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Abstract
Lung transplantation provides a treatment option for many individuals with advanced lung disease due to cystic fibrosis (CF). Since the first transplants for CF in the 1980s, survival has improved and the opportunity for transplant has expanded to include individuals who previously were not considered candidates for transplant. Criteria to be a transplant candidate vary significantly among transplant programs, highlighting that the engagement in more than one transplant program may be necessary. Individuals with highly resistant CF pathogens, malnutrition, osteoporosis, CF liver disease, and other comorbidities may be suitable candidates for lung transplant, or if needed, multi-organ transplant. The transplant process involves several phases, from discussion of prognosis and referral to a transplant center, to transplant evaluation, to listing, transplant surgery, and care after transplant. While the availability of highly effective CF transmembrane conductance regulator (CFTR) modulators for many individuals with CF has improved lung function and slowed progression to respiratory failure, early discussion regarding transplant as a treatment option and referral to a transplant program are critical to maximizing opportunity and optimizing patient and family experience. The decision to be evaluated for transplant and to list for transplant are distinct, and early referral may provide a treatment option that can be urgently executed if needed. Survival after transplant for CF is improving, to a median survival of approximately 10 years, and most transplant survivors enjoy significant improvement in quality of life.
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Hong BA, Schuller D, Yusen RD, Barr ML. Pediatric Living Lung Donor Transplant Candidates: Psychiatric Status of Utilized and Non-Utilized Donors. J Clin Psychol Med Settings 2021. [PMID: 33881658 DOI: 10.1007/s10880-021-09777-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2021] [Indexed: 10/21/2022]
Abstract
Living donor lung (lobar) transplantation has greatly decreased in the past decade due to the success of the lung allocation score (LAS) system, instituted in 2005 by the Organ Procurement and Transplantation Network (OPTN). Between 1993 and 2006, 460 living lung donor transplants were performed in the United States with 369 donations occurring at the University of Southern California and Washington University in St. Louis. These two centers accounted for over 80% of all living donor lung transplants between 1994 and 2006. All potential donors received a psychological/psychiatric evaluation as part of the donor selection process, which is standard practice in the United States, Europe, and Asia. Utilized and non-utilized lung donors were compared in terms of their psychiatric history and present status. Results indicated that 31% (N = 54) of the total sample had a lifetime prevalence of a psychiatric disorder, which is less than that the 46% lifetime rate for the general population (Kessler in Arch Gen Psychiatry 62:593-602, 2005). This study did find that psychiatric history or status was not exclusion factor for transplant surgery in either group. This observation about psychiatric issues in potential living lung donors should be useful to transplant centers who utilize adult live donors of any solid organ type for pediatric recipients and in Japan where live donor lung transplants still represent a significant proportion of lung transplants (Date in J Thorac Dis 8: S631-S636, 2016).
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Pilewski JM. Lung Transplantation for Cystic Fibrosis. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Rady N, Kini A, Go JA, Al Othman B, Lee AG. Bilateral central retinal/ophthalmic artery occlusion and near-complete ophthalmoplegia after bilateral lung transplant. Am J Ophthalmol Case Rep 2019; 16:100569. [PMID: 31788576 PMCID: PMC6880121 DOI: 10.1016/j.ajoc.2019.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/18/2019] [Accepted: 11/04/2019] [Indexed: 11/24/2022] Open
Abstract
Purpose Recognize a rare yet existing risk of severe visual loss as a postoperative complication of bilateral lung transplant. Observations A 62-year-old male had undergone bilateral lung transplant for end-stage idiopathic pulmonary fibrosis and emphysema overlap syndrome. The operation was initially off-pump; however, during the left lung transplantation, cardiopulmonary bypass conversion was necessary to maintain intraoperative hemodynamic stability. On post-operative day 4, shortly after extubation and full recovery from sedation, the patient reported bilateral no light perception vision. There were no other associated neurologic symptoms. A computed tomographic (CT) of the head, cranial magnetic resonance (MR) scan of the head, MR angiogram of the circle of Willis and neck were negative. Neuro-ophthalmologic examination revealed no light perception vision in both eyes(OU). The pupils were non-reactive to light (amaurotic pupils). The intraocular pressure measured 18 mm Hg OU, and complete bilateral ophthalmoplegia was present. The fundus exam showed bilateral pallid optic disc edema, cherry red spots, with arteriolar attenuation, and mildly dilated and tortuous veins. Stroke work up was negative. Conclusions and importance A case of post-operative visual loss and ophthalmoplegia carrying significant and permanent quality of life implications. It questions the role disruption of homeostasis during cardiopulmonary bypass contributes for this outcome.
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Affiliation(s)
- Nadine Rady
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Ashwini Kini
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6550 Fannin St, Houston, TX, 77030, USA
| | - Jonathan A Go
- Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Bayan Al Othman
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6550 Fannin St, Houston, TX, 77030, USA
| | - Andrew G Lee
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, 6550 Fannin St, Houston, TX, 77030, USA.,Department of Ophthalmology, Neurology and Neurosurgery, Weill Cornell Medicine, 1305 York Ave, New York, NY, 10021, USA.,Department of Ophthalmology, University of Texas Medical Branch, 700 University Blvd, Galveston, TX, 77555, USA.,University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030, USA.,Texas A and M College of Medicine, 8447 Bryan Rd, Bryan, TX, 77807, USA.,Department of Ophthalmology, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242, USA
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Jauregui A, Deu M, Romero L, Roman A, Moreno A, Armengol M, Solé J. Lung Transplantation in Cystic Fibrosis and the Impact of Extracorporeal Circulation. Arch Bronconeumol 2018; 54:313-9. [PMID: 29534846 DOI: 10.1016/j.arbres.2018.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Lung disease is the major cause of death among cystic fibrosis (CF) patients, affecting 80% of the population. The impact of extracorporeal circulation (ECC) during transplantation has not been fully clarified. This study aimed to evaluate the outcomes of lung transplantation for CF in a single center, and to assess the impact of ECC on survival. METHODS We performed a retrospective observational study of all trasplanted CF patients in a single center between 1992 and 2011. During this period, 64 lung transplantations for CF were performed. RESULTS Five- and 10-year survival of trasplanted patients was 56.7% and 41.3%, respectively. Pre-transplantation supplemental oxygen requirements and non-invasive mechanical ventilation (NIMV) do not seem to affect survival (P=.44 and P=.63, respectively). Five- and 10-year survival among patients who did not undergo ECC during transplantation was 75.69% and 49.06%, respectively, while in those did undergo ECC during the procedure, 5- and 10-year survival was 34.14% and 29.87%, respectively (P=.001). PaCO2 is an independent risk factor for the need for ECC. CONCLUSIONS The survival rates of CF patients undergoing lung transplantation in our hospital are similar to those described in international registries. Survival is lower among patients receiving ECC during the procedure. PaCO2 is a risk factor for the need for ECC during lung transplantation.
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Mohite PN, Sabashnikov A, Patil NP, Garcia-Saez D, Zych B, Zeriouh M, Romano R, Soresi S, Reed A, Carby M, De Robertis F, Bahrami T, Amrani M, Marczin N, Simon AR, Popov AF. The role of cardiopulmonary bypass in lung transplantation. Clin Transplant 2016; 30:202-9. [DOI: 10.1111/ctr.12674] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Prashant N. Mohite
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Anton Sabashnikov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Nikhil P. Patil
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Diana Garcia-Saez
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Bartlomeij Zych
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Mohamed Zeriouh
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Rosalba Romano
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Simona Soresi
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Anna Reed
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Martin Carby
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Fabio De Robertis
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Toufan Bahrami
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Mohamed Amrani
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Nandor Marczin
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Andre R. Simon
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
| | - Aron-Frederik Popov
- Department of Cardiothoracic Transplantation & Mechanical Circulatory Support; Royal Brompton & Harefield NHS Foundation Trust; Harefield Hospital; Harefield Middlesex UK
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Lynch JP, Sayah DM, Belperio JA, Weigt SS. Lung transplantation for cystic fibrosis: results, indications, complications, and controversies. Semin Respir Crit Care Med 2015; 36:299-320. [PMID: 25826595 DOI: 10.1055/s-0035-1547347] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Survival in patients with cystic fibrosis (CF) has improved dramatically over the past 30 to 40 years, with mean survival now approximately 40 years. Nonetheless, progressive respiratory insufficiency remains the major cause of mortality in CF patients, and lung transplantation (LT) is eventually required. Timing of listing for LT is critical, because up to 25 to 41% of CF patients have died while awaiting LT. Globally, approximately 16.4% of lung transplants are performed in adults with CF. Survival rates for LT recipients with CF are superior to other indications, yet LT is associated with substantial morbidity and mortality (∼50% at 5-year survival rates). Myriad complications of LT include allograft failure (acute or chronic), opportunistic infections, and complications of chronic immunosuppressive medications (including malignancy). Determining which patients are candidates for LT is difficult, and survival benefit remains uncertain. In this review, we discuss when LT should be considered, criteria for identifying candidates, contraindications to LT, results post-LT, and specific complications that may be associated with LT. Infectious complications that may complicate CF (particularly Burkholderia cepacia spp., opportunistic fungi, and nontuberculous mycobacteria) are discussed.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David M Sayah
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
| | - S Sam Weigt
- Division of Pulmonary, Critical Care Medicine, Clinical Immunology and Allergy, Department of Internal Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, California
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Mohite PN, Garcia-saez D, Sabashnikov A, Patil NP, Weymann A, Popov A, Shibani S, Zych B, Reed A, Carby M, Derobertis F, Simon AR, Amrani M. No-clamp technique for pulmonary artery and venous anastomoses in lung transplantation. J Heart Lung Transplant 2014; 33:1133-8. [DOI: 10.1016/j.healun.2014.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 05/15/2014] [Accepted: 05/28/2014] [Indexed: 11/18/2022] Open
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Abstract
During the past 20 years, lung transplantation (LTX) has evolved and it is now accepted as a mainstream modality for care of patients with severe life-threatening respiratory diseases that are refractory to maximal conventional therapies. Improvements in surgical techniques and in antirejection medications have resulted in prolonged survival in these patients. Several studies have explored quality of life after LTX and its improvement has been noted especially in the early period between 3 and 6 months. This article discusses the salient features of the physiology of breathing and sleep disturbances before and after LTX and its alterations during sleep.
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Affiliation(s)
- Paola Pierucci
- Lung Transplant Unit, St Vincents Hospital, 390 Victoria Street, Darlinghurst, Sydney 2010, Australia
| | - Monique Malouf
- Lung Transplant Unit, St Vincents Hospital, 390 Victoria Street, Darlinghurst, Sydney 2010, Australia.
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Klinzing S, Brandi G, Raptis DA, Wenger U, Weber D, Stehberger PA, Inci I, Béchir M. Influence on ICU course, outcome and costs for lung transplantation after implementation of the new Swiss transplantation law. Transplant Res 2014; 3:9. [PMID: 24690254 PMCID: PMC3975267 DOI: 10.1186/2047-1440-3-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 03/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Swiss organ allocation system for donor lungs was implemented on 1 July 2007. The effects of this implementation on patient selection, intensive care unit course, outcomes and intensive care costs are unknown. METHODS The first 37 consecutive lung transplant recipients following the implementation of the new act were compared with the previous 42 lung transplant recipients. RESULTS Following implementation of the new law, baseline characteristics and cumulative one-year patient survival were comparable in both groups (88.1% vs 83.8%, P = 0.58). The costs for each case increased by 35,000 euros after adoption of the new law. Stratifying patients after implementation of the law according to urgency status shows that urgent patients required longer mechanical ventilation (P = 0.04), a longer ICU stay (P = 0.045) and a longer hospital stay (P = 0.04) and ICU costs (median 64,050 euros) were higher compared to regular patients. CONCLUSION The new transplantation law has increased ICU costs with the implementation of the Swiss organ allocation system. Patients listed as 'urgent' contribute significantly to the increase in ICU costs.
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Affiliation(s)
| | | | | | | | | | | | | | - Markus Béchir
- Surgical Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland.
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Nash KL, Collier JD, French J, McKeon D, Gimson AES, Jamieson NV, Wallwork J, Bilton D, Alexander GJM. Cystic fibrosis liver disease: to transplant or not to transplant? Am J Transplant 2008; 8:162-9. [PMID: 17973959 DOI: 10.1111/j.1600-6143.2007.02028.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Biliary cirrhosis complicates some adults with cystic fibrosis (CF) and may require transplantation. Cardio-respiratory disease severity varies such that patients may require liver transplantation, heart/lung/liver (triple) grafts or may be too ill for any procedure. A 15-year experience of adults with CF-related liver disease referred for liver transplantation is presented with patient survival as outcome. Twelve patients were listed for triple grafting. Four died of respiratory disease after prolonged waits (4-171 weeks). Eight underwent transplantation (median wait 62 weeks); 5-year actuarial survival was 37.5%. Four died perioperatively; only one is alive at 8-years. Eighteen patients underwent liver transplant alone (median wait 7 weeks); 1- and 5-year actuarial survival rates were 100% and 69%. Three long-term survivors required further organ replacement (two heart/lung and one renal). Two others were turned down for heart/lung transplantation and four have significant renal impairment. Results for triple grafting were poor with unacceptable waiting times. Results for liver transplant alone were satisfactory, with acceptable waiting times and survival. However, further grafts were required and renal impairment was frequent. The policy of early liver transplantation for adults with CF with a view to subsequent heart/lung or renal transplantation needs assessment in the context of long-term outcome.
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Affiliation(s)
- K L Nash
- Liver Transplant Unit, Addenbrooke's Hospital, Hills Road, Cambridge, UK.
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Abstract
Transplantation in patients who have cystic fibrosis (CF) presents important challenges regarding candidate selection and preoperative management, technical obstacles in the perioperative period, the postoperative management of medical comorbidities related to CF, and the psychosocial impact of transplantation. This article outlines some of these challenges and describes recent advances in approaching this endeavor in patients who have CF.
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Affiliation(s)
- Hilary J Goldberg
- Department of Medicine, Harvard Medical School, PBB Clinics-3, 75 Francis Street, Boston, MA 02115, USA.
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Solares CA, Citardi MJ, Budev M, Batra PS. Management of frontal sinus mucoceles with posterior table erosion in the pretransplant cystic fibrosis population. Am J Otolaryngol 2007; 28:110-4. [PMID: 17362816 DOI: 10.1016/j.amjoto.2006.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2006] [Revised: 06/15/2006] [Accepted: 07/30/2006] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic rhinosinusitis has been described as a universal finding in cystic fibrosis (CF). Much of the literature has focused on pediatric population with a relative paucity of data on adult CF patients. In this report, we review our experience with management of frontal sinus mucoceles with posterior table (PT) erosion diagnosed by imaging in asymptomatic adult CF patients presenting for pretransplant evaluation. STUDY DESIGN Retrospective chart analysis. MATERIALS AND METHODS Adult CF patients presenting with frontal sinus mucoceles from January 2003 to December 2005 comprised the focus of the study. Charts were reviewed for age, sex, clinical presentation, culture results, complications, and outcome. RESULTS Fifty-nine CF patients undergoing lung transplant evaluation were seen in the outpatient rhinology clinic. Among these, 3 patients presented with asymptomatic frontal sinus mucoceles with PT erosion. The average age was 28.7 years (range, 23-38 years) and male-female ratio was 1:2. Two patients were managed with computer-aided endoscopic frontal sinusotomy during the pretransplant period. In the third patient, surgery was performed post transplantation when the patient was clinically stable. Intraoperative cultures grew Pseudomonas aeruginosa in all cases. No intraoperative surgical complications were encountered. One patient required overnight ventilatory support and was extubated successfully after 24 hours. Endoscopic patency of the frontal sinusotomy was confirmed at mean follow-up of 12.7 months (range, 4-22 months). CONCLUSIONS This preliminary report describes asymptomatic frontal sinus mucoceles with PT erosion in CF patients presenting for transplant evaluation. A high index suspicion must be maintained to avoid an inordinate delay in diagnosis given the potential risk of intracranial complications with this clinical entity.
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Affiliation(s)
- C Arturo Solares
- Section of Nasal and Sinus Disorders, Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
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Vricella LA, Karamichalis JM, Ahmad S, Robbins RC, Whyte RI, Reitz BA. Lung and heart-lung transplantation in patients with end-stage cystic fibrosis: the Stanford experience. Ann Thorac Surg 2002; 74:13-7; discussion 17-8. [PMID: 12118744 DOI: 10.1016/s0003-4975(02)03634-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bilateral lung (BLTx) and heart-lung transplantation have gained wide acceptance as treatment of end-stage lung disease from cystic fibrosis. We reviewed our 13-year experience with thoracic transplantation for cystic fibrosis with an operative approach that favors use of cardiopulmonary bypass for BLTx. METHODS Sixty-four patients with cystic fibrosis underwent heart-lung transplantation (n = 22, 34.4%) or BLTx (n = 42, 65.6%) between 1988 and 2000. Mean age and weight at transplantation were 29 +/- 8 years and 51 +/- 11 kg, respectively. Mean follow-up for survivors was 4.4 +/- 3.6 years. Immunosuppression regimen included cyclosporine, tapered corticosteroids, azathioprine, and induction therapy with OKT3 (murine monoclonal antibodies) or rabbit antithymocyte globulin. Cardiopulmonary bypass was used in all but 5 patients (7.8%). However, in 8 (19%) of the 42 patients having BLTx, only the grafting of the second lung was performed with cardiopulmonary bypass. RESULTS The operative mortality rate was 1.6%. The actuarial survival rates at 1 year, 3 years, 5 years and 10 years were 93.2%, 77.7%, 61.8%, and 48.1%, respectively, with no significant difference between BLTx and heart-lung transplantation. The major hospital complications were pneumonia (n = 11, 17.2%) and bleeding (n = 8, 12.5%). Clinically significant reperfusion injury was observed in 6 patients, 3 of whom required reintubation. Freedom from acute lung rejection beyond 1 year was 47.7%. One patient underwent late retransplantation, and 4 required bronchial stenting. Obliterative bronchiolitis accounted for eight (50.0%) of 16 late deaths. CONCLUSIONS Though postoperative bleeding and pneumonia are still of concern, satisfactory early and intermediate-term results can be expected in patients undergoing BLTx or heart-lung transplantation for cystic fibrosis. Cardiopulmonary bypass can be used for BLTx with no adverse impact on intermediate and long-term outcomes.
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Affiliation(s)
- Luca A Vricella
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California 94305-5407, USA.
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Abstract
Previous studies have indicated that pulmonary infection with Burkholderia cepacia is associated with poor clinical outcome after lung transplantation in cystic fibrosis (CF). Many treatment centers consider B. cepacia infection an absolute contraindication to lung transplantation. However, the B. cepacia complex actually consists of several closely related bacterial species. Although each of these has been isolated from CF sputum culture, certain species are much more frequently recovered than others, and it is not yet clear whether all species have the same potential for virulence in CF. Additional study is needed to better define the relative risks associated with each species of the B. cepacia complex.
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Affiliation(s)
- J J LiPuma
- Department of Pediatrics and Communicable Diseases, University of Michigan Medical School, Ann Arbor, Michigan 48109-0646, USA.
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Affiliation(s)
- N Marczin
- Department of Cardiothoracic Surgery and Anaesthetics, National Heart and Lung Institute, Imperial College of Science Technology and Medicine, Harefield Hospital, United Kingdom
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Abstract
OBJECTIVE The purpose of this study was to compare outcomes after heart-lung or double-lung transplantation in patients undergoing transplantation because of end-stage suppurative lung disease. METHODS We reviewed our experience in patients with cystic fibrosis or bronchiectasis who had heart-lung or double-lung transplantation between January 1988 and September 1997. Twenty-three patients (14 male, 21 cystic fibrosis) had heart-lung transplantation and 24 patients (8 male, 19 cystic fibrosis) had double-lung transplantation. There were no statistically significant differences between the groups in age, weight, preoperative creatinine level, cytomegalovirus status, maintenance immunosuppression, or donor demographics. Patients received induction therapy with monoclonal (OKT3) or polyclonal (rabbit anti-thymocyte globulin) antibody. RESULTS Sixteen of 24 patients had double-lung transplantation after 1994 whereas 13 of 22 patients had heart-lung transplantation before 1991, allowing longer follow-up for the heart-lung group. Mean waiting times for transplantation were 270 +/- 245 days (heart-lung) and 361 +/- 229 days (double-lung; P =.20). The 1-, 3-, and 5-year actuarial survival figures were respectively 86%, 82%, and 65% (heart-lung) and 96%, 75%, and unavailable (double-lung; P = no significant difference). The 1-, 3-, and 5-year rates of freedom from obliterative bronchiolitis were respectively 77%, 61%, and 45% (heart-lung) and 86%, 78%, and unavailable (double-lung; P = no significant difference). Linearized overall infection rates (events/100 patient-days) were 2.05 +/- 0.33 (heart-lung) and 2.34 +/- 0.34 (double-lung; P = NS) at 3 months. Thirty-day survival was 100% (heart-lung) and 96% (double-lung). There were 7 late deaths among heart-lung recipients (3 obliterative bronchiolitis, 2 infection, 0 graft coronary artery disease, 2 other) whereas 2 late deaths related to obliterative bronchiolitis occurred in double-lung recipients. Graft coronary artery disease (all stenoses < 50%) affected 15% of heart-lung survivors, whereas 3 double-lung recipients (12.5%) required either bronchial dilatation or stenting. CONCLUSION Heart-lung and double-lung transplantation provide similar palliation for patients with end-stage suppurative lung disease. Therefore double-lung transplantation should be the preferred operation for most patients with end-stage suppurative lung disease.
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Affiliation(s)
- C W Barlow
- Falk Cardiovascular Research Center, Stanford University School of Medicine, Stanford, CA 94305-5407, USA
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Marom EM, McAdams HP, Palmer SM, Erasmus JJ, Sporn TA, Tapson VF, Davis RD, Goodman PC. Cystic fibrosis: usefulness of thoracic CT in the examination of patients before lung transplantation. Radiology 1999; 213:283-8. [PMID: 10540673 DOI: 10.1148/radiology.213.1.r99oc12283] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the usefulness of thoracic computed tomography (CT) in the pre-lung transplantation examination of patients with cystic fibrosis (CF). MATERIALS AND METHODS Fifty-six patients (age range, 12-42 years) with CF were evaluated for possible lung transplantation from 1991 to 1997. Twenty-six of these patients underwent bilateral lung transplantation, 19 were awaiting transplantation at the time of the study, seven died before transplantation, and four were excluded for psychosocial concerns. Preoperative chest radiographic and CT findings were reviewed and correlated with clinical, operative, and pathology records. RESULTS In seven patients, discrete, 1-2-cm pulmonary nodules were detected at CT. Five of these patients underwent transplantation; the nodules were found to be mucous impactions. No malignancy was found in any of the patients who underwent transplantation. Pretransplantation sputum cultures grew Aspergillus fumigatus in seven patients, none of whom had radiologic findings suggestive of Aspergillus infection. Radiographic or CT findings were suggestive of mycetoma in five cases, but no such tumors were found at transplantation. The accuracies of chest radiography and CT for the detection of pleural disease in 48 hemithoraces were 81% (n = 39) and 69% (n = 33), respectively. The radiologic findings of pleural thickening did not influence the surgical approach in any patient. CONCLUSION Thoracic CT has little utility in the routine pre-lung transplantation examination of patients with CF.
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Affiliation(s)
- E M Marom
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA
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22
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Abstract
STUDY OBJECTIVES (1) Report our experience with referral for lung transplantation. (2) Review survival in cvstic fibrosis (CF) patients without lung transplantation after FEV1 remains < 30% predicted for 1 years. DESIGN Retrospective review. SETTING A university hospital CF center. PATIENTS (1) Forty-five patients referred for lung transplantation evaluation, and (2) 178 patients without Burkholderia sp infection, with the above FEVl criterion. MAIN OUTCOME MEASURE Survival. MEASUREMENTS AND RESULTS (1) One- and 2-year survival after transplantation was 55% and 45%, respectively. However, among patients without transplants with FEVl < 30% predicted, median survival, 1986 to 1990, ie, before the transplant era, was 4.6 years with 25% living > 9 years (before 1986, 25% lived > 6 vears). (2) Survival after transplantation was not correlated to any of the following: age, sex, genotype, FEVI percent predicted, insulin-dependent diabetes mellitus, or with waiting time before transplantation, and did not seem to be correlated to serum bicarbonate or percent ideal body weight. Four of five patients already infected with Burkholderia species died within 5 months of transplantation; the fifth died at 17 months. All five died of pulmonary or extrapulmonarv infection with Burkholderia species CONCLUSIONS Use of FEV! < 30% predicted to automatically establish transplantation eligibility could lead to decreased overall survival for CF patients. Referral for evaluation and transplantation should also be based on oxygen requirement, rate of deterioration, respiratory microbiology, quality of life, frequency of IV antibiotic therapy, and other considerations. If pulmonary status has unexpectedly improved when the patient is at or near the top of the waiting list, total survival may be improved by "inactivating the patient" until progression is again evident.
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Affiliation(s)
- C F Doershuk
- LeRoy W. Matthews Cystic Fibrosis Center, Department of Pediatrics, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland, and Case Western Reserve University, OH, USA.
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Abstract
OBJECTIVE Document the safety of paranasal sinus surgery in cystic fibrosis patients and review the changing trends in paranasal sinus surgery in the cystic fibrosis population. STUDY DESIGN Retrospective review. MATERIALS AND METHODS Chart review of cystic fibrosis patients who underwent paranasal sinus surgery from 1955 to 1997. RESULTS Indications for surgery included chronic sinusitis, nasal obstruction, purulent rhinorrhea, head pain, and pyocele. Average duration of anesthesia was 2.1 hours. The complication rate from general anesthesia was zero. Excessive bleeding and significant hypoxia did not occur. CONCLUSIONS Paranasal sinus surgery and general anesthesia can be safely performed in cystic fibrosis patients. The indications for paranasal sinus surgery are changing from symptomatic nasal obstruction to pre-lung transplantation care. Today, treatment has evolved to include placement of sinus catheters for direct topical instillation of antibiotics and consideration of maxillary and frontal sinus obliteration.
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Affiliation(s)
- D L Schulte
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Caronia CG, Silver P, Nimkoff L, Gorvoy J, Quinn C, Sagy M. Use of bilevel positive airway pressure (BIPAP) in end-stage patients with cystic fibrosis awaiting lung transplantation. Clin Pediatr (Phila) 1998; 37:555-9. [PMID: 9773239 DOI: 10.1177/000992289803700906] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nine consecutive end-stage patients with cystic fibrosis (CF) awaiting lung transplantation were admitted to the pediatric intensive care unit (PICU) in respiratory decompensation. They all received noninvasive bilevel positive airway pressure (BIPAP) support and were evaluated to determine whether or not it improved their oxygenation and provided them with long-term respiratory stability. BIPAP was applied to all patients after a brief period of assessment of their respiratory status. Inspiratory and expiratory positive airway pressures (IPAP, EPAP) were initially set at 8 and 4 cm H2O respectively. IPAP was increased by increments of 2 cm H2O and EPAP was increased by 1 cm H2O increments until respiratory comfort was achieved and substantiated by noninvasive monitoring. Patients were observed in the PICU for 48 to 72 hours and then discharged to home with instructions to apply BIPAP during night sleep and whenever subjectively required. Regular follow-up visits were scheduled through the hospital-based CF clinic. The patients' final IPAP and EPAP settings ranged from 14 to 18 cm H2O and 4 to 8 cm H2O, respectively. All nine patients showed a marked improvement in their respiratory status with nocturnal use of BIPAP at the time of discharge from the PICU. Their oxygen requirement dropped from a mean of 4.6 +/- 1.1 L/min to 2.3 +/- 1.5 L/min (P < 0.05). Their mean respiratory rate decreased from 34 +/- 4 to 28 +/- 5 breaths per minute (P < 0.05). The oxygen saturation of hemoglobin measured by pulse oximetry, significantly increased from a mean of 80% +/- 15% to 91% +/- 5% (P < 0.05). The patients have been followed up for a period of 2 to 43 months and have all tolerated the use of home nocturnal BIPAP without any reported discomfort. Six patients underwent successful lung transplantation after having utilized nocturnal BIPAP for 2, 6, 14, 15, 26, and 43 months, respectively. Three patients have utilized home BIPAP support for 2, 3, and 19 months, respectively, and continue to await lung transplantation. An acute development of refractory respiratory failure resulted in the demise of the remaining three patients after having utilized BIPAP for 3, 6, and 10 months, respectively. The authors conclude that BIPAP therapy improves the respiratory status of decompensating end-stage CF patients. It is well tolerated for long-term home use and provides an extended period of respiratory comfort and stability for CF patients awaiting lung transplantation.
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Affiliation(s)
- C G Caronia
- Division of Critical Care Medicine, Children's Hospital, New Hyde Park, NY, USA
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25
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Egan TM, Detterbeck FC, Mill MR, Gott KK, Rea JB, McSweeney J, Aris RM, Paradowski LJ. Lung transplantation for cystic fibrosis: effective and durable therapy in a high-risk group. Ann Thorac Surg 1998; 66:337-46. [PMID: 9725366 DOI: 10.1016/s0003-4975(98)00496-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to review our experience with lung transplantation in patients with end-stage cystic fibrosis. METHODS Eight-two patients with cystic fibrosis have undergone bilateral lung transplantation (n=76) or bilateral lower lobe transplantation (n=6) since October 1990. RESULTS Actuarial survival for the entire cohort is 79% at 1 year and 57% at 5 years. The development of bronchiolitis obliterans syndrome is the leading cause of death after the first year. Freedom from bronchiolitis obliterans syndrome is 84% at 1 year and 51% at 3 years. Pulmonary function tests improve dramatically in recipients. There was no association between death within 1 year and recipient age, weight, graft ischemic time, cytomegalovirus seronegativity, or the presence of pan-resistant organisms. Similarly, there was no association between the development of bronchiolitis obliterans syndrome within 2 years and ischemic time, number of rejection episodes, cytomegalovirus seronegativity, or the presence of panresistant organisms. CONCLUSIONS Despite their poor nutritional status and the presence of multiply resistant organisms, patients with cystic fibrosis can undergo bilateral lung transplantation with acceptable morbidity and mortality.
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Affiliation(s)
- T M Egan
- Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill 27599-7065, USA
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26
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Abstract
OBJECTIVE Colonization of the lung and mediastinal lymph nodes with multi-resistant bacteria, diabetes and malnutrition represent potential risk factors for lung transplantation in cystic fibrosis. We therefore reviewed our experience in this patient population. METHODS Between December 1988 and March 1997, 219 lung and heart-lung transplantations were performed at our institution. Of these, 39 procedures were done in 35 patients with cystic fibrosis. All candidates (mean age 26 years) were oxygen dependent (preoperative mean PO2: 44.8 +/- 9.1 Torr, preoperative mean PCO2: 53.4 +/- 10.5 Torr, one patient on respirator). Of the primary operations, 34 were performed as bilateral sequential lung transplants, one as a heart-lung transplantation. RESULTS Mean duration on respirator for survivors was 3.1 (1-12) days, mean ICU and hospital stay were 4.7 (1-13) and 28 (12-79) days, respectively. The 3-month mortality rate was 5.7% (two patients died due to acute graft failure on days 36 and 73). Other causes of death in the follow-up were cerebral bleeding (one patient) and chronic graft failure (three patients). The survival rates were 91% at 1 year, 83% at 3 years and 76% at 5 years. In eight patients, a bronchiolitis obliterans syndrome (BOS) developed (in four cases grade 3). The freedom of BOS (grade 1 or more) at 1, 3 and 5 years was 87, 79 and 55%, respectively. Four retransplantations were performed. Of the 29 patients alive, only seven are physically limited. CONCLUSION Bilateral lung transplantation for cystic fibrosis allows for acceptable early- and long-term results. Postoperative survival is not impaired by infection, diabetes and malnutrition. Long-term functional outcome seems to be comparable to lung transplantation in patients without infectious pulmonary disease.
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Affiliation(s)
- K Wiebe
- Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Germany
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27
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Abstract
Cystic fibrosis (CF) is an inherited disease in which the fundamental physiological defect is failure of cAMP regulation of chloride transport. More than 90% of patients with CF will die of chronic, suppurative, obstructive lung disease, with the median survival in the United States currently being 29 years of age. Currently, although other therapies are being aggressively investigated, bilateral lung transplantation offers the only hope for short-term and mid-term survival in patients with CF and end-stage pulmonary disease. Since 1989, 103 bilateral sequential lung transplants (BLT) for CF have been performed at our institution (46 pediatric, 48 adult, 9 redo) at a mean age of 21+/-10 years. Cardiopulmonary bypass was used in all but one pediatric (age <18) transplantation, and in 15% of adults. The hospital mortality rate was 4.9%, with 80% of early deaths related to infection. Bronchial anastomotic complications occurred with equal frequency in the pediatric and the adult populations (7.3%). One- and 3-year actuarial survival rates are 84% and 61%, respectively (no significant difference between pediatric and adult age groups; average follow-up 2.1+/-1.6 years). Mean forced expiratory volume in 1 second increased from 25%+/-9% pretransplantation to 79%+/-35% 1 year posttransplantation. Acute rejection occurred 1.7 times per patient-year, with the majority of these episodes taking place the first 6 months posttransplantation. Need for treatment of lower respiratory infections occurred 1.2 times per patient in the first year after transplantation. Actuarial freedom from bronchiolitis obliterans was 63% at 2 years and 43% at 3 years. Redo transplantation was performed only in the pediatric population, and was associated with an early mortality of 33%. Eight living donor transplants (4 primary transplants, 4 redo transplants) were performed with an early survival of 87.5%. Patients with end-stage CF can undergo BLT with morbidity and mortality comparable with that observed in pulmonary transplantation for other disease entities.
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Affiliation(s)
- E N Mendeloff
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
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28
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Abstract
This article describes the authors' current technical preferences for the performance of isolated single lung transplantation and bilateral sequential single lung transplantation. The current techniques are the result of lessons learned in the performance of over 400 lung transplant operations at Washington University School of Medicine since 1987.
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Affiliation(s)
- B F Meyers
- Department of Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO 63110, USA
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29
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Gammie JS, Cheul Lee J, Pham SM, Keenan RJ, Weyant RJ, Hattler BG, Griffith BP. Cardiopulmonary bypass is associated with early allograft dysfunction but not death after double-lung transplantation. J Thorac Cardiovasc Surg 1998; 115:990-7. [PMID: 9605066 DOI: 10.1016/s0022-5223(98)70396-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess the effect of cardiopulmonary bypass on allograft function and recipient survival in double-lung transplantation. METHODS Retrospective review of 94 double-lung transplantations. RESULTS Cardiopulmonary bypass was used in 37 patients (CPB); 57 transplantations were accomplished without bypass (no-CPB). Bypass was routinely used for patients with pulmonary hypertension (n = 27) and for two recipients undergoing en bloc transplantation. Cardiopulmonary bypass was required in eight (12.3%) of the remaining 65 patients. Mean ischemic time was longer in the CPB group (346 vs 315 minutes, p = 0.04). The CPB group required more perioperative blood (11.4 vs 6.0 units, p = 0.01). Allograft function, assessed by the arterial/alveolar oxygen tension ratio, was better in the no-CPB group at 12 and 24 hours after operation (0.54 vs 0.39 at 12 hours, p = 0.002; and 0.63 vs 0.38 at 24 hours, p = 0.001). The CPB group had more severe pulmonary infiltrates at both 1 and 24 hours (p = 0.005). Diffuse alveolar damage was more common in the CPB group (69% vs 35%, p = 0.002). Median duration of intubation was longer in the CPB group (10 days) than in the no-CPB group (2 days, p = 0.002). The 30-day mortality rate (13.5% vs 7.0% in the CPB and no-CPB groups) and 1-year survival (65% vs 67%, CPB and no-CPB) were not significantly different. CONCLUSIONS In the absence of pulmonary hypertension, cardiopulmonary bypass is only occasionally necessary in double-lung transplantation. Bypass is associated with substantial early allograft dysfunction after transplantation.
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Affiliation(s)
- J S Gammie
- Division of Cardiothoracic Surgery, The University of Pittsburgh Medical Center, PA, USA
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30
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Mendeloff EN, Huddleston CB, Mallory GB, Trulock EP, Cohen AH, Sweet SC, Lynch J, Sundaresan S, Cooper JD, Patterson GA. Pediatric and adult lung transplantation for cystic fibrosis. J Thorac Cardiovasc Surg 1998; 115:404-13; discussion 413-4. [PMID: 9475536 DOI: 10.1016/s0022-5223(98)70285-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This paper was undertaken to review the experience at our institution with bilateral sequential lung transplantation for cystic fibrosis. METHODS Since 1989, 103 bilateral sequential lung transplants for cystic fibrosis have been performed (46 pediatric, 48 adult, 9 redo); the mean age was 21 +/- 10 years. Cardiopulmonary bypass was used in all but one pediatric (age <18) transplant, and in 15% of adults. RESULTS Hospital mortality was 4.9%, with 80% of early deaths related to infection. Bronchial anastomotic complications occurred with equal frequency in the pediatric and the adult populations (7.3%). One- and 3-year actuarial survival are 84% and 61%, respectively (no significant difference between pediatric and adult age groups; average follow-up 2.1 +/- 1.6 years). Mean forced expiratory volume in 1 second increased from 25% +/- 9% before transplantation to 79% +/- 35% 1 year after transplantation. Acute rejection occurred 1.7 times per patient-year, with most episodes taking place within the first 6 months after transplantation. The need for treatment of lower respiratory tract infections occurred 1.2 times per patient in the first year after transplantation. Actuarial freedom from bronchiolitis obliterans was 63% at 2 years and 43% at 3 years. Redo transplantation was performed only in the pediatric population and was associated with an early mortality of 33%. Eight living donor transplants (four primary transplants, four redo transplants) were performed with an early survival of 87.5%. CONCLUSION Patients with end-stage cystic fibrosis can undergo bilateral lung transplantation with morbidity and mortality comparable to that seen in pulmonary transplantation for other disease entities.
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Affiliation(s)
- E N Mendeloff
- Department of Surgery, Washington University School of Medicine, St. Louis, Mo, USA
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31
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Piotrowski JA, Splittgerber FH, Donovan TJ, Ratjen F, Zerkowski HR. Single-lung transplantation in a patient with cystic fibrosis and an asymmetric thorax. Ann Thorac Surg 1997; 64:1456-8; discussion 1458-9. [PMID: 9386721 DOI: 10.1016/s0003-4975(97)00925-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report metachronous single-lung transplantation for cystic fibrosis after contralateral pneumonectomy. Kyphoscoliosis and mediastinal shift required careful donor-lung sizing with computed tomography and was not dependent on typical parameters. Severe reperfusion injury was treated with nitric oxide, C1-esterase inhibitor, and continuous venovenous hemodialysis. The patient was extubated on the fifth postoperative day and is alive and well. We conclude that single-lung transplantation after contralateral pneumonectomy for patients with cystic fibrosis and an asymmetric chest and evident lung volume mismatch may be an acceptable functional therapeutic option.
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Affiliation(s)
- J A Piotrowski
- Department of Thoracic and Cardiovascular Surgery, Essen University Medical School, Germany
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32
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Abstract
BACKGROUND There is controversy over whether colonization with drug-resistant organisms is a contraindication to lung transplantation. METHODS We undertook a retrospective review of the results of lung transplantation for patients with cystic fibrosis (CF) at Duke University Medical Center. RESULTS As of May 1996, 21 patients with CF underwent bilateral lung transplantation. The first patient died within 24 h of transplantation from sepsis due to Stenotrophomonas maltophilia. Of the remaining 20 patients, 17 (85%) are alive and in stable condition. The three deaths were related primarily to bronchiolitis obliterans at 4 and 18 months in two patients and to cytomegalovirus pneumonitis at 5 months in the other patient. The 17 surviving patients have been followed up for a mean of 13 months (range, 0.5 to 34 months). Most of them were colonized and infected with multidrug-resistant organisms before transplantation. Following transplantation, 11 patients had complications from infections. One patient had bacteremia due to a panresistant Burkholderia cepacia and was treated successfully. Two patients had bacteremia and wound infection due to Burkholderia gladioli, previously thought to be pathogenic only in plants. Both patients were treated successfully. Of the six patients with Aspergillus fumigatus isolated from cultures before transplantation, only one had invasive disease following transplantation and responded to treatment. CONCLUSION The organisms present before transplantation were not the primary cause of mortality in our patient population. Our findings suggest that lung transplantation should be considered in CF patients infected with multidrug-resistant organisms.
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Affiliation(s)
- S S Kanj
- Department of Medicine, Duke University Medical Center, and the Durham Veterans Administration Medical Center, NC 27710, USA
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33
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Abstract
Pediatric lung transplantation is becoming more common, and with increasing experience there is increasing success. The most common indications for considering lung transplantation are cystic fibrosis, pulmonary vascular disease (usually due to congenital heart disease), and fibrotic lung disease. The contraindications and complications are similar to adult transplant patients, although post-transplant lymphoproliferative disease and airway complications may occur more frequently. The patients with cystic fibrosis face additional obstacles to the success of transplantation: airway colonization with Gram-negative organisms, pancreatic insufficiency, glucose intolerance, and osteoporosis. The survival for children is comparable to adults, reaching about 65% at 1 year, and 69% at 2 years.
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Affiliation(s)
- P C Stillwell
- Department of Pediatrics, Cleveland Clinic Foundation, Ohio, USA
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34
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Horan BF, Cutfield GR, Davies IM, Harrison GA, Hughes E, Matheson JN, Scarf M, Spratt P. Problems in the management of the airway during anesthesia for bilateral sequential lung transplantation performed without cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1996; 10:387-90. [PMID: 8725424 DOI: 10.1016/s1053-0770(96)80104-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- B F Horan
- Brian Dwyer Department of Anaesthetics, St Vincent's Hospital, Darlinghurst, NSW, Australia
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35
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Affiliation(s)
- R M Kotloff
- Program for Advanced Lung Disease and Lung Transplantation, Pulmonary and Critical Care Division, Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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36
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Abstract
Patients with cystic fibrosis (CF) are being considered in increasing numbers as candidates for lung transplantation, despite earlier concerns that their nutritional status and the infective nature of their lung disease would contribute to increased morbidity and mortality. We undertook a retrospective analysis of patients with CF referred for consideration of lung transplant to identify factors that helped to select suitable transplant candidates and to identify characteristics that predicted death while on the waiting list. Analysis of 95 referred patients with CF demonstrated a high rate of suitability (78%) by our criteria. The mean weight of listed patients with CF was 77% predicted, and the mean FEV1 was 20% predicted. Sixteen percent of listed patients with CF died awaiting transplant. The FEV1 of these patients was significantly lower than that of patients who survived to transplant. This study implies that patients with CF are being referred for transplant late in the course of their disease. Earlier referral may lead to an increase in the number of patients with CF undergoing successful lung transplantation.
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Affiliation(s)
- P Ciriaco
- Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, USA
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37
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Hasan A, Corris PA, Healy M, Wrightson N, Gascoigne AD, Waller DA, Wilson I, Hilton CJ, Gould FK, Forty J. Bilateral sequential lung transplantation for end stage septic lung disease. Thorax 1995; 50:565-6. [PMID: 7597674 PMCID: PMC1021232 DOI: 10.1136/thx.50.5.565] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Bilateral sequential lung transplantation (BSLT) has been widely adopted as an alternative to combined heart and lung transplantation for the management of end stage septic lung disease in many transplant centres. METHODS A retrospective review was undertaken of the first 32 consecutive patients with septic lung disease to undergo BSLT at the Freeman Hospital. RESULTS Between April 1988 and October 1994 32 patients underwent BSLT. Survival at 30 days was 85% and actuarial survival at one year was 70%. Improved pulmonary function was seen in all surviving patients. CONCLUSION BSLT for septic lung disease offers comparable survival to heart-lung transplantation, with excellent functional results. Long term results may be superior because the disadvantages of transplanting the heart are avoided.
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Affiliation(s)
- A Hasan
- Department of Cardiothoracic Surgery, Freeman Hospital, Newcastle upon Tyne, UK
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38
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Abstract
Chronic rhinosinusitis is extremely common in patients with cystic fibrosis. It causes numerous problems in these patients and can put them at risk for life-threatening illness. Potential problems include nasal obstruction, congestion, sinus pain and pressure, infection (usually with Pseudomonas organisms), hyposmia or anosmia, and the seeding of bacteria into the lower respiratory tract. Cystic fibrosis patients with chronically infected sinuses are at increased risk for pneumonia following lung transplantation. A prophylactic protocol has been developed for the management of chronic sinusitis in patients with cystic fibrosis. These patients are fully evaluated at the Nasal Dysfunction Clinic of the University of California, San Diego (UCSD), Medical Center. Based on the results of the evaluation, they are treated with endoscopic sinus surgery, partial middle turbinectomy, septoplasty, and a large middle meatal maxillary antrostomy. Surgery is followed by a rigorous regimen of pulsatile hypotonic saline nasal irrigation to wash away tenacious cystic secretions. Tobramycin (Nebcin) is given once daily in the nasal irrigant to inhibit the growth of Pseudomonas organisms. At the USCD Nasal Dysfunction Clinic, this prepulmonary transplantation protocol is now used in all cystic fibrosis patients with chronic sinusitis.
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Affiliation(s)
- T M Davidson
- Department of Surgery, University of California San Diego Medical Center 92103-8895, USA
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39
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Abstract
A canine bilateral single-lung transplantation model was used to evaluate 21-hour lung preservation with low-potassium dextran glucose solution. Donor lungs were flushed with low-potassium dextran glucose solution (50 mL/kg), inflated with 100% oxygen (35 mL/kg), and preserved at 8 degrees C. Bilateral single-lung transplantation was performed without using cardiopulmonary bypass. The ischemic times to the right and left lungs were designed to be 3 and 6 hours, respectively, in group 1 (n = 5) and 18 and 21 hours in group 2 (n = 6). After bilateral single-lung transplantation, animals were maintained on a ventilator for 12 hours and lung function, including arterial blood gas and pulmonary hemodynamics, was measured. All 5 dogs in group 1 and 5 of 6 dogs in group 2 completed bilateral single-lung transplantation successfully and survived for 12 hours with excellent lung function. Arterial oxygen tension and mean pulmonary artery pressure were stable during the 12-hour assessment period in both groups and did not differ significantly from donor values. Twelve hours after reperfusion, mean arterial oxygen tension (inspired oxygen fraction = 1.0) was 590 +/- 18 mm Hg in group 1 and 604 +/- 8 mm Hg in group 2. After the 12-hour assessment period, the animals were extubated and immunosuppressed. Two dogs in group 2 survived for 7 and 8 days, respectively, with a mean arterial oxygen tension of 74 mm Hg on room air at 5 days.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- H Date
- Department of Surgery II, Okayama University Medical School, Japan
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40
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Egan TM, Detterbeck FC, Mill MR, Paradowski LJ, Lackner RP, Ogden WD, Yankaskas JR, Westerman JH, Thompson JT, Weiner MA. Improved results of lung transplantation for patients with cystic fibrosis. J Thorac Cardiovasc Surg 1995; 109:224-34; discussion 234-5. [PMID: 7531796 DOI: 10.1016/s0022-5223(95)70383-7] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients with cystic fibrosis pose particular challenges for lung transplant surgeons. Earlier reports from North American centers suggested that patients with cystic fibrosis were at greater risk for heart-lung or isolated lung transplantation than other patients with end-stage pulmonary disease. During a 3 1/2 year period, 44 patients with end-stage lung disease resulting from cystic fibrosis underwent double lung transplantation at this institution. During the same interval, 18 patients with cystic fibrosis died while waiting for lung transplantation. The ages of the recipients ranged from 8 to 45 years, and mean forced expiratory volume in 1 second was 21% predicted. Seven patients had Pseudomonas cepacia bacteria before transplantation. Bilateral sequential implantation with omentopexy was used in all patients. There were no operative deaths, although two patients required urgent retransplantation because of graft failure. Cardiopulmonary bypass was necessary in six procedures in five patients and was associated with an increased blood transfusion requirement, longer postoperative ventilation, and longer hospital stay. Actuarial survival was 85% at 1 year and 67% at 2 years. Infection was the most common cause of death within 6 months of transplantation (Pseudomonas cepacia pneumonia was the cause of death in two patients), and bronchiolitis obliterans was the most common cause of death after 6 months. Actuarial freedom from development of clinically significant bronchiolitis obliterans was 59% at 2 years. Results of pulmonary function tests improved substantially in survivors, with forced expiratory volume in 1 second averaging 78% predicted 2 years after transplantation. Double lung transplantation can be accomplished with acceptable morbidity and mortality in patients with cystic fibrosis.
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Affiliation(s)
- T M Egan
- Division of Cardiothoracic Surgery (Department of Surgery), University of North Carolina at Chapel Hill
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41
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Abstract
Bilateral lung and heart-lung transplantation are indicated for cystic fibrosis children with end-stage lung disease. This article discusses the current criteria for inclusion-exclusion, surgical techniques, and results.
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Affiliation(s)
- H Shennib
- McGill University, Montreal, Quebec, Canada
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42
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Dettelbach MA, Hirsch BE, Weissman JL. Pseudomonas cepacia of the temporal bone: malignant external otitis in a patient with cystic fibrosis. Otolaryngol Head Neck Surg 1994; 111:528-32. [PMID: 7524007 DOI: 10.1177/019459989411100425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- M A Dettelbach
- Department of Otolaryngology, University of Pittsburgh School of Medicine, PA
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43
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Brenken U, Mungroop H, Boer W, Meuzelaar J, Mannes G. The use of cardiopulmonary bypass for lung transplantation is not associated with major blood loss or increased mortality. J Cardiothorac Vasc Anesth 1994. [DOI: 10.1016/1053-0770(94)90561-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wilson JM, Engelhardt JF, Grossman M, Simon RH, Yang Y. Gene therapy of cystic fibrosis lung disease using E1 deleted adenoviruses: a phase I trial. Hum Gene Ther 1994; 5:501-19. [PMID: 7519452 DOI: 10.1089/hum.1994.5.4-501] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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Carré P, Rousseau H, Lombart L, Didier A, Dahan M, Fournial G, Léophonte P. Balloon dilatation and self-expanding metal Wallstent insertion. For management of bronchostenosis following lung transplantation. The Toulouse Lung Transplantation Group. Chest 1994; 105:343-8. [PMID: 8306726 DOI: 10.1378/chest.105.2.343] [Citation(s) in RCA: 72] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Here we report our experience on the use of balloon dilatation or self-expandable metal Wallstent implantation, or both, for the management of twelve bronchial stenoses in ten lung transplant recipients during the past two years. Both techniques were carried out endoscopically, under fluoroscopic guidance and without general anesthesia. Both methods were straightforward, well tolerated, and resulted in immediate symptomatic and functional improvement. The first-line treatment relied on Wallstent insertion (n = 4) or on balloon dilatation (n = 8). Early restenosis occurred in four of eight dilated stenoses and subsequently led to Wallstent insertion. Following Wallstent implantation, growth of granulation tissue occurred in one case and necessitated repeated balloon dilatations inside the stent during the following months. On two occasions, the stenosis was located such that the lower end of the Wallstent overlapped the upper lobe bronchus orifice. This necessitated laser therapy to eliminate the filaments of the stent crossing the lobar orifice, preventing subsequent obstruction. Laser therapy was followed, in one case, by a fibroinflammatory stenosis which was successfully treated by balloon dilatation inside the prosthesis. At the time of writing, the mean +/- SE of the follow-up after Wallstent implantation is 15.3 +/- 2.7 (range: 6 to 32) months. Most Wallstent prostheses are overgrown with bronchial epithelium. We conclude (1) that self-expanding metal Wallstent implantation is a safe procedure and good alternative to silicone stent insertion for the treatment of bronchostenosis following lung transplantation, provided granulomas are not present and (2) that balloon dilatation, although possibly leading to recurrences, can be used to allow inflammatory tissue to mature or to dilate restenoses inside the Wallstent.
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Affiliation(s)
- P Carré
- Rangueil Hospital, Toulouse, France
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Massard G, Shennib H, Metras D, Camboulives J, Viard L, Mulder DS, Tchervenkov CI, Morin JF, Giudicelli R, Noirclerc M. Double-lung transplantation in mechanically ventilated patients with cystic fibrosis. Ann Thorac Surg 1993; 55:1087-91; discussion 1091-2. [PMID: 8494415 DOI: 10.1016/0003-4975(93)90012-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Many lung transplant programs consider ventilator dependence as a contraindication for transplantation. Among 54 patients in whom bilateral lung transplantations for cystic fibrosis were performed by the Joint Marseille-Montreal Lung Transplant Program, 10 were ventilator dependent. Three of them died in the early postoperative period (30%): 2 as a result of cerebral anoxia and sepsis, 1 of Pseudomonas cepacia pneumonia. Two patients died at 15 and 19 months after transplantation of obliterative bronchiolitis and secondary bacterial pneumonitis. Another 2 patients in whom obliterative bronchiolitis developed underwent retransplantation with a heart-lung block; 1 of those was operated on at 12 months and is well at 29 months after his initial transplantation; the second was operated on at 34 months and died of primary graft failure. Three other patients are alive and well at 3, 11, and 14 months after transplantation. Actuarial survival at 1 year was 70%. The postoperative course and the infectious and rejection complications were no different from those in patients who underwent transplantation while spontaneously breathing. Obliterative bronchiolitis developed in 66% of patients at risk (2 of 6 patients surviving more than 6 months). We conclude that transplantation in mechanically ventilated patients with cystic fibrosis is not associated with an increase in morbidity or mortality after bilateral lung transplantation. Long-term survival, as in patients who undergo transplantation while spontaneously breathing, is limited by the development of obliterative bronchiolitis.
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Affiliation(s)
- G Massard
- Joint Marseille-Montreal Lung Transplant Program, Marseille, France
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