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Serrao G, Vinayak M, Nicolas J, Subramaniam V, Lai AC, Laskey D, Kini A, Seethamraju H, Scheinin S. The Evaluation and Management of Coronary Artery Disease in the Lung Transplant Patient. J Clin Med 2023; 12:7644. [PMID: 38137713 PMCID: PMC10743826 DOI: 10.3390/jcm12247644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023] Open
Abstract
Lung transplantation can greatly improve quality of life and extend survival in those with end-stage lung disease. In order to derive the maximal benefit from such a procedure, patients must be carefully selected and be otherwise healthy enough to survive a high-risk surgery and sometimes prolonged immunosuppressive therapy following surgery. Patients therefore must be critically assessed prior to being listed for transplantation with close attention paid towards assessment of cardiovascular health and operative risk. One of the biggest dictators of this is coronary artery disease. In this review article, we discuss the assessment and management of coronary artery disease in the potential lung transplant candidate.
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Affiliation(s)
- Gregory Serrao
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (M.V.); (J.N.); (V.S.); (A.C.L.); (D.L.); (A.K.); (H.S.); (S.S.)
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2
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Tran T, Kashem MA, Firoz A, Yanagida R, Shigemura N, Toyoda Y. Lung transplant survival with past and concomitant cardiac revascularization. J Heart Lung Transplant 2023; 42:1334-1340. [PMID: 37187320 DOI: 10.1016/j.healun.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Coronary artery disease is common among lung transplant (LTx) candidates and has historically been viewed as a contraindication to the procedure. Survival outcomes of lung transplant recipients with concomitant coronary artery disease who had prior or perioperative revascularization remain a topic of conversation. METHODS A retrospective analysis of all single and double lung transplant patients from Feb, 2012 to Aug, 2021 at a single center was performed (n = 880). Patients were split into 4 groups: (1) those who received a preoperative percutaneous coronary intervention, (2) those who received preoperative coronary artery bypass grafting, (3) those who received coronary artery bypass grafting during transplantation, and (4) those who had lung transplantation without revascularization. Groups were compared for demographics, surgical procedure, and survival outcomes using STATA Inc. A p value< 0.05 was considered significant. RESULTS Most patients receiving LTx were male and white. Pump type (p = 0.810), total ischemic time (p = 0.994), warm ischemic time (p = 0.479), length of stay (p = 0.751), and lung allocation score (p = 0.332) were not significantly different between the four groups. The no revascularization group was younger than the other groups (p<0.01). The diagnosis of Idiopathic Pulmonary Fibrosis was predominant in all groups except the no revascularization group. The pre-coronary artery bypass grafting group had a higher portion of single LTx procedures (p = 0.014). Kaplan-Meier analysis showed no significantly different survival rates after post-LTx between the groups (p = 0.471). Cox Regression analysis showed diagnosis significantly impacted survival rates (p 0.009). CONCLUSIONS Preoperative or intraoperative revascularization did not affect survival outcomes in lung transplant patients. Selected patients with coronary artery disease may benefit when intervened during lung transplant procedures.
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Affiliation(s)
- Theresa Tran
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Mohammed A Kashem
- Division of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA
| | - Ahad Firoz
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Roh Yanagida
- Division of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA
| | - Norihisa Shigemura
- Division of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University Hospital, Philadelphia, PA.
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3
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Meng E, Jiang SM, Servito T, Payne D, El-Diasty M. Lung transplantation and concomitant cardiac surgical procedures: A systematic review and meta-analysis. J Card Surg 2022; 37:3342-3352. [PMID: 35811496 DOI: 10.1111/jocs.16740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/25/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lung transplantation is an effective treatment option for end-stage lung diseases. In some cases, these patients may also have underlying cardiac disease which may require surgical intervention before or during transplantation. Concomitant cardiac surgery may often be preferred, as reduced lung function precludes these patients from pre-transplant surgery. Our meta-analysis sought to examine the impact of lung transplantation paired with concomitant cardiac surgery on long-term mortality. METHODS We conducted a systematic review of the MEDLINE, Embase, and Cochrane databases. Our primary outcome was overall mortality. Secondary outcomes included length of stay (LOS) in hospital and serious postoperative complication rates. We used a meta-analytic model to determine the differences in the above outcomes between patients who underwent lung transplantation with or without concomitant cardiac surgery. RESULTS Out of the 1876 articles screened, 7 met our pre-determined inclusion criteria. Lung transplantation with concomitant cardiac surgery was not associated with increased mortality compared to lung transplantation alone (hazard ratio = 1.02; 95% confidence interval [CI] = 0.80-1.31; I2 = 0%; p = .99). LOS in hospital was not significantly different between groups (standardized mean difference = 0.32; 95% CI = -0.91 to 1.55). Postoperative complication rates were also reported but not analyzed due to missing data. CONCLUSIONS There was no significant difference in mortality rates in patients undergoing lung transplantation with or without concomitant cardiac surgery at 1, 3, and 5 years. However, postoperative complication rates were higher in the concomitant group. The decision to perform concomitant procedures should be tailored to each patient's clinical condition.
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Affiliation(s)
- Eric Meng
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Stephanie M Jiang
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Therese Servito
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Darrin Payne
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
| | - Mohammad El-Diasty
- Division of Cardiac Surgery, Queen's University, Kingston, Ontario, Canada
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4
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Sinha N, Balayla G, Braghiroli J. Coronary artery disease in lung transplant patients. Clin Transplant 2020; 34:e14078. [PMID: 32940380 DOI: 10.1111/ctr.14078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/13/2020] [Accepted: 08/28/2020] [Indexed: 01/11/2023]
Abstract
Coronary artery disease (CAD) is a pathology often found in patients with end-stage lung disease. Although in the past CAD might have been considered an absolute contraindication, modern revascularization techniques have helped increase the number of transplants performed in this population. However, discrepancies in the guidelines for perioperative evaluation and risk mitigation strategies for the ischemic cardiac burden are present in the current literature. This is a review of the available data regarding perioperative evaluation, revascularization tactics, postoperative management, and survival rate that patients with different grades of coronary artery disease present after lung transplantation.
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Affiliation(s)
- Neeraj Sinha
- Division of Pulmonary and Critical Care Medicine, Transplant Pulmonology, University of Miami, Miami, FL, USA
| | - Galit Balayla
- Department of General Medicine, Central University of Venezuela, Caracas, Venezuela
| | - Joao Braghiroli
- Division of Interventional Cardiology, Jackson Health System, Miami, FL, USA
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5
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Restoring Blood Supply to the Heart While Replacing the Lungs: Is It Worth the Risk? Transplantation 2019; 103:1986-1987. [PMID: 30801520 DOI: 10.1097/tp.0000000000002610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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6
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Makey IA, Sui JW, Huynh C, Das NA, Thomas M, Johnson S. Lung transplant patients with coronary artery disease rarely die of cardiac causes. Clin Transplant 2018; 32:e13354. [DOI: 10.1111/ctr.13354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/03/2018] [Accepted: 07/15/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Ian A. Makey
- Department of Cardiothoracic Surgery Mayo Clinic; Jacksonville Florida
| | - Jin W. Sui
- Long School of Medicine, University of Texas Health San Antonio; San Antonio Texas
| | - Charles Huynh
- Long School of Medicine, University of Texas Health San Antonio; San Antonio Texas
| | - Nitin A. Das
- Department of Cardiothoracic Surgery; University of Texas Health, San Antonio Texas
| | - Mathew Thomas
- Department of Cardiothoracic Surgery Mayo Clinic; Jacksonville Florida
| | - Scott Johnson
- Department of Cardiothoracic Surgery; University of Texas Health, San Antonio Texas
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7
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How important is coronary artery disease when considering lung transplant candidates? J Heart Lung Transplant 2016; 35:1453-1461. [DOI: 10.1016/j.healun.2016.03.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 03/01/2016] [Accepted: 03/27/2016] [Indexed: 12/30/2022] Open
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Biniwale R, Ross D, Iyengar A, Kwon OJ, Hunter C, Aboulhosn J, Gjertson D, Ardehali A. Lung transplantation and concomitant cardiac surgery: Is it justified? J Thorac Cardiovasc Surg 2016; 151:560-6. [DOI: 10.1016/j.jtcvs.2015.10.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/05/2015] [Accepted: 10/01/2015] [Indexed: 01/24/2023]
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Chaikriangkrai K, Jyothula S, Jhun HY, Estep J, Loebe M, Scheinin S, Torre-Amione G. Impact of pre-operative coronary artery disease on cardiovascular events following lung transplantation. J Heart Lung Transplant 2016; 35:115-121. [DOI: 10.1016/j.healun.2015.08.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 07/04/2015] [Accepted: 08/22/2015] [Indexed: 11/27/2022] Open
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10
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Manoushagian S, Meshkov A. Evaluation of solid organ transplant candidates for coronary artery disease. Am J Transplant 2014; 14:2228-34. [PMID: 25220486 DOI: 10.1111/ajt.12915] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 05/30/2014] [Accepted: 06/29/2014] [Indexed: 01/25/2023]
Abstract
Solid organ transplantation has increased in frequency in the United States, having evolved from an area of experimentation into accepted therapy for end-organ failure. As organ transplantation has become more common, the average age of transplant recipients has increased, thus increasing the potential for multiple comorbidities including coronary artery disease (CAD). CAD has been shown to be a major cause of morbidity and mortality in kidney, lung and liver transplant recipients. Identification of CAD in solid organ transplant candidates allows for stratification of short- and long-term risk, ensuring proper use of valuable allograft resources while guiding further patient management. Assessment of asymptomatic transplant candidates for CAD is difficult. Many patients undergo stress echocardiography or nuclear imaging, which have demonstrated inconsistent rates of sensitivity and specificity for the detection of CAD in these patient populations. Cardiac computed tomography is a potential tool for detecting CAD in these populations, but has questionable utility at this time. Coronary angiography has an important role in detecting CAD in high-risk transplant candidates, affecting their long-term management and risk.
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Affiliation(s)
- S Manoushagian
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA
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11
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Preoperative mild-to-moderate coronary artery disease does not affect long-term outcomes of lung transplantation. Transplantation 2014; 97:1079-85. [PMID: 24646771 DOI: 10.1097/01.tp.0000438619.96933.02] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coronary artery disease has a high prevalence among lung transplant recipients and has historically been a contraindication to transplant at many institutions. In patients with mild-to-moderate coronary artery disease (Mod-CAD) undergoing lung transplant, outcomes are not well defined. METHODS All patients who underwent pulmonary transplantation from January 1996 through November 2010 with pretransplant coronary angiogram were included in our study. Recipients of multivisceral, redo, and lobar lung transplants and those who underwent pretransplant coronary revascularization were excluded. Patients were grouped into Mod-CAD or no-coronary artery disease group (No-CAD). Primary end point was overall survival. Secondary end points were 30-day events and the need for posttransplant coronary revascularization. RESULTS Approximately 539 patients were included in the study: 362 in the No-CAD, 177 in the Mod-CAD group. Patients with Mod-CAD were predominantly male, older, and had a higher body mass index. No difference in either perioperative morbidity and mortality (Mod-CAD, 4.2% vs. No-CAD 3.3%, P=0.705) or late overall mortality was shown between groups. Mod-CAD patients had a shorter hospitalization (median: 12 days vs. 14 days, P=0.009) and required a higher rate of late coronary revascularization procedures (PCI: Mod-CAD vs. No-CAD, 0.3% vs. 4.0%, P=0.0035; CABG: Mod-CAD vs. No-CAD, 0.3% vs. 2.3%, P=0.0411). CONCLUSIONS Mod-CAD does not appear to be associated with increased perioperative morbidity or decreased survival after transplant. Coronary artery disease may worsen and require coronary revascularization in patients with risk factors for disease progression. In these patients, close follow-up and screening for progression of coronary artery disease may help prevent late cardiac morbidity.
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12
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Jones RM, Enfield KB, Mehrad B, Keeley EC. Prevalence of obstructive coronary artery disease in patients undergoing lung transplantation: case series and review of the literature. Catheter Cardiovasc Interv 2013; 84:1-6. [PMID: 24136925 DOI: 10.1002/ccd.25261] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 10/14/2013] [Indexed: 11/11/2022]
Abstract
BACKGROUND Coronary angiography is commonly performed prior to lung transplantation, but its utility is unproven. METHODS We conducted a single-center retrospective analysis of consecutive patients referred for coronary angiography as part of a pre-operative evaluation for lung transplantation and reviewed the literature for prior series. RESULTS A total of 89 patients, 48 men and 41 women were included. Obstructive (≥70% stenosis) CAD was present in 9 (10%), non-obstructive (<70% stenosis) CAD in 24 (27%), and no angiographic evidence of CAD in 56 (63%) patients. We found 13 previously published series in the literature, in which a total of 1998 patients underwent coronary angiography pre-lung transplant. Together with our 89 patients, obstructive CAD was found in 11%. CONCLUSIONS In conclusion, given the low prevalence of obstructive CAD in patients referred for lung transplantation, the inherent risk of angiography, and unproven benefit of detection of obstructive CAD, the utility of routine coronary angiography in this population requires validation in prospective studies.
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Affiliation(s)
- Robert M Jones
- Department of Medicine, University of Virginia, Charlottesville, Virginia
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13
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Castleberry AW, Martin JT, Osho AA, Hartwig MG, Hashmi ZA, Zanotti G, Shaw LK, Williams JB, Lin SS, Davis RD. Coronary revascularization in lung transplant recipients with concomitant coronary artery disease. Am J Transplant 2013; 13:2978-88. [PMID: 24102830 PMCID: PMC4332513 DOI: 10.1111/ajt.12435] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 07/16/2013] [Accepted: 07/20/2013] [Indexed: 01/25/2023]
Abstract
Coronary artery disease (CAD) is not uncommon among lung transplant candidates. Several small, single-center series have suggested that short-term outcomes are acceptable in selected patients who undergo coronary revascularization prior to, or concomitant with, lung transplantation. Our objective was to evaluate perioperative and intermediate-term outcomes in this patient population at our institution. We performed a retrospective, observational cohort analysis of 898 lung transplant recipients between 1997 and 2010. Pediatric, multivisceral, lobar or repeat transplantations were excluded, resulting in 791 patients for comparative analysis, of which 49 (median age 62, 79.6% bilateral transplant) underwent concurrent coronary artery bypass and 38 (median age 64, 63.2% bilateral transplant) received preoperative percutaneous coronary intervention (PCI). Perioperative mortality, overall unadjusted survival and adjusted hazard ratio for cumulative risk of death were similar among both revascularization groups as well as controls. The rate of postoperative major adverse cardiac events was also similar among groups; however, concurrent coronary artery bypass was associated with longer postoperative length of stay, more time in the intensive care unit and more postoperative days requiring ventilator support. These results suggest that patients with CAD need not be excluded from lung transplantation. Preferential consideration should be given to preoperative PCI when feasible.
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Affiliation(s)
- A. W. Castleberry
- Department of Surgery, Duke University Medical Center, Durham, NC,Corresponding author: Anthony W. Castleberry,
| | - J. T. Martin
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY
| | - A. A. Osho
- Duke University School of Medicine, Durham, NC
| | - M. G. Hartwig
- Department of Surgery, Duke University Medical Center, Durham, NC,Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Z. A. Hashmi
- Division of Cardiothoracic Surgery, Indiana University Health, Indianapolis, IN
| | - G. Zanotti
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - L. K. Shaw
- Duke Clinical Research Institute, Durham, NC
| | - J. B. Williams
- Department of Surgery, Duke University Medical Center, Durham, NC,Division of Thoracic Surgery, Duke University Medical Center, Durham, NC,Duke Clinical Research Institute, Durham, NC
| | - S. S. Lin
- Department of Surgery, Duke University Medical Center, Durham, NC,Division of Thoracic Surgery, Duke University Medical Center, Durham, NC,Department of Immunology and Department of Pathology, Duke University Medical Center, Durham, NC
| | - R. D. Davis
- Department of Surgery, Duke University Medical Center, Durham, NC,Division of Thoracic Surgery, Duke University Medical Center, Durham, NC
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Sherman W, Rabkin DG, Ross D, Saggar R, Lynch JP, Belperio J, Saggar R, Hamilton M, Ardehali A. Lung transplantation and coronary artery disease. Ann Thorac Surg 2011; 92:303-8. [PMID: 21718862 DOI: 10.1016/j.athoracsur.2011.04.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 03/31/2011] [Accepted: 04/04/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) remains a relative contraindication to lung transplantation. We have offered lung transplantation and coronary revascularization to selected patients with discrete CAD and preserved left ventricular function. The purpose of this report is the following: (1) to examine the short-term and medium-term outcome of patients after coronary revascularization and lung transplantation; and (2) to compare the short-term and medium-term outcome of this cohort to a matched group of lung transplant recipients without CAD. METHODS From January 2000 to March 2010, 27 patients with CAD underwent coronary revascularization and lung transplantation. The control group was matched based on age, diagnosis, lung allocation score, and type of procedure. RESULTS Lung transplant recipients with CAD and the control group had similar incidence of primary graft dysfunction (grade III). The duration of mechanical ventilation, intensive care unit stay, and hospital stay were the same. At a mean follow-up of 3 years, the incidence of composite adverse cardiac events was similar in the 2 groups. CONCLUSIONS Lung transplant recipients with CAD and the control group also had similar medium-term survival. Lung transplantation can be considered in patients with preexistent CAD with acceptable early and medium-term outcomes.
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Affiliation(s)
- William Sherman
- Division of Cardiothoracic Surgery, Department of Surgery, Pulmonary and Critical Care Medicine, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, California 90095, USA
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15
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Rama-Maceiras P, Díaz-Allegue M, Pato-López O, Ramos-López L, Rey-Rilo T, Bonome-González C. [Perioperative treatment of a man receiving a left-lung transplant combined with coronary revascularization without use of extracorporeal circulation: with a brief review of pathophysiology and the literature]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2010; 57:425-430. [PMID: 20857638 DOI: 10.1016/s0034-9356(10)70269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Patients with significant coronary artery disease were once traditionally rejected as candidates for lung transplants because of higher risk of morbidity and mortality. We report the case of a man who received a left lung transplant and coronary revascularization without extracorporeal circulation in a combined surgical procedure after being diagnosed with significant coronary disease during the preoperative study for acceptance as a candidate for lung transplantation. We review the history of such combination procedures, which are changing clinicians' attitudes as to appropriate therapeutic approaches to take for complex patients. We also discuss the possible advantages of performing surgery without extracorporeal circulation. To our knowledge, this is the first report of a combined procedure that took place in a Spanish hospital.
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Affiliation(s)
- P Rama-Maceiras
- Servicio de Anestesiología y Reanimación. Complejo Hospitalario Universitario. A Coruña.
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16
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Abstract
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.
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Affiliation(s)
- Namrata Patel
- Division of Pulmonary and Critical Care Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania 19140, USA.
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17
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Choong CK, Meyers BF, Guthrie TJ, Trulock EP, Patterson GA, Moazami N. Does the presence of preoperative mild or moderate coronary artery disease affect the outcomes of lung transplantation? Ann Thorac Surg 2006; 82:1038-42. [PMID: 16928531 DOI: 10.1016/j.athoracsur.2006.03.039] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Revised: 03/10/2006] [Accepted: 03/15/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Significant coronary artery disease (CAD) is an exclusion criterion for lung transplantation at most centers. However, the impact of preoperative noncritical CAD (single or multivessel mild <30% or moderate 30% to 50% stenosis) on the outcomes of lung transplantation is unknown. METHODS A retrospective review of 268 adult patients who underwent lung transplantation between June 1998 and June 2003 at Barnes-Jewish Hospital, a tertiary care center affiliated with Washington University School of Medicine, was performed. RESULTS Two hundred ten patients had coronary angiography performed as part of their pretransplantation evaluation. Among these patients, 177 patients had no CAD, and 33 patients (mild, 16; moderate, 17) had noncritical CAD. Patients with noncritical CAD were older (59 versus 55 years, p < 0.001) and had a higher prevalence of diabetes (24% versus 9%, p = 0.014) and systemic hypertension (58% versus 36%, p = 0.004) than patients without CAD. There was no significant difference in the underlying lung disease, other comorbidities, type of lung transplantation performed, early postoperative complications, and hospital or late mortality between recipients with or without CAD. Among the patients with noncritical CAD, there was no hospital mortality and no late cardiac mortality. Three recipients with preoperative moderate CAD developed late ischemic cardiac events, and revascularization was performed in 2 of these recipients. Long-term survival was similar among recipients with or without preoperative CAD. CONCLUSIONS Preoperative noncritical (mild or moderate) CAD was not associated with increased perioperative morbidity or mortality, and it did not adversely affect short-term or long-term survival. Late ischemic events developed in 18% of the recipients with moderate CAD disease with no effect on mortality.
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Affiliation(s)
- Cliff K Choong
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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18
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Reed A, Snell GI, McLean C, Williams TJ. Outcomes of patients with interstitial lung disease referred for lung transplant assessment. Intern Med J 2006; 36:423-30. [PMID: 16780448 DOI: 10.1111/j.1445-5994.2006.01103.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with interstitial lung disease (ILD) very frequently die before the opportunity to receive lung transplantation (LTx). This retrospective study describes the clinical course of 86 patients with ILD referred for LTx assessment between January 1999 and December 2002. AIMS (i) To describe the outcomes, (ii) to identify reasons of delay to transplantation, (iii) to describe the causes of death/complications and (iv) to assess the pathological diagnosis and concordance with explanted lung pathology. METHODS Data were collected from the case notes of all patients with ILD referred to the Alfred Hospital over a 4-year period. RESULTS Twenty women and 66 men, mean age of 55 +/- 8 years, were referred for LTx assessment. Forty-five patients were deemed not suitable for LTx and 41 were listed. Twenty-two patients underwent transplantation, 16 died on the waiting list and 7 are still on the waiting list. Complications were frequent (e.g. pulmonary embolism, malignancy and infection) and carried high mortality. Patients dying on the waiting list appeared generally to be in accelerated decline, dying shortly after listing, with no evidence in their lung function test assessment predicting them as a poor prognosis group. CONCLUSIONS Serious complications and death on the waiting list of patients with idiopathic pulmonary fibrosis are high, not apparently because of delayed referral but usually in patients undergoing very rapid decline.
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Affiliation(s)
- A Reed
- Department of Allergy, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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19
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Ben-Dor I, Shitrit D, Kramer MR, Iakobishvili Z, Sahar G, Hasdai D. Is Routine Coronary Angiography and Revascularization Indicated Among Patients Undergoing Evaluation for Lung Transplantation? Chest 2005; 128:2557-62. [PMID: 16236923 DOI: 10.1378/chest.128.4.2557] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES To review coronary artery disease (CAD) prevalence among lung transplantation (LTx) candidates, the time interval from coronary angiography (CA) to LTx/death, and post-revascularization outcomes. BACKGROUND CA is advised for LTx candidates because significant CAD is a contraindication for LTx. METHODS We monitored all LTx candidates from 1997 who underwent CA. Significant CAD was defined as stenosis > or = 70% in diameter. RESULTS Of 118 candidates > 40 years old (68.3% men; median age, 58 years; 25 to 75th interquartiles, 53 to 61 years), 59 patients underwent LTx, 56 patients were eligible for LTx, and 3 patients were excluded due to CAD. Significant CAD was detected in 21 patients (17.8%), nonsignificant CAD was found in 21 patients (17.8%), and no CAD was found in 76 patients (64.4%), without significant differences in the demographic/clinical profile among patients with or without significant CAD. Among 21 patients with significant CAD, 12 patients (57.1%) underwent successful percutaneous coronary intervention (PCI), 1 patient had failed to respond to PCI, and 8 patients (38.1%) had no intervention. After PCI, one patient had periprocedural infarction, one patient had stent thrombosis, and one patient had symptomatic restenosis. The median time interval CA to LTx/death/last visit among the 115 candidates was 166 days (interquartiles, 48 to 410 days). Death occurred before LTx in 30 patients (53.5%) during a follow-up of 312 days (interquartiles, 46 to 664 days) and after LTx in 14 patients (23.7%) during a follow-up of 142 days (interquartiles, 73 to 304 days), without any difference in outcome based on severity of CAD in the two groups (p = 0.7 and p = 0.6, respectively). CONCLUSIONS CAD prevalence among LTx candidates is low and cannot be accurately predicted by risk factors. Revascularization may be associated with complications, and the time interval between revascularization and LTx may be long. Conversely, certain patients with significant CAD underwent LTx without complications. The practice of routine CA and revascularization prior to LTx should be reconsidered, and perhaps reserved for selected patients with high-risk features.
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Affiliation(s)
- Itsik Ben-Dor
- Department of Cardiology, Rabin Medical Center, 39 Jabotinsky St, Petah Tikva, Israel 49100
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Abstract
PURPOSE OF REVIEW Interstitial lung disease includes a heterogeneous group of disorders that leads to respiratory insufficiency and death in a significant number of patients. Lung transplantation is a therapeutic option in select candidates. RECENT FINDINGS The indications, transplant procedure options, and outcomes continue to evolve. Various recipient comorbidities influence the choice of procedure in patients with interstitial lung disease. Single lung transplants are used as the procedure of choice and bilateral transplants are reserved for patients with suppurative lung disease and patients with pulmonary hypertension. Issues unique to patients with interstitial lung disease affect the morbidity, mortality and recurrence of the disease. SUMMARY Lung transplantation is an effective therapy for respiratory failure in interstitial lung disease with survival following transplant being similar to that achieved in transplant recipients with other diseases.
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Affiliation(s)
- Raed Alalawi
- Division of Pulmonary and Critical Care Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Seoane L, Arcement LM, Valentine VG, McFadden PM. Long-term survival in lung transplant recipients after successful preoperative coronary revascularization. J Thorac Cardiovasc Surg 2005; 130:538-41. [PMID: 16077424 DOI: 10.1016/j.jtcvs.2004.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Coronary artery disease is considered a contraindication to lung transplantation. We studied effect of pre-lung transplantation nonobstructive coronary artery disease and revascularized coronary artery disease on long-term lung transplant survival. METHODS Clinical courses of 172 lung transplant recipients from December 1990 to May 2003 were reviewed. Significant coronary artery disease, defined as left main stenosis of greater than 50% or other epicardial vessel stenosis of greater than 70%, was present in 7 patients; 6 received percutaneous coronary intervention and 1 received coronary artery bypass grafting before transplantation. RESULTS Groups were similar with regard to sex, race, or length of intensive care days. The group with normal coronary arteries was significantly younger than the groups with coronary artery disease. The revascularized group had a significant increase in dysrhythmias (P < .003) and 1-, 3-, and 5-year survivals of 85%, 85%, and 69%, respectively. Those with insignificant coronary artery disease (14 patients) demonstrated a 1-, 3-, and 5-year survival of 64%, 40%, and 32%, respectively. The normal coronary group (151 patients) had a 1-, 3-, and 5-year survival of 75%, 58%, and 40%, respectively. The revascularized group had a significant survival advantage compared with that of the insignificant coronary artery disease group (P < .04, log-rank test). CONCLUSION Long-term survival of lung transplant recipients with revascularized coronary arteries is similar to that of subjects with normal coronary arteries, despite an increased incidence of dysrhythmias. Lung transplant recipients with insignificant coronary artery disease had a worse survival than the revascularized group. More studies are needed to ascertain the cause and determine the optimal management for lung transplant recipients with insignificant coronary artery disease.
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Affiliation(s)
- Leonardo Seoane
- Ochsner Multi-Organ Transplant Center, Department of Surgery, New Orleans, LA 70121, USA.
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22
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Hartigan PM, Pedoto A. Anesthetic Considerations for Lung Volume Reduction Surgery and Lung Transplantation. Thorac Surg Clin 2005; 15:143-57. [PMID: 15707352 DOI: 10.1016/j.thorsurg.2004.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Anesthetic considerations for lung transplantation and LVRS have been reviewed, with an emphasis on critical intraoperative junctures and decision points. Cognizance of these issues promotes coordinated and optimal care and provides the potential to improve outcome in this particularly high-risk population.
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Affiliation(s)
- Philip M Hartigan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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23
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Abstract
Lung transplantation remains the only therapeutic option shown to improve survival for many end-stage interstitial lung diseases. Although idiopathic pulmonary fibrosis is the most common indication, transplantation has been performed for many other diseases. This article reviews the current indications and outcomes for the procedure and problems encountered in lung transplantation for interstitial lung diseases. The role of transplant for specific diseases also is discussed.
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Affiliation(s)
- Brandon S Lu
- Division of Pulmonary and Critical Care Medicine, Loyola University Medical Center, 2160 South 1st Avenue, Maywood, IL 60153, USA
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24
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Abstract
The transplant recipient has traded a life-threatening illness for a chronically immunosuppressed state. Subsequent anesthetic management for non-transplant surgical procedures may be challenging. The anesthesia provider must be aware of the degree of post-transplant organ dysfunction and alter anesthesia techniques accordingly. This article reviews the anesthetic concerns for patients who have undergone a variety of organ transplants.
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Affiliation(s)
- Mark T Keegan
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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25
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Patel VS, Palmer SM, Messier RH, Davis RD. Clinical outcome after coronary artery revascularization and lung transplantation. Ann Thorac Surg 2003; 75:372-7; discussion 377. [PMID: 12607642 DOI: 10.1016/s0003-4975(02)04639-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Presence of coronary artery disease (CAD) in otherwise eligible lung transplant candidates is considered a contraindication to lung transplantation. We reviewed the clinical outcome of our experience in lung transplant recipients with operable coronary artery disease and normal left ventricular function. METHODS Medical records of all transplant recipients with coronary artery disease were reviewed. Data analyzed include demographics, coronary angiograms, coronary artery revascularization procedure, and clinical outcome after lung transplantation. RESULTS Between April 1992 and August 2001, 354 lung transplant procedures were performed. Eighteen patients (5%) had significant CAD (greater than 50% stenoses). Six male patients (mean age 59 years) underwent percutaneous transluminal coronary angioplasty/stent and after lung transplantation all were discharged after a median hospital stay of 8.5 days. All recipients are alive at a median follow-up time of 14.5 months after their transplant. Twelve male patients (mean age 58 years) had combined coronary artery bypass grafting and lung transplantation. All recipients were discharged after a median hospital stay of 16 days. Nine recipients are alive at a median follow-up time of 7.5 months after transplant. One-year survival by the Kaplan-Meier method is 88% for the 18 patients with coronary artery disease who underwent revascularization and lung transplantation. CONCLUSIONS Despite the traditional criteria of excluding all eligible transplant candidates due to coronary artery disease, coronary revascularization in select candidates with favorable anatomy and normal left ventricular function can allow patients to undergo lung transplantation with acceptable outcomes.
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Affiliation(s)
- Vijay S Patel
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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Lee R, Meyers BF, Sundt TM, Trulock EP, Patterson GA. Concomitant coronary artery revascularization to allow successful lung transplantation in selected patients with coronary artery disease. J Thorac Cardiovasc Surg 2002; 124:1250-1. [PMID: 12447202 DOI: 10.1067/mtc.2002.125651] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Richard Lee
- Division of Cardiothoracic Surgery, Washington University, St Louis, MO 63110, USA
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28
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Bostom AD, Brown RS, Chavers BM, Coffman TM, Cosio FG, Culver K, Curtis JJ, Danovitch GM, Everson GT, First MR, Garvey C, Grimm R, Hertz MI, Hricik DE, Hunsicker LG, Ibrahim H, Kasiske BL, Kennedy M, Klag M, Knatterud ME, Kobashigawa J, Lake JR, Light JA, Matas AJ, McDiarmid SV, Miller LW, Payne WD, Rosenson R, Sutherland DER, Tejani A, Textor S, Valantine HA, Wiesner RH. Prevention of post-transplant cardiovascular disease--report and recommendations of an ad hoc group. Am J Transplant 2002; 2:491-500. [PMID: 12118892 DOI: 10.1034/j.1600-6143.2002.20602.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Andrew D Bostom
- Department of Surgery, University of Minnesota, MMC-328 Mayo, Minneapolis 55455, USA
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29
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Kaza AK, Dietz JF, Kern JA, Jones DR, Robbins MK, Fiser SM, Long SM, Bergin JD, Kron IL, Tribble CG. Coronary risk stratification in patients with end-stage lung disease. J Heart Lung Transplant 2002; 21:334-9. [PMID: 11897521 DOI: 10.1016/s1053-2498(01)00387-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Significant coronary artery disease (CAD) has been a contraindication for listing patients for lung transplantation. We hypothesize that coronary risk stratification can help identify a sub-set of patients who need additional diagnostic tools and intervention. METHODS We performed a retrospective review of 72 consecutive patients who underwent lung transplantation at our institution from 1995 to 2000. Further, a review of patients who are currently listed for transplantation yielded 48 patients. We then identified the various risk factors for CAD, the diagnostic tools used, and pre-operative intervention. Risk factors identified included smoking history, diabetes, hypertension, hypercholesterolemia, CAD, congestive heart failure, age >50, and arrhythmias. Based on these risk factors, the patients were then classified into 2 groups: low risk (< or =1 risk factors) and high risk (> or =2 risk factors). We identified the patients in each group who underwent coronary angiography (CA), those with angiographic evidence of CAD, and those who received pre-operative intervention. RESULTS Of the 72 patients who underwent lung transplantation, 48 were identified as at high risk for CAD. Of these, 5 patients had CAD diagnosed before surgery using CA, and 1 patient received pre-operative intervention. Of the 48 patients currently on the lung transplant list, we identified 28 patients as high risk for CAD, 12 of whom were noted to have CA, and 2 of whom received pre-operative intervention. CONCLUSIONS Although CAD was once a contraindication for lung transplantation, pre-operative risk stratification allows identification of CAD with CA in a high-risk group. We believe that by using appropriate pre-operative cardiac intervention, patients with severe CAD could successfully undergo lung transplantation.
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Affiliation(s)
- Aditya K Kaza
- Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-1359, USA
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Monforte V, Roman A, Avilés B, Domingo E, Bravo C, Soler J, Morell F. Coronary angiography in patients undergoing evaluation for lung transplantation. Transplant Proc 2002; 34:187. [PMID: 11959242 DOI: 10.1016/s0041-1345(01)02721-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- V Monforte
- Servicios de Neumología, Cardiología, and Cirugia Torácica, Hospital General Vall d'Hebron, Barcelona, Spain
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31
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Affiliation(s)
- D L DeMeo
- Lung Transplant Program, Pulmonary and Critical Care Unit, Bigelow 808, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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32
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Abstract
Lung transplantation has become a viable treatment option for patients with end-stage lung disease. Donor selection and organ allocation must follow specific guidelines. Single, bilateral, and living-donor lobar transplantation have all been performed successfully for a variety of diseases. Complications include reimplantation response and airway complications. Rejection may occur in the hyperacute, acute, or chronic settings and requires judicious management with immunosuppression. Infection and malignancy remain potential complications of the commitment to lifelong systemic immunosuppression. Survival statistics have remained encouraging and continue to improve with experience. Improved exercise tolerance and quality of life have been demonstrated in the years following transplantation. Remaining obstacles include limited donor organ availability, long-term graft function, and patient survival. However, ongoing advances in immune tolerance and standardized training of physicians in the care of transplant patients should carry lung transplant forward in the twenty-first century.
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Affiliation(s)
- D L DeMeo
- Pulmonary and Critical Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114, USA.
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Snell GI, Walters EH, Kotsimbos TC, Williams TJ. Idiopathic pulmonary fibrosis: in need of focused and systematic management. Med J Aust 2001; 174:137-40. [PMID: 11247617 DOI: 10.5694/j.1326-5377.2001.tb143187.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is an increasingly recognised, serious lung disease. A recent International Consensus Statement has redefined the term "idiopathic pulmonary fibrosis", restricting its use to the entity previously described as "usual interstitial pneumonia" and reclassifying some of the more benign inerstitial lung diseases formerly included under IPF. There is insufficient quality evidence for the effectiveness of current medical therapies for IPF. Lung transplantation provides a potential surgical therapeutic option for selected individuals with IPF, but referral for transplant needs to be made as early as possible. Multidisciplinary clinics specialising in interstitial lung disease have a potential role in determining which patients may benefit from novel and existing medical therapies and which patients should be referred for lung transplantation.
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Affiliation(s)
- G I Snell
- Department of Respiratory Medicine, Alfred Hospital, Prahran, VIC.
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34
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Abstract
Lung transplantation is able to provide dramatic gains in pulmonary function to patients with advanced pulmonary emphysema. At the present time, however, transplantation is available to a strictly defined pool of candidates, and outcomes are limited by numerous respiratory and nonrespiratory postoperative complications. Further progress is needed in expanding the supply of donor lungs, minimizing perioperative complications, and optimizing postoperative immunologic management.
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Affiliation(s)
- L L Schulman
- Department of Medicine, Lung Transplant Service, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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