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Fabyan KD, Chandel A, King CS. Pulmonary Hypertension in Interstitial Lung Disease: Management Options to Move Beyond Supportive Care. Curr Pulmonol Rep 2023; 12:1-8. [PMID: 37362782 PMCID: PMC10200699 DOI: 10.1007/s13665-023-00311-2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review delineates current diagnostic and management strategies for pulmonary hypertension due to interstitial lung disease (PH-ILD). Recent Findings The INCREASE trial, a phase III multicenter, randomized, placebo-controlled trial demonstrated both improved 6-min walk distance and decreased disease progression with inhaled treprostinil. This pivotal trial led to inhaled treprostinil becoming the first FDA approved medication for treatment of PH-ILD. The availability of this treatment has generated subsequent recommendations for the screening for PH in patients with ILD. As a result, it is becoming increasingly important for clinicians to gain awareness and familiarity with the evolving management options for PH-ILD. Summary The management of PH-ILD has its roots in goal-directed treatment of the underlying lung disease. However, recent medication advances and ongoing clinical studies are opening opportunities for more disease-specific treatment.
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Affiliation(s)
- Kimberly D. Fabyan
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, 8901, Rockville Pike, Bethesda, MD 20889 USA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care, Walter Reed National Military Medical Center, 8901, Rockville Pike, Bethesda, MD 20889 USA
| | - Christopher S. King
- Advanced Lung Disease and Transplant Program, Inova Heart and Vascular Institute, Inova Fairfax Hospital, 3330 Gallows Road, Falls Church, VA 22003 USA
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Thomas C, Chandel A, King CS, Aryal S, Brown AW, Khangoora V, Nyquist A, Singhal A, Fonseca OC, Shlobin O, Nathan SD. Prevalence of pulmonary hypertension in patients with COVID-19 related lung disease listed for lung transplantation: A UNOS registry analysis. Pulm Circ 2023; 13:e12228. [PMID: 37091120 PMCID: PMC10114532 DOI: 10.1002/pul2.12228] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/11/2023] [Accepted: 04/09/2023] [Indexed: 04/25/2023] Open
Abstract
COVID-19 related lung disease (CRLD) has emerged as an indication for lung transplantation (LT) in highly select patients. The prevalence and prognostic implication of coexisting pulmonary hypertension (PH) in patients with CRLD listed for LT is not known. Adult patients in the United Network for Organ Sharing database listed for LT for COVID-19 related acute respiratory distress syndrome or fibrosis through March 2022 were identified. The prevalence and impact of precapillary PH on pre- and posttransplantation survival was determined. Time-to-event analysis was used to compare outcomes between those with and without precapillary PH. We identified 245 patients listed for LT for CRLD who had right heart catheterization data available at the time of registry listing. Median age of the cohort was 54 years (interquartile range [IQR]: 46, 60), 56 (22.9%) were female, and the median lung allocation score was 81.3 (IQR: 53.3, 89.4). The prevalence of precapillary PH at the time of transplant listing was 27.9%. There was no significant difference in pretransplant mortality in patients with and without precapillary PH (sHR: 0.5; 95% confidence interval [CI]: 0.1-1.7, p = 0.261). A total of 187 patients ultimately underwent LT; of those, 60 (31.0%) were identified as having precapillary PH during the waitlist period. Posttransplantation survival was similar between patients with and without pretransplant precapillary PH (hazard ratio: 0.96; 95% CI: 0.2-3.7, p = 0.953). We observed a high rate of concomitant precapillary PH in patients listed for LT for CRLD. Though common, coexisting precapillary PH was not associated with a significant difference in either pre- or post-transplantation outcomes.
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Affiliation(s)
- Christopher Thomas
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Abhimanyu Chandel
- Department of Pulmonary and Critical Care MedicineWalter Reed National Military Medical CenterBethesdaMarylandUSA
| | - Christopher S. King
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Shambhu Aryal
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - A. Whitney Brown
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Vikramjit Khangoora
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Alan Nyquist
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Anju Singhal
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Onix Cantres Fonseca
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Oksana Shlobin
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
| | - Steven D. Nathan
- Inova Heart and Vascular Institute, Advanced Lung Disease and Transplant ProgramInova Fairfax HospitalFalls ChurchVirginiaUSA
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Foroutan F, Malik A, Clark KE, Buchan TA, Yang H, Cheong GHL, Pezzutti O, Kim I, Gupta R, Tan C, Samman A, Friesen EL, Akhtar A, Rigobon A, Stein M, Nunez JJY, Sidhu A, Heels-Ansdell D, Guyatt G, Meade MO. Predictors of 1-year Mortality after Adult Lung Transplantation: Systematic Review and Meta-analyses. J Heart Lung Transplant 2022; 41:937-951. [DOI: 10.1016/j.healun.2022.03.017] [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] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 03/07/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022] Open
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Abstract
Pulmonary arterial hypertension (PAH) is a progressive fatal disease. Although medical therapies have improved the outlook for these patients, there still exists a cohort of patients with PAH who are refractory to these therapies. Lung transplantation (LT), and in certain cases heart-lung transplantation (HLT), is a therapeutic option for patients with severe PAH who are receiving optimal therapy yet declining. ECMO may serve as a bridge to transplant or recovery in appropriate patients. Although, the mortality within the first 3 months after transplant is higher in PAH recipients than the other indications for LT, and the long-term survival after LT is excellent for this group of individuals. In this review, we discuss the indications for LT in PAH patients, when to refer and list patients for LT, the indications for double lung transplant (DLT) versus HLT for PAH patients, types of advanced circulatory support for severe PAH, and short and long-term outcomes in transplant recipients with PAH.
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Affiliation(s)
- Marie M Budev
- Lung and Heart Lung Transplant Program, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A -90, Cleveland, OH 44195, USA.
| | - James J Yun
- Lung Transplant Program, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue, Desk J4-1, Cleveland, OH 44195, USA
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Xu J, Qin Z, Wang Y, Hu C, Wang G, Gu Z, Yuan S, Chen J, Huang D, Wang Z. The prognostic value of peak arterial lactate levels within 72 h of lung transplantation in identifying patient outcome. J Thorac Dis 2020; 12:7365-7373. [PMID: 33447426 PMCID: PMC7797848 DOI: 10.21037/jtd-20-3445] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 12/14/2022]
Abstract
Background Lactic acidosis is often seen in lung transplantation (LTx). Postoperative lactate is frequently associated with poor outcome in postoperative and critically ill patients. Our aim was to evaluate the predictive value of postoperative peak lactate levels within 72 h of LTx for 30-day and late mortality. Methods We evaluated patients who underwent LTx from January 2015 to September 2017. All admitted patients were classified according to the peak lactate level (PL) within 72 h of surgery: PL <5 mmol/L (Group 1); PL =5–10 mmol/L (Group 2), and PL >10 mmol/L (Group 3). We performed logistic regression analysis and used Cox regression models to identify the peak lactate level as a predictive factor for 30-day and late mortality, respectively. Results Of 255 eligible patients, mean age 55.61±12.16, mean lactate 4.99±2.93 and 80% male, and 40% had hyperlactatemia (PL >5 mmol/L) after LTx. The 30-day mortality rate was 17.9%, 28.9% and 68.8% in the three groups, respectively (P<0.05). Multivariate regression analyses revealed postoperative PL as a notable predictor of 30-day mortality [odds ratio =2.62 (1.42–4.84), P=0.002] as well as for late mortality [hazard ratio =2.70 (1.13–6.42), P=0.025]. Conclusions The postoperative peak lactate level within 72 h of surgery was an independent predictor for 30-day and late mortality in LTx patients.
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Affiliation(s)
- Jingjing Xu
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhong Qin
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Yanjuan Wang
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Chunxiao Hu
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Guilong Wang
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhengfeng Gu
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Shengjie Yuan
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Jingyu Chen
- Department of Lung Transplant Group, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China.,Jiangsu Key Laboratory of Organ Transplantation, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Dongxiao Huang
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China
| | - Zhiping Wang
- Department of Anesthesiology, the Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, China.,Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Shiiya H, Sato M, Shinozaki-Ushiku A, Konoeda C, Kitano K, Nakajima J. Exacerbation of Secondary Pulmonary Hypertension by Flat Chest after Lung Transplantation. Ann Thorac Cardiovasc Surg 2020; 28:298-301. [PMID: 33148928 PMCID: PMC9433883 DOI: 10.5761/atcs.cr.20-00230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Indexed: 11/16/2022] Open
Abstract
A 40-year-old woman with idiopathic pleuroparenchymal fibroelastosis (IPPFE) and flat chest underwent left single lung transplantation (SLT). Although she had developed over-systemic pulmonary arterial pressure (PAP) at transplantation, it was alleviated. However, her PAP gradually increased again. Her transplanted lung was well-inflated, but progression of fibrosis in her right native lung appeared to have caused a mediastinal shift, and her flat chest caused obstruction of the outflow tract of the pulmonary vein. She died of heart failure and associated infection 1.5 years after transplantation. An autopsy confirmed irreversible pulmonary arterial and venous changes in the transplanted lung, suggestive of chronic pressure overload. The flat chest associated with IPPFE can affect pulmonary circulation after SLT.
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Affiliation(s)
- Haruhiko Shiiya
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Hokkaido, Japan
| | - Masaaki Sato
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Aya Shinozaki-Ushiku
- Department of Pathology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Chihiro Konoeda
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kentaro Kitano
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Jun Nakajima
- Department of Thoracic Surgery, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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Martin AK, Renew JR, Jayaraman AL, Murray AW, Fritz AV, Ramakrishna H. Analysis of Outcomes in Lung Transplantation. J Cardiothorac Vasc Anesth 2019; 33:1455-1466. [DOI: 10.1053/j.jvca.2018.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Indexed: 01/04/2023]
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Meyer KC. Lung transplantation for pulmonary sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2019; 36:92-107. [PMID: 32476942 DOI: 10.36141/svdld.v36i2.7163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 02/04/2019] [Indexed: 01/15/2023]
Abstract
Although relatively few patients with pulmonary sarcoidosis develop advanced disease that progresses to respiratory insufficiency despite receiving best practice pharmacologic interventions, lung transplantation may be the only therapeutic option for such patients to both prolong survival and provide improved quality of life. Lung transplant can be successfully performed for patients with end-stage pulmonary sarcoidosis, and post-transplant survival is similar to that for other transplant indications such as idiopathic pulmonary fibrosis. However, appropriate timing of referral, comprehensive assessment of potential candidates for lung transplant, placement of patients on the lung transplant waiting list when within the transplant window as appropriate, choosing the best procedure (bilateral versus single lung transplant), and optimal peri-operative and post-transplant management are key to successful lung transplant outcomes for patients with sarcoidosis.
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Affiliation(s)
- Keith C Meyer
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
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Spratt JR, Tomic R, Brown RZ, Rudser K, Loor G, Hertz M, Shumway S, Kelly RF. Single Versus Bilateral Lung Transplantation for Idiopathic Pulmonary Fibrosis in the Lung Allocation Score Era. J Surg Res 2019; 234:84-95. [PMID: 30527505 DOI: 10.1016/j.jss.2018.08.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 08/03/2018] [Accepted: 08/24/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal disease. Lung transplantation is the only therapy associated with prolonged survival. The ideal transplant procedure for IPF is unclear. Outcomes after single transplantation (SLTx) versus bilateral lung transplantation (BLTx) in IPF patients after introduction of the Lung Allocation Score were examined. METHODS Records of patients undergoing lung transplantation for IPF at our institution between May 2005 and March 2017 were reviewed to examine the effect of transplant laterality. Primary outcomes were overall, rejection-free, and bronchiolitis obliterans (BOS)-free survival at 1 and 5 years post-transplant. RESULTS Lung transplantation was performed in 151 IPF patients post-Lung Allocation Score. Most recipients were male with average age 59 ± 8 years. SLTx was performed in 94 patients (62%). In the overall cohort, comparative survival between SLTx and BLTx was similar at 1 and 5 years before and after adjusting for age and pulmonary hypertension (PH). SLTx was associated with shorter ventilator time and intensive care unit stay and trended toward improved survival over BLTx in patients without PH. CONCLUSIONS The use of SLTx versus BLTx in IPF did not correspond to significantly different survival adjusting for age and PH. BLTx was associated with prolonged postoperative ventilation and length of stay compared with SLTx. Patients without PH, all older patients, and patients with PH and advanced disease should be considered for SLTx for IPF.
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Cottini SR, Brandi G, Pagnamenta A, Weder W, Schuepbach RA, Béchir M, Huber LC, Benden C. Pulmonary hypertension is not a risk factor for grade 3 primary graft dysfunction after lung transplantation. Clin Transplant 2018; 32:e13251. [DOI: 10.1111/ctr.13251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/21/2023]
Affiliation(s)
- Silvia R. Cottini
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Giovanna Brandi
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Alberto Pagnamenta
- Department of Intensive Care Medicine of the Ente Ospedaliero Cantonale (EOC): Intensive Care Unit of Regional Hospital of Mendrisio; Mendrisio Switzerland
- Unit of Clinical Epidemiology; Ente Ospedaliero Cantonale; Bellinzona Switzerland
| | - Walter Weder
- Division of Thoracic Surgery; University Hospital Zurich; Zurich Switzerland
| | - Reto A. Schuepbach
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
| | - Markus Béchir
- Surgical Intensive Care Medicine; University Hospital Zurich; Zurich Switzerland
- Swiss Paraplegic Center; Nottwil Switzerland
| | - Lars C. Huber
- Division of Pulmonology; University Hospital Zurich; Zurich Switzerland
- Clinic for Internal Medicine; City Hospital Triemli; Zurich Switzerland
| | - Christian Benden
- Division of Pulmonology; University Hospital Zurich; Zurich Switzerland
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Abstract
INTRODUCTION While many pharmacologic therapies for the treatment of idiopathic pulmonary fibrosis (IPF) have been evaluated via randomized, placebo-controlled clinical trials (RCTs) conducted over the past two decades, most therapies have been shown to be ineffective or even potentially harmful. However, a number of recently completed RCTs have shown significant efficacy for pirfenidone and nintedanib for the treatment of IPF. Areas covered: This manuscript reviews recent advances in the management of IPF and other forms of fibrosing interstitial lung disease (ILD) with an emphasis on IPF. The material upon which this discussion is based was obtained from various published texts and manuscripts identified via literature searching (e.g. PubMed). Expert commentary: Anti-fibrotic drugs are now available for clinical use and perceived as standard-of-care therapies that have the potential to blunt disease progression for many patients with IPF. However, these agents do not necessarily stop disease progression or have a significant impact on mortality, and more effective pharmacologic therapies are needed for patients with IPF. Additionally, whether anti-fibrotic agents can be effective therapies for other forms of pulmonary fibrosis, which often have radiologic and histopathologic manifestations that mimic IPF, is being evaluated in a number of RCTs.
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Affiliation(s)
- Keith C Meyer
- a Department of Medicine , University of Wisconsin School of Medicine and Public Health - Medicine , K4/910 Clinical Science Center 600 Highland Avenue Madison, Madison , WI , 53792-9988 , USA
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Subramaniam K, Nazarnia S. Noteworthy Literature Published in 2016 for Thoracic Organ Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2017; 21:45-57. [DOI: 10.1177/1089253216688537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This article is first in the series to review the published literature on perioperative issues in patients undergoing thoracic solid organ transplantations. We present recent literature from 2016 on preoperative considerations, organ preservation, intraoperative anesthesia management, surgical techniques, postoperative complications, and the impact of perioperative management on short- and long-term outcomes that are pertinent to thoracic transplantation anesthesiologists.
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