Acute and chronic pleural complications in lung transplantation

Characterizing Risk Factors Associated With Recurrent Pleural Effusions in the Lung Transplant Recipients

BACKGROUND

Pleural effusions remain a common postoperative complication following lung transplantation, occurring in 10% to 26% of cases. We aimed to explore potential clinical or radiographic features associated with clinically significant post-lung transplant pleural effusions requiring repeat interventions for their management.

METHODS

Lung transplantation recipients who underwent thoracentesis at our institution between June 2012 and October 2022 were reviewed. In total, 77 patients were included. Data were collected via the electronic health record and adjudicated through direct chart review. Patients were stratified by the need for a single thoracentesis (control group) or additional interventions, including serial thoracentesis, pigtail placement, and surgery (composite group). The computed tomography (CT) of the chest before the first thoracentesis was reviewed by a thoracic radiologist who was blinded to patient outcome.

RESULTS

Single thoracentesis was used to manage 25 (32.5%) patients, 4 (5.2%) required multiple thoracenteses, 42 (54.5%) required a pigtail catheter, and 6 (7.8%) required decortication for definitive management. In the composite group compared with the control group, who were managed by a single thoracentesis, there was an increased incidence of loculations (36.8% vs. 8%, P=0.01), rounded atelectasis (22.8% vs. 4%, P=0.05), and larger effusion size (P=0.01). The composite group had higher pleural fluid eosinophils (0.33% vs. 0% in control, P = <0.01) and monocytes (14.8% vs. 7.3%, P=0.04) levels.

CONCLUSION

Baseline imaging, such as larger effusion size, loculations and rounded atelectasis, and pleural fluid cell profile with increased eosinophils and monocytes, can potentially identify clinically significant and refractory pleural effusions.

Lung transplantation in pulmonary sarcoidosis

Sarcoidosis is a systemic inflammatory disease of unknown etiology and variable clinical course. Pulmonary sarcoidosis is the most common presentation and accounts for most morbidity and mortality related to sarcoidosis. While sarcoidosis generally has good outcomes, few patients experience chronic disease. A minority of patients progress to a specific phenotype of sarcoidosis referred to advanced pulmonary sarcoidosis (APS) which includes advanced fibrosis, pulmonary hypertension and respiratory failure, leading to high morbidity and mortality. In patients with advanced disease despite medical therapy, lung transplantation may be the last viable option for improvement in quality of life. Though post-transplant survival is similar to that of other end-stage lung diseases, it is imperative that patients are evaluated and referred early to transplant centers with experience in APS. A multidisciplinary approach and clinical experience are crucial in detecting the optimal timing of referral, initiating comprehensive transplantation evaluation and listing, discussing surgical approach, and managing perioperative and post-transplant care. This review article seeks to address these aspects of lung transplantation in APS.

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.

Investigating the relationship between the number and activity of natural killer cells with increased cytomegalovirus and CMV disease after kidney transplantation

BACKGROUND

Cytomegalovirus (CMV) infections caused by the cytomegalovirus are one of the most common problems in patients after kidney transplant. We examined the association of the relationship between the number and activity of natural killer cells with increased cytomegalovirus and its related disease after kidney transplantation.

MATERIAL AND METHODS

In this analytical study, 58 new transplant patients in the Labbafinejad Hospital, who did not have any evidence of CMV infection, were evaluated based on the number and percentage of CD56+/16+, CD56+/16-, and CD69+ Natural Killer (NK) cells.

RESULTS

The results of this study showed that CD16+ and CD56+ cells in the group of CMV Ag-positive patients are less than negative patients (p = 0.003) and the difference between the two groups are significant (p = 0.01). However, CD69+ cells did not differ significantly between the two groups (p = 0.1). Moreover, the absolute number of CD16+ and CD56+ cells declined significantly after infection with CMV unlike the CMV Ag - group(p = 0.003).

DISCUSSION

These results indicate that kidney transplant patients suffering from CMV infection after transplantation have a significantly reduced total number of NK cells. On the other hand, a slight decrease in the number of NK subgroups was observed with an increase in the peak serum levels of cyclosporine. As a consequence of these findings, it can be assumed that more dosage and a higher level of the drug will result in more severe immunosuppression and, consequently, increased susceptibility to CMV infections. Thus, taking the right dose of the drug would prevent viral infections and immune system from over-activation.

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.

Alterations in Pulmonary Physiology with Lung Transplantation

Lung transplant is a treatment option for patients with end-stage lung diseases; however, survival outcomes continue to be inferior when compared to other solid organs. We review the several anatomic and physiologic changes that result from lung transplantation surgery, and their role in the pathophysiology of common complications encountered by lung recipients. The loss of bronchial circulation into the allograft after transplant surgery results in ischemia-related changes in the bronchial artery territory of the allograft. We discuss the role of bronchopulmonary anastomosis in blood circulation in the allograft posttransplant. We review commonly encountered complications related to loss of bronchial circulation such as allograft airway ischemia, necrosis, anastomotic dehiscence, mucociliary dysfunction, and bronchial stenosis. Loss of dual circulation to the lung also increases the risk of pulmonary infarction with acute pulmonary embolism. The loss of lymphatic drainage during transplant surgery also impairs the management of allograft interstitial fluid, resulting in pulmonary edema and early pleural effusion. We discuss the role of lymphatic drainage in primary graft dysfunction. Besides, we review the association of late posttransplant pleural effusion with complications such as acute rejection. We then review the impact of loss of afferent and efferent innervation from the allograft on control of breathing, as well as lung protective reflexes. We conclude with discussion about pulmonary function testing, allograft monitoring with spirometry, and classification of chronic lung allograft dysfunction phenotypes based on total lung capacity measurements. We also review factors limiting physical exercise capacity after lung transplantation, especially impairment of muscle metabolism. © 2023 American Physiological Society. Compr Physiol 13:4269-4293, 2023.

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.

The Future of Cardiothoracic Surgical Critical Care Medicine as a Medical Science: A Call to Action

Cardiothoracic surgical critical care medicine (CT-CCM) is a medical discipline centered on the perioperative care of diverse groups of patients. With an aging demographic and an increase in burden of chronic diseases the utilization of cardiothoracic surgical critical care units is likely to escalate in the coming decades. Given these projections, it is important to assess the state of cardiothoracic surgical intensive care, to develop goals and objectives for the future, and to identify knowledge gaps in need of scientific inquiry. This two-part review concentrates on CT-CCM as its own subspeciality of critical care and cardiothoracic surgery and provides aspirational goals for its practitioners and scientists. In part one, a list of guiding principles and a call-to-action agenda geared towards growth and promotion of CT-CCM are offered. In part two, an evaluation of selected scientific data is performed, identifying gaps in CT-CCM knowledge, and recommending direction to future scientific endeavors.

Surgical Complications of Lung Transplantation

Lung transplantation is a life-saving intervention and the most effective therapy for select patients with irreversible lung disease. Despite the effectiveness of lung transplantation, it is a major operation with several opportunities for complications. For example, recipient and donor factors, technical issues, early postoperative events, and immunology can all contribute to potential complications. This article highlights some of the key surgery-related complications that can undermine a successful lung transplantation. The authors offer their expert opinion and experience to help practitioners avoid such complications and recognize and treat them early should they occur.

Early Postoperative Management of Lung Transplant Recipients

The early postoperative period after lung transplantation is a critical time. Prompt recognition and treatment of primary graft dysfunction can alter long-term allograft function. Cardiovascular, gastrointestinal, renal, and hematologic derangements are common and require close management to limit their negative sequelae.

Complications of Lung Transplantation: Update on Imaging Manifestations and Management

As lung transplantation has become the most effective definitive treatment option for end-stage chronic respiratory diseases, yearly rates of this surgery have been steadily increasing. Despite improvement in surgical techniques and medical management of transplant recipients, complications from lung transplantation are a major cause of morbidity and mortality. Some of these complications can be classified on the basis of the time they typically occur after lung transplantation, while others may occur at any time. Imaging studies, in conjunction with clinical and laboratory evaluation, are key components in diagnosing and monitoring these conditions. Therefore, radiologists play a critical role in recognizing and communicating findings suggestive of lung transplantation complications. A description of imaging features of the most common lung transplantation complications, including surgical, medical, immunologic, and infectious complications, as well as an update on their management, will be reviewed here. Keywords: Pulmonary, Thorax, Surgery, Transplantation Supplemental material is available for this article. © RSNA, 2021.

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.

Extracorporeal membrane oxygenation as a bridge to lung transplantation in a Turkish lung transplantation program: our initial experience

Lung transplantation is a life-saving treatment for patients with end-stage lung disease. Although the number of lung transplants has increased over the years, the number of available donor lungs has not increased at the same rate, leading to the death of transplant candidates on waiting lists. In this paper, we presented our initial experience with the use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation. Between December 2016 and August 2018, we retrospectively reviewed the use of ECMO as a bridge to lung transplantation. Thirteen patients underwent preparative ECMO for bridging to lung transplantation, and seven patients successfully underwent bridging to lung transplantation. The average age of the patients was 45.7 years (range, 19–62 years). The ECMO support period lasted 3–55 days (mean, 18.7 days; median, 13 days). In seven patients, bridging to lung transplantation was performed successfully. The mean age of patients was 49.8 years (range 42–62). Bridging time was 3–55 days (mean, 19 days; median, 13 days). Two patients died in the early postoperative period. Five patients survived until discharge from the hospital. One-year survival was achieved in four patients. ECMO can be used safely for a long time to meet the physiological needs of critically ill patients. The use of ECMO as a bridge to lung transplantation is an acceptable treatment option to reduce the number of deaths on the waiting list. Despite the successful results achieved, this approach still involves risks and complications.

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.

Peak post-transplant lung function in bilateral lung transplant recipients using a prediction model based on donor and recipient demographic characteristics

RATIONALE

There are no reliable methods to predict lung function following lung transplantation. We sought to devise a prediction model of peak pulmonary function testing (PFT) post-transplant based on donor and recipient demographic characteristics.

METHODS

Single center retrospective analysis of bilateral lung transplant recipients between 2011 and 2015 without evidence of allograft dysfunction in the first year was performed. Peak PFT post-transplant was determined by serially measured FEV1 and FVC. Using the NHANES III equation, donor demographic characteristics were used to calculate predicted lung function. Multivariable linear regression helped determine which donor and recipient characteristics affected peak lung function and identify the discrepancy between donor predicted and recipient observed PFT post-transplant.

RESULTS

146 donor/recipient patients were analyzed. 80 had obstructive lung disease, 66 had restrictive disease. Peak post-transplant FEV1 and FVC was reached in 64.30 ± 48.96 and 78.14 ± 50.68 weeks, respectively. Spirometry values peaked earlier in restrictive lung disease recipients. Higher peak FEV1 was significantly associated with younger donor age, non-African American donor race, male recipient sex, greater recipient height, underlying obstructive lung disease. Greater absolute differences between donor predicted and observed FEV1 were significantly associated with male donor sex, greater donor height, non-African-American donor race, female recipient sex, greater recipient height.

CONCLUSIONS

Donor and recipient characteristics can help predict lung function post-transplant. Patients without complications in the first year post-transplant may take greater than one year to achieve peak lung function. Such predictions can help guide clinical decision making in the right setting.

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.

Use of Ultrasonography for Lung Transplant Recipients on Postoperative Care

The authors report their findings regarding lung ultrasound profiles in a population of transplant recipients. Twenty-two patients were studied once each in multiple different ultrasound windows focusing on pleural, lung, and diaphragmatic signatures. All studies were performed in presumably otherwise healthy recipients at an outpatient follow-up visit at least 3 months after transplantation. Those with recent pulmonary infections or decline in lung function were excluded from enrollment. The majority of scans revealed otherwise normal lungs with lung sliding, but there were more abnormalities than one would expect in a healthy control group. Lung ultrasonography will likely never replace other cross-sectional imaging given its inherent visual limitations but adds another modality to interrogate the lung/pleural interface and diaphragmatic function.

Medical Course and Complications After Lung Transplantation

Lung transplant prolongs life and improves quality of life in patients with end-stage lung disease. However, survival of lung transplant recipients is shorter compared to patients with other solid organ transplants, due to many unique features of the lung allograft. Patients can develop a multitude of noninfectious (e.g., primary graft dysfunction, pulmonary embolism, rejection, acute and chronic, renal insufficiency, malignancies) and infectious (i.e., bacterial, fungal, and viral) complications and require complex multidisciplinary care. This chapter discusses medical course and complications that patients might experience after lung transplantation.

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.

Imaging features of intrathoracic complications of lung transplantation: What the radiologists need to know

Lung transplantation has been a method for treating end stage lung disease for decades. Despite improvements in the preoperative assessment of recipients and donors as well as improved surgical techniques, lung transplant recipients are still at a high risk of developing post-operative complications which tend to impact negatively the patients’ outcome if not recognised early. The recognised complications post lung transplantation can be broadly categorised into acute and chronic complications. Recognising the radiological features of these complications has a significant positive impact on patients’ survival post transplantation. This manuscript provides a comprehensive review of the radiological features of post lung transplantations complications over a time continuum.

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.

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.

Managing complications following lung transplantation

Lung transplantation has become a proven therapeutic option for patients with end-stage lung disease, extending life and providing improved quality of life to those who otherwise would continue to be breathless and oxygen-dependent. Over the past 20 years, considerable experience has been gained in understanding the multitude of medical and surgical issues that impact upon patient survival. Today, clinicians have an armamentarium of tools to manage diverse problems such as primary graft dysfunction, acute and chronic allograft rejection, airway anastomotic issues, infectious complications, renal dysfunction, diabetes and osteoporosis, hematological and gastrointestinal problems, malignancy, and other unique issues that confront immunosuppressed solid organ transplant recipients.

Cardiopulmonary magnetic resonance imaging in children after lung transplantation: preliminary observations

BACKGROUND

Lung transplantation carries a guarded prognosis and is burdened by short-term and long-term complications that affect the airway, lungs, and vasculature. In this pilot study we aimed to assess the feasibility of magnetic resonance imaging (MRI) in 8 pediatric patients after lung transplantation.

METHODS

The 8 patients in the study were aged between 9 and 17 years and were clinically stable. The scan protocol included MR angiography, phase contrast imaging of the pulmonary arteries and veins, ventricular volumetry, lung parenchyma imaging, and lung volumetry.

RESULTS

This protocol was successfully done in all patients. Lung volumes measured by MRI correlated well with those by body plethysmography (r = 0.83, p = 0.01). Angiography detected caliber differences between the donor and recipient pulmonary arteries in 5 patients. One patient had hemodynamically relevant pulmonary vein stenosis, as evidenced by MR angiography, a reduction in ipsilateral flow, and an abnormal pulmonary venous flow profile. Three patients had mild left (2 patients) or right (1 patient) ventricular systolic dysfunction. One patient had left main bronchus compression, and 3 patients showed varying degrees of pleural thickening.

CONCLUSIONS

Our preliminary experience suggests that cardiopulmonary MRI is feasible in pediatric lung transplant recipients and that it provides clinically useful information, especially on the vascular and bronchial anastomoses. However, the value of MRI for routine follow-up in pediatric lung transplant patients needs to be determined in a larger cohort.

Chronic allograft dysfunction

Chronic, progressive, and irreversible loss of lung function is the major medium-term and long-term complication after lung transplantation and the leading cause of death. Over the past decade, progress has been made in understanding the pathogenesis of bronchiolitis obliterans. Alloimmune factors and nonalloimmune factors may contribute to its development. Understanding the precise mechanism of each type of chronic allograft dysfunction may open up the field for new preventive and therapeutic interventions. This article reviews major new insights into the clinical aspects, pathophysiology, risk factors, diagnosis, and management of chronic allograft dysfunction after lung transplantation.

Review Article: Anemia post—lung transplantation: mechanisms and approach to diagnosis

Anemia is a common complication in post-lung transplant recipients. Although its mechanism is often multifactorial, clinicians should investigate an eventual underlying explanation to provide the best care. Among the reasons for anemia in lung transplant recipients, blood loss should be thought within the first few days after surgery. Later on, immune-mediated mechanisms, microangiopathic hemolytic anemia and reduction in red blood cell production mediated by viruses, drugs and infiltrative disorders prevail. This article reviews the mechanisms of anemia in post—lung transplant patients and provides an algorithm towards its approach.

Effect of lung transplant and volume reduction surgery on respiratory muscle function

Lung transplantation and lung volume reduction surgery have opened a new therapeutic era for patients with advanced emphysema. In addition to providing impressive clinical benefits, they have helped us better understand how the chest wall and respiratory muscles adapt to chronic hyperinflation. This article reviews the effects of these procedures on respiratory muscle and chest wall function. Inspiratory (including diaphragm) and expiratory muscle strength are often close to normal after unilateral and bilateral transplantation, although some patients have marked weakness. After bilateral transplantation for emphysema, graft volume is normal at full inflation but remains greater than normal at end expiration, which results from structural changes in the chest wall. In contrast, patients with unilateral transplantation have a reduction in graft volume at full inflation. The mediastinum is displaced toward the graft at end expiration, which reduces the surface area of the diaphragm on the transplanted side, and it moves toward the native lung during tidal and full inspiration and toward the graft during tidal and forced expiration. Lung volume reduction produces an increase in contractility, length and surface area of the diaphragm, and increases its contribution to tidal volume; at the same time, neural drive to the muscle and respiratory load are reduced, such that diaphragm neuromechanical coupling is improved. Diaphragm configuration and rib cage dimensions are only minimally affected by the procedure. Single-lung transplantation and lung volume reduction favorably impact on the disadvantageous size interaction by which the lungs are functionally restricted by the chest wall in emphysema.

Amiodarone pulmonary toxicity after lung transplantation

Atrial fibrillation occurs frequently after lung transplantation and is commonly treated with amiodarone. Pulmonary toxicity may result from amiodarone exposure and is characterized by non-specific respiratory manifestations. To our knowledge, there are no reports of this complication occurring after lung transplantation. We present a patient who developed radiologic evidence of amiodarone deposition in the lungs after bilateral lung transplantation.

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.

Postoperative complications of lung transplantation: radiologic findings along a time continuum

In the past decade, lung transplantation has become established as an accepted therapy for end-stage pulmonary disease. Complications of lung transplantation that may occur in the immediate or longer postoperative term include mechanical problems due to a size mismatch between the donor lung and the recipient thoracic cage; malposition of monitoring tubes and lines; injuries from ischemia and reperfusion; acute pleural events; hyperacute, acute, and chronic rejection; pulmonary infections; bronchial anastomotic complications; pulmonary thromboembolism; upper-lobe fibrosis; primary disease recurrence; posttransplantation lymphoproliferative disorder; and native lung complications such as hyperinflation, malignancy, and infection. Radiologic imaging--particularly chest radiography, computed tomography (CT), and high-resolution CT--is critical for the early detection, evaluation, and diagnosis of complications after lung transplantation. To enable the selection of an effective and relevant course of therapy and, ultimately, to decrease morbidity and mortality among lung transplant recipients, radiologists at all levels of experience must be able to recognize and understand the imaging manifestations of posttransplantation complications.