Worldwide trends in heart and lung transplantation: Guarding the most precious gift ever

How Would We Treat Our Own Cystic Fibrosis With Lung Transplantation?

Lung transplantation is the only therapy for patients with end-stage lung disease. In advanced lung diseases such as cystic fibrosis (CF), life expectancy increases, and it is important to recognize extrapulmonary comorbidities. Cardiovascular involvement, including pulmonary hypertension, right-heart failure, and myocardial dysfunction, are manifest in the late stages of CF disease. Besides right-heart failure, left-heart dysfunction seems to be underestimated. Therefore, an optimal anesthesia and surgical management risk evaluation in this high-risk patient population is mandatory, especially concerning the perioperative use of mechanical circulatory support. The use of an index case of an older patient with the diagnosis of cystic fibrosis demonstrates the importance of early risk stratification and strategy planning in a multidisciplinary team approach to guarantee successful lung transplantation.

Lung Transplantation in India: a Brief Review, Landmarks, Indian Scenario, and our Experience

Lung transplantation is gaining widespread acceptance as the preferred therapeutic option for selected cases of end-stage lung disease in India. The indications of lung transplantation are increasing, with better post-operative survival, including the COVID affected lung, if we choose our patients well. The national acceptance of expanded criteria in lung donation, streamlining of the process of lung transplantation by governmental, and non-governmental organizations and significant increase in the number of organ donations in India have strengthened the lung transplantation program within the country. Through this article, we describe a brief history, the process, and our experience of lung transplantation since we started our program in 2017 until date.

Challenges, experiences, and postoperative outcomes in setting up first successful lung transplant unit in India

Background

Lung transplantation (LT) has emerged as a definitive cure for a plethora of end-stage lung diseases (ESLDs). With improvements in immune-suppression protocols, the posttransplantation survival rates have gone up.

Aim

The study reported the initial experience of the India's single largest lung transplant program on clinicopathological profile, procedures, challenges encountered, and outcomes.

Settings and Design

A retrospective analysis was done from data available at three centers of Institute of Heart and Lung Transplant, Gleneagles Global Hospitals across Chennai, Bengaluru, and Mumbai.

Materials and Methods

A total of 132 patients underwent lung (single or bilateral) or combined heart and lung transplant between April 2017 and March 2020. All the participants had 30 days' follow-up. Postoperative complications, graft rejection, and 30-day mortality were reported. Kaplan-Meier survival analysis and logistic regression analysis were performed.

Statistical Analysis Used

Kaplan-Meier survival and binary logistic regression was performed.

Results

Interstitial lung diseases, 65.91%, were the most common diagnosis. Bilateral LT (81.3%) was the most common type of LT performed. Grade III primary graft dysfunction was observed in 16 (12.1%). Distal airway stenosis (21.97%) was the most common complication followed by anastomotic stenosis (14.30%). Gram-negative bacterial sepsis (52%) was the leading cause of death. Cumulative probability of survival at 1 month was 0.85 (95% confidence interval [CI] 0.80-0.92), and at 1 year, it was 0.78 (95% CI, 0.72-0.86).

Conclusion

This study establishes the fact that despite multiple challenges, LT is a viable option for selected patients with ESLDs in India and should encourage early referrals to a transplant center.

Novel heat shock protein 90 inhibitor improves cardiac recovery in a rodent model of donation after circulatory death

OBJECTIVE

Organ donation after circulatory death (DCD) is a potential solution for the shortage of suitable organs for transplant. Heart transplantation using DCD donors is not frequently performed due to the potential myocardial damage following warm ischemia. Heat shock protein (HSP) 90 has recently been investigated as a novel target to reduce ischemia/reperfusion injury. The objective of this study is to evaluate an innovative HSP90 inhibitor (HSP90i) as a cardioprotective agent in a model of DCD heart.

METHODS

A DCD protocol was initiated in anesthetized Lewis rats by discontinuation of ventilation and confirmation of circulatory death by invasive monitoring. Following 15 minutes of warm ischemia, cardioplegia was perfused for 5 minutes at physiological pressure. DCD hearts were mounted on a Langendorff ex vivo heart perfusion system for reconditioning and functional assessment (60 minutes). HSP90i (0.01 μmol/L) or vehicle was perfused in the cardioplegia and during the first 10 minutes of ex vivo heart perfusion reperfusion. Following assessment, pro-survival pathway signaling was evaluated by western blot or polymerase chain reaction.

RESULTS

Treatment with HSP90i preserved left ventricular contractility (maximum + dP/dt, 2385 ± 249 vs 1745 ± 150 mm Hg/s), relaxation (minimum -dP/dt, -1437 ± 97 vs 1125 ± 85 mm Hg/s), and developed pressure (60.7 ± 5.6 vs 43.9 ± 4.0 mm Hg), when compared with control DCD hearts (All P = .001). Treatment abrogates ischemic injury as demonstrated by a significant reduction of infarct size (2,3,5-triphenyl-tetrazolium chloride staining) of 7 ± 3% versus 19 ± 4% (P = .03), troponin T release, and mRNA expression of Bax/Bcl-2 (P < .05).

CONCLUSIONS

The cardioprotective effects of HSP90i when used following circulatory death might improve transplant organ availability by expanding the use of DCD hearts.

Readmission and resource utilization after orthotopic heart transplant versus ventricular assist device in the National Readmissions Database, 2010-2014

BACKGROUND

As the technology of ventricular assist devices continues to improve, the morbidity and mortality for patients with a ventricular assist device is expected to approach that of orthotopic heart transplantation. The present study was performed to compare perioperative outcomes, readmission, and resource utilization between ventricular assist device implantation and orthotopic heart transplantation, using a national cohort.

METHODS

Patients who underwent either orthotopic heart transplantation or ventricular assist device implantation from 2010 to 2014 in the National Readmission Database were selected.

RESULTS

Of the 12,111 patients identified during the study period, 5,440 (45%) received orthotopic heart transplantation, while 6,671 (55%) received ventricular assist devices. Readmissions occurred frequently after ventricular assist device implantation and orthotopic heart transplantation, with greater rates at 30 days (29% versus 24%, P=.005) and 6 months (62% versus 46%, P < .001) for the ventricular assist device cohort. Cost of readmission was greater among ventricular assist device patients at 30 days ($29,115 versus $21,586, P=.0002) and 6 months ($34,878 versus $20,144, P = .0106).

CONCLUSION

Readmission rates and costs for patients with a ventricular assist device remain greater than their orthotopic heart transplantation counterparts. Given the projected increases in ventricular assist device utilization and limited transplant donor pool, further emphasis on cost containment and decreased readmissions for patients undergoing a ventricular assist device is essential to the viability of such therapy in the era of value-based health care delivery.