Mechanical thrombectomy for acute pulmonary embolism in lung transplant recipients

The rates of pulmonary embolism (PE) are high among lung transplant (LT) recipients. Management is challenging because of elevated bleeding risks and inadequacy of conventional PE risk stratification tools. New percutaneous large bore mechanical thrombectomy catheters are being increasingly used effectively to debulk thrombus and restore flow immediately. We describe the use of mechanical thrombectomy (MT) in 8 LT recipients. All patients were diagnosed with intermediate/high-risk proximal PE involving the allograft and underwent successful MT within 30 hours of diagnosis. Estimated blood loss was between 200 and 450 cc, with 3 patients requiring blood transfusions. Improvement in heart rate and oxygenation was seen in all 8 patients after the procedure. In the 30 days after MT, 7 of 8 patients survived. One patient died from major bleeding occurred 16 days after MT and 5 days after venoarterial extracorporeal membrane oxygenator decannulation. Mechanical thrombectomy may provide a feasible management strategy in select LT recipients with pulmonary embolism.

Reflux Surgery in Lung Transplantation: A Multicenter Retrospective Study

BACKGROUND

Aspiration has been associated with graft dysfunction after lung transplantation, leading some to advocate for selective use of fundoplication despite minimal data supporting this practice.

METHODS

We performed a multicenter retrospective study at 4 academic lung transplant centers to determine the association of gastroesophageal reflux disease and fundoplication with bronchiolitis obliterans syndrome and survival using Cox multivariable regression.

RESULTS

Of 542 patients, 136 (25.1%) underwent fundoplication; 99 (18%) were found to have reflux disease without undergoing fundoplication. Blanking the first year after transplantation, fundoplication was not associated with a benefit regarding freedom from bronchiolitis obliterans syndrome (hazard ratio [HR], 0.93; 95% CI, 0.58-1.49) or death (HR, 0.97; 95% CI, 0.47-1.99) compared with reflux disease without fundoplication. However, a time-dependent adjusted analysis found a slight decrease in mortality (HR, 0.59; 95% CI, 0.28-1.23; P = .157), bronchiolitis obliterans syndrome (HR, 0.68; 95% CI, 0.42-1.11; P = .126), and combined bronchiolitis obliterans syndrome or death (HR, 0.66; 95% CI, 0.42-1.04; P = .073) in the fundoplication group compared with the gastroesophageal reflux disease group.

CONCLUSIONS

Although a statistically significant benefit from fundoplication was not determined because of limited sample size, follow-up, and potential for selection bias, a randomized, prospective study is still warranted.

The Past, Present, and Near Future of Lung Allocation in the United States

The first official donor lung allocation system in the United States was initiated by the United Network of Organ Sharing in 1990. The initial policy for lung allocation was simple with donor lungs allocated based on ABO match and the amount of time the candidates accrued on the waiting list. Donor offers were first given to candidates' donor service area. In March 2005, the implementation of the lung allocation score (LAS) was the major change in organ allocation. International adoption of the LAS-based allocation system can be seen worldwide.

Early posttransplant reductions in club cell secretory protein associate with future risk for chronic allograft dysfunction in lung recipients: results from a multicenter study

BACKGROUND

Chronic lung allograft dysfunction (CLAD) increases morbidity and mortality for lung transplant recipients. Club cell secretory protein (CCSP), produced by airway club cells, is reduced in the bronchoalveolar lavage fluid (BALF) of lung recipients with CLAD. We sought to understand the relationship between BALF CCSP and early posttransplant allograft injury and determine if early posttransplant BALF CCSP reductions indicate later CLAD risk.

METHODS

We quantified CCSP and total protein in 1606 BALF samples collected over the first posttransplant year from 392 adult lung recipients at 5 centers. Generalized estimating equation models were used to examine the correlation of allograft histology or infection events with protein-normalized BALF CCSP. We performed multivariable Cox regression to determine the association between a time-dependent binary indicator of normalized BALF CCSP level below the median in the first posttransplant year and development of probable CLAD.

RESULTS

Normalized BALF CCSP concentrations were 19% to 48% lower among samples corresponding to histological allograft injury as compared with healthy samples. Patients who experienced any occurrence of a normalized BALF CCSP level below the median over the first posttransplant year had a significant increase in probable CLAD risk independent of other factors previously linked to CLAD (adjusted hazard ratio 1.95; p = 0.035).

CONCLUSIONS

We discovered a threshold for reduced BALF CCSP to discriminate future CLAD risk; supporting the utility of BALF CCSP as a tool for early posttransplant risk stratification. Additionally, our finding that low CCSP associates with future CLAD underscores a role for club cell injury in CLAD pathobiology.

Anti-fibrotic therapy and lung transplant outcomes in patients with idiopathic pulmonary fibrosis

BACKGROUND

It is unclear whether continuing anti-fibrotic therapy until the time of lung transplant increases the risk of complications in patients with idiopathic pulmonary fibrosis.

OBJECTIVES

To investigate whether the time between discontinuation of anti-fibrotic therapy and lung transplant in patients with idiopathic pulmonary fibrosis affects the risk of complications.

METHODS

We assessed intra-operative and post-transplant complications among patients with idiopathic pulmonary fibrosis who underwent lung transplant and had been treated with nintedanib or pirfenidone continuously for ⩾ 90 days at listing. Patients were grouped according to whether they had a shorter (⩽ 5 medication half-lives) or longer (> 5 medication half-lives) time between discontinuation of anti-fibrotic medication and transplant. Five half-lives corresponded to 2 days for nintedanib and 1 day for pirfenidone.

RESULTS

Among patients taking nintedanib (n = 107) or pirfenidone (n = 190), 211 (71.0%) had discontinued anti-fibrotic therapy ⩽ 5 medication half-lives before transplant. Anastomotic and sternal dehiscence occurred only in this group (anastomotic: 11 patients [5.2%], p = 0.031 vs patients with longer time between discontinuation of anti-fibrotic medication and transplant; sternal: 12 patients [5.7%], p = 0.024). No differences were observed in surgical wound dehiscence, length of hospital stay, or survival to discharge between groups with a shorter versus longer time between discontinuation of anti-fibrotic therapy and transplant.

CONCLUSION

Anastomotic and sternal dehiscence only occurred in patients with idiopathic pulmonary fibrosis who discontinued anti-fibrotic therapy < 5 medication half-lives before transplant. The frequency of other intra-operative and post-transplant complications did not appear to differ depending on when anti-fibrotic therapy was discontinued.

REGISTRATION

clinicaltrials.gov NCT04316780: https://clinicaltrials.gov/ct2/show/NCT04316780.

Advanced Circulatory Support and Lung Transplantation in Pulmonary Hypertension

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.

Pre-transplant vaccination compliance in adult heart and lung transplant recipients

BACKGROUND

Vaccine preventable diseases can affect solid organ transplant recipients post-transplant. Therefore, the administration of vaccines and assessment of serologic response should be prioritized in the pre-transplant period.

METHODS

This single-center, retrospective study included 349 adult heart or lung transplant candidates between December 1, 2017 and November 30, 2019. We describe vaccination or serologic status for hepatitis A, hepatitis B, tetanus, pneumococcal, influenza, and other recommended vaccinations among heart or lung transplant candidates.

RESULTS

Eighty-two heart transplant candidates (91%) and 77 lung transplant candidates (30%) received an ID consult prior to transplant. More patients completed the pneumococcal series (66.7% vs. 28.6%, P = .045) in the heart transplant group that received an ID consult. In the lung transplant group, patients with an ID consult demonstrated higher rates of immunity to hepatitis A (84.4% vs. 72.9%, P = .047), hepatitis B (75.3% vs. 56.9%, P = .005), and measles (71.4% vs. 52.5%, P = .005) compared to those without.

CONCLUSIONS

Our results demonstrate the value of consulting ID and administering vaccinations in the early evaluation phase, prior to transplant listing. Opportunities remain to better optimize vaccination rates prior to transplant in heart and lung transplant candidates.

Evaluating resilience as a predictor of outcomes in lung transplant candidates

BACKGROUND

Resilience represents the capacity to adapt to adversity. Resilience can improve following behavioral interventions. We examined lung transplant candidates' resilience as a novel predictor using the Connor-Davidson Resilience Scale (RISC-10).

METHODS

Waitlisted candidates at six centers were mailed questionnaires from 9/16/2015 to 10/1/2019. Follow-up surveys were collected annually and post-transplant. Outcomes were recorded through February 17, 2020. Primary outcome was pre-transplant death/delisting. Analyses included t test or chi-square for group comparisons, Pearson's correlation coefficients for strength of relationships, and Cox proportional-hazard models to evaluate associations with outcomes, adjusting for age, sex, and mood.

RESULTS

Participation was 55.3% (N = 199). Baseline RISC-10 averaged 32.0 ± 5.6 and did not differ by demographics, primary transplant diagnosis, or disease severity markers. RISC-10 did not correlate to the commonly utilized Psychosocial Assessment of Candidates for Transplant [PACT] or Stanford Integrated Psychosocial Assessment for Transplantation [SIPAT] tools. Scores < 26.3 (representing > 1 standard deviation below population average) occurred in 16% and were associated with pre-transplant death or delisting, adjusted Hazard Ratio of 2.60 (95% Confidence Interval 1.23-5.77; P = .01).

CONCLUSION

One in six lung candidates had low resilience, predicting increased pre-transplant death/delisting. RISC-10 did not correlate with PACT or SIPAT; resilience may represent a novel risk factor.

COVID-19 and lung transplant patients

COVID-19 is a novel respiratory disease leading to high rates of acute respiratory failure requiring hospital admission. It is unclear if specific patient populations such as lung transplant patients are at higher risk for COVID-19. Some reports suggest that transplant patients may not be at higher risk if proper social distancing and preventive measures are employed. Efforts to ensure the safety of wait-listed patients, transplant recipients, and healthcare workers are underway. Recommendations for the care of lung transplant patients during the COVID-19 pandemic are discussed and will likely change as the pandemic evolves.

Perspectives on donor lung allocation from both sides of the Atlantic: The United States

Donor lung allocation in the United States focuses on decreasing waitlist mortality and improving recipient outcomes. The implementation of allocation policy to match deceased donor lungs to waitlisted patients occurs through a unique partnership between government and private organizations, namely the Organ Procurement and Transplantation Network under the Department of Health and Human Services and the United Network for Organ Sharing. In 2005, the donor lung allocation algorithm shifted toward the prioritization of medical urgency of waitlisted patients instead of time accrued on the waitlist. This led to the Lung Allocation Score, which weighs over a dozen clinical variables to predict a 1-year estimate of survival benefit, and is used to prioritize waitlisted patients. In 2017, the use of local allocation boundaries was eliminated in favor of a 250 nautical mile radius from the donor hospital as the first unit of distance used in allocation. The next upcoming iteration of donor allocation policy is expected to use a continuous distribution algorithm where all geographic boundaries are eliminated. There are additional opportunities to improve donor lung allocation, such as for patients with high antibody titers with access to a limited number of donors.

A single-institution study of concordance of pathological diagnoses for interstitial lung diseases between pre-transplantation surgical lung biopsies and lung explants

BACKGROUND

By comparing diagnoses made by pre-transplant surgical lung biopsy (SLB) and the final pathologic diagnosis of the explanted pathology (EP), we aimed to study the factors that could impact pathologic diagnoses in patients with interstitial lung disease (ILD).

METHODS

We retrospectively reviewed the lung transplant database at Cleveland Clinic [01/01/2006-12/31/2013] to include all lung transplant recipients with a prior diagnosis of ILD. Two pulmonary pathologists independently reviewed each SLB and lung explant. The diagnoses were labeled as concordant (same diagnosis on SLB and explant) or discordant (diagnosis on SLB and explant were different) by consensus.

RESULTS

Of 389 patients transplanted for ILD, 217 had an SLB before transplant. Pathological diagnoses were concordant in 190 patients (87.6%) [165 UIP (86.8%), 13 NSIP (6.8%), 8 CHP (4.2%) and 4 other diagnoses (2.1%). In 27 cases (12.4%), the diagnosis on SLB differed from EP. 8/27 were diagnosed with UIP on SLB and of these, 5 were re-classified as NSIP. 14/19 (73.7%) patients with a SLB diagnosis "other than UIP" were re-categorized as UIP based on explant. Discordant cases had a greater time between SLB and EP than concordant cases (1553 days vs 1248 days).

CONCLUSIONS

The pathologic diagnosis of ILD by SLB prior to lung transplant is accurate in most patients, but may be misleading in a small subset of patients. The majority of discordant cases that were reclassified as UIP could be due to a sampling error, or perhaps, an increased time from the date of the SLB to transplant. Future studies examining how multidisciplinary consensus diagnosis affects this discordance are necessary.

Human leukocyte antigens antibodies after lung transplantation: Primary results of the HALT study

Donor-specific antibodies (DSA) to mismatched human leukocyte antigens (HLA) are associated with worse outcomes after lung transplantation. To determine the incidence and characteristics of DSA early after lung transplantation, we conducted a prospective multicenter observational study that used standardized treatment and testing protocols. Among 119 transplant recipients, 43 (36%) developed DSA: 6 (14%) developed DSA only to class I HLA, 23 (53%) developed DSA only to class II HLA, and 14 (33%) developed DSA to both class I and class II HLA. The median DSA mean fluorescence intensity (MFI) was 3197. We identified a significant association between the Lung Allocation Score and the development of DSA (HR = 1.02, 95% CI: 1.001-1.03, P = .047) and a significant association between DSA with an MFI ≥ 3000 and acute cellular rejection (ACR) grade ≥ A2 (HR = 2.11, 95% CI: 1.04-4.27, P = .039). However, we did not detect an association between DSA and survival. We conclude that DSA occur frequently early after lung transplantation, and most target class II HLA. DSA with an MFI ≥ 3000 have a significant association with ACR. Extended follow-up is necessary to determine the impact of DSA on other important outcomes.

Lung transplant: Candidates for referral and the waiting list

For patients with end-stage lung diseases, lung transplant may significantly extend survival and improve quality of life. Identifying patients that are likely to benefit from a lung transplant is essential to positive outcomes and to maximizing life expectancy for each patient. Prompt referral to and communication with an experienced lung transplant center allows for timely completion of the formal evaluation of candidacy and placement on the organ transplant waiting list. This article summarizes the selection criteria for lung transplant candidates, including when physicians should refer patients to transplant centers for evaluation and placement on the lung transplant waiting list.

Increased Intraoperative Fluid Administration Is Associated with Severe Primary Graft Dysfunction After Lung Transplantation

BACKGROUND

Severe primary graft dysfunction (PGD) is a major cause of early morbidity and mortality in patients after lung transplantation. The etiology and pathophysiology of PGD is not fully characterized and whether intraoperative fluid administration increases the risk for PGD remains unclear from previous studies. Therefore, we tested the hypothesis that increased total intraoperative fluid volume during lung transplantation is associated with the development of grade-3 PGD.

METHODS

This retrospective cohort analysis included patients who had lung transplantation at the Cleveland Clinic between January 2009 and June 2013. We used multivariable logistic regression with adjustment for donor, recipient, and perioperative confounding factors to examine the association between total intraoperative fluid administration and development of grade-3 PGD in the initial 72 postoperative hours. Secondary outcomes included time to initial extubation and intensive care unit length of stay.

RESULTS

Grade-3 PGD occurred in 123 of 494 patients (25%) who had lung transplantation. Patients with grade-3 PGD received a larger volume of intraoperative fluid (median 5.0 [3.8, 7.5] L) than those without grade-3 PGD (3.9 [2.8, 5.2] L). Each intraoperative liter of fluid increased the odds of grade-3 PGD by approximately 22% (adjusted odds ratio, 1.22; 95% confidence interval [CI], 1.12-1.34; P <0.001). The volume of transfused red blood cell concentrate was associated with grade-3 PGD (1.1 [0.0, 1.8] L for PGD-3 vs 0.4 [0.0, 1.1 for nongrade-3 PGD] L; adjusted odds ratio, 1.7; 95% CI, 1.08-2.7; P = 0.002). Increased fluid administration was associated with longer intensive care unit stay (adjusted hazard ratio, 0.92; 97.5% CI, 0.88-0.97; P < 0.001) but not with time to initial tracheal extubation (hazard ratio, 0.97; 97.5% CI, 0.93-1.02; P = 0.17).

CONCLUSIONS

Increased intraoperative fluid volume is associated with the most severe form of PGD after lung transplant surgery. Limiting fluid administration may reduce the risk for development of grade-3 PGD and thus improve early postoperative morbidity and mortality after lung transplantation.

Acanthosis Nigricans following Single Lung Transplantation: A Case Report

Acanthosis nigricans was observed 3 months after single lung transplantation in a 51-year-old African American woman with idiopathic pulmonary fibrosis. The patient had no endocrinological abnormalities and was not taking any medications known to cause acanthosis nigricans; extensive investigation did not reveal an underlying malignant process. Because acanthosis nigricans may occur as a paraneoplastic phenomenon, it is important to rule out an underlying malignancy. This is especially important in solid-organ transplant recipients receiving chronic immunosuppressive therapy.

Endobronchial ultrasonography-guided transbronchial needle aspiration, an effective modality for sampling targeted thoracic lesions in adult lung transplant recipients

INTRODUCTION

Lung transplantation (LTx) is performed for end-stage lung diseases that would be otherwise fatal. Pulmonary allograft recipients are a unique patient population as they are at high risk for malignancy and infectious complications due to the need for immunosuppression. Endobronchial ultrasonography (EBUS)-guided fine-needle aspiration (FNA) is a minimally invasive technique for evaluating abnormalities of the mediastinum/lungs. To our knowledge, this report is the first in the literature addressing targeted EBUS-FNA biopsies in patients who have undergone LTx.

MATERIAL AND METHODS

During 5 years from May 1, 2009 to May 1, 2014, 582 patients underwent LTx at the Cleveland Clinic. A review of records indicated that 14 of these patients later underwent EBUS-FNA. Demographic and diagnostic parameters were recorded.

RESULTS

A total of 14 patients (mean age 64 years) underwent EBUS-FNA after LTx. The mean interval between LTx and EBUS-FNA was 15 months. EBUS-FNA yielded cytologic material diagnostic of malignancy in 10 patients (71%) with one-half of those cases being squamous carcinomas.

CONCLUSIONS

EBUS-FNA is a useful diagnostic modality in lung allograft recipients and is of value in confirming and staging thoracic malignancies in this population. Carcinoma subtyping is feasible by EBUS-FNA, and performance of ancillary studies to confirm clonality in post-transplant lymphoproliferative disorders is possible.

Too high for transplantation? Single-center analysis of the lung allocation score

BACKGROUND

Recent studies using United Network for Organ Sharing data suggest that lung transplantation in patients with high lung allocation scores (LAS) may lead to organ and resource wastage. Therefore, to determine whether a LAS cutoff value should be considered, we evaluated the relation of LAS to waitlist and posttransplant mortality in our center to determine if it could identify patients for whom listing for transplantation may be futile.

METHODS

From May 1, 2005 to July 1, 2010, 537 adults were listed and 426 underwent primary lung transplantation at our institution. Endpoints were mortality before and after lung transplantation. The relationships of LAS at listing to waitlist mortality and of pretransplant LAS to posttransplant mortality were both analyzed by multiphase hazard function methodology.

RESULTS

Higher LAS was strongly associated with waitlist mortality (p<0.0001), with the highest quartile (LAS ranging from 47 to 95) experiencing 75% mortality within a year of listing. Although early (p=0.05), but not late (p=0.4), posttransplant survival was associated with higher LAS at transplantation, once other clinical characteristics predictive of early mortality were accounted for, neither waitlist nor pretransplant LAS was independently related to posttransplant mortality (p=0.12).

CONCLUSIONS

Higher LAS strongly predicts higher mortality on the lung transplantation waitlist, underscoring the value of LAS in prioritizing patients with the highest scores for transplantation. Early posttransplant mortality is modestly higher with higher pretransplant LAS, but the data of our center do not suggest a value above which transplantation should be denied as futile. This suggests that donor organs and resources are not being wasted.

Comparative study of bronchial artery revascularization in lung transplantation

OBJECTIVE

Restoring dual blood supply to transplanted lungs by bronchial artery revascularization (BAR) remains controversial. We compared outcomes after lung transplantation performed with and without BAR.

METHODS

From December 2007 to July 2010, 283 patients underwent transplantation; 187 were 18 years or older, without previous or concomitant cardiac surgery. Of these patients, 27 underwent BAR in a pilot study to test success, safety, effectiveness, and teachability. A propensity score was generated to match BAR patients and 54 routine non-BAR patients. Follow-up was 1.3 ± 0.68 years.

RESULTS

BAR was angiographically successful in 26 (96%) of 27 patients. BAR and non-BAR patients had similar skin-to-skin time (P = .07) and postoperative hospital stays (P = .2), but more reoperations for bleeding (P = .002). Tracheostomy was performed in 9 (33%) of 27 BAR and 10 (19%) of 54 non-BAR patients (P = .2, log-rank). One BAR (3.7%) and 4 non-BAR (7.4%) patients required extracorporeal membrane oxygenation (P = .7). Airway ischemia was observed in 1 BAR (3.7%) versus 12 non-BAR (22%) patients (P = .03); anastomotic intervention was required in no BAR versus 8 non-BAR (15%) patients (P = .04). Hospital mortality was 1 of 27 versus 2 of 54 (P = .9). BAR patients had lower early biopsy tissue rejection grades (P = .008) and fewer pulmonary (P < .04) and bloodstream (P < .02) infections. Forced 1-second expiratory volume was similar (P > .2); 3 BAR versus 9 non-BAR patients developed bronchiolitis obliterans syndrome (BOS) (P = .14, log-rank). During follow-up, 4 BAR and 8 non-BAR patients died (P = .6, log-rank).

CONCLUSIONS

BAR is safe, with comparable early outcomes. Benefits of BAR include reduced airway ischemia and complications, lower biopsy tissue grades, fewer infections, and delay of BOS. A multicenter study is needed to establish these benefits.

Impact of pulmonary hemodynamics on 6-min walk test in idiopathic pulmonary fibrosis

OBJECTIVES

Pulmonary hypertension (PH) has been associated with decreased functional capacity in patients with advanced idiopathic pulmonary fibrosis (IPF). We aimed to evaluate the true impact of altered pulmonary hemodynamics on functional capacity in a cohort of patients with IPF.

METHODS

Between January 1990 and December 2007, 124 patients [73M/51F; 111 Caucasians] with IPF underwent right heart catheterization and 6-min walk test (6MWT). Pulmonary arterial hypertension (PAH) was defined as mPAP≥25 and pulmonary artery occlusion pressure (PAOP)≤15mmHg, and Pre-PH as mPAP>20 and <25mmHg with PAOP<15mmHg. Demographic, hemodynamic, spirometric, and 6MWT data were collected.

RESULTS

Fifty four (44%) patients had PH. There were no significant differences between the PH and the non-PH groups in measures of pulmonary function other than PaO(2). Patients with PH and PAH had significantly lower 6-min walk distance (6MWD) (p=0.008 and p=0.03 respectively) and distance saturation product (DSP) (p=0.002 and p=0.006 respectively) compared to non-PH patients. Mean pulmonary arterial pressure (mPAP) was the best predictor of 6MWD by multivariate analysis (p=0.0006). Increasing mPAP was associated with a statistically significant decline in 6MWD (p=0.02) and DSP (p=0.01). Patients with 'Pre-PH' had lower 6MWD compared to patients with mPAP≤20mmHg (p=0.07).

CONCLUSIONS

Relative to measures of pulmonary function and hypoxia, altered pulmonary hemodynamics had a greater impact on 6MWD in patients with IPF. Higher mPAP was associated with more significant exercise impairment. Mild abnormalities in pulmonary hemodynamics (so called 'Pre-PH') were associated with reduced 6MWD.

Matching donor to recipient in lung transplantation: How much does size matter?

OBJECTIVE

The impact of size matching between donor and recipient is unclear in lung transplantation. Therefore, we determined the relation of donor lung size to 1) posttransplant survival and 2) pulmonary function as measured by forced expiratory volume in 1 second.

METHODS

From 1990 to 2006, 469 adults underwent lung transplantation with lungs from donors aged 7 to 70 years. Donor and recipient total lung capacities were calculated using established formulae (predicted total lung capacity), and actual recipient lung size was measured in the pulmonary function laboratory. Disparity between donor and recipient lung size was expressed as a ratio of donor predicted total lung capacity to recipient predicted total lung capacity-the predicted total lung capacity ratio-and predicted donor total lung capacity to actual recipient total lung capacity-the actual total lung capacity ratio. Survival was measured by multiphase hazard methodology and repeated measures of National Health and Nutrition Examination Survey-normalized forced expiratory volume in 1 second analyzed by temporal decomposition.

RESULTS

Predicted total lung capacity ratio and actual total lung capacity ratio ranged widely, from 0.55 to 1.59 and 0.52 to 4.20, respectively. Overall survival was unaffected by predicted total lung capacity ratio (P = .3) or actual total lung capacity ratio (P = .5). Patients with emphysema and an actual total lung capacity ratio of 0.67 or less or 1.03 or greater had higher predicted mortality (P = .01). During the first posttransplant year, forced expiratory volume in 1 second increased and then gradually declined. Predicted total lung capacity ratio and actual total lung capacity ratio had a small impact on forced expiratory volume in 1 second, primarily in the late phase after transplant in a disease-specific manner.

CONCLUSION

Size matching between donor and recipient using predicted total lung capacity ratio and actual total lung capacity ratio is an effective technique. Wide discrepancies in lung sizing do not affect overall posttransplant survival or pulmonary function. Therefore, a greater degree of lung size mismatch can likely be accepted, thereby improving patients' odds of undergoing transplantation.

Successful double lung transplantation in 2 patients with severe scoliosis

Recipient scoliosis has been considered a contraindication to lung transplant. We report two cases of patients with severe scoliosis that underwent successful bilateral lung transplant and highlight patient selection, complications and outcomes.

Accuracy of the physical examination in evaluating pleural effusion

A careful physical examination is a valuable and noninvasive means of assessing pleural effusion and should be routinely performed in every patient in whom this condition is suspected. Although physical examination is less accurate than ultrasonography or computed tomography in detecting a pleural effusion, the sensitivity and specificity of the different physical signs of pleural effusion may be comparable to those of conventional chest radiography.

Early experience with lung transplantation using donors after cardiac death

Lung transplantations that utilize donor organs after cardiac death (DCD) can substantially increase the number of available allografts for waiting recipients. Unfortunately, reported clinical outcomes are limited and widespread acceptance is slow. To further examine the potential of this modality, the results of 4 patients transplanted with DCD organs, implementing a protocol of controlled organ retrieval (Maastricht Classification III), were reviewed. There were no operative deaths; extracorporeal membrane oxygenation was required in 1 patient secondary to severe primary graft dysfunction. Three patients are alive and well at 4, 15 and 21 months; 1 patient died at 34 months with bronchiolitis obliterans syndrome, in part attributable to medication non-compliance.

Spirometry after transplantation: how much better are two lungs than one?

BACKGROUND

The purpose of this study was to determine how much double lung transplantation improves lung function over single lung transplantation and to identify predictors of lung function after transplantation.

METHODS

From February 1990 to November 2005, 463 adults underwent lung transplantation. Among 379 of these patients (82%), 6372 evaluations of postoperative normalized forced expiratory volume in 1 second (FEV(1)) and forced vital capacity (FVC) were analyzed using longitudinal temporal decomposition methods for repeated continuous measurements. We characterized the time course of postoperative spirometry, compared it between double and single lung transplantation, and identified its modulators.

RESULTS

FEV(1) (% of predicted) was only somewhat better after double than single lung transplantation (65%, 58%, and 59% vs 51%, 43%, and 40% at 1, 3, and 5 years, p = 0.03), as was FVC (% of predicted) (67%, 68%, and 66% vs 62%, 56%, and 51%, p < 0.0001). Both FEV1% and FVC% increased sharply to 1 year. For double lung transplantation, these values persisted, with minimal decline to 5 years; but for single lung transplantation, they continuously declined to 5 years. Values for double lung transplantation remained higher than for single lung transplantation at all time points but never approached twice the value. Patients undergoing double lung transplantation for emphysema had the highest postoperative FEV1% and FVC%, but also the lowest values for single lung transplantation; the benefit of double lung transplantation was between these values for other diagnoses.

CONCLUSIONS

Spirometry weakly favors double lung over single lung transplantation. The advantage of spirometry values alone may not justify double lung transplantation.

Decortication after lung transplantation

BACKGROUND

Compromise of a pulmonary allograft by restrictive or infectious pleural-space pathology may be amenable to surgical intervention; however, the role of decortication in this patient population has not yet been substantiated. To address this issue, indications and outcomes of decortication after lung transplantation were examined at our institution.

METHODS

From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%).

RESULTS

Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days.

CONCLUSIONS

Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.

Treating pulmonary arterial hypertension: cautious hope in a deadly disease

Advances have brought cautious hope for patients with this progressive and deadly disease. Intravenous prostanoids are still the most effective long-term medications, but oral options are available for select patients who are closely monitored. General internists and specialists in pulmonary, cardiac, and rheumatic diseases each have their role in managing these patients.

Lung transplantation for idiopathic pulmonary fibrosis

BACKGROUND

Outcomes of lung transplantation for idiopathic pulmonary fibrosis (IPF) are thought to be worse than those for other indications, although the reasons are unknown. In addition, the choice of single versus double lung transplantation is unclear. To guide decision-making, we (1) compared survival of patients receiving transplantation for IPF with survival of patients receiving transplantation for non-IPF diagnoses, (2) identified risk factors for mortality after transplantation for IPF, and (3) ascertained whether double lung transplantation for IPF confers a survival advantage.

METHODS

From February 1990 to November 2005, 469 patients underwent lung transplantation, 82 for IPF. Multiphase hazard modeling was used to identify risk factors, and propensity matching was used to compare survival of IPF and non-IPF patients and to assess the effect of single versus double lung transplantation.

RESULTS

Survival estimates after transplantation for IPF were 95%, 73%, 56%, and 44% at 30 days and 1, 3, and 5 years, somewhat worse than for matched non-IPF patients (p = 0.03). Risk factors for mortality were earlier date of transplantation (p = 0.07), single lung transplantation (p = 0.03), and higher wedge pressure (p = 0.003). Survival for double versus single lung transplantation was 81% versus 67% at 1 year and 55% versus 34% at 5 years; however, among matched non-IPF patients, corresponding survivals were 88% versus 71% at 1 year and 72% versus 48% at 5 years (p = 0.3).

CONCLUSIONS

Survival after lung transplantation for IPF is worse than after other indications for transplantation when multiple clinical variables are accounted for. Survival may be improved by double lung transplant.

Diagnostic strategies for suspected pulmonary arterial hypertension: a primer for the internist

Pulmonary arterial hypertension should be considered in patients who present with nonspecific symptoms such as dyspnea or dizziness after more common causes have been ruled out. Echocardiography can help in the diagnosis: special attention should be given to assess the tricuspid valve and right ventricular function. Before starting treatment, a patient should undergo right heart catheterization to accurately measure the pressures and assess right ventricular function, which help in appropriate selection of therapy.