Infectious complications associated with bronchial anastomotic dehiscence in lung transplant recipients

INTRODUCTION

Bronchial anastomotic dehiscence (AD) is an uncommon complication following lung transplantation that carries significant morbidity and mortality. The objective of this study was to characterize fungal and bacterial infections in ADs, including whether infections following AD were associated with progression to bronchial stenosis.

METHODS

This was a single-center study of 615 lung transplant recipients between 6/1/2015 and 12/31/2021. Airway complications were defined according to ISHLT consensus guidelines.

RESULTS

22 of the 615 recipients (3.6%) developed an AD. Bronchial ischemia or necrosis was common prior to dehiscence (68.1%). Fourteen (63.6%) recipients had bacterial airway infections, most commonly with Gram-negative rods, prior to dehiscence. Thirteen (59.1%) recipients had an associated pleural infection, most commonly with Candida species (30.8%). Post-dehiscence Aspergillus species were isolated in 4 recipients, 3 of which were de novo infections. Eleven had bacterial infections prior to dehiscence resolution, most commonly with Pseudomonas aeruginosa. Eleven recipients developed airway stenosis requiring dilation and/or stenting. Development of secondary infection prior to AD resolution was not associated with progression to stenosis (OR = .41, 95% CI = .05-3.30, p = .41).

CONCLUSIONS

Gram-negative bacterial infections are common before and after AD. Pleural infection should be suspected in most cases. Infections prior to healing were not associated with subsequent development of airway stenosis.

Risk factors and prognosis of airway complications in lung transplant recipients: A systematic review and meta-analysis

BACKGROUND

Airway complications (AC) are one of leading causes of morbidity and mortality after lung transplant (LTx), but their predictors and outcomes remain controversial. This study aimed to identify potential risk factors and prognosis of AC.

METHODS

A systematic review was performed by searching PubMed, Embase, and Cochrane Library. All observational studies reporting outcome and potential factors of AC after LTx were included. The incidence, mortality, and estimated effect of each factor for AC were pooled by using the fixed-effects model or random-effects model.

RESULTS

Thirty-eight eligible studies with 52,116 patients undergoing LTx were included for meta-analysis. The pooled incidence of AC was 12.4% (95% confidence interval [CI] 9.5-15.8) and the mean time of occurrence was 95.6 days. AC-related mortality rates at 30-days, 90-days, 6 months, 1 year, and 5 years were 6.7%, 17.9%, 18.2%, 23.6%, and 66.0%, respectively. Airway dehiscence was the most severe type with a high mortality at 30 days (60.9%, 95% CI 20.6-95.2). We found that AC was associated with a higher risk of mortality in LTx recipients (hazard ratio [HR] 1.71, 95% CI 1.04-2.81). Eleven significant predictors for AC were also identified, including male donor, male recipient, diagnosis of COPD, hospitalization, early rejection, postoperative infection, extracorporeal membrane oxygenation, mechanical ventilation, telescopic anastomosis, and bilateral and right-sided LTx.

CONCLUSION

AC was significantly associated with higher mortality after LTx, especially for dehiscence. Targeted prophylaxis for modifiable factors and enhanced early bronchoscopy surveillance after LTx may improve the disease burden of AC.

Impact of Antifibrotic Treatment on Postoperative Complications in Patients with Interstitial Lung Diseases Undergoing Lung Transplantation: A Systematic Review and Meta-Analysis

Antifibrotic treatment has been approved for reducing disease progression in fibrotic interstitial lung disease (ILD). As a result of increased bleeding risk, some experts suggest cessation of antifibrotics prior to lung transplantation (LT). However, extensive knowledge regarding the impact of antifibrotic treatment on postoperative complications remains unclear. We performed a comprehensive search of several databases from their inception through to 30 September 2021. Original studies were included in the final analysis if they compared postoperative complications, including surgical wound dehiscence, anastomosis complication, bleeding complications, and primary graft dysfunction, between those with and without antifibrotic treatment undergoing LT. Of 563 retrieved studies, 6 studies were included in the final analysis. A total of 543 ILD patients completing LT were included, with 161 patients continuing antifibrotic treatment up to the time of LT and 382 without prior treatment. Antifibrotic treatment was not significantly associated with surgical wound dehiscence (RR 1.05; 95% CI, 0.31-3.60; I² = 0%), anastomotic complications (RR 0.88; 95% CI, 0.37-2.12; I² = 31%), bleeding complications (RR 0.76; 95% CI, 0.33-1.76; I² = 0%), or primary graft dysfunction (RR 0.87; 95% CI, 0.59-1.29; I² = 0%). Finally, continuing antifibrotic treatment prior to LT was not significantly associated with decreased 1-year mortality (RR 0.80; 95% CI, 0.41-1.58; I² = 0%). Our study suggests a similar risk of postoperative complications in ILD patients undergoing LT who received antifibrotic treatment compared to those not on antifibrotic therapy.

ECMO support as a bridge to lung transplantation is an independent risk factor for bronchial anastomotic dehiscence

BACKGROUND

Airway complications are frequent after lung transplantation (LT), as they affect up to 23% of recipients. The implication of perioperative extracorporeal membrane oxygenation (ECMO) support and haemodynamic instability has never been specifically assessed. The first aim of this study was to explore the impact of perioperative ECMO support on bronchial anastomotic dehiscence (BAD) at Day 90 after LT.

METHODS

This prospective observational monocentric study analysed BAD in all consecutive patients who underwent LT in the Bichat Claude Bernard Hospital, Paris, France, between January 2016 and May 2019. BAD visible on bronchial endoscopy and/or tomodensitometry was recorded. A univariate analysis was performed (Fisher's exacts and Mann-Whitney tests), followed by a multivariate analysis to assess independent risk factors for BAD during the first 90 days after LT (p < 0.05 as significant). The Paris North Hospitals Institutional Review Board approved the study.

RESULTS

A total of 156 patients were analysed. BAD was observed in the first 90 days in 42 (27%) patients and was the main cause of death in 22 (14%) patients. BAD occurred during the first month after surgery in 34/42 (81%) patients. ECMO support was used as a bridge to LT, during and after surgery in 9 (6%), 117 (75%) and 40 (27%) patients, respectively. On multivariate analysis, ECMO as a bridge to LT (p = 0.04) and septic shock (p = 0.01) were independent risk factors for BAD.

CONCLUSION

ECMO as a bridge to LT is an independent risk factor for BAD during the first 90 days after surgery. Close monitoring of bronchial conditions must be performed in these high-risk recipients.

Outpatient Pharmacologic Management of Lung Transplant Candidates on the Waiting List

The medical care of patients awaiting lung transplantation is complex and requires the treatment of active medical conditions, including lung disease, while at the same time maintaining candidacy for transplantation. Some medications that would otherwise be considered routine may create undesirable challenges or complications in the perioperative setting. Therefore, a comprehensive assessment of the risks and benefits of these medications must take into account both their potential utility in managing a patient's current disease state, as well as the risks of compromising postlung transplant outcomes. In this review, we summarize the available data regarding several medications that are commonly used to treat patients with a variety of lung diseases, but that may impact a patient's course on the waiting list or in the posttransplant period.

Midterm outcomes of venovenous extracorporeal membrane oxygenation as a bridge to lung transplantation: Comparison with nonbridged recipients

OBJECTIVES

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is increasingly being used in acutely deteriorating patients with end-stage lung disease as a bridge to transplantation (BTT). It can allow critically ill recipients to remain eligible for lung transplants (LTx) while reducing pretransplant deconditioning. We analyzed early- and midterm postoperative outcomes of patients on VV-ECMO as a BTT and the impact of preoperative VV-ECMO on posttransplant survival outcomes.

METHODS

All consecutive LTx performed at our institution between January 2012 and December 2018 were analyzed. After matching, BTT patients were compared with nonbridged LTx recipients.

RESULTS

Out of 297 transplanted patients, 21 (7.1%) were placed on VV-ECMO as a BTT. After matching, we observed similar 30-day mortality between BTT and non-BTT patients (4.6% vs. 6.6%, p = .083) despite a higher incidence of early postoperative complications (need for ECMO, delayed chest closure, and acute kidney injury). Furthermore, preoperative VV-ECMO did not appear associated with 30-day or 1-year mortality in both frequentist and Bayesian analysis (odds ratio [OR]: 0.35, 95% confidence interval: 0.03-3.49, p = .369; OR: 0.27, 95% credible interval: 0.01-3.82, p = 84.7%, respectively). In sensitivity analysis, both subgroups were similar in respect to 30-day (7.8% vs. 6.5%, p = .048) and 1-year mortality (12.5% vs. 18%, p = .154).

CONCLUSIONS

Patients with acute refractory respiratory failure while waiting for LTx represent a high-risk cohort of patients. VV-ECMO as a BTT is a reasonable strategy in adult patients with acceptable operative mortality and 1-year survival comparable to non-BTT patients.

Extracorporeal membrane oxygenation as a bridge vs. non-bridging for lung transplantation: A systematic review and meta-analysis

Whether extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (BTT) can achieve a similar survival to non-BTT remains controversial. We conducted this meta-analysis to compare the outcomes between ECMO BTT and non-BTT to facilitate better clinical decision-making. Seven databases were searched for eligible studies comparing ECMO BTT and non-BTT. The primary endpoints included survival, intraoperative indicators, postoperative hospitalization indicators, and postoperative complications. Nineteen studies (involving 7061 participants) were included in the final analysis. The outcomes of overall survival, overall survival rate, graft survival rate, in-hospital mortality, postoperative hospital days, postoperative intensive care unit days, postoperative ventilation time, blood transfusion volume, and postoperative complications were all better in the non-BTT group. The total mortality in ECMO bridging was 23.03%, in which the top five causes of death were right heart failure (8.03%), multiple organ failure (7.03%), bleeding (not cranial) (4.67%), cranial bleeding (3.15%), and sepsis (2.90%). In summary, Non-BTT is associated with better survival and fewer complications compared to BTT. When ECMO may be the only option, the patient and medical team need to realize the increased risk of ECMO by complications and survival.