Extended criteria donor organ use for heart-lung transplantation in the modern era

BACKGROUND

Demand for donor hearts and lungs exceeds their supply. Extended Criteria Donor (ECD) organs are used to help meet this demand, but their impact on heart-lung transplantation outcomes is poorly characterized.

METHODS AND RESULTS

The United Network for Organ Sharing was queried for data on adult heart-lung transplantation recipients (n = 447) from 2005‒2021. Recipients were stratified based on whether they received ECD hearts and/or lungs. Morbidity was analyzed using Kruskal-Wallis, chi-square, and Fisher's exact tests. Mortality was analyzed using Kaplan-Meier estimation, log-rank tests and Cox regression. Sixty-five (14.5%) patients received two ECD organs, 134 (30.0%) received only an ECD lung, and 65 (14.5%) only an ECD heart. Recipients of two ECD organs were older, more likely to have diabetes, and more likely transplanted from 2015‒2021 (p < 0.05). Groups did not differ by pre-transplant diagnosis, intensive care unit disposition, life support use, or hemodynamics. Group five-year survival rates ranged from 54.5% to 63.2% (p = 0.428). Groups did not differ by 30-day mortality, strokes, graft rejection, or hospital length of stay.

CONCLUSIONS

Using ECD hearts and/or lungs for heart-lung transplantation is not associated with increased mortality and is a safe strategy for increasing donor organ supply in this complex patient population.

Current Situation and Prognostic Evolution of Combined Heart-lung Transplantation in a European Union Country

Background

This study aims to evaluate the entire experience in heart-lung transplantation (HLTx) in a country of the European Union with 47 million inhabitants according to the etiologies that motivated the procedure.

Methods

A retrospective study on 1,751 consecutive transplants (HLTx: 78) was performed from 1990 to 2020 in two centers. Overall survival, adjusted for clinical profile and etiological subgroups, was compared. 7 subgroups were considered: 1) Cardiomyopathy with pulmonary hypertension (CM + PH). 2) Eisenmenger syndrome. 3) Congenital heart disease (CHD). 4) Idiopathic pulmonary arterial hypertension (IPAH). 5) Cystic fibrosis. 6) Chronic obstructive pulmonary disease (COPD)/Emphysema. 7) Diffuse interstitial lung disease (ILD).

Results

Early mortality was 44% and that of the rest of the follow-up was 31%. There were differences between HTLx and HTx in survival, also comparing groups with a similar clinical profile with propensity score (p= 0.04). Median survival was low in CM + PH (18 days), ILD (29 days) and CHD (114 days), intermediate in Eisenmenger syndrome (600 days), and longer in IPAH, COPD/Emphysema and cystic fibrosis.

Conclusion

HLTx has a high mortality. The etiological analysis is of the utmost interest to make the most of the organs and improve survival.

[Clinical feature changes of a COVID-19 patient from mild to critical condition and cardiopulmonary pathological results]

Objective: To analyse the clinical history, laboratory tests and pathological data of a patient who suffered from novel coronavirus pneumonia(COVID-19) and provide reference for the clinical treatment of similar cases. Methods: Data of clinical manifestation, laboratory examination, bronchoscopy, echocardiography and cardiopulmonary pathological results were retrospectively reviewed in a case of COVID-19 with rapid exacerbation from mild to critical condition. Results: This patient hospitalized at day 9 post 2019 novel coronavirus(2019-nCoV) infection, experienced progressive deterioration from mild to severe at day 12, severe to critical at day 18 and underwent extracorporeal membrane oxygenation(ECMO) and continuous renal replacement therapy(CRRT) as well as heart lung transplantation during day 28-45 post infection, and died at the second day post heart and lung transplantation. The patient had suffered from hypertension for 8 years. At the early stage of the disease, his symptoms were mild and the inflammatory indices increased and the lymphocyte count decreased continuously. The patient's condition exacerbated rapidly with multi-organ infections, and eventually developed pulmonary hemorrhage and consolidation, pulmonary hypertension, right heart failure, malignant ventricular arrhythmias, liver dysfunction, etc. His clinical manifestations could not be improved despite viral RNAs test results became negative. The patient underwent lung and heart transplantation and finally died of multi organ failure at the second day post lung and heart transplantation. Pathological examination indicated massive mucus, dark red secretions and blood clots in bronchus. The pathological changes were mainly diffused pulmonary hemorrhagic injuries and necrosis, fibrosis, small vessel disease with cardiac edema and lymphocyte infiltration. Conclusions: The clinical course of severe COVID-19 can exacerbate rapidly from mild to critical with lung, liver and heart injuries.

Heart-lung transplantation for idiopathic pulmonary arterial hypertension and giant pulmonary artery aneurysm - case report

Backgound

Idiopathic pulmonary arterial hypertension (IPAH) is a rare condition that requires lung transplantation in patients’ refractory to medical therapy. Pulmonary artery aneurysm (PAA) is a documented complication of IPAH however, optimal management and timing of intervention for this rare entity is not well understood.

Case report

We report a case of a 51-year-old female who underwent heart-lung transplantation for IPAH and giant PAA. The extreme size of the PAA and underlying pathology encountered in this case precluded both lung transplantation and conventional aneurysm repair.

Conclusion

This case demonstrates that heart-lung transplantation is a good surgical option for IPAH complicated by giant sized PAA and right heart failure.

Idarucizumab in High-risk Thoracic Surgery

Direct oral anticoagulants have suggested a favorable profile compared with vitamin K antagonists. However, the lack of treatment to reverse the effect of direct oral anticoagulants has limited its use in some patients who require rapid reversal of anticoagulation, as those included in the transplant waiting list. Idarucizumab is a recently approved drug to reverse the anticoagulant effect of dabigatran. However, the clinical experience when using this drug is scarce. Herein, we present a clinical case on anticoagulation reversal with idarucizumab to perform heart and lung transplantation in a patient with Eisenmenger syndrome.

Overview of Lung Transplantation, Heart-Lung Transplantation, Liver-Lung Transplantation, and Combined Hematopoietic Stem Cell Transplantation and Lung Transplantation

Lung transplantation (LTx) has evolved to represent the therapy of choice for many patients with end-stage lung diseases. Appropriate candidate selection for LTx is an important determinant of a positive outcome from transplantation. Posttransplantation survival has steadily improved, but long-term survival continues to be a challenge with a median survival of 5.8 years. Similarly, combined heart-lung transplantation and simultaneous liver-lung transplantation has been performed successfully in select patients who are not expected to survive either organ transplant alone. Moreover, LTx has been performed in patients who develop end-stage pulmonary complications following hematopoietic stem cell transplantation.

Clinical Outcomes of Heart-Lung Transplantation: Review of 10 Single-Center Consecutive Patients

BACKGROUND

Heart-lung transplantation (HLT) has provided hope to patients with end-stage lung disease and irreversible heart dysfunction. We reviewed the clinical outcomes of 10 patients who underwent heart-lung transplantation at Asan Medical Center.

METHODS

Between July 2010 and August 2014, a total of 11 patients underwent HLT at Asan Medical Center. After excluding one patient who underwent concomitant liver transplantation, 10 patients were enrolled in our study. We reviewed the demographics of the donors and the recipients' baseline information, survival rate, cause of death, and postoperative complications. All patients underwent follow-up, with a mean duration of 26.1±16.7 months.

RESULTS

Early death occurred in two patients (20%) due to septic shock. Late death occurred in three patients (38%) due to bronchiolitis obliterans (n=2) and septic shock (n=1), although these patients survived for 22, 28, and 42 months, respectively. The actuarial survival rates at one year, two years, and three years after HLT were 80%, 67%, and 53%, respectively.

CONCLUSION

HLT is a procedure that is rarely performed in Korea, even in medical centers with large heart and lung transplant programs. In order to achieve acceptable clinical outcomes, it is critical to carefully choose the donor and the recipient and to be certain that all aspects of the transplant procedure are planned in advance with the greatest care.

[The place of extra-corporeal oxygenation in pulmonary diseases]

Extra-corporeal membrane oxygenation (ECMO) effectively replaces the lung in providing oxygenation and carbon dioxide (CO2) removal. For some years, and in parallel to the H1N1 influenza pandemic, this technique has gained interest in relation to significant technological improvements, leading to new concepts of "awake and mobile ECMO" or rehabilitation with ECMO. Finally, the publication of randomized controlled trials giving encouraging results in the adult respiratory distress syndrome (ARDS) has helped to validate this technique and further studies are warranted. This general review aims to outline the definition, classification and principles of ECMO and to give some current information about the indications and possibilities of the technique to the pulmonologist and intensivist. Further possible uses for this technique include extra-corporeal removal of CO2 during hypercapnic respiratory failure and assistance during lung transplantation from the preoperative to the early postoperative period.

Heart-lung transplantation: adult indications and outcomes

Combined heart-lung transplantation remains the only definitive therapy for patients who have both end-stage heart failure and end-stage lung failure. The most common indication is congenital heart disease (CHD) and the proportion is increasing for acquired heart disease concomitant with pulmonary hypertension and/or intrinsic lung diseases. Previously, idiopathic pulmonary hypertension was the most common indication. However, it has been shown that right ventricular failure can be reversed after double lung transplantation. Therefore, patients with idiopathic pulmonary arterial hypertension (IPAH) should not undergo combined heart-lung transplantation unless left ventricular dysfunction co-exists. The ISHLT registry data shows survival after heart-lung transplantation is improving, but still its survival rates are 71% at 3 months, 63% at 1 year, 44% at 5 years and 31% at 10 years. With appropriate patient selection and surgical expertise, these outcomes should improve further.

Anesthesia for non-pulmonary surgical intervention following lung transplantation: two cases report

The survival rate after lung transplantation has increased in recent years, leading to an increase in non-pulmonary conditions that require surgical intervention. These post-transplant surgical procedures, however, are associated with high mortality and morbidity rates. Intra-abdominal conditions are the most common reasons for surgical intervention. We describe here two patients who underwent abdominal surgery under general anesthesia following lung transplantation. One patient underwent cholecystectomy due to cholecystitis after heart-lung transplantation, and the other patient had an exploratory laparotomy for duodenal ulcer perforation after double lung transplantation. Depending on the type of transplant intervention, the physiology of the transplanted lung must be considered for general anesthesia. Knowledge of underlying conditions and immunosuppressive therapy following transplantation are important for safe and effective general anesthesia.

Lung transplantation: an overview of candidacy and outcomes

BACKGROUND

Various factors must be taken into account when considering lung transplantation, including candidacy, contraindications, and outcomes.

METHODS

This article presents a review of the data and literature on lung transplantation, tracking the evolution of the treatment as it applies to different conditions, as well as an examination of patient survival rates in relation to pathology and treatment.

RESULTS

Timely referral and careful selection of candidates for lung transplantation maximize the outcomes of the procedure, resulting in a longer lifespan with improved physical health for patients.

CONCLUSION

Lung transplantation is a therapeutic option for patients with various lung diseases. Adapting treatment options and follow-up treatment to the individual patient's lifestyle and pathology optimizes patient survival rates after transplantation.

Subclinical peritonitis due to perforated sigmoid diverticulitis 14 years after heart-lung transplantation

Acute complicated diverticulitis, particularly with colon perforation, is a rare but serious condition in transplant recipients with high morbidity and mortality. Neither acute diverticulitis nor colon perforation has been reported in young heart-lung grafted patients. A case of subclinical peritonitis due to perforated acute sigmoid diverticulitis 14 years after heart-lung transplantation is reported. A 26-year-old woman, who received heart-lung transplantation 14 years ago, presented with vague abdominal pain. Physical examination was normal. Blood tests revealed leukocytosis. Abdominal X-ray showed air-fluid levels while CT demonstrated peritonitis due to perforated sigmoid diverticulitis. Sigmoidectomy and end-colostomy (Hartmann’s procedure) were performed. Histopathology confirmed perforated acute sigmoid diverticulitis. The patient was discharged on the 8th postoperative day after an uneventful postoperative course. This is the first report of acute diverticulitis resulting in colon perforation in a young heart-lung transplanted patient. Clinical presentation, even in peritonitis, may be atypical due to the masking effects of immunosuppression. A high index of suspicion, urgent aggressive diagnostic investigation of even vague abdominal symptoms, adjustment of immunosuppression, broad-spectrum antibiotics, and immediate surgical treatment are critical. Moreover, strategies to reduce the risk of this complication should be implemented. Pretransplantation colon screening, prophylactic pretransplantation sigmoid resection in patients with diverticulosis, and elective surgical intervention in patients with nonoperatively treated acute diverticulitis after transplantation deserve consideration and further studies.