
- S S Huerd
- Divisions of Cardiothoracic Surgery, Pulmonary Medicine, and Anesthesiology, University of Colorado Health Sciences Center, Denver, CO 80262, USA
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Ueno T, Smith JA, Snell GI, Williams TJ, Kotsimbos TC, Rabinov M, Esmore DS. Bilateral sequential single lung transplantation for pulmonary hypertension and Eisenmenger's syndrome. Ann Thorac Surg 2000; 69:381-7. [PMID: 10735667 DOI: 10.1016/s0003-4975(99)01082-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lung transplantation, with and without intracardiac repair for pulmonary hypertension (PH) and Eisenmenger's syndrome (EIS), has become an alternative transplant strategy to combined heart and lung transplantation (HLT). METHODS Thirty-five patients with PH or EIS underwent either bilateral sequential single lung transplantation (BSSLT, group I, n = 13) or HLT (group II, n = 22). Another 74 patients, who underwent BSSLT for other indications, served as controls (group III). Immediate allograft function, early and medium-term outcomes, lung function, and 2-year survival were compared between the groups. RESULTS Comparisons between groups I and II showed no significant difference in any variables except percent predicted forced vital capacity. Immediate allograft function was significantly inferior (p < 0.05) and the blood loss was greater (p < 0.01) in group I when compared with those in group III. However, this resulted in no significant difference in early and medium-term outcomes, and 2-year survival between the 2 groups. CONCLUSIONS BSSLT for PH and EIS can be performed as an alternative procedure to HLT without an increase in early and medium-term morbidity and mortality. Results are comparable with BSSLT performed for other indications.
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Affiliation(s)
- T Ueno
- Heart and Lung Transplant Service, Alfred Hospital, Victoria, Australia
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Khan SU, Salloum J, O'Donovan PB, Mascha EJ, Mehta AC, Matthay MA, Arroliga AC. Acute pulmonary edema after lung transplantation: the pulmonary reimplantation response. Chest 1999; 116:187-94. [PMID: 10424524 DOI: 10.1378/chest.116.1.187] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although the development of noncardiogenic pulmonary edema or pulmonary reimplantation response (PRR) after lung transplantation has been well described, the incidence has not been established and the relationship of PRR to clinical risk factors has not been analyzed. STUDY OBJECTIVES (1) To describe the incidence of PRR in lung transplant recipients, (2) to identify the predictors of PRR, (3) to examine the correlation of suspected predictors with the severity of PRR, and (4) to evaluate the impact of PRR on morbidity and mortality of lung transplant recipients. DESIGN Retrospective review of clinical records and radiographic studies. SETTING Tertiary care referral center. PATIENTS Ninety-nine consecutive patients with end-stage lung disease undergoing lung transplantation between February 1990 and October 1995. METHODS Review of clinical records and postoperative chest radiographs of all lung transplant recipients to identify patients who experienced PRR. Chest radiographs of patients with PRR were graded for severity on a scale of 0 (none) to 5 (very severe). Demographic, pre- and perioperative factors were also evaluated along with short- and long-term survival of patients with PRR. RESULTS Fifty-six of 99 lung transplant recipients (57%) experienced PRR. The median ischemia time of patients with and without PRR was 168 and 180 min, respectively (p = 0.62). The incidence of PRR was 51% in patients without preoperative pulmonary hypertension, 78% in mild to moderate pulmonary hypertension, and 58% in patients with severe pulmonary hypertension (p = 0.10). Incidence and severity of PRR was similar in patients receiving right, left, or double-lung transplantation. Similarly, age and sex of the recipients and underlying lung disease did not affect the incidence or severity of PRR. The incidence and severity of PRR was higher in patients undergoing cardiopulmonary bypass during lung transplantation. Patients with PRR had prolonged duration of mechanical ventilation and ICU stay. Overall, PRR did not affect the survival of the patients. However, survival of female lung transplant recipients was significantly better than male recipients (median survival, 60 vs 21 months; p = 0.02). CONCLUSIONS Acute pulmonary edema or PRR occurs frequently (57%) after lung transplantation. In this series, PRR was not associated with a prolonged ischemia time, preoperative pulmonary hypertension, the type of lung transplant, underlying lung disease, or age or sex of recipients. However, use of cardiopulmonary bypass during surgery was associated with increased incidence and severity of PRR. Also, the development of PRR resulted in prolonged mechanical ventilation and a longer ICU stay, but did not affect survival. Female lung transplant recipients survived significantly longer than male recipients. The reason for this difference in survival is unclear.
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Affiliation(s)
- S U Khan
- Department of Pulmonary and Critical Care Medicine, The Cleveland Clinic Foundation, OH 44195, USA
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Westerlind A, Nilsson F, Ricksten SE. The use of continuous positive airway pressure by face mask and thoracic epidural analgesia after lung transplantation. Gothenburg Lung Transplant Group. J Cardiothorac Vasc Anesth 1999; 13:249-52. [PMID: 10392672 DOI: 10.1016/s1053-0770(99)90258-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the clinical use of continuous positive airway pressure (CPAP) and thoracic epidural analgesia (TEA) after lung transplantation (LTx). DESIGN Retrospective case series. SETTING Cardiothoracic intensive care unit (ICU) at a university hospital. PARTICIPANTS All heart-lung, bilateral, and single-lung transplant recipients between 1990 and 1996 at this institution (n = 102). INTERVENTIONS Postoperative pain was controlled by a thoracic epidural infusion of bupivacaine, 1 mg/mL, and sufentanil, 1 microg/mL. After extubation, CPAP, 5 to 10 cm H2O by face mask, was used to prevent reperfusion edema. MEASUREMENTS AND MAIN RESULTS In 99 patients, the length of ventilation (LOV) was a median of 4.3 hours (range, 1.0 to 312.0 hours). The median LOV was 8.0 hours (range, 1.5 to 41.0 hours) in the heart-lung recipients, 4.5 hours (range, 2.0 to 47.0 hours) in the bilateral-lung recipients, and 3.5 hours (range, 1.0 to 312.0 hours) in the single-lung recipients. Three transplant recipients, all with primary pulmonary hypertension, were prematurely extubated and reintubated because of pulmonary edema. Twelve hours after extubation, the median oxygenation index (PaO2/F(I)O2, PaO2 in kilopascal units) was greater than 35. The median ICU length of stay for all transplant recipients was 4 days (range, 2 to 270 days). CONCLUSION The postoperative use of CPAP and TEA is associated with early and safe tracheal extubation after LTx and may shorten ICU stay.
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Affiliation(s)
- A Westerlind
- Department of Cardiothoracic Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Göteborg, Sweden
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Bîrsan T, Kranz A, Mares P, Artemiou O, Taghavi S, Zuckermann A, Klepetko W. Transient left ventricular failure following bilateral lung transplantation for pulmonary hypertension. J Heart Lung Transplant 1999; 18:304-9. [PMID: 10226894 DOI: 10.1016/s1053-2498(98)00050-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bilateral lung transplantation is an established therapy for end-stage pulmonary hypertension. Its early postoperative outcome may be biased by various complications resulting in unexpected deterioration of the patient in terms of hemodynamics and blood gases. METHODS We have reviewed the early postoperative course of patients who underwent bilateral lung transplantation for pulmonary hypertension at our institution and analyzed all available data, especially hemodynamic measurements, echocardiographic documentation and therapeutical strategies, in those cases where cardiac dysfunction was found to be responsible for clinical deterioration. RESULTS Three out of 20 lung transplant recipients operated for pulmonary hypertension experienced severe respiratory insufficiency accompanied by hemodynamic decompensation during the first days after surgery. Clinical and laboratory findings together with results of echocardiography and pulmonary artery catheterism helped establish the diagnosis of left ventricular failure. This proved to be transitory, but the response to therapy (inotropic drugs, afterload reduction and eventually prostaglandins) was very variable. Adequately treated, this complication did not preclude the outcome of transplantation by itself. CONCLUSION Left ventricular failure is a possible complication after lung transplantation for pulmonary hypertension. Echocardiography and pulmonary artery catheterism may be useful adjuvant diagnostic tools, beside routine physical examination, chest X-ray, and laboratory analysis. Therapy of this complication must be adapted individually and may be complex.
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Affiliation(s)
- T Bîrsan
- Department of Cardiothoracic Surgery, University of Vienna, Austria
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Park SJ, Savitt MA, Bolman RM. Single or double lung transplantation for pulmonary hypertension. J Thorac Cardiovasc Surg 1999; 117:404-5. [PMID: 10049035 DOI: 10.1016/s0022-5223(99)70448-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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