Single Lung Transplant Remains a Viable Option for Patients With Severe Secondary Pulmonary Hypertension.

BACKGROUND: Although double lung transplant is recommended in patients with severe secondary pulmonary hypertension (SPH), our institutional experiences suggest a role for single lung transplant in these patients. Here, we review our experience prioritizing single lung transplant in patients with SPH to minimize their surgical burden. METHODS: We conducted a retrospective review of our lung transplant database to identify patients with SPH who underwent single lung transplant. Patients were stratified as either mild SPH (mean pulmonary artery pressure 25-40 mm Hg) or severe SPH (mean pulmonary artery pressure >40 mm Hg). Singe lung recipients without PH transplanted over the same time were also examined. RESULTS: Between January 2017 and December 2019, 318 patients underwent single lung transplantation; 217 had mild SPH (68%), and 59 had severe SPH (18.5%). Forty-two patients without PH underwent single lung transplant. When the groups were compared, significantly higher pulmonary vascular resistance was noted in the severe SPH group, and obesity was noted in both the mild and severe SPH groups. Although the severe SPH group required more intraoperative cardiopulmonary support (37.3% versus 10.3% versus 4.7%, P < 0.05), there were no significant differences in most major postoperative parameters, including the duration of postoperative mechanical ventilation or the incidence of severe primary graft dysfunction. Survival 1 y posttransplant was not significantly different among the groups (93.2% versus 89.4% versus 92.9%, P = 0.58). CONCLUSIONS: Our experience supports the option of single lung transplantation with appropriate intraoperative mechanical circulatory support in patients with SPH. This strategy is worth pursuing, especially with ongoing donor lung shortages.

Early and late results of mitral valve repair with anterior leaflet patch augmentation.

OBJECTIVES: The aim of this study was to determine the long-term results of mitral valve (MV) repair with anterior leaflet patch augmentation. METHODS: Between 2012 and 2015, 45 patients underwent MV repair using the anterior leaflet patch augmentation technique at our institution. The mean age of the patients was 65.9 ± 13.0 years (16 males). We reviewed the MV pathology and the surgical techniques used and assessed the early and late results. RESULTS: In terms of MV pathology, 43 patients (95.6%) had pure mitral regurgitation (MR) and 2 patients (4.4%) had mixed mitral stenosis and MR. Rheumatic changes were seen in 18 patients (40.0%). Postoperative echocardiography showed that 95.6% of patients had none to mild MR. During a median follow-up period of 5.5 years (range 0.1-8.3 years), there were 8 late deaths. Nine patients (20%) required reoperation. The mean interval between the initial operation and redo operation was 3.7 ± 3.1 years (range: 0.4-7.8 years). The causes of reoperation included patch dehiscence (n = 4), progression of mitral stenosis (n = 2), band dehiscence (n = 1), patch enlargement (n = 1) and unknown (n = 1). Eight patients underwent MV replacement and 1 underwent repeat MV repair. The freedom from reoperation at 3 and 5 years was 85.7 ± 6.7% and 81.2 ± 7.7%, respectively. CONCLUSIONS: Anterior leaflet patch augmentation can provide excellent early results in the majority of the patients even in the presence of rheumatic pathology; however, we observed late reoperation in 20% of patients. Thus, this technique should be used with caution and careful follow-up with serial echocardiography is essential.

Postoperative Bronchial Complications After Lung Transplantation Related to Anastomosis Suture.

BACKGROUND: Postoperative bronchial anastomotic complications are not uncommon in lung transplant recipients. We investigated 2 surgical techniques (continuous and interrupted sutures) during bronchial anastomosis, comparing survival and postoperative bronchial complications. METHODS: We retrospectively analyzed 421 patients who were transplanted in our center (February 2012 to March 2018). Patients were divided according to bronchial anastomotic technique (continuous or interrupted). Demographics and clinical parameters were compared for significance (P < .05). Comparison of postoperative morbidity included bronchial complications, venovenous extracorporeal membrane oxygenation support, and intervention requirements. Survival was assessed using Kaplan-Meier curve and log-rank tests (P < .05). RESULTS: Of the 421 patients, 290 underwent bronchial anastomoses with continuous suture; 44 of these patients had postoperative bronchial complications (15.2%). Contrarily, 131 patients underwent the interrupted suture technique; 9 patients in this group had postoperative bronchial complications (6.9%). Demographics and clinical parameters included age, sex, ethnicity, etiology, lung allocation score, body mass index, donor age, lung transplant type, cardiopulmonary bypass usage, surgical approaches, and median length of stay. Postoperative complications (continuous vs interrupted) were bronchial complications (P = .017), venovenous extracorporeal membrane oxygenation support (P = .41), venoarterial extracorporeal membrane oxygenation support (P = .38), and complications requiring dilatation with stent placement (P = .09). Kaplan-Meier curve showed better survival in the interrupted group (P = .0002). CONCLUSIONS: Our study demonstrated the comparable postoperative results between the continuous and interrupted technique.

Pulmonary endarterectomy.

Chronic thromboembolic pulmonary hypertension is an underdiagnosed condition. Patients typically present with the symptoms of right heart failure. Diagnosis is usually done by radionuclide ventilation/perfusion (VQ) scan, high-quality multidetector computed tomography (CT) or pulmonary angiography at expert centers. Pulmonary endarterectomy remains the corner stone in management of chronic thromboembolic pulmonary hypertension. Deep hypothermic circulatory arrest is commonly used for the operation at most centers. In-hospital mortality ranges from 1.7 to 14.2%. Pulmonary hemorrhage, reperfusion lung injury, and right ventricular failure remain major early post-operative concerns. Five-year survival is reported to be 76 to 89%. Long-term outcome depends on residual pulmonary hypertension. Balloon pulmonary angioplasty and medical management play an adjunctive role. Here, we provide a comprehensive review on surgical management of chronic thromboembolic pulmonary hypertension.

Comparing outcomes in patients with end-stage chronic obstructive pulmonary disease: single versus bilateral lung transplants.

OBJECTIVES: Debate continues on whether a bilateral (BLT) or a single lung transplantation (SLT) is preferred for patients with end-stage chronic obstructive pulmonary disease (COPD). The purpose of this study is to examine the interplay between patient age and transplant type on survival outcomes. METHODS: We performed a retrospective study of lung transplants for COPD at our centre from February 2012 to March 2020 (n = 186). Demographics and clinical parameters were compared between patients based on their age (≤65 vs >65 years old) and type of transplant (single vs bilateral). Cox proportional hazards regression was also performed. P-values <0.05 were considered significant. RESULTS: Of the 186 patients with COPD who received lung transplants, 71 (38.2%) received BLTs and 115 (61.8%) received SLTs. There was no significant difference in survival outcomes when looking at patients with single versus BLTs (P = 0.870). There was also no difference in survival between the 2 age groups ≤65 versus > 65 years (P = 0.723). The Cox model itself also did not show a statistically significant improvement in survival outcomes (P = 0.126). CONCLUSIONS: Lung transplant outcomes in patients with end-stage COPD demonstrated non-inferior results in patients with an SLT compared to patients with a BLT. When we compared the age groups, neither transplant type showed superior survival benefits, suggesting there may be some utility in an SLT in younger recipients.

Determination of cardiovascular dysfunction before initiation of extracorporeal membrane oxygenation in septic shock.

Extracorporeal membrane oxygenation (ECMO) is being increasingly used in patients having sepsis-induced cardiovascular dysfunction. We report successful use of venovenous ECMO in septic shock secondary to pneumonia in the presence of severe left ventricular dysfunction. We also discuss the quantitative evaluation of cardiovascular dysfunction, which provides important input in choosing the type of ECMO in septic shock. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-020-01119-4.

Veno-arterial extracorporeal membrane oxygenationas a bridge to cytolytic therapy.

We describe a case of successful use of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), as a bridge to cytoreductive therapy, in a patient with large mediastinal mass due to T cell lymphoblastic leukemia, complicated by acute cardiorespiratory compromise from mechanical compression and pulmonary embolism.

Serum dilutions as a predictive biomarker for peri-operative desensitization: An exploratory approach to transplanting sensitized heart candidates.

Antibody-mediated rejection (AMR) of cardiac allografts mediated by anti-HLA Donor Specific Antibodies (DSA) is one of the major barriers to successful transplantation for the treatment of end-stage heart failure. Therapeutic plasma exchange (TPE) is a first-line treatment for pre-transplant desensitization. However, indications for treatment regimens and treatment end-points have not been well established. In this study, we investigated how sera dilutions could guide TPE regimens for effective peri-operative desensitization and early AMR treatment. Our data show that 1:16 dilutions of EDTA-treated sera and 1.5 volume TPE reduce anti-HLA class I and class II antibody levels in the same manner and, therefore, allows to predict which antibodies would respond to peri-operative TPE. We successfully applied this approach to transplanting three highly sensitized cardiac recipients (CPRA 85-93%) with peri-operative desensitization based on a virtual crossmatch performed on 1:16 diluted serum. Furthermore, we have used sera dilutions to guide DSA treatment post-transplant. Although these findings have to be confirmed in a larger prospective study, our data suggest that serum dilutions can serve as a predictive biomarker to guide peri-operative desensitization and post-transplant immunologic management.

Prior and Perioperative Revascularization Does Not Affect Survival in Lung Transplant Patients.

BACKGROUND: Coronary artery disease is common in lung transplant patients and has historically been viewed as a contraindication to the procedure. Although this mindset is changing, the effect of prior or perioperative revascularization on lung transplant survival outcomes is not adequately established. METHODS: We performed a single-center retrospective analysis of all single and double lung transplant patients from 2012 to 2018 (n = 468). Patients were split into 4 groups: (1) patients who received a preoperative percutaneous coronary intervention (n = 34), (2) those who received coronary artery bypass grafting (CABG) before transplantation (n = 25), (3) those that received concomitant CABG during transplantation (n = 29), and (4) those who had lung transplantation with no need for revascularization (n = 380). Groups were compared for demographics, surgical procedure, and survival outcomes. RESULTS: The no-revascularization group was statistically younger than the rest (P = .001). The lung allocation score trended toward being higher in the concomitant coronary artery bypass group (P = .03). All groups were predominantly diagnosed with idiopathic pulmonary fibrosis. The proportion of patients with chronic obstructive pulmonary disease was greatest in the group not requiring revascularization (P = .001). Patients with previous CABG were more likely to receive a single lung transplant than a double one (21 versus 4; P = .054). Length of stay, posttransplant survival, and postoperative adverse events were similar among all groups. CONCLUSIONS: Results suggest that preoperative or intraoperative revascularization does not negatively affect survival in lung transplant patients; lung recipients with coronary artery disease have comparable survival when adequately revascularized.

Impact of extracorporeal membrane oxygenation or mechanical ventilation as bridge to combined heart-lung transplantation on short-term and long-term survival.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) and mechanical ventilation (MV) can be used as a bridge to heart-lung transplantation (HLT). The goal of this study was to determine if pretransplantation ECMO or MV affects survival in HLT. METHODS: The United Network for Organ Sharing database was reviewed for all adult patients receiving HLT from 1995 to 2011. The primary outcome measured was risk-adjusted all cause mortality. RESULTS: There were 542 adult patients received HLT during the study period. Of these, 15 (2.8%) required ECMO and 22 (4.1%) required MV as a bridge to transplantation. The groups were evenly matched with regards to recipient age, recipient gender, ischemic time, donor age, and donor gender. The ECMO cohort had worse survival than the control group at 30 days (20.0% vs. 83.5%) and 5 years (20.0% vs. 47.4%; P<0.001). When compared with control, patients requiring MV had worse survival at 1 month (77.3% vs. 83.5%) and 5 years (26.5% vs. 47.4%; P<0.001). The use of ECMO (hazard ratio [HR]=3.820, 95% confidence interval [CI]=1.600-9.116; P=0.003) or MV (HR=2.011, 95% CI=1.069-3.784; P=0.030) as a bridge to transplantation was independently associated with mortality on multivariate analysis. Recipient female gender was associated with survival (HR=0.754, 95% CI=0.570-0.998; P=0.048). CONCLUSIONS: HLT recipients bridged by MV or ECMO have increased short-term and long-term mortality. Further studies are needed to optimize survival in these high-risk patients.

Surgical management of tricuspid valve endocarditis in systemically infected patients.

BACKGROUND AND AIM OF THE STUDY: Isolated bacterial tricuspid valve (TV) endocarditis is usually managed medically. Whilst the indications and optimal timing for surgical treatment of the condition have not been clearly defined, it is hypothesized that early surgery in patients who are bacteremic and/or have evidence of systemic seeding is superior to medical treatment. METHODS: All cases of isolated TV endocarditis reported between 2006 and 2011 at the authors' institution were reviewed. Patients with bacteremia and/or systemic seeding who were treated surgically after short-term medical therapy were compared to an equivalent group of patients who remained under long-term medical treatment only. RESULTS: A total of 45 patients with isolated TV endocarditis showed evidence of bacteremia and/or systemic seeding. Of these patients, 10 (22.2%) were treated surgically with valve repair or replacement, and 35 (77.8%) received long-term medical therapy only. The 30-day and one-year survival rates in both groups were comparable (100% versus 88.6%, p = 0.27). Patients treated surgically had clear blood cultures sooner (2.0 versus 6.7 days, p = 0.04), defervesced earlier (0 versus 9.0 days, p = 0.02), and demonstrated a complete resolution of TV vegetations (100% versus 30.0%, p = 0.003). Change in creatinine clearance (+22.1 versus +11.6 ml/min, p = 0.40) and durations of vasopressor support (6.8 versus 8.9 h, p = 0.86), mechanical ventilation (8.5 versus 32.2 h, p = 0.44), ICU stay (148.1 versus 53.8 h, p = 0.14) and total hospital stay (32.1 versus 24.6 days, p = 0.22) were not different between groups. Long-term echocardiogram surveillance demonstrated a higher prevalence of moderate-severe tricuspid regurgitation in the medically treated patients (75.0 versus 0.0%, p < 0.001). None of the patients treated surgically was readmitted with prosthetic valve endocarditis. CONCLUSION: Early surgery is warranted in patients with isolated TV endocarditis who are bacteremic and/or systemically infected despite optimal medical therapy.

Single-lung transplantation can be performed with acceptable outcomes using selected donors with heavy smoking history.

BACKGROUND: We attempt to determine if adult, single-lung transplantation could be performed with acceptable results in heavy-smoking donors (HSDs; > 20 pack-years). METHODS: The United Network of Organ Sharing database was examined for adult single-lung transplantation from 2005 to 2011. RESULTS: Of the 3,704 single-lung transplantations, 498 (13.4%) were from HSDs. The 2 groups were similar in recipient age (60.6 vs. 60.7 years, p = 0.20), male gender (61.3% vs. 59.8%, p = 0.54), ischemic time (4.1 vs. 4.2 hours, p = 0.11), and pre-transplant forced expiratory volume in 1 second (FEV1; 41.1% vs. 40.0% predicted). Recipients of HSDs had lower lung allocation score (39.7 vs. 38.0, p = 0.02), less human leukocyte antigen mismatches (4.6 vs. 4.5, p = 0.01), and higher class I panel reactive antibody (2.9% vs. 3.8%, p < 0.001). HSDs were older (33.0 vs. 41.3 years, p < 0.001) and less likely male (62.5 vs. 56.0%, p = 0.01). Recipients with HSDs had longer length of stay (20.5 vs. 23.0 days, p < 0.001) and lower peak FEV1 after single-lung transplantation (80.1% vs. 73.4%, p < 0.001). Freedom from bronchiolitis obliterans syndrome (p = 0.64), post-single-lung transplantation decrement in FEV1 (p = 0.07), and median survival (1,516 vs. 1,488 days, p = 0.10) were similar. Multivariable analysis found receiving lungs from actively smoking HSDs was associated with mortality (hazard ratio [HR], 1.23, 95% confidence interval [CI], 1.05-1.45; p = 0.01). Use of HSDs who were not actively smoking was not associated with mortality (HR, 0.84; 95% CI, 0.59-1.19; p = 0.33). Mortality was associated with recipient age, longer ischemic time, race mismatch, class I panel reactive antibody > 10%, mechanical ventilation, and extracorporeal membrane oxygenation as a bridge to transplantation. CONCLUSIONS: Although single-lung transplantation with actively smoking HSDs results in worse results, outcomes are acceptable and should continue to be considered.

Double-lung transplantation can be safely performed using donors with heavy smoking history.

BACKGROUND: Lung transplantation using grafts from donors with a history of heavy smoking (>20 pack-years) is thought to confer worse prognosis. We attempt to determine if adult, double-lung transplantation can be safely performed with lungs from heavy-smoking donors (HSD). METHODS: The United Network for Organ Sharing (UNOS) database was examined for adult, double-lung transplants from 2005 to 2011. RESULTS: Of 5,900 double-lung transplants, 766 (13.0%) were from HSDs. The two groups were similar in recipient age (49.8 vs 50.5 years, p = 0.15), male sex (56.9% vs 56.5%, p = 0.87), and lung allocation score (45.8 vs 44.9, p = 0.18). Recipients of lungs from HSDs had lower forced expiratory volume in 1 second (FEV1; 34.3 vs 36.1% predicted, p = 0.04), longer ischemic time (5.75 vs 5.58 hours, p = 0.01), less human leukocyte antigen mismatch (4.51 vs 4.62, p = 0.01), and lower class I plasma reactive antigens (2.64 vs 3.69%, p = 0.001). HSDs were older (40.9 vs 32.6 years, p < 0.001) and less likely male (51.7 vs 59.7%, p < 0.001). Recipients of lungs from HSDs had longer median length of stay (18.0 vs 17.0 days, p < 0.001). Freedom from bronchiolitis obliterans syndrome (p = 0.09), decrement in FEV1 (p = 0.12), peak FEV1 (79.8% vs 79.0%, p = 0.51), and median survival (2,043 vs 1,928 days, p = 0.69) were not different. On multivariate analysis, HSD lungs were not associated with death (hazard ratio, 1.003; 95% confidence interval, 0.867 to 1.161, p = 0.96). Death was associated with donor age, ischemic time, race mismatch, mechanical ventilation, and extracorporeal membranous oxygenation before transplantation. CONCLUSIONS: Double-lung transplantation can be safely performed with lungs from donors with a heavy smoking history.

Cardiac transplantation can be safely performed with low donor-to-recipient body weight ratios.

BACKGROUND: United Network for Organ Sharing adult heart transplant criteria recommend against using same-sex donors with a donor-recipient body weight ratio <0.7. The same criteria recommend against a female donor to male recipient body weight ratio <0.9. We attempted to determine if transplantation with low donor-recipient body weight ratios can be safely performed. METHODS AND RESULTS: Transplants with same-sex donor-recipient body weight ratio <0.7 and female donor-male recipient body weight ratio <0.9 were compared with age- and sex-matched control subjects with ideally matched donor weights. Of the 123 patients undergoing transplantation, 23 met low donor-recipient body weight ratio criteria. This cohort was compared with 22 ideally weight-matched patients. There was no difference in survival at 1, 5, and 10 years (P = .68). Freedom from rejection (52.2 vs 50.0%; P = 1.0), creatinine clearance change (-1.3 vs 5.7 mL/min; P = .88), duration of inotropic support (191.5 vs 208.8 h; P = .65), and duration of mechanical ventilation (156.3 vs 84.5 h; P = .52) were similar. Intensive care (290.5 vs 368.6 h; P = .71) and hospital length of stay (35.4 vs 36.7 d; P = .94) were not different. CONCLUSIONS: Accepted donor-recipient weight match criteria may be extended to increase the donor pool.