Complications in the native lung after single lung transplantation

Native lung surgery after single lung transplantation: clinical characteristics and outcomes

PURPOSE

Single lung transplantation (SLT) is a viable option for patients with end-stage pulmonary parenchymal and vascular diseases. However, various diseases can occur in native lungs after SLT.

METHODS

Between January 2000 and December 2021, 35 patients underwent cadaveric SLT and survived for more than 30 days in our hospital. Among these 35 patients, 10 required surgery for diseases that developed in their native lungs. The clinical characteristics of these 10 patients and the outcomes of native lung surgery (NLS) were investigated.

RESULTS

Among these ten patients, the indications for lung transplantation were chronic obstructive pulmonary disease and idiopathic interstitial pneumonia in three patients each, and lymphangioleiomyomatosis and collagen vascular disease-related interstitial pneumoniain two patients each. The causes of NLS included pneumothorax (n = 4), primary lung cancer (n = 2), native lung hyperinflation (n = 2), and pulmonary aspergilloma (n = 2). The surgical procedures were pneumonectomy (n = 7), lobectomy (n = 2), and alveolar-pleural fistula repair (n = 1). Only one postoperative complication, empyema, was treated with antibiotics. The 5-year overall survival rates after transplantation with and without NLS were 70.0% and 80.0%, respectively, and did not differ to a statistically extent (p = 0.56).

CONCLUSION

NLS is an effective treatment option for diseases that develop in the native lungs after SLT.

Elderly lung transplant recipients show acceptable long-term outcomes for lung transplantation: A propensity score-matched analysis

PURPOSE

Although the performance lung transplantation (LTx) in the elderly (≥ 60 years) has increased globally, the situation in Japan remains quite different, because the age limit at registration for cadaveric transplantation is 60 years. We investigated the long-term outcomes of LTx in the elderly in Japan.

METHODS

This was a single-center retrospective study. We divided the patients into two groups according to age: the younger group (< 60 years; Y group; n = 194) and the elderly group (≥ 60 years; E group; n = 10). We performed three-to-one propensity score matching to compare the long-term survival between the E and Y groups.

RESULTS

In the E group, the survival rate was significantly worse (p = 0.003), and single-LTx was more frequent (p = 0.036). There was a significant difference in the indications for LTx between the two groups (p < 0.001). The 5-year survival rate after single-LTx in the E group was significantly lower than that in the Y group (p = 0.006). After propensity score matching, the 5-year survival rates of the two groups were comparable (p = 0.55). However, the 5-year survival rate after single-LTx in the E group was significantly lower than that in the Y group (p = 0.007).

CONCLUSION

Elderly patients showed acceptable long-term survival after LTx.

Single vs Bilateral Lung Transplant in the Management of Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Lung transplantation is recommended for select patients with end-stage chronic obstructive pulmonary disease (COPD). However, a consensus has not been reached regarding the optimal choice of lung transplantation: single lung transplants (SLTs) vs bilateral lung transplants (BLTs). This meta-analysis aimed to evaluate the safety and efficacy of SLT compared with BLT in managing end-stage COPD.

METHODS

Cochrane, Embase, PubMed, and Scopus were searched for articles by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022343408).

RESULTS

Seven studies of 311 screened met the eligibility criteria, with a total of 10,652 patients with end-stage COPD, SLT (n = 6233), or BLT (n = 4419). Overall survival rates of BLT group were more favorable than SLT group at 1 (odds ratio [OR] = 1.29, 95% CI: 1.16, 1.43, I2 = 0%), 5 (OR = 1.46, 95% CI: 1.35, 1.58, I2 = 23%), and 10 years (OR = 1.71, 95% CI: 1.57, 1.87, I2 = 12%) as well as the hazard ratio (HR = 0.73, 95% CI: 0.70, 0.76, I2 = 40%). Subgroup analysis on survival rates of alpha-1 antitrypsin deficiency also displayed a trend favoring BLT compared with SLT at 1 (OR = 1.60, 95% CI: 1.24, 2.08, I2 = 28%), 5 (OR = 1.84, 95% CI: 1.50, 2.26, I2 = 42%), and 10 years (OR = 1.98, 95% CI: 1.59, 2.48, I2 = 47%) as well as the HR (HR = 0.67, 95% CI: 0.35, 1.28, I2 = 82%).

CONCLUSION

Compared with SLT, BLT seems to demonstrate more favorable trends in survival rates for the management of end-stage COPD. Despite the promising results, the groups have significant heterogeneity in baseline characteristics. Further prospective studies with extended follow-up periods are needed to ascertain the efficacy of treatment.

Factors affecting complications development and mortality after single lung transplant

Lung transplantation (LT) is a life-saving therapeutic procedure that prolongs survival in patients with end-stage lung disease. Furthermore, as a therapeutic option for high-risk candidates, single LT (SLT) can be feasible because the immediate morbidity and mortality after transplantation are lower compared to sequential single (double) LT (SSLTx). Still, the long-term overall survival is, in general, better for SSLTx. Despite the great success over the years, the early post-SLT period remains a perilous time for these patients. Patients who undergo SLT are predisposed to evolving early or late postoperative complications. This review emphasizes factors leading to post-SLT complications in the early and late periods including primary graft dysfunction and chronic lung allograft dysfunction, native lung complications, anastomosis complications, infections, cardiovascular, gastrointestinal, renal, and metabolite complications, and their association with morbidity and mortality in these patients. Furthermore, we discuss the incidence of malignancy after SLT and their correlation with immunosuppression therapy.

Impacts of single nucleotide polymorphisms in Fc gamma receptor IIA (rs1801274) on lung transplant outcomes among Japanese lung transplant recipients

This study aimed to analyze the influences of single nucleotide polymorphisms (SNPs) in Fc gamma receptor IIA (FCGR2A) on postoperative outcomes after lung transplantation (LTx). We enrolled 191 lung transplant recipients (80 undergoing living-donor lobar lung transplants [LDLLTs] and 111 undergoing deceased-donor lung transplants [DDLTs]) in this study. We identified SNPs in FCGR2A (131 histidine [H] or arginine [R]; rs1801274) and reviewed the infectious complication-free survival after ICU discharge. The SNPs in FCGR2A comprised H/H (n=53), H/R (n=24), and R/R (n=3) in LDLLT, and H/H (n=67), H/R (n=42), and R/R (n=2) in DDLT. Recipients with H/H (H/H group) and those with H/R or R/R (R group) were compared in the analyses of infectious complications. In multivariate analyses, the R group of SNPs in FCGR2A was associated with pneumonia-free survival (HR: 2.52 [95% confidence interval {CI}: 1.35-4.71], p=0.004), fungal infection-free survival (HR: 2.50 [95% CI: 1.07-5.84], p=0.035), and cytomegalovirus infection-free survival (HR: 2.24 [95% CI: 1.07-4.69], p=0.032) in LDLLT but it was not associated with infectious complication-free survival in DDLT. Therefore, in LDLLT, more attention to infectious complications might need to be paid for LTx recipients with H/R or R/R than for those with H/H.

The influence of the native lung on early outcomes and survival after single lung transplantation

Objective

To determine whether problems arising in the native lung may influence the short-term outcomes and survival after single lung transplantation (SLT), and therefore should be taken into consideration when selecting the transplant procedure.

Patients and methods

Retrospective review of 258 lung transplants performed between June 2012 and June 2019. Among them, 161 SLT were selected for the analysis. Complications in the native lung were recorded and distributed into two groups: early and late complications (within 30 days or after 30 days post-transplant). Donor and recipient preoperative factors, 30-day mortality and survival were analysed and compared between groups by univariable and multivariable analyses, and adjusting for transplant indication.

Results

There were 161 patients (126M/35F; 57±7 years) transplanted for emphysema (COPD) (n = 72), pulmonary fibrosis (IPF) (n = 77), or other indications (n = 12). Forty-nine patients (30%) presented complications in the native lung. Thirty-day mortality did not differ between patients with or without early complications (6% vs. 12% respectively; p = 0.56). Twelve patients died due to a native lung complication (7.4% of patients; 24% of all deaths). Survival (1,3,5 years) without vs. with late complications: COPD (89%, 86%, 80% vs. 86%, 71%, 51%; p = 0.04); IPF (83%, 77%, 72% vs. 93%, 68%, 58%; p = 0.65). Among 30-day survivors: COPD (94%, 91%, 84% vs. 86%, 71%, 51%; p = 0.01); IPF (93%, 86%, 81% vs. 93%, 68%, 58%; p = 0.19). Native lung complications were associated to longer ICU stay (10±17 vs. 33±96 days; p<0.001), longer postoperative intubation (41±85 vs. 99±318 hours; p = 0.006), and longer hospital stay (30±24 vs. 45±34 days; p = 0.03). The presence of late native lung problems predicted survival in COPD patients (OR: 2.55; p = 0.07).

Conclusion

The native lung is a source of morbidity in the short-term and mortality in the long-term after lung transplantation. This should be taken into consideration when choosing the transplant procedure, especially in COPD patients.

Native lung complications after living-donor lobar lung transplantation

BACKGROUND

Living-donor lobar lung transplantation (LDLLT) is viable for critically ill patients in situations of donor shortage. Because it is sometimes difficult to find 2 ideal living donors with suitable graft sizes, we developed native lung-sparing procedures, including single LDLLT and native upper lobe-sparing LDLLT. This study aimed to investigate native lung complications (NLCs) in native lung-sparing LDLLT.

METHODS

Between April 2002 and March 2019, 92 LDLLTs and 124 cadaveric lung transplantations (CLTs) were performed at the Kyoto University Hospital. Our prospectively maintained database and clinical records were reviewed to compare NLCs among recipients who underwent native lung-sparing LDLLT (n = 21) with those among recipients who underwent single CLT (n = 61).

RESULTS

Among 21 recipients who underwent native lung-sparing LDLLT, 11 NLCs occurred in 8 recipients. No fatal NLC was noted; however, 2 required surgical intervention. Post-transplant survival was not significantly different between native lung-sparing LDLLT recipients with NLCs and those without NLCs. The incidence of NLCs was comparable between native lung-sparing LDLLT recipients and single CLT recipients (8/21 vs 26/61, p = 0.80); however, NLCs occurred significantly later in LDLLT recipients than in CLT recipients (median: 665 vs 181.5 days after transplantation, p = 0.014).

CONCLUSIONS

NLCs after native lung-sparing LDLLT had favorable outcomes. Therefore, native lung-sparing LDLLT is a useful treatment option for severely ill patients who cannot wait for CLT. However, it is important to recognize that NLCs may occur later in LDLLT than in CLT.

Lung transplantation for emphysema

Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.

Transplant options for end stage chronic obstructive pulmonary disease in the context of multidisciplinary treatments

Lung transplantation (LTx) in advanced stage chronic obstructive pulmonary disease (COPD) patients is associated with significant improvement in lung function and exercise capacity. However, demonstration that the procedure also provides a survival benefit has been more elusive compared to other respiratory conditions. Identification of patients with increased risk of mortality is crucial: a low forced expiratory volume in 1 second (FEV₁) is perhaps the most common reason for referral to a lung transplant center, but in itself is insufficient to identify which COPD patients will benefit from LTx. Many variables have to be considered in the selection of candidates, time for listing, and choice of procedure: age, patient comorbidities, secondary pulmonary hypertension, the balance between individual and community benefit. This review will discuss patient selection, transplant listing, potential benefits and critical issues of bilateral (BLTx) and single lung (SLTx) procedure, donor-to-recipient organ size-matching; furthermore, it will describe LTx outcomes and its effects on recipient survival and quality of life.

Bilateral versus single lung transplantation: are two lungs better than one?

There is a long-standing debate over whether single or bilateral lung transplant provides better short and long-term clinical outcomes. We performed a detailed PubMed search on relevant clinical research publications on single (SLT) and bilateral lung transplantation (BLT). We included studies that were published before and after the implementation of the lung allocation score (LAS). We reviewed disease-specific short- and long-term outcomes associated with each transplantation technique. The majority of published studies are retrospective cohort studies that use institutional data or large patient registries. Outcomes associated with transplantation technique vary by disease specific indication, age, and patient severity. Over the past decade, the relative proportion of bilateral lung transplantation has increased. Increasing adoption of bilateral lung transplant likely reflects the general acceptance of several advantages associated with the technique. However, making a clear, evidence-based decision is difficult in light of the fact that there has never been and probably never will be a randomized trial. Our institutional preference is bilateral lung transplant. However, consideration for the technique should still be made on a case-by-case basis.

Evaluation of Respiratory Dynamics in an Asymmetric Lung Compliance Model

Background

Unilateral lung hyperinflation develops in lungs with asymmetric compliance, which can lead to vital instability. The aim of this study was to investigate the respiratory dynamics and the effect of airway diameter on the distribution of tidal volume during mechanical ventilation in a lung model with asymmetric compliance.

Methods

Three groups of lung models were designed to simulate lungs with a symmetric and asymmetric compliance. The lung model was composed of two test lungs, lung1 and lung2. The static compliance of lung1 in C15, C60, and C120 groups was manipulated to be 15, 60, and 120 ml/cmH₂O, respectively. Meanwhile, the static compliance of lung2 was fixed at 60 ml/cmH₂O. Respiratory variables were measured above (proximal measurement) and below (distal measurement) the model trachea. The lung model was mechanically ventilated, and the airway internal diameter (ID) was changed from 3 to 8 mm in 1-mm increments.

Results

The mean ± standard deviation ratio of volumes distributed to each lung (V_L1/V_L2) in airway ID 3, 4, 5, 6, 7, and 8 were in order, 0.10 ± 0.05, 0.11 ± 0.03, 0.12 ± 0.02, 0.12 ± 0.02, 0.12 ± 0.02, and 0.12 ± 0.02 in the C15 group; 1.05 ± 0.16, 1.01 ± 0.09, 1.00 ± 0.07, 0.97 ± 0.09, 0.96 ± 0.06, and 0.97 ± 0.08 in the C60 group; and 1.46 ± 0.18, 3.06 ± 0.41, 3.72 ± 0.37, 3.78 ± 0.47, 3.77 ± 0.45, and 3.78 ± 0.60 in the C120 group. The positive end-expiratory pressure (PEEP) of lung1 was significantly increased at airway ID 3 mm (1.65 cmH₂O) in the C15 group; at ID 3, 4, and 5 mm (2.21, 1.06, and 0.95 cmH₂O) in the C60 group; and ID 3, 4, and 5 mm (2.92, 1.84, and 1.41 cmH₂O) in the C120 group, compared to ID 8 mm (P < 0.05).

Conclusions

In the C15 and C120 groups, the tidal volume was unevenly distributed to both lungs in a positive relationship with lung compliance. In the C120 group, the uneven distribution of tidal volume was improved when the airway ID was equal to or less than 4 mm, but a significant increase of PEEP was observed.

Lung cancer: a rare indication for, but frequent complication after lung transplantation

Lung transplantation is an effective and safe therapy for carefully selected patients suffering from a variety of end-stage pulmonary diseases. Lung cancer negatively affects prognosis, particularly in patients who are no longer candidates for complete resection. Lung transplantation can be considered for carefully selected and well staged lung cancer patients with proven, lung-limited, multifocal, (minimally invasive) adenocarcinoma in situ (AIS) (previously called bronchioloalveolar cell carcinoma) causing respiratory failure. Despite a substantial risk of tumour recurrence (33-75%), lung transplantation may offer a survival benefit (50% at 5 years) with best palliation of their disease. Reports on lung transplantation for other low-grade malignancies are rare. Lung transplant candidates at higher risk for developing lung cancer [mainly previous smokers with chronic obstructive lung disease (COPD) and idiopathic pulmonary fibrosis (IPF) or older patients] should be thoroughly and repeatedly screened for lung cancer prior to listing, and preferably also during waiting list time if longer than 1 year, including the use of PET-CT scan and EBUS-assisted bronchoscopy in case of undefined, but suspicious pulmonary abnormalities. Double-lung transplantation should now replace single-lung transplantation in these high-risk patients because of a 6-9% prevalence of lung cancer developing in the remaining native lung. Patients with unexpected, early stage bronchial carcinoma in the explanted lung may have favourable survival without recurrence. Early PET-CT (at 3-6 months) following lung transplantation is advisable to detect early, subclinical disease progression. Donor lungs from (former) smokers should be well examined at retrieval. Suspicious nodules should be biopsied to avoid grafting cancer in the recipient. Close follow-up with regular visits and screening test in all recipients is needed because of the increased risk of developing a primary or secondary cancer in the allograft from either donor or recipient origin.

Risks and Epidemiology of Infections After Lung or Heart–Lung Transplantation

Nowadays, lung transplantation is an established treatment option of end-stage pulmonary parenchymal and vascular disease. Post-transplant infections are a significant contributor to overall morbidity and mortality in the lung transplant recipient that, in turn, are higher than in other solid organ transplant recipients. This is likely due to several specific factors such as the constant exposure to the outside environment and the colonized native airway, and the disruption of usual mechanisms of defense including the cough reflex, bronchial circulation, and lymphatic drainage. This chapter will review the common infections that develop in the lung or heart–lung transplant recipient, including the general risk factors for infection in this population, and specific features of prophylaxis and treatment for the most frequent bacterial, viral, and fungal infections. The effects of infection on lung transplant rejection will also be discussed.

Significance of single lung transplantation in the current situation of severe donor shortage in Japan

OBJECTIVE

Although bilateral lung transplantation is the procedure of choice internationally, single lung transplantation is preferred in Japan because of the severe donor shortage except in cases of contraindications to single lung transplantation. This study aimed to evaluate the clinical characteristics of single lung transplant recipients and outcomes of this procedure at one of the largest lung transplant centers in Japan.

METHODS

Between April 2002 and May 2015, 57 cadaveric lung transplantations (33 single and 24 bilateral) were performed in Kyoto University Hospital. The clinical characteristics of the lung transplant recipients and outcomes of these procedures, including overall survival and postoperative complications, were investigated.

RESULTS

Overall, the 1-, 3-, and 5-year survival rates were 86, 77, and 72 %, respectively, with a median follow-up period of 1.9 years. There was no significant difference in survival between patients who underwent single lung transplantations and those who underwent bilateral lung transplantations (p = 0.92). The median waiting time was significantly shorter for single lung transplant patients than for bilateral lung transplant patients (p = 0.02). Native lung complications were seen in 14 out of 33 patients (42 %) who underwent single lung transplantation. There was no significant difference in survival between patients with and without postoperative native lung complications.

CONCLUSIONS

Single lung transplantation has been performed with acceptable outcomes in our institution. In the current situation of severe donor shortage in Japan, single lung transplantation can remain the first choice of treatment except in cases of contraindications to single lung transplantation.

Sepsis in the severely immunocompromised patient

The prevention and treatment of sepsis in the immunocompromised host present a challenging array of diagnostic and management issues. The neutropenic patient has a primary defect in innate immune responses and is susceptible to conventional and opportunistic pathogens. The solid organ transplant patient has a primary defect in adaptive immunity and is susceptible to a myriad of pathogens that require an effective cellular immune response. Risk for infections in organ transplant recipients is further complicated by mechanical, vascular, and rejection of the transplanted organ itself. The immune suppressed state can modify the cardinal signs of inflammation, making accurate and rapid diagnosis of infection and sepsis difficult. Empiric antimicrobial agents can be lifesaving in these patients, but managing therapy in an era of progressive antibiotic resistance has become a real issue. This review discusses the challenges faced when treating severe infections in these high-risk patients.

Thoracoscopic native lung pneumonectomy after single lung transplant: initial experience with 2 cases†

Single lung transplants (SLTs) leave in place a diseased lung, a potential source of complications. Native lung pneumonectomy is occasionally indicated. We present 2 cases of native lung complications (NLCs) managed with video-assisted thoracoscopic surgery (VATS) pneumonectomy at our institution, a procedure never reported in this context before. Case 1 involves a 59-year old gentleman with refractory, invasive pulmonary aspergillosis of the native lung, 5 years after SLT for idiopathic pulmonary fibrosis. Case 2 involves a 66-year old gentleman with α-1 antitrypsin deficiency who developed severe haemoptysis and intraparenchymal haemorrhage in the native lung 12 years after SLT. A VATS pneumonectomy was performed in both cases because we believed it would facilitate wound healing and hasten recovery in immunosuppressed patients. Our short-term results align with this hypothesis. We conclude that VATS pneumonectomy is a feasible, adequate and safe procedure in this patient population; larger series are needed to draw definitive conclusions.

Lung transplantation for emphysema: impact of age on short- and long-term survival

OBJECTIVES

Overall, emphysema (EMP) is the most common indication for lung transplantation. The majority of patients present with chronic obstructive pulmonary disease (COPD) and less frequently with alpha-1 antitrypsin deficiency (A1ATD). We analysed the results of lung transplants performed for EMP in order to identify the impact of age on short- and long-term outcome.

METHODS

A retrospective analysis was undertaken of the 108 consecutive lung transplants for EMP performed at our institution from November 1992 to August 2013 (77 COPD, 31 A1ATD). Retransplantations were excluded.

RESULTS

The median age was 56 years (range 31-68). Thirty-day mortality rate was 3.7%. One- and 5-year survival rates in COPD and A1ATD recipients were comparable (P = 0.8). The 1- and 5-year survival rates for recipients aged <60 years old were significantly better than the age group of ≥60 years (91 and 79 vs 84 and 54%, P = 0.05). Since 2007, the 1- and 5-year survival for these two age groups were 96 and 92 vs 86 and 44%, respectively, P = 0.04, log-rank test). For the following parameters, we were not able to find any difference to affect survival rates: use of intraoperative extracorporeal membrane oxygenation, waiting list time, sex, graft size reduction, body mass index and diagnosis. In multivariate analysis, age at transplantation (≥60 years old) (HR 2.854; 95% confidence interval (CI) 1.338-6.08, P = 0.008) and unilateral lung transplantation (HR 15.2; 95% CI 3.2-71.9, P = 0.009) were independent risk factors for mortality.

CONCLUSIONS

COPD and A1ATD recipients have similar overall long-term survival. Recipients aged ≥60 years and unilateral lung transplants were risk factors for mortality.

Right native lung pneumonectomy due to over inflation three years after left single lung transplantation for pulmonary lymphangioleiomyomatosis

Native lung hyperinflation (NLH) is one of the known complications after single lung transplantation (SLT). Generally, satisfactory results are achieved in patients undergoing SLT when simultaneous (or second stage) volume reduction of the contralateral native lung is performed. Contralateral native lung pneumonectomy after SLT is rarely reported. In this article, we report a case of a successful, right pneumonectomy of the native lung, 3 years after a left single lung transplant for pulmonary lymphangioleiomyomatosis (PLAM). The patient's pulmonary function and quality of life improved significantly after a right pneumonectomy of the native lung.

Lung volume reduction surgery for native lung hyperinflation following single-lung transplantation for emphysema: which patients?

OBJECTIVES

Lung transplantation is an established treatment for patients with advanced emphysema. Double-lung transplantation is favoured to avoid complications following single-lung transplantation, including native lung hyperinflation. Nonetheless, single-lung transplantation continues due to limited donor organ availability. The aim of this study was to evaluate the pre-operative assessment, surgical techniques and outcomes in patients undergoing lung volume reduction surgery for native lung hyperinflation.

METHODS

Eight patients underwent lung volume reduction surgery for native lung hyperinflation between October 2008 and April 2011. Symptoms, pre-operative evaluation, peri-operative morbidity, length of stay, pulmonary function and survival were examined. The mean follow-up was 17 months.

RESULTS

Participants underwent high resolution CT and bronchoscopy with transbronchial biopsy and bronchial washings to exclude alternative causes for deterioration in pulmonary function tests. V/Q scan was performed to assess the contribution of each lung to overall function. Measurement of inspiratory airflow resistance in each lung was performed in one case. Seven patients underwent multiple wedge resections and one underwent bilobectomy. All patients survived to hospital discharge, and mean length of stay was 13.9 days. Functional improvement was demonstrated in all cases at follow-up, with a mean percentage increase of 29.3% in forced expiratory volume in one second and 21.6% in forced vital capacity. Symptomatic improvement was also reported by all patients post-operatively.

CONCLUSIONS

Lung volume reduction surgery for native lung hyperinflation is an effective treatment strategy with an acceptable level of surgical risk. Patient selection, however, remains vital. The non-anatomical multiple wedge excision technique used here was as effective as anatomical lung volume reduction surgery used in other series. With regard to pre-operative assessment, the measurement of single-lung inspiratory airflow resistance is of particular interest. We feel that this may provide an additional method of differentiating between native lung hyperinflation and obliterative bronchiolitis prior to surgery, thus improving patient selection.

Single-lung transplantation: does side matter?

OBJECTIVE

Single-lung transplantation (SLTx) is a valid treatment option for patients with non-suppurative end-stage pulmonary disease. This strategy helps to overcome current organ shortage. Side is usually chosen based on pre-transplant quantitative perfusion scan, unless specific recipient considerations or contralateral lung offer dictates opposite side. It remains largely unknown whether outcome differs between left (L) versus right (R) SLTx.

METHODS

Between July 1991 and July 2009, 142 first SLTx (M/F=87/55; age=59 (29-69) years) were performed from 142 deceased donors (M/F=81/61; age=40 (14-66) years) with a median follow-up of 32 (0-202) months. Indications for SLTx were emphysema (55.6%), pulmonary fibrosis (36.6%), primary pulmonary hypertension (0.7%), and others (7.0%). Recipients of L-SLTx (n=72) and R-SLTx (n=70) were compared for donor and recipient characteristics and for early and late outcome.

RESULTS

Donors of L-SLTx were younger (37 (14-65) vs 43 (16-66) years; p=0.033). R-SLTx recipients had more often emphysema (67.1% vs 44.4%; p=0.046) and replacement of native lung with ≥ 50% perfusion (47.1% vs 23.6%; p=0.003). The need for bypass, time to extubation, intensive care unit (ICU) and hospital stay, and 30-day mortality did not differ between groups. Overall survival at 1, 3, and 5 years was 78.4%, 60.5%, and 49.4%, respectively, with a median survival of 60 months, with no significant differences between sides. Forced expiratory volume in 1s (FEV₁) improved (p<0.01) in both groups to comparable values up to 36 months. Complications overall (44.4% vs 50.0%) or in allograft (25.0% vs 24.3.0%) as well as time to bronchiolitis obliterans syndrome (BOS) (35 months) and 5-year freedom from BOS (68.9% vs 75.0%) were comparable after L-SLTx versus R-SLTx, respectively. There were no differences in all causes of death (p=0.766). On multivariate analysis, BOS was a strong negative predictor for survival (hazard ratio (HR) 6.78; p<0.001), whereas side and mismatch for perfusion were not.

CONCLUSION

The preferred side for SLTx differed between fibrotic versus emphysema recipients. Transplant side does not influence recipient survival, freedom from BOS, complications, or pulmonary function after SLTx. Besides surgical considerations in the recipient, offer of a donor lung opposite to the preferred side should not be a reason to postpone the transplantation until a better-matched donor is found.

[Lung hyperinflation after single lung transplantation to treat emphysema]

Despite preventive measures, lung hyperinflation is a relatively common complication following single lung transplantation to treat pulmonary emphysema. The progressive compression of the graft can cause mediastinal shift and respiratory failure. In addition to therapeutic strategies such as independent ventilation, the treatment consists of the reduction of native lung volume by means of lobectomy or lung volume reduction surgery. We report two cases of native lung hyperinflation after single lung transplantation. Both cases were treated by means of lobectomy or lung volume reduction surgery.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Comparison of wait times and mortality for idiopathic pulmonary fibrosis patients listed for single or bilateral lung transplantation

BACKGROUND

Lung transplantation is the one form of solid-organ transplantation in which there is the option for patients to receive one or two organs. Idiopathic pulmonary fibrosis (IPF) candidates can be accommodated by either procedure but the decision about these two options remains controversial. Therefore, we sought to determine whether IPF patients listed for bilateral lung transplantation only had longer wait times and higher mortality on the waiting list than those listed for single lungs only. Patients with chronic obstructive pulmonary disease (COPD) were also analyzed as a comparison group.

METHODS

This study was a retrospective analysis of the Organ Procurement and Transplantation Network database of patients with IPF and COPD listed for lung transplantation between May 2005 and December 2007. An analysis of wait times and mortality in this era as well as the pre-lung allocation score (pre-LAS) era of 2002 to 2004 was performed.

RESULTS

Of the 1,339 patients with IPF listed for lung transplantation, 31.7% were listed for bilateral lung transplantation only, 41% for single-lung transplantation only and 27.3% for either procedure. Patients listed for the bilateral procedure only were at greater risk of dying on the transplant list (p < 0.003), and were less likely to receive a lung transplant (p < 0.012). No difference in outcomes was seen in the COPD patients. Comparatively, in the pre-LAS era, wait times and mortality on the list for IPF patients were significantly greater for all forms of transplantation.

CONCLUSIONS

There has been a significant improvement in wait times and mortality for IPF patients since the inception of the LAS system. Nonetheless, despite the goal of transplant equity, IPF patients listed for bilateral lung transplantation might have a clinically meaningful increased risk of pre-transplant mortality. The choice of procedures therefore needs to be made with careful consideration of patients' survival both pre- and post-transplantation. Evaluation of transplant outcomes should not only be based on post-transplant survival, but should also account for the impact of the choice of procedure.

Epidemiology of invasive aspergillosis and risk factors in non neutropaenic patients

INTRODUCTION

Invasive aspergillosis is a major cause of mortality in allogeneic bone marrow transplant recipients and patients treated for blood malignancies. The diagnostic tools, treatments and preventive strategies, essentially developed for neutropaenic patients, have not been assessed in populations whose immune systems are considered to be competent.

STATE OF THE ART

Beside the standard picture of chronic Aspergillus infection, the incidence of invasive aspergillosis is increasing in non neutropaenic patients, such as those with chronic lung diseases or systemic disease treated with long-term immunosuppressive drugs and solid organ transplant recipients. This study reviews the specific features of invasive aspergillosis in non neutropaenic subjects (NNS) and discusses the value of the diagnostic tools and treatment in this population.

PROSPECTS

A better understanding of the pathophysiology and the epidemiological characteristics of invasive aspergillosis would provide a means of adapting the staging and classification of the disease for NNS.

CONCLUSIONS

Invasive aspergillosis is under diagnosed in NNS who may already be colonised when they receive immunosuppressive treatment; this can lead to an adverse outcome in patients who are considered to be a moderate risk population.

Mycophenolate mofetil reduces alveolar inflammation, acute rejection and graft loss due to bronchiolitis obliterans syndrome after lung transplantation

BACKGROUND

Bronchiolitis obliterans syndrome (BOS) is still the main complication after lung transplantation. Besides other improvements in post-operative management, newer immunosuppressive regimens might decrease the devastating sequelae of this complication.

METHODS

We compared the prospectively collected data of lung transplant recipients treated either with azathioprine (AZA; n = 48) or mycophenolate mofetil (MMF; n = 108), who underwent regular monthly surveillance bronchoscopies for at least 6 post-operative months.

RESULTS

Patients on MMF had significantly fewer acute (P < 0.001) and recurrent (P < 0.001), as well as less severe rejection episodes (P = 0.01). In addition, MMF significantly reduced the number of alveolar lymphocytes, eosinophils and neutrophils (P < 0.001), and decreased the hemosiderin score reflecting non-specific alveolar-capillary damage (P < 0.001). Although there was no change in the three stages of BOS, there was a trend towards improved survival (P = 0.062) and a significant decrease in graft loss due to BOS (P = 0.049) in patients receiving MMF.

CONCLUSIONS

Immunosuppression with MMF significantly decreased the incidence, severity and recurrence of acute rejection episodes in lung transplant recipients. Parameters of alveolar inflammation and alveolar-capillary damage were also decreased. As a potential consequence, MMF significantly reduced graft loss due to BOS and tended to improve overall survival in these patients.

Native lung complications in single-lung transplant recipients and the role of pneumonectomy

Single-lung transplant recipients may develop complications in their native lungs that may have an impact on outcomes. One potential therapeutic option is native lung pneumonectomy. The purpose of this study was to assess the impact of native lung complications on post-transplant survival in single-lung transplant recipients. We also aimed to determine the morbidity and mortality associated with native lung pneumonectomy (NLP). A retrospective review of all single-lung transplant recipients at our institution from January 1, 1998 to July 15, 2008 was performed. Patients were stratified to one of three groups: no native lung complications; native lung complications requiring native lung pneumonectomy; and native lung complications not managed with native lung pneumonectomy. Survival post-transplant and post-native lung complication were the primary end-points of the study. Significant native lung complications developed in 25 of 180 single-lung transplants (13.8%). Median post-transplant survival was lower in single-lung transplant recipients with significant native lung complications (3.2 years vs 5.3 years, p = 0.002). NLP was performed in 11 patients. Post-operative complications developed in 4 of 11 cases (36.4%), but all patients survived to hospital discharge. There was no significant difference in median survival between single-lung transplant recipients undergoing native lung pneumonectomy and single-lung transplant recipients without native lung complications (4.3 years vs 5.1 years, p = 0.478). Native lung complications impact post-transplant survival in single-lung transplant recipients and may partly explain why outcomes with single-lung transplantation are inferior to those of bilateral lung transplantation. NLP can be performed with acceptable morbidity and mortality.

How invasive aspergillosis may have a beneficial effect after single lung transplantation

We report the case of a 52-year-old female, who received a left single lung transplantation for end-stage smoking-induced emphysema in 1997. During the last 4 years, she experienced a progressive decline in FEV1, which we attributed to the development of bronchiolitis obliterans syndrome, stage 2. In 2007 she experienced an invasive aspergillosis of the native lung upper lobe, which resolved after 3 months of adequate treatment with voriconazole. After resolution of the infection, both FVC (forced vital capacity) and FEV1 became surprisingly better, due to fibrosis of the affected lobe, compatible with infection-induced volume reduction of the native lung.

Transplantation in Chronic Obstructive Pulmonary Disease

Lung transplantation is a surgical option for patients who fail optimization of medical treatment for the severe symptoms that result from COPD. This review will discuss patient selection, transplant listing, and the surgical technique for transplantation in COPD. Furthermore, it will describe transplant outcomes and its effects on recipient survival, pulmonary function, exercise capacity, respiratory muscle function, and quality of life. The respective roles of transplantation and lung volume reduction surgery as therapies for advanced disease will be outlined.

Lung volume reduction surgery and lung transplantation in chronic obstructive pulmonary disease

Medical treatment of emphysema does not alter the natural progression of the disease. Surgical techniques are an attractive conceptual approach to treat hyperinflation in these patients. Lung volume reduction surgery and lung transplantation are appropriate therapeutic options for a selected population with emphysema. We will review the available evidence to support these approaches.

Lung

Experiments with animals in the 1940 and 1950s demonstrated that lung transplantation was technically possible [33]. In 1963, Dr. James Hardy performed the first human lung transplantation. The recipient survived 18 days, ultimately succumbing to renal failure and malnutrition [58]. From 1963 through 1978, multiple attempts at lung transplantation failed because of rejection and complications at the bronchial anastomosis. In the 1980s, improvements in immunosuppression, especially the introduction of cyclosporin A, and enhanced surgical techniques led to renewed interest in organ transplantation. In 1981, a 45-year-old-woman received the first successful heart–lung transplantation for idiopathic pulmonary arterial hypertension (IPAH) [106]. She survived 5 years after the procedure. Two years later the first successful single lung transplantation for idiopathic pulmonary fibrosis (IPF) [128] was reported, and in 1986 the first double lung transplantation for emphysema [25] was performed.

Pulmonary nocardiosis after lung transplantation: CT findings in 7 patients and review of the literature

OBJECTIVE

The purpose of this study is to review reported radiographic clues to the diagnosis of pulmonary nocardiosis, as well as to describe and illustrate the high-resolution computed tomography findings of 7 patients with pulmonary nocardiosis after lung transplantation.

CONCLUSIONS

Computed tomography findings of pulmonary nocardiosis after lung transplantation consist predominantly of nodules and cavitary lesions without any significant zonal or anatomic distribution. The diagnosis of pulmonary nocardiosis requires a high index of suspicion, as presenting symptoms are nonspecific, initial visualization is often not possible with routine stains, and identification requires prolonged cultures.

Mechanics of Respiratory Muscles in Single-Lung Transplant Recipients

BACKGROUND

Emphysema and pulmonary fibrosis force the patients to breathe at an abnormal lung volume, which alters the lengths of the respiratory muscles and thereby their work capability is reduced. After single-lung transplantation, muscle function is restored on the side of the transplant but it may be asymmetric to that on the side of the native diseased lung.

OBJECTIVE

Investigating the hypothesis that single-lung transplantation induces mechanical asymmetry of the respiratory muscles on the two sides.

METHODS

Simultaneously noninvasive measurements of inspiratory and expiratory mouth pressure, airflow rate and electromyography signals from the sternomastoid, external intercostal, rectus abdominis and external oblique muscles were acquired during different breathing maneuvers. The study group included 10 single-lung transplant recipients (5 with pulmonary fibrosis and 5 with emphysema) and 10 healthy controls.

RESULTS

Analysis of the finding shows a significant lower global strength of the respiratory muscles of single-lung transplant recipients compared to that of healthy subjects. No significant difference in the EMG signals of respiratory muscles was found either between the different groups or between the sides of the transplant and the native lung in the patient groups. Both single-lung transplant recipients and healthy subjects demonstrated high EMG activity of the inspiratory muscles during inspiration at different breathing efforts.

CONCLUSION

Patients after single-lung transplantation have lower respiratory muscle strength than healthy subjects, but apparently normal electrical activity. The lower global respiratory muscle strength emphasizes the importance of their rehabilitation before and after single-lung transplantation.

Pulmonary tuberculosis in lung and heart-lung transplantation: fifteen years of experience in a single center in Spain

The increase in the number of solid organ transplants has resulted in an increased incidence of opportunistic infections, including infection by typical and atypical mycobacteria, with risk of developing tuberculosis. Pretransplant chemoprophylaxis with isoniazid has become increasingly common in an attempt to prevent the disease. The source of infection in tuberculosis (TB) may be difficult to identify. Infection may be caused by reactivation of a primary infection in the recipient, reactivation of a lesion from the donor lung, or primary infection. There are few reports on TB in lung transplantation. Incidence in the reported series ranges from 6.5% to 10%. Our series of 7 patients out of a total 271 patients (2.58%) represents a rate higher than reported for the general Spanish population, 26.7/10(5) inhabitants and for lung transplant candidates (0.18%). Our aim was to evaluate the incidence, clinical signs, and outcome of TB in our series of patients undergoing lung transplantation in the 15 years since inception of the program (February 1990 to December 2004). Morbidity and mortality was high (42.8%), but limited to patients in whom treatment was not administered or could not be successfully completed. However, early detection and treatment are essential.

Breathing power of respiratory muscles in single-lung transplanted emphysematic patients

Single-lung transplantation may induce asynchronous performance between the respiratory muscles of the chest. The objective of this study was to investigate the influence of a single transplanted lung on respiratory muscle mechanics. The force and power of the sternomastoid, external intercostal and external oblique muscles were evaluated throughout a range of respiratory maneuvers in emphysematic patients with a single transplanted lung and compared with that of healthy subjects. A significant differences was observed between the force, work and power of the muscles on the two sides of the chest in emphysematic patients (P<0.05). The control group demonstrated higher averaged maximal force, work and power. The total work done during either inspiration or expiration by the external intercostal and external oblique muscles on the side of the transplanted lung were higher compared with that of the native lung side and compared with the control group. The asynchrony between the lungs after single-lung transplant leads to asynchronous muscle force and work and lesser muscle strength compared to healthy subjects.

Thoracoscopy and transplantation: a new attractive tool

BACKGROUND

Transplanted patients on immunosuppressive treatment have an increased risk of infections or neoplasms. Transplantation candidates with infection or a suspected malignancy are excluded from transplantation. In patients already transplanted, thoracoscopy can resolve complications or treat the pulmonary pathology without compromising the precarious existing reactive equilibrium. These patients require an approach that is as least traumatic as possible.

METHODS

From September 1991 to December 2000, of 2068 videothoracoscopic procedures carried out at our hospital, 2 were in patients who had undergone transplantation and 3 in candidates for kidney, liver, and bone marrow transplantation. Starting from our personal experience in videothoracoscopy as a diagnostic and therapeutic approach, the possibilities of the method in the field of transplantation are reported by a review of the literature carried out by consulting the reference systems of the most important data banks.

CONCLUSIONS

In our experience, videothoracoscopy had a major impact on the management of candidates for transplant, because it allowed us to rule out or treat conditions that would have determined exclusion from a transplant program. In transplanted patients, videothoracoscopy allows a correct diagnosis and treatment with minimal trauma.

Nocardia infection in lung transplant recipients

BACKGROUND

Nocardia is responsible for infection in both normal and immunocompromised hosts. Organ transplant recipients are increasingly recognized as a sub-group of immunocompromised patients in whom nocardia is an important pathogen. The frequency of nocardia in organ transplant recipients varies between 0.7% and 3%. Nocardia infection has largely been reported in heart, kidney and liver transplant recipients. Presentations of nocardia in lung transplant recipients have been restricted primarily to case reports. The present study reviews the clinical and epidemiologic characteristics of nocardia infection in lung transplant recipients at our institution.

METHODS

A retrospective cohort study of 473 lung transplant recipients from January 1991 to November 2000 was done at a university hospital. Patient demographics, immunosuppressive regimen at the time of isolation of nocardia species, use of trimethoprim-sulfamethoxazole for Pneumocystis carinii prophylaxis, rejection episodes in the preceding 6 months, concurrent pathogens, site of infection, radiologic findings and treatment and outcome were recorded.

RESULTS

Nocardia infection was found in 2.1% (10 of 473) of our lung transplant recipients. Median time of onset was 34.1 months after transplantation. Nocardia species included N farcinica in 30% (3 of 10), N nova in 30% (3 of 10), N asteroides complex in 30% (3 of 10) and N brasiliensis in 10% (1 of 10) of patients. Post-transplant diabetes was present in 50% (5 of 10) of patients. The primary indication for lung transplantation was emphysema in 40% (4 of 10). Native lung involvement was noted in 75% (3 of 4) of patients with single lung transplant. Breakthrough nocardia infection were noted in 6 patients who were receiving trimethoprim-sulfamethoxazole prophylaxis for P carinii pneumonia; all breakthrough isolates remained susceptible to trimethoprim-sulfamethoxazole. Overall mortality was 40% (4 of 10). All patients (3 of 3) with infection due to N farcinica, except 1 (1 of 7) with infection due to other nocardia species, died. Seventy-five percent (3 of 4) of deaths were attributable to nocardia infection.

CONCLUSIONS

Nocardia infection tended to involve the native lung in single lung transplant recipients. Trimethoprim-sulfamethoxazole for P carinii prophylaxis at the doses given was not protective against nocardiosis in these patients. Infection with N farcinica was associated with poor outcome. Thus, species identification and extended courses of antibiotics based on antimicrobial susceptibility testing are important in management of these patients.

Epidemiology and management of infections after lung transplantation

Lung transplantation has become an accepted treatment for end-stage pulmonary parenchymal and vascular diseases. Infections still are the most common cause of early and late morbidity and mortality in lung transplant recipients. Bacterial infections comprise approximately half of all infectious complications. Cytomegalovirus (CMV) infections and disease have become less frequent, because of prophylaxis with ganciclovir. Because CMV is also involved in the pathogenesis of obliterative bronchiolitis, the frequency of this infection may also reduce the occurrence of this main obstacle to successful lung transplantation. Invasive fungal infections remain a problem, but they have also decreased in frequency because of better control of risk factors such as CMV disease and preemptive antifungal therapy. Nonherpes respiratory viral infections have emerged as a serious problem. Their severity may be reduced by treatment with ribavirin. Meticulous postoperative surveillance, however, is still crucial for the management of lung transplant patients with respect to early detection and treatment of rejection and infection.

Complications (excluding hyperinflation) involving the native lung after single-lung transplantation: incidence, radiologic features, and clinical importance

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.