Lung Transplantation in Pulmonary Hypertension: A Multidisciplinary Unit's Management Experience.

BACKGROUND: Prognosis assessment of pulmonary hypertension (PH) is multifactorial and placement of patients on the lung transplantation (LT) waiting list requires the weighing of a complex set of criteria. The aim of this retrospective cohort study was to analyze a series of patients treated in our unit at the moment of their inclusion on the LT waiting list and long-term survival after LT. MATERIAL AND METHODS: Baseline characteristics, LT outcomes, and survival were evaluated in all patients diagnosed with pulmonary arterial hypertension (PAH) and pulmonary veno-occlusive disease (PVOD) who were included on the LT waiting list in 2011-2016. RESULTS: Thirty-three patients were listed with a diagnosis of PAH or PVOD. Patients had an average age of 43 ± 12 years and 71% were female. The median time between PAH diagnosis and inclusion on the LT waiting list was 62.5 months (interquartile range [IQR], 6-93.3 months). Twenty-eight patients (84%) underwent double LT. The difference between the waiting time in urgent cases (1.5 months; IQR, 0.4-4.2 months) and in elective cases (7.4 months; IQR, 2.7-16.2 months) was significant (P < .049). The 28 patients with PAH/PVOD in our hospital had a 95% short-term survival after LT both at 1 and at 3 months, without variance between urgent and elective LT. Longer-term survival rate was 84% both at 12 and 36 months. CONCLUSIONS: There is great complexity in determining the appropriate time for transplantation referral and inclusion on the waiting list for patients with PAH/PVOD so that LT can be more realistically incorporated into the treatment algorithm for PAH. LT offers a good short- and long-term survival in patients with PAH/PVOD.

Conducta de los profesionales sanitarios ante las recomendaciones de profilaxis de endocarditis infecciosa en nuestro medio: ¿se siguen las guías? / Behaviour of health professionals concerning the recommendations for prophylaxis for infectious endocarditis in our setting: Are the guidelines followed?

Objetivos. Las pautas de profilaxis de endocarditis infecciosa recomendadas por las guías de práctica clínica han cambiado recientemente. Se desconoce en nuestro medio si se siguen correctamente las pautas actuales. Nuestro objetivo es describir las actitudes de diferentes profesionales sanitarios ante ellas. Material y métodos. Hemos realizado una encuesta en Córdoba, mediante un cuestionario online con 16 ítems sobre este tema. Se seleccionó aleatoriamente una muestra de 180 profesionales (20 cardiólogos, 80 dentistas, 80 médicos de atención primaria), de la cual contestaron 173. Resultados. La mitad eran varones, teniendo más de 20 años de ejercicio profesional el 52%. El 88,3% consideró que la profilaxis de endocarditis es efectiva (cardiólogos, 77,8%, dentistas, 93,7%, p=0,086). En general, se realiza profilaxis en las situaciones de riesgo claramente establecidas (>90% de los encuestados), pero también en una alta proporción de casos sin riesgo de endocarditis, que oscila entre el 30 y el 60% según los procedimientos (más los dentistas, entre el 36 y 67%, seguidos de los médicos de atención primaria, entre el 28 y 59%). Las pautas antibióticas usadas son muy variadas, siendo los médicos de primaria los que se alejan más de lo recomendado (solo un 25,8% usaban la pauta recomendada, frente a un 54,4% de dentistas y un 72,2% de cardiólogos, p=0,002). Conclusiones. El seguimiento de las recomendaciones sobre profilaxis de endocarditis debe mejorarse en nuestro medio, observándose una tendencia, sobre todo en no cardiólogos, a una «sobreindicación» de la misma (AU)

Objectives. The prophylaxis regimens for infectious endocarditis recommended by the clinical practice guidelines have recently changed. We do not know whether the current regimens are correctly followed in our setting. Our objective was to describe the approaches of various health professionals concerning these guidelines. Material and methods. We conducted a survey in Cordoba, using a 16-item online questionnaire on this topic. We randomly selected a sample of 180 practitioners (20 cardiologists, 80 dentists and 80 primary care physicians), of whom 173 responded. Results. Half of the participants were men; 52% had more than 20 years of professional experience. Some 88.3% of the participants considered that prophylaxis of endocarditis is effective (77.8% of the cardiologists, 93.7% of the dentist; p=.086). In general, prophylaxis is performed in conditions of clearly established risk (>90% of those surveyed). However, prophylaxis is also performed in a high proportion of cases with no risk of endocarditis, varying between 30 and 60% according to the procedure (mostly the dentists, between 36 and 67%, followed by the primary care physicians, between 28 and 59%). The antibiotic regimens employed varied significantly. The primary care physicians were furthest from the recommended regimen (only 25.8% used the recommended regimen vs. 54.4% of dentists and 72.2% of cardiologists; p=.002). Conclusions. Compliance with the recommendations on prophylaxis for endocarditis should be improved in our setting. We observed a tendency, especially among noncardiologists, to 'overindicate' the prophylaxis (AU)

Behaviour of health professionals concerning the recommendations for prophylaxis for infectious endocarditis in our setting: Are the guidelines followed? / Conducta de los profesionales sanitarios ante las recomendaciones de profilaxis de endocarditis infecciosa en nuestro medio: ¿se siguen las guías?

OBJECTIVES: The prophylaxis regimens for infectious endocarditis recommended by the clinical practice guidelines have recently changed. We do not know whether the current regimens are correctly followed in our setting. Our objective was to describe the approaches of various health professionals concerning these guidelines. MATERIAL AND METHODS: We conducted a survey in Cordoba, using a 16-item online questionnaire on this topic. We randomly selected a sample of 180 practitioners (20 cardiologists, 80 dentists and 80 primary care physicians), of whom 173 responded. RESULTS: Half of the participants were men; 52% had more than 20 years of professional experience. Some 88.3% of the participants considered that prophylaxis of endocarditis is effective (77.8% of the cardiologists, 93.7% of the dentist; p=.086). In general, prophylaxis is performed in conditions of clearly established risk (>90% of those surveyed). However, prophylaxis is also performed in a high proportion of cases with no risk of endocarditis, varying between 30 and 60% according to the procedure (mostly the dentists, between 36 and 67%, followed by the primary care physicians, between 28 and 59%). The antibiotic regimens employed varied significantly. The primary care physicians were furthest from the recommended regimen (only 25.8% used the recommended regimen vs. 54.4% of dentists and 72.2% of cardiologists; p=.002). CONCLUSIONS: Compliance with the recommendations on prophylaxis for endocarditis should be improved in our setting. We observed a tendency, especially among noncardiologists, to "overindicate" the prophylaxis.

Analysis of patients referred to a lung transplantation unit.

This cross-sectional, concurrent and descriptive study presents the decisions regarding patients referred to our Lung Transplantation Unit (LTxU). Each patient is discussed in a multidisciplinary clinical session (phase I), rejecting some and accepting others for assessment in our LTxU (phase II) according to criteria of the National and International Guidelines for Transplantation. A protocol assessment in phase II, leads to a decision to reject, accept, or follow-up the candidate for LTx. Among 214 evaluation requests received in our unit from May 2008 to December 2011, 37 patients (17%) were rejected based on the information sent to our LTxU. Among the patients evaluated in phase II, 62 (28.9%) were put on the waiting list, 125 (58.4%) were rejected, and twenty-seven (12.6%) were postponed for future reconsideration, results that were similar to those described in the literature. The main disease referred for LTx was obstructive airflow (n = 98; 45.7%), followed by interstitial lung disease (ILD; n = 66; 30.8%), cystic fibrosis or bronchiectasis (n = 20; 9.3%), or primary pulmonary hypertension group 1 (n = 20; 9.3%). Ten patients (4.6%) were diagnosed with other respiratory diseases. Most patients (n = 165; 77.1%) lived in the region of our hospital (Madrid). The main reasons to reject patients for LTx were malnutrition, severe disease in other organs, toxic habits, and refusal of treatment. Finally, one out of four referred patients was accepted for LTx. In addition to serious comorbidities in various organs, a high percentage of patients who were not accepted for LTx because of these factors might have been of accepted had these conditions been corrected before patient referral.

Development of a non-heart-beating donor program and results after the first year.

Our lung transplant unit began activity in October 2008. We have performed 37 lung transplants with a hospital mortality of 2.7% (n = 1). The need for a greater number of donors and the presence of an already existent non-heart-beating donor (NHBD) program for abdominal grafts and tissues encouraged us to consider assessing lung grafts from these donors. It was necessary to develop a new multiorgan preservation methodology, "bithermia preservation." The clinical experience with which during the first year June 2010 to July 2011, including 15 NHBDs is presented herein. The chest x-ray was normal in 6 donors (40%) and 7 had pulmonary infiltrates. Bronchoscopy was normal in 8 donors (53%) but 3 had abundant bleeding airway secretions and signs of bronchoaspiration. Preservation procedures were performed in 6 donors. Pulmonary functional evaluation in 4 donors showed gas measurements to be adequate in 75% of cases. Three double-lung grafts were judged to be valid for implantation, among which we performed 3 lung transplantations, 1 bilateral and 2 unilaterals, while 2 grafts were offered to the National Transplant Organization for other units. No transplant suffered primary graft dysfunction; all 3 showed excellent function allowing early extubation in 2 cases. There was no in-hospital mortality. All 3 patients are alive and leading normal lives; none has bronchiolitis obliterans syndrome. In conclusion, the "bithermia preservation" methodology achieved adequate lung preservation in NHBDs, allowing liver, kidneys, and lungs to be obtained from the same donor.

Complicaciones del tratamiento quirúrgico tras radioterapia y quimioterapia neoadyuvantes en el cáncer no microcítico de pulmón. Análisis de una serie de 16 pacientes / Complications of surgery after radiotherapy and adjuvant chemotherapy in non-small cell lung cancer. Analysis of a series of 16 patients

Propósito: Comparar la morbimortalidad postoperatoria de pacientes con cáncer de células no pequeñasde pulmón tratados con dosis completas de radioterapia de inducción (>59 Gy) y con dosis estándarde radioterapia (≤ 5 Gy).Material y métodos: Revisamos los pacientes con CNMP que desde diciembre del año 2000recibieron tratamiento quirúrgico con intención curativa tras quimioradioterapia ± quimioterapia de inducciónen nuestro centro (n=16.). Se recogen los datos de complicaciones postoperatorias, tiempo ylocalización de las recidivas, metástasis y supervivencia de los pacientes.Resultados: No se produjo ningún caso de mortalidad perioperatoria. Las diferencias en la incidenciade complicaciones postoperatorias en ambos grupos no es estadísticamente significativa(p<0,197). La supervivencia actuarial a los 2 años es del 66,6%.Conclusión: En nuestro medio parece seguro el tratamiento quirúrgico tras dosis plenas de radioterapiaen el CNMP

Purpose: To compare the postoperative morbimortality of patients with non-small cell lungcancer (NSCLC) patients treated employing a full dose of induction radiotherapy (>59 Gy) with thosereceiving a standard dose of radiotherapy (≤ 45 Gy).Material and methods: A retrospective analysis of patients with NSCLC treated by surgeryafter chemo-radiotherapy ± chemotherapy in our institution since December 2000 (n=16) is made.Data about survival, postoperative morbidity, and time and site of recurrence or metastases areconsidered.Results: There was no perioperative mortality. No statistical differences were found inpostoperative morbidity when comparing both groups of radiation (p<0.197).The two years actuarialsurvival rate was 66.6 %.Conclusion: In our experience, it seems reasonable to offer surgery to patients with NSCLC evenwhen they have received a full dose induction radiotherapy

[Improvements in lung preservation: 3 years' experience with a low-potassium dextran solution]. / Mejoras en la preservación pulmonar. Tres años de experiencia con una solución de dextrano bajo en potasio.

OBJECTIVE: Lung preservation quality is a crucial factor in the success of a lung transplant. In October 2000 we stopped using Euro-Collins (EC) lung preservation solution and began using a low potassium dextran solution (Perfadex [PER]). The objective of the present study was to assess outcome with the 2 solutions. MATERIAL AND METHODS: We analyzed the results of 68 lung transplants in which PER was used and compared the results with those of a historical control group consisting of the same number of transplants in which EC was used. RESULTS: There were no significant differences in the ages and diagnoses of the recipients in the 2 groups. Waiting list time was longer in the PER group. The most frequent cause of donor death in the EC group was craniocerebral trauma (62%), whereas in the PER group it was cerebral hemorrhage (54%). In the PER group more double lung transplants were performed than in the EC group (78% and 53% respectively; P=.002). There were no differences in the use of extracorporal circulation or ischemia time between the 2 groups. Early graft function, based on the patient's oxygenation index (ratio of PaO2 to inspired oxygen fraction [FiO2]) on arrival at the intensive care unit, was similar in the 2 groups. The incidence of severe graft failure (PaO2/FiO2<150 mm Hg) was significantly lower in the PER group than in the EC group (16% and 37% respectively; P=.01). No significant differences in hours of mechanical ventilation or postoperative mortality between the 2 patient series were found. CONCLUSIONS: Use of the newer lung preservation solution --PER-- led to a 50% lower incidence of severe ischemia-reperfusion graft injury during the early recovery from lung transplantation.

Mejoras en la preservación pulmonar. Tres años de experiencia con una solución de dextrano bajo en potasio / Improvements in lung preservation: 3 years' experience with a low-potassium dextran solution

OBJETIVO: La calidad de la preservación pulmonar es uno de los aspectos más determinantes en el éxito del trasplante pulmonar. En octubre del año 2000 modificamos nuestra solución de preservación pulmonar, que hasta entonces era el Euro-Collins (EC), y comenzamos a utilizar una solución de dextrano bajo en potasio, comercializada como Perfadex (PER). El objetivo de este estudio es analizar los resultados de ambos métodos. MATERIAL Y MÉTODOS: Hemos analizado los resultados de 68 trasplantes pulmonares con PER y los hemos comparado con los de una serie retrospectiva del mismo número de trasplantes realizados con EC. RESULTADOS: No existen diferencias significativas respecto a la edad o el diagnóstico de los receptores entre ambos grupos. El tiempo en lista de espera fue mayor en el grupo de PER. La causa de muerte del donante más frecuente del grupo EC fue el traumatismo craneoencefálico (62%), mientras que en el grupo de PER fue la hemorragia cerebral (54%). En el grupo de PER se realizaron más trasplantes bipulmonares que en el de EC (el 78 y el 53%, respectivamente; p = 0,002). No hay diferencias en la indicación de circulación extracorpórea o tiempos de isquemia entre ambos grupos. Se evaluó la función pulmonar temprana a través del índice de oxigenación (PaO2/FiO2) a la llegada a la unidad de cuidados intensivos, que fue comparable entre ambos grupos. La incidencia de disfunción grave del injerto (PaO2/FiO2 < 150 mmHg) fue significativamente inferior en el grupo de PER frente al de EC (el 16 y el 37%, respectivamente; p = 0,01). No encontramos diferencias significativas respecto a las horas de ventilación mecánica ni en cuanto a la mortalidad postoperatoria entre las 2 series. CONCLUSIONES: Con la aplicación clínica de esta nueva solución de preservación pulmonar se obtiene una reducción del 50% en la incidencia de la lesión de isquemia-reperfusión grave del injerto en el postoperatorio inmediato del trasplante pulmonar

OBJECTIVE: Lung preservation quality is a crucial factor in the success of a lung transplant. In October 2000 we stopped using Euro-Collins (EC) lung preservation solution and began using a low potassium dextran solution (Perfadex [PER]). The objective of the present study was to assess outcome with the 2 solutions. MATERIAL AND METHODS: We analyzed the results of 68 lung transplants in which PER was used and compared the results with those of a historical control group consisting of the same number of transplants in which EC was used. RESULTS: There were no significant differences in the ages and diagnoses of the recipients in the 2 groups. Waiting list time was longer in the PER group. The most frequent cause of donor death in the EC group was craniocerebral trauma (62%), whereas in the PER group it was cerebral hemorrhage (54%). In the PER group more double lung transplants were performed than in the EC group (78% and 53% respectively; P=.002). There were no differences in the use of extracorporal circulation or ischemia time between the 2 groups. Early graft function, based on the patient’s oxygenation index (ratio of PaO2 to inspired oxygen fraction [FiO2]) on arrival at the intensive care unit, was similar in the 2 groups. The incidence of severe graft failure (PaO2/FiO2<150 mm Hg) was significantly lower in the PER group than in the EC group (16% and 37% respectively; P=.01). No significant differences in hours of mechanical ventilation or postoperative mortality between the 2 patient series were found. CONCLUSIONS: Use of the newer lung preservation solution —PER— led to a 50% lower incidence of severe ischemiareperfusion graft injury during the early recovery from lung transplantation

Successful bilateral lung transplantation from a methanol-poisoned donor.

The shortage of suitable organ donors is an important limiting factor that is making the evaluation of marginal donors necessary and, consequently, allowing expansion of standard donor criteria for organ removal. Lung procurement after methanol poisoning is anecdotal; in fact, there is only one published case in literature and that case showed a successful outcome. In this report, we describe a case of lung donation from a previously healthy individual who died from methanol poisoning. Both lungs were successfully implanted to a 20-year-old man who suffered from cystic fibrosis. This case report is new evidence that lung transplantation from methanol-poisoned donors may be safely performed with a good outcome.

Consecuencias fisiopatológicas de la cirugía de reducción de volumen en pacientes con enfisema / Pathophysiological consequences of lung volume reduction surgery in patients with emphysema

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[Mediastinoscopy in the diagnosis of mediastinal disease. An analysis of 181 explorations]. / La mediastinoscopia para el diagnóstico de la enfermedad mediastínica: análisis de 181 exploraciones.

To validate our experience with standard cervical mediastinoscopy (SCM) and extended cervical mediastinoscopy (ECM) to diagnose mediastinal nodes and masses, we studied 181 patients between January 1992 and February 2001. SCM and ECM were indicated for diagnostic staging of nodes related to bronchogenic carcinoma (Group I) or of mediastinal masses (Group II). An SCM was performed in all cases to explore the paratracheal region (2R, 2L, 4R, 4L, 7, 10R and 10L); in 21 additional cases, an ECM was performed to explore the aortopulmonary window or the subaortic region (area 5) and the para-aortic region (area 6). In Group I, the sensitivity of SCM was 93.6% and specificity was 100%; the positive predictive value (PPV) was 100%, the negative predictive value (NPV) was 82.8%, and the diagnostic yield was 95.1%. The sensitivity of ECM was 91% and specificity was 100%; PPV was 100%, NPV 93.3% and yield was 96%. In Group II, the sensitivity was 93.3%, specificity 100%, PPV 100%, NPV 81.2% and diagnostic yield 94.8%. The sensitivity of ECM in this group was 80%, specificity was 100%, PPV 100%, NPV 66.7% and yield 85.7%. A 2.7% complication rate was observed, with one case of bleeding after injury to the superior vena cava, one tracheal lesion, one recurring paralysis and two cases of surgical wound infection. The mean postoperative stay was 36 hours and mortality was zero. We conclude that SCM is highly specific for the evaluation of mediastinal node involvement in bronchogenic carcinoma and it is the approach of choice when a diagnosis of lesions located in the mid-mediastinal region has not been reached. ECM is a valid, safe alternative to anterior mediastinotomy for staging nodes and masses occupying para-aortic zones or the aortopulmonary window, with good diagnostic yield, low morbidity and absence of mortality.

La mediastinoscopia para el diagnóstico de la enfermedad mediastínica: análisis de 181 exploraciones / Mediastinoscopy in the diagnosis of mediastinal disease. An analysis of 181 explorations

Para validar nuestra experiencia con la utilización de la mediastinoscopia cervical estándar (MCS) y la mediastinoscopia cervical extendida (MCE) en el diagnóstico de las adenopatías y masas del mediastino, se ha realizado este estudio entre enero de 1992 y febrero de 2001 sobre 181 pacientes. La MCS y MCE se han indicado para la estadificación ganglionar por carcinoma broncogénico (grupo I) y en el diagnóstico de las masas mediastínicas (grupo II). En todos los casos se ha efectuado una MCS para explorar la región paratraqueal (2R, 2L, 4R, 4L, 7, 10R, 10L) y en 32, además, una MCE para la ventana aortopulmonar o región subaórtica (área 5) y región paraaórtica (área 6). En el grupo I, la MCS ha demostrado una sensibilidad (S) del 93,6 per cent, especificidad (E) del 100 per cent, un valor predictivo positivo (VPP) del 100 per cent, un valor predictivo negativo (VPN) del 82,8 per cent y una rentabilidad diagnóstica (RD) del 95,1 per cent. La MCE ha tenido una S del 91 per cent, E del 100 per cent, VPP del 100 per cent, VPN del 93,3 per cent y una RD del 96 per cent. Para el grupo II, la MCS ha presentado una S del 93,3 per cent, E 100 per cent, VPP 100 per cent, VPN 81,2 per cent y una RD del 94,8 per cent mientras que la MCE en este grupo ha tenido una S del 80 per cent, E del 100 per cent, VPP 100 per cent, VPN 66,7 per cent y una RD del 85,7 per cent. El porcentaje de complicaciones ha sido del 2,7 per cent, destacando un sangrado por lesión de la vena cava superior, una laceración traqueal, una parálisis recurrencial y 2 casos de infección de la herida quirúrgica. La estancia media postoperatoria ha sido de 36 h y la mortalidad nula. Concluimos que la MCS es una técnica de gran especificidad en la valoración de la afección ganglionar mediastínica por carcinoma broncogénico y la prueba de elección ante la imposibilidad o ausencia de diagnóstico en las lesiones localizadas en el mediastino medio. La MCE es una alternativa válida y segura a la mediastinotomía anterior en la valoración de las adenopatías y masas que ocupan las regiones paraaórtica y ventana aortopulmonar, presentando una elevada rentabilidad diagnóstica, una baja morbilidad y una nula mortalidad. Para validar nuestra experiencia con la utilización de la mediastinoscopia cervical estándar (MCS) y la mediastinoscopia cervical extendida (MCE) en el diagnóstico de las adenopatías y masas del mediastino, se ha realizado este estudio entre enero de 1992 y febrero de 2001 sobre 181 pacientes. La MCS y MCE se han indicado para la estadificación ganglionar por carcinoma broncogénico (grupo I) y en el diagnóstico de las masas mediastínicas (grupo II). En todos los casos se ha efectuado una MCS para explorar la región paratraqueal (2R, 2L, 4R, 4L, 7, 10R, 10L) y en 32, además, una MCE para la ventana aortopulmonar o región subaórtica (área 5) y región paraaórtica (área 6). En el grupo I, la MCS ha demostrado una sensibilidad (S) del 93,6 per cent, especificidad (E) del 100 per cent, un valor predictivo positivo (VPP) del 100 per cent, un valor predictivo negativo (VPN) del 82,8 per cent y una rentabilidad diagnóstica (RD) del 95,1 per cent. La MCE ha tenido una S del 91 per cent, E del 100 per cent, VPP del 100 per cent, VPN del 93,3 per cent y una RD del 96 per cent. Para el grupo II, la MCS ha presentado una S del 93,3 per cent, E 100 per cent, VPP 100 per cent, VPN 81,2 per cent y una RD del 94,8 per cent mientras que la MCE en este grupo ha tenido una S del 80 per cent, E del 100 per cent, VPP 100 per cent, VPN 66,7 per cent y una RD del 85,7 per cent. El porcentaje de complicaciones ha sido del 2,7 per cent, destacando un sangrado por lesión de la vena cava superior, una laceración traqueal, una parálisis recurrencial y 2 casos de infección de la herida quirúrgica. La estancia media postoperatoria ha sido de 36 h y la mortalidad nula. Concluimos que la MCS es una técnica de gran especificidad en la valoración de la afección ganglionar mediastínica por carcinoma broncogénico y la prueba de elección ante la imposibilidad o ausencia de diagnóstico en las lesiones localizadas en el mediastino medio. La MCE es una alternativa válida y segura a la mediastinotomía anterior en la valoración de las adenopatías y masas que ocupan las regiones paraaórtica y ventana aortopulmonar, presentando una elevada rentabilidad diagnóstica, una baja morbilidad y una nula mortalidad (AU)

[The treatment of pneumothorax by small-caliber drainage without a water seal]. / Tratamiento del neumotórax con drenaje fino sin sello de agua.

The authors describe their experience in treating 72 patients with pneumothorax by placement of a drainage tube of 2.2 mm internal diameter equipped with a Heimlich valve. Full lung expansion was achieved with this method in 93% of the cases. Mean hospital stay was 4.05 days (Sx = 3.4, minimum 1, maximum 20). In 7 (10.7%) cases out of 64 who were discharged and followed as outpatients, there was recurrence of pneumothorax. With these results the authors conclude that the system used is valid for treating pneumothorax and that large drains and water seals are not necessary in most cases.