Pleural complications in lung transplant recipients

Case Report of Needle Disruption of the Retroperitoneal Lymph Nodes for Refractory Chylothorax After Double Lung Transplantation

Chylothorax is a rare complication after double lung transplantation. We report a case of a 55-year-old man with idiopathic pulmonary fibrosis. He underwent a double lung transplantation with venoarterial extracorporeal membrane support. The surgery was uncomplicated; however, his postoperative course was complicated with a refractory chylothorax that started postoperative day 4. Medical management could not control the chylothorax, including nil per os, total parenteral nutrition, and octreotide administration. After failed percutaneous embolization via lymphangiography and surgical ligation of the thoracic duct and pleurodesis via video-assisted thoracoscopic surgery, percutaneous needle disruption of the retroperitoneal lymph nodes was performed. After this procedure, the chylothorax resolved quickly. Percutaneous needle disruption of the retroperitoneal lymph node is safe and effective for refractory chylothorax. This technique can be one of the main modalities to manage chylothorax after lung transplantation.

Common Noninfectious Complications Following Lung Transplantation

According to the Scientific Registry of Transplant Recipients, both transplant volume and survival among lung transplant recipients are improving over time. However, the outcomes of lung transplantation remain challenged by multiple thoracic and extrathoracic complications. With improving lung transplant survival, patients experience prolonged exposure to chronic immunosuppressive agents that can lead to multiple infectious and noninfectious complications. This article focuses on most common noninfectious complications with significant clinical impact.

Lung transplantation for lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare cystic lung disease, associated with respiratory symptoms of dyspnea and spontaneous pneumothorax, along with various extra-thoracic manifestations. Often a progressive disease, albeit slowly, patients can develop chronic and severe respiratory failure and require supplemental oxygen. Lung transplantation (LTX) can offer improved duration and quality of life for patients with end-stage lung disease due to LAM. There are several unique considerations for LTX in LAM patients, and disease-specific complications of LAM prior to LTX can affect management decisions. Furthermore, there are several possible post-transplant issues specific to LAM. In this review, we discuss evaluation and management, disease-specific complications (both pre- and post-transplant), and outcomes for LAM patients undergoing lung transplantation.

Bacterial infections in lung transplantation

Lung transplantation has lower survival rates compared to other than other solid organ transplants (SOT) due to higher rates of infection and rejection-related complications, and bacterial infections (BI) are the most frequent infectious complications. Excess morbidity and mortality are not only a direct consequence of these BI, but so are subsequent loss of allograft tolerance, rejection, and chronic lung allograft dysfunction due to bronchiolitis obliterans syndrome (BOS). A wide variety of pathogens can cause infections in lung transplant recipients (LTRs), including a number of nosocomial pathogens and other multidrug-resistant (MDR) pathogens. Although pneumonia and intrathoracic infections predominate, LTRs are at risk of a number of types of infections. Risk factors include altered anatomy and function of airways, impaired immunity, the microbial flora of the donor and recipient, underlying medical conditions, and genetic factors. Further work on immune monitoring has the potential to improve outcomes. The infecting agents can be derived from the donor lung, pre-existing recipient flora, or acquired from the environment over time. Certain infections may preclude lung transplantation, but this varies from center to center, and more recent studies suggest fewer patients should be disqualified. New molecular methods allow microbiome studies of the lung, gut, and other sites that may further our knowledge of how airway colonization can result in infection and allograft loss. Surveillance, early diagnosis, and aggressive antimicrobial therapy of BI is critical in LTRs. Antibiotic resistance is a major barrier to successful management of these infections. The availability of new agents for MDR Gram-negatives may improve outcomes. Other new therapies, such as bacteriophage therapy, show promise for the future. Finally, it is important to prevent infections through peri-transplant prophylaxis, vaccination, and infection control measures.

Lung Transplantation in COPD

Chronic obstructive pulmonary disease (COPD) remains one of the leading causes of morbidity and mortality both in the United States and worldwide. Despite advances in medical treatment including smoking cessation, bronchodilator therapy, oxygen administration, and pulmonary rehabilitation, patients with advanced COPD still suffer significant debility. For select patients with severe COPD, there are additional surgical options including lung volume reduction surgery and ultimately lung transplantation.This article discusses the history, clinical indications, selection of candidates, choice of procedure, and outcomes of lung transplantation in patients with advanced COPD. In addition, certain aspects of potential short- and long-term complications of transplantation will also be discussed.

Imaging Course of Lung Transplantation: From Patient Selection to Postoperative Complications

Lung transplant is increasingly performed for the treatment of end-stage lung disease. As the number of lung transplants and transplant centers continues to rise, radiologists will more frequently participate in the care of patients undergoing lung transplant, both before and after transplant. Potential donors and recipients undergo chest radiography and CT as part of their pretransplant assessment to evaluate for contraindications to transplant and to aid in surgical planning. After transplant, recipients undergo imaging during the postoperative hospitalization and also in the long-term outpatient setting. Radiologists encounter a wide variety of conditions leading to end-stage lung disease and a myriad of posttransplant complications, some of which are unique to lung transplantation. Familiarity with these pathologic conditions, including their imaging findings and their temporal relationship to the transplant, is crucial to accurate radiologic interpretation. Knowledge of the surgical techniques and expected postoperative appearance prevents confusing normal posttransplant imaging findings with complications. A basic understanding of the indications, contraindications, and surgical considerations of lung transplant aids in imaging interpretation and protocoling and also facilitates communication between radiologists and transplant physicians. Despite medical and surgical advances over the past several decades, lung transplant recipients currently have an average posttransplant life expectancy of only 6.7 years. As members of the transplant team, radiologists can help maximize patient survival and hopefully increase posttransplant life expectancy and quality of life in the coming decades. ^©RSNA, 2021 An invited commentary by Bierhals is available online. Online supplemental material is available for this article.

Early postoperative complications in lung transplant recipients

Lung transplantation has become an established therapy for end-stage lung diseases. Early postoperative complications can impact immediate, mid-term, and long-term outcomes. Appropriate management, prevention, and early detection of these early postoperative complications can improve the overall transplant course. In this review, we highlight the incidence, detection, and management of these early postoperative complications in lung transplant recipients.

Pleural space management after lung transplant: Early and late outcomes of pleural decortication

BACKGROUND

Pleural complications after lung transplant may restrict allograft expansion, requiring decortication. However, its extent, indications, risk factors, and effect on allograft function and survival are unclear.

METHODS

From January 2006 to January 2017, 1,039 patients underwent primary lung transplant and 468 had pleural complications, 77 (16%) of whom underwent 84 surgical decortications for pleural space management. Multivariable time-related analysis was performed to identify risk factors for decortication. Mixed-effect longitudinal modeling was used to assess allograft function before and after decortication.

RESULTS

Cumulative number of decortications per 100 transplants was 1.8, 7.8, and 8.8 at 1 month, 1 year, and 3 years after transplant, respectively. Indications for the 84 decortications were complex effusion in 47 (56%), fibrothorax in 17 (20%), empyema in 11 (13%), and hemothorax in 9 (11%). Thoracoscopic operations were performed in 52 (62%) and full lung re-expansion was achieved in 76 (90%). Complications occurred after 30 (36%) decortications, with 15 pulmonary complications (18%), including 2 patients requiring extracorporeal support due to worsening function. Ten reinterventions occurred via thoracentesis (2), tube thoracostomy (1), and reoperation (7). In-hospital and 30-day mortality was 5.2% (n = 4/77). Forced expiratory volume in 1 second increased from 50% to 60% within the first year after decortication, followed by a slow decline to 55% at 5 years. Postdecortication survival was 87%, 68%, and 48% at 1, 3, and 5 years, respectively.

CONCLUSIONS

Despite high risk of reoperative surgery, decortication after lung transplant allows salvage of pleural space and graft function with a reasonable morbidity profile.

Characteristics and clinical implications of pleural effusions after lung transplantation: A retrospective analysis of 195 thoracocenteses in 113 patients

Despite advances in lung transplantation (LTx), morbidity, and mortality are high. We hypothesized that pleural effusions requiring thoracocentesis lead to poor outcomes after LTx. We performed a single-center retrospective analysis of thoracocenteses after initial hospital discharge in LTx patients between March 2008 and September 2020 to identify risk factors, etiologies, and outcomes. Of the 1223 patients included, 113 patients (9.2%) required a total of 195 thoracocenteses. The cumulative incidence of thoracocentesis was 10.6% at 1 year and 14.2% at 5 years after transplantation. We observed a bimodal distribution of pleural effusion onset with a threshold at 6 months. Late-onset effusions were mostly of malignant or cardiac origin. We observed a high rate of nonspecific effusions (41.5%) irrespective of the timepoint post-transplantation. Patients with late-onset effusions had significantly lower survival compared to a matched controlled group (HR 2.43; 95% CI (1.27-4.62). All pulmonary function parameters were significantly decreased in patients requiring thoracocentesis compared to matched controls. Male sex and re-transplantation were risk factors for pleural effusions. In conclusion, pleural effusions requiring thoracocentesis occur frequently in LTx patients and lead to a reduced long-term allograft function. Late-onset effusions are associated with a lower survival.

Pulmonary Lymphangioleiomyomatosis originates in the pleural mesothelial cell population

Lymphangioleiomyomatosis (LAM) is a cystic lung disease mainly affecting women, in which degradation of the lung parenchyma is associated with a cell of unknown provenance, known as a LAM cell. LAM cells carry TSC2 mutations and can be identified in the lung parenchyma by their expression of both smooth muscle actin and antigens characteristic of melanocytes and melanocytic tumors. The nature of the cell-of-origin of LAM is controversial, and despite continued research effort remains elusive. Further, it has not been possible to culture pulmonary LAM cells in vitro, and current research relies on cells and animal models which may not recapitulate all features of the disease. We noted aberrant expression of melanoma antigens in pleural mesothelial cells in lung tissue from LAM patients, indicating that these cells could be the precursors of parenchymal LAM cells. We hypothesise that loss of tuberin function following TSC2 mutation in the mesothelial cell lineage gives rise to the cell-of-origin of pulmonary LAM (P-LAM), and of other associated conditions commonly noted in LAM patients. The unique properties of mesothelial cells provide a straightforward explanation of the diverse presentation of LAM.

Clinical approach and review of causes of a chylothorax

A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.

Incidence, Management, and Outcomes of Chylothorax after Lung Transplantation: A Single-center Experience

Background

The objective of this study was to determine the incidence and outcomes of chylothorax after lung transplantation.

Methods

We conducted a retrospective review of our institutional lung transplant registry of 504 adult transplantations done from 2001 to 2015 and identified seven patients (1.38%) with chylothorax. Electronic health records were then analyzed to determine demographics, indications for surgery, management, and outcomes. Survival curves were plotted using the Kaplan-Meier method.

Results

Chylothorax presented in the first week in four (62.5%) patients, and approximately one month later in the remaining three. Nonsurgical management was initially attempted in all patients and succeeded in three (42.9%). Elective surgical ligation of the thoracic duct (LTD) was successful in two (66.7%) out of three patients in whom it was performed. One patient required emergent reoperation for clamshell thoracotomy dehiscence from severe chylothorax. Thoracic duct embolization was attempted but unsuccessful in two patients. Subsequently, one of these patients received a peritoneal-venous shunt and the other underwent LTD. Chylothorax permanently resolved in six patients (85.7%). There were no mortalities directly related to chylothorax. The median time to resolution was 11 days (range: 7-60). The mean survival in months for chylothorax patients was 29.2 (SE 3.1) and 78.2 (SE 2.9) for the remaining patients (p = 0.37). The median survival was not reached for the chylothorax group and was 71.8 months (95% CI: 58.0-83.9) for the rest.

Conclusion

Chylothorax is rare after lung transplantation but can lead to major comorbidities and prolonged hospital stay. In our experience, nonsurgical management was successful in up to 40% of patients. LTD should be considered in those who fail conservative management. 

Pleural catheter placement and intrapleural fibrinolysis following lung transplantation

BACKGROUND

This study aimed to investigate the characteristics of lung transplant recipients requiring additional pleural drainage catheters early post-lung transplantation and to determine the safety and efficacy of intrapleural fibrinolytics in these patients.

METHODS

A retrospective review of lung transplant recipients at a single center was performed. Patient and transplant characteristics, placement of pleural drainage catheters within 90 days of transplant, and use of intrapleural fibrinolytics were determined.

RESULTS

Out of 128 patients who underwent lung transplantation, 54 patients required 86 additional chest tubes, the majority of which were size 14 French or smaller. Pleural effusion was the most common indication for tube placement. Patients who required additional chest tubes were more likely to have chronic obstructive pulmonary disease than those who did not. Use of intrapleural fibrinolytics led to radiographic improvement in 77.8% of patients and was not associated with bleeding, pneumothorax, or mortality within 30 days.

CONCLUSIONS

Use of small-bore chest tubes and intrapleural fibrinolytics can be safe and effective in lung transplant recipients with persistent pleural effusions.

Infective endocarditis due to Burkholderia cepacia in a neonate: a case report

Background

Burkholderia is a pathogen that is rarely seen in clinical cases. However, this organism is being found more commonly in hospitals.

Case presentation

A female Indonesian newborn was referred to our neonatal intensive care unit because of respiratory distress. The newborn had been delivered the previous night via cesarean section. A physical examination revealed intercostal retractions and weak cry. The newborn’s gestational history was preterm, small for gestational age, and preterm premature ruptured membrane for 14 hours. Continuous positive airway pressure was administered. A multiple-antibiotic regimen consisting of ampicillin-sulbactam, gentamicin, meropenem, and ceftriaxone was initiated. Insertion of a central catheter was performed. The patient’s laboratory results were low blood albumin and globulin, anemia, and leukopenia. A blood culture revealed Burkholderia cepacia that was resistant to multiple antimicrobial agents. A chest x-ray showed infiltrate on both lung fields. Echocardiography showed two vegetations on the tricuspid valve.

Conclusions

B. cepacia is a rare cause of infective endocarditis. With its capability to colonize water and grow on microbicides, the presence of B. cepacia in a patient’s blood warrants further investigation in institutions providing care. This might not be the first publication on this topic.

Imaging of Lung Transplantation

Lung transplantation has become a viable treatment option for end-stage lung disease. Common indications for lung transplantation are chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis, cystic fibrosis, alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension. Either single or bilateral lung transplantation can be performed, but bilateral lung recipients appear to have a better median survival than single lung recipients. Complications after lung transplantation are common and may have nonspecific clinical and radiologic manifestations. The time point at which these complications occur relative to the date of transplant is crucial in formulating a differential diagnosis and recognizing them accurately. Significant advances in imaging techniques and recognition of air trapping in exhalation images and other patterns /distribution of parenchymal abnormalities have led to routine use of HRCT for diagnostic evaluation in patients manifesting respiratory decline in the lung transplant recipient.

Utility of transthoracic needle biopsy after lung transplantation

The purpose of this study was to assess the diagnostic yield and complications of CT-guided transthoracic needle biopsy (TTNB) after lung transplantation. A database search identified all TTNB performed in lung transplant patients over a 14-year period. Forty-two biopsies in transplant patients (transplant group) were identified and matched to the next biopsy performed in native lungs by the same operator (nontransplant group) as a control. Primary outcomes recorded were diagnosis, diagnostic yield, pneumothorax requiring intervention, and symptomatic pulmonary hemorrhage. Biopsy outcomes were classified as diagnostic, not specifically diagnostic, and nondiagnostic. Patients in the transplant group were younger (P < .002). Emphysema along the biopsy trajectory was more commonly seen in the nontransplant group (P < .0006). Needle gauge, size of lesion, pleural punctures, lesion depth, and number of passes were not significantly different. Diagnostic yield was 71% in the transplant group and 91% in the nontransplant group. There were 20 of 42 (48%) malignant nodules in the transplant group compared to 31 of 44 (70%) nodules in the nontransplant group (P = .05). There were no complications in the transplant group. The nontransplant group had two pneumothoraces requiring intervention. TTNB after lung transplant is safe with a moderate diagnostic yield. Nonmalignant lesions are more common after lung transplantation.

Visceral subpleural hematoma of the left diaphragmatic surface following left upper division segmentectomy

Background

Pulmonary visceral subpleural hematoma is rare. We report visceral subpleural hematoma of the left diaphragmatic surface following left upper division segmentectomy. This very rare case was difficult to distinguish from thoracic abscess.

Case presentation

A 68-year-old man with hypertension had undergone video-assisted thoracoscopic left upper division segmentectomy for suspected lung carcinoma. Deep vein thrombosis of the lower leg was identified and edoxaban, a so-called novel oral anticoagulant, was started on postoperative day 7. The chest drainage tube was removed on postoperative day 12 because of persistent air leakage, but fever appeared the same day. Computed tomography revealed a cavity with mixed air and fluid, so antibiotics were started on suspicion of abscess. Computed tomography-guided drainage was attempted, but proved unsuccessful. Fever continued and surgical investigation was therefore performed. Visceral subpleural hematoma was identified under the diaphragmatic surface of the left basal lung. We excised the pleura, then performed drainage and applied running sutures. The parenchyma and visceral pleura were covered with polyglycolic acid sheet and fibrin glue. Edoxaban was restarted on postoperative day 12 of video-assisted thoracoscopic surgery and no recurrence of hematoma has been revealed.

Conclusions

Visceral subpleural hematoma after thoracic surgery is extremely rare. Furthermore, correct diagnosis was difficult and surgery offered a good diagnostic and therapeutic procedure.

Hemothorax following lung transplantation: incidence, risk factors, and effect on morbidity and mortality

BACKGROUND

Hemothorax after lung transplantation may result in increased post-operative morbidity and mortality. Risk factors for developing hemothorax and the outcomes of patients who develop hemothorax have not been well studied.

METHODS

A retrospective chart review was performed on all patients who underwent lung transplantation at a single center between March 2009 and July 2014. Comparison was made between patients with and without hemothorax post-transplant.

RESULTS

There were 132 lung transplantations performed during the study period. Hemothorax was a complication in 17 (12.9 %) patients, occurring an average of 9 days after transplant. No difference was found between the hemothorax and non-hemothorax groups with respect to age, preoperative anticoagulation, lung allocation score, prior thoracotomy, coagulation profile, use of cardiopulmonary bypass, ischemic time, or postoperative P/F ratio. There was a trend towards a higher incidence of hemothorax in patients with underlying sarcoidosis and re-transplantation (p = 0.13 and 0.17, respectively). Hemothorax developed early (<48 h post-operatively) in 5 patients and presented in a delayed manner (≥48 h post-operatively) in 12 patients. Delayed hemothorax occurred primarily in the setting of anticoagulation (10 out of 12 patients). The hemothorax group had decreased ventilator-free days (p = 0.006), increased ICU length of stay (p = 0.01) and increased hospital length of stay (p = 0.005). Hemothorax was also associated with reduced 90-day survival (p = 0.001), but similar 1, 3, and 5-year survival (p = 0.63, p = 0.30, and p = 0.25), respectively).

CONCLUSION

The development of hemothorax is associated with increased morbidity and decreased short-term survival. Hemothorax may present either within the first 48 h after surgery or in a delayed fashion, most commonly in the setting of anticoagulation.

Critical Care Aspects of Lung Transplant Patients

Major strides have been made in lung transplantation during the 1990s and it has become an established treatment option for patients with advanced lung disease. Due to improvements in organ preservation, surgical techniques, postoperative intensive care, and immunosuppression, the risk of perioperative and early mortality (less than 3 months after transplantation) has declined [1]. The transplant recipient now has a greater chance of realizing the benefits of the long and arduous waiting period.

Despite these improvements, suboptimal long-term outcomes continue to be shaped by issues such as opportunistic infections and chronic rejection. Because of the wider use of lung transplantation and the longer life span of recipients, intensivists and ancillary intensive care unit (ICU) staff should be well versed with the care of lung transplant recipients.

In this clinical review, issues related to organ donation will be briefly mentioned. The remaining focus will be on the critical care aspects of lung transplant recipients in the posttransplant period, particularly ICU management of frequently encountered conditions. First, the groups of patients undergoing transplantation and the types of procedures performed will be outlined. Specific issues directly related to the allograft, including early graft dysfunction from ischemia-reperfusion injury, airway anastomotic complications, and infections in the setting of immunosuppression will be emphasized. Finally nonpulmonary aspects of posttransplant care and key pharmacologic points in the ICU will be covered.

Imaging in lung transplants: Checklist for the radiologist

Post lung transplant complications can have overlapping clinical and imaging features, and hence, the time point at which they occur is a key distinguisher. Complications of lung transplantation may occur along a continuum in the immediate or longer postoperative period, including surgical and mechanical problems due to size mismatch and vascular as well as airway anastomotic complication, injuries from ischemia and reperfusion, acute and chronic rejection, pulmonary infections, and post-transplantation lymphoproliferative disorder. Life expectancy after lung transplantation has been limited primarily by chronic rejection and infection. Multiple detector computed tomography (MDCT) is critical for evaluation and early diagnosis of complications to enable selection of effective therapy and decrease morbidity and mortality among lung transplant recipients.

Matching donor to recipient in lung transplantation: How much does size matter?

OBJECTIVE

The impact of size matching between donor and recipient is unclear in lung transplantation. Therefore, we determined the relation of donor lung size to 1) posttransplant survival and 2) pulmonary function as measured by forced expiratory volume in 1 second.

METHODS

From 1990 to 2006, 469 adults underwent lung transplantation with lungs from donors aged 7 to 70 years. Donor and recipient total lung capacities were calculated using established formulae (predicted total lung capacity), and actual recipient lung size was measured in the pulmonary function laboratory. Disparity between donor and recipient lung size was expressed as a ratio of donor predicted total lung capacity to recipient predicted total lung capacity-the predicted total lung capacity ratio-and predicted donor total lung capacity to actual recipient total lung capacity-the actual total lung capacity ratio. Survival was measured by multiphase hazard methodology and repeated measures of National Health and Nutrition Examination Survey-normalized forced expiratory volume in 1 second analyzed by temporal decomposition.

RESULTS

Predicted total lung capacity ratio and actual total lung capacity ratio ranged widely, from 0.55 to 1.59 and 0.52 to 4.20, respectively. Overall survival was unaffected by predicted total lung capacity ratio (P = .3) or actual total lung capacity ratio (P = .5). Patients with emphysema and an actual total lung capacity ratio of 0.67 or less or 1.03 or greater had higher predicted mortality (P = .01). During the first posttransplant year, forced expiratory volume in 1 second increased and then gradually declined. Predicted total lung capacity ratio and actual total lung capacity ratio had a small impact on forced expiratory volume in 1 second, primarily in the late phase after transplant in a disease-specific manner.

CONCLUSION

Size matching between donor and recipient using predicted total lung capacity ratio and actual total lung capacity ratio is an effective technique. Wide discrepancies in lung sizing do not affect overall posttransplant survival or pulmonary function. Therefore, a greater degree of lung size mismatch can likely be accepted, thereby improving patients' odds of undergoing transplantation.

Diagnosis and outcome of early pleural space infection following lung transplantation

BACKGROUND

Despite the frequent occurrence of pleural effusions in lung transplant recipients, little is known about early posttransplant pleural space infections. We sought to determine the predictors and clinical significance of pleural infection in this population.

METHODS

We analyzed 455 consecutive lung transplant recipients and identified patients who had undergone sampling of pleural fluid within 90 days posttransplant. A case-control analysis was performed to determine the characteristics that predict infection and the impact of infection on posttransplant survival.

RESULTS

Pleural effusions undergoing drainage occurred in 27% of recipients (124 of 455 recipients). Ninety-six percent of effusions were exudative. Pleural space infection occurred in 27% of patients (34 of 124 patients) with effusions. The incidence of infection did not differ significantly by native lung disease or type of transplant operation. Fungal pathogens accounted for > 60% of the infections; Candida albicans was the predominant organism found. Bacterial etiologies were present in 25% of cases. Infected pleural effusions had elevated lactate dehydrogenase levels (p = 0.036) and markedly increased neutrophil levels in the pleural space (p < 0.0001) compared to noninfected effusions. A pleural neutrophil percentage of > 21% provides a sensitivity of 70% and a specificity of 79% for correctly identifying an infection. Patients with pleural space infection had a diminished 1-year survival rate compared to those without infection (67% vs 87%, respectively; p = 0.002).

CONCLUSION

Pleural infection with fungal or bacterial pathogens commonly complicates lung transplantation, and an elevated neutrophil level in the pleural fluid is the most sensitive and specific indicator of infection.

Anesthetic Considerations for Lung Transplantation

Lung transplantation is the definitive treatment for end-stage lung disease. The number of lung transplantations performed is limited by the number of donors available and is far outnumbered by the potential recipients on the waiting list. Advances in surgical methods, organ preservation, and immunosuppression have decreased the morbidity and mortality associated with this procedure during the last few decades. Specific anesthetic concerns are associated with lung transplantation, including careful preoperative assessment of pulmonary and cardiac function, adequate venous access and monitors, and ventilation techniques, such as 1-lung ventilation and lung-protective strategies to decrease the risks of reperfusion injury, barotrauma, and re-expansion pulmonary edema. Intraoperative transesophageal echocardiography, cardiopulmonary bypass, and inhaled nitric oxide can also be important tools for the anesthesiologist to optimize patient care during this challenging procedure.

Decortication after lung transplantation

BACKGROUND

Compromise of a pulmonary allograft by restrictive or infectious pleural-space pathology may be amenable to surgical intervention; however, the role of decortication in this patient population has not yet been substantiated. To address this issue, indications and outcomes of decortication after lung transplantation were examined at our institution.

METHODS

From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%).

RESULTS

Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days.

CONCLUSIONS

Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.

Lung Transplantation

The first human lung transplantation (LuTX) was performed by Dr James Hardy (Hardy et al. 1963) in June 1960 at the University of Mississippi in a patient with unresectable lung cancer and obstructive pneumonitis. The patient received immunosuppression with azathioprine (Aza) and irradiation, but he died due to renal failure after 17 days.

Noninfectious Pulmonary Complications After Lung Transplantation

This article reviews several important noninfectious pulmonary complications that threaten survival, pulmonary function, and quality of life after lung transplantation. Topics reviewed include primary graft dysfunction (PGD), native lung hyperinflation, anastomotic complications, phrenic nerve injury, pleural complications, lung cancer, pulmonary toxicity associated with immunosuppressive medications, and exercise limitation.

Pleural Space Problems After Living Lobar Transplantation

BACKGROUND

We reviewed our experience with adult living lobar lung transplant (LL) recipients to assess whether size and shape mismatch of the donor organ to the recipient pre-disposes to the development of pleural space problems (PSP).

METHODS

Eighty-seven LL were performed on 84 adult recipients from 1993 through 2003. Seventy-six patients had cystic fibrosis. Patient records were examined for PSP, defined as air leak or bronchopleural fistula for more than 7 days; pneumothorax, loculated pleural effusions, or empyema in 68 patients for which complete data were available.

RESULTS

There were 24 PSP identified for an overall incidence of 35%. The most common PSP was air leak/bronchopleural fistula, accounting for 38% of PSP. The second most common PSP was loculated pleural effusion (21% of PSP). Empyema was uncommon (2 patients, 3% of total patients) in our series of patients despite the large population of cystic fibrosis patients. In 4 of these patients, computed tomography-guided drainage was used for loculated effusions after chest tube removal. Three LL patients underwent surgery for persistent air leak and required muscle flap repair. One of these required subsequent omental transfer. Two LL patients required decortication for empyema. Many patients with PSP could be managed without further surgical intervention (14/24 patients). Donor-recipient height mismatch was not significantly different between PSP and non-PSP patients (p = 0.53).

CONCLUSIONS

The incidence of PSP in LL recipients is similar to that reported in the literature on cadaveric transplant recipients. The relatively small lobe in the potentially contaminated chest cavity of cystic fibrosis recipients does not significantly pre-dispose to development of empyema despite immunosuppression. Many PSP can be managed non-operatively, although early aggressive intervention for large air leaks and judicious chest tube management are essential for a good outcome.

Implante lobar autólogo pós pneumonectomia: modelo experimental em cães

OBJETIVO: Estudar no implante lobar autólogo a eficiência da anastomose brônquica simples, a perfusão pulmonar e as complicações devido a desproporção doador/receptor. MÉTODOS: Estudou-se 15 cães submetidos à pneumonectomia esquerda, e reimplante do lobo caudal. Estudou-se a perfusão pulmonar e a anastomose brônquica, respectivamente, por cintilografia e por broncografia. O sacrifício ocorreu aproximadamente 200 dias após a cirurgia para o estudo das anastomoses e medidas de volumes e pesos pulmonares. RESULTADOS: Quatro cães foram a óbito, um por deiscência precoce de anastomose brônquica, 1 com infecção e outros 2 por infarto pulmonar devido a oclusão da veia pulmonar no local da anastomose. A perfusão relativa do pulmão direito e esquerdo foram em média respectivamente 72,7% e 27,3%. A broncografia não mostrou nem estenose nem outras alterações na anastomose brônquica. No momento do sacrifício o lobo caudal ocupava totalmente a cavidade pleural sem que houvesse evidentes desvios do mediastino. CONCLUSÕES: O estudo mostrou que a sutura brônquica término-terminal desprotegida não levou a complicações anastomóticas. Não houve complicações pelo fato do lobo implantado ter ocupado somente metade da cavidade pleural. As complicações mais importantes foram o infarto pulmonar e deiscência total da parede torácica. Tanto a broncografia como a cintilografia se mostraram eficientes respectivamente, para o estudo da anastomose brônquica e da perfusão relativa do pulmão funcionante in vivo.

Acute and chronic pleural complications in lung transplantation

BACKGROUND

Lung transplant recipients may have pleural complications. However, the influence of these complications on the prognosis is not well known.

METHODS

We analyzed pleural complications and clinical and radiologic data from 100 patients who underwent lung transplantation in a general hospital in a 9-year period. Pre-operative evaluation, surgical protocol, immunosuppressive regimen, and follow-up were carried out systematically. Chest computerized tomography (CT) was performed at 3 and 12 months after transplantation.

RESULTS

All patients had early post-operative pleural effusion ipsilateral to the graft, which required drainage for a mean of 19.3 days (range, 5-52 days). Thirty-four patients had 43 acute pleural complications: 15 hemothoraxes, 10 persistent air leaks, 8 pneumothoraxes, 7 transient air leaks, and 3 empyemas. Multivariate analysis showed hemothorax and persistent air leak were associated with increased post-operative mortality (p = 0.024, p = 0.011, respectively). Post-operative mortality was not associated with any pre-transplant variable. Chest CT findings at 3 months revealed > or =1 pleural alteration in 58 of 70 patients (83%): 34 post-operative residual ipsilateral pleural effusions; 36 pleural thickenings; and 3 residual pneumothoraxes, 1 with a coexisting bronchial dehiscence. Chest CT at 12 months showed pleural alterations in 50 of 58 patients (86%): pleural thickening in 48, calcification in 4, and residual pleural effusion in 4.

CONCLUSIONS

Pleural complications are common in lung transplant recipients. Hemothorax and persistent air leak are associated with increased post-operative mortality. Chest CT showed pleural alterations in most patients 12 months after transplantation.

Pleural effusions in lung transplant recipients: image-guided small-bore catheter drainage

PURPOSE

To assess the efficacy of treating pleural effusions in lung transplant recipients with small-bore catheter drainage.

MATERIALS AND METHODS

Chest radiographs and computed tomographic (CT) scans obtained in 31 lung transplant recipients who had pleural effusions treated with catheter drainage were retrospectively reviewed. Duration of drainage and volume of fluid drained were recorded. Results were evaluated 1 and 3 months after chest tube removal. There was complete response (CR) when no pleural fluid remained, partial response (PR) when fluid remaining was less than the pretreatment level, and no response (NR) when fluid recurred to a level at or above the pretreatment level. Associations between cause of effusion (empyema, parapneumonic effusion, rejection, other), response (CR, PR, NR), and type of transplantation (unilateral, bilateral) were examined by using chi2 tests.

RESULTS

Of 31 patients, 25 had bilateral effusions; eight of these 25 patients had small-bore catheters inserted bilaterally. Nine patients had multiple sequential catheter insertions. Duration of drainage ranged from 2 to 44 days (median, 6 days). Fluid output was 110-9,726 mL (median, 1,350 mL). One-month follow-up data were available for 31 of 39 treated pleural effusions: 11 (35%) had CR, 18 (58%) had PR, and two (6%) had NR (percentages do not add up to 100% due to rounding). Three-month follow-up data were available for 28 of 39 treated effusions: 22 (79%) had CR, five (18%) had PR, and one (4%) had NR (percentages do not add up to 100% due to rounding). One- and 3-month response rates, respectively, were not related to cause of effusion (P =.82 and.535) or type of transplantation (P =.568 and >.999).

CONCLUSION

Small-bore catheter drainage of persistent pleural effusions in lung transplant recipients is usually successful, but drainage is often prolonged and may require multiple catheter placements.

Critical care issues in lung and heart transplantation

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.

Late postoperative pleural effusion following lung transplantation: characteristics and clinical implications

OBJECTIVE

Pleural effusions are extremely common in the early postoperative period after lung transplantation (LTX). It occurs in all transplant recipients, and like pleural fluid following other cardiothoracic surgery is bloody, exudative and neutrophil predominant. There was no information, however, on the characteristics of the late (14-45 days) postoperative pleural fluid after LTX. The purpose of this study was to describe the characteristics and the clinical implications of late postoperative pleural effusion after LTX.

METHODS

Thirty-five patients underwent TX between May 1997 and May 2001. Seven patients (20%) developed late postoperative pleural effusion. Thoracentesis were performed in these patients and the white blood cell counts, cell differential as well as biochemical parameters were determined.

RESULTS

The median time for late pleural effusion appearance was 23 days (range, 14-34 days) after TX. The pleural effusions were medium in size (700 ml, range, 100-1300), exudative in all the patients and had lymphocyte predominance. No evidence of fluid recurrence or clinical deterioration was noted in these patients.

CONCLUSION

Late-onset exudative lymphocytic pleural effusion after LTX is not uncommon. When there is no evidence of rejection or infection, it usually has a benign, favorable outcome.

Late-onset chylothorax after heart-lung transplantation

Chylothorax has rarely been reported after heart and lung transplantation. We describe a case of a bilateral chylothorax that occurred in a 53-year-old man 4 months after heart-lung transplantation and review the three additional reports in the literature of chylothorax after heart transplantation. Chyle drainage may cause compromise of the transplant patient. The good nutritional status of our recipient, however, allowed conservative therapy with chest tube drainage and enteral low-fat diet, without the need for surgical intervention. We concluded that chylothorax can presents late after lung transplantation and that conservative treatment should be considered in patients with good nutritional status.

Perioperative care of the lung transplant patient

Improvements in the perioperative management of lung transplant recipients have produced a 90% survival in the first 30 days following surgery. Detailed attention to donor organ procurement and preservation of the allograft are important in ensuring an early successful outcome. Early antibacterial administration based on donor or pretransplant cultures and antiviral therapy in CMV-negative recipients assist in avoiding early infectious complications. Development of hypoxemia or hemodynamic instability in the perioperative period requires a rapid, systematic evaluation with attention to mechanical, immunologic, or infectious causes. Nonpulmonary complications are not infrequent in lung transplant recipients.

Burkholderia cepacia complex: a contraindication to lung transplantation in cystic fibrosis?

Previous studies have indicated that pulmonary infection with Burkholderia cepacia is associated with poor clinical outcome after lung transplantation in cystic fibrosis (CF). Many treatment centers consider B. cepacia infection an absolute contraindication to lung transplantation. However, the B. cepacia complex actually consists of several closely related bacterial species. Although each of these has been isolated from CF sputum culture, certain species are much more frequently recovered than others, and it is not yet clear whether all species have the same potential for virulence in CF. Additional study is needed to better define the relative risks associated with each species of the B. cepacia complex.