Not All Septal Defects Are Equal: Outcomes of Bilateral Lung Transplant With Cardiac Defect Repair vs Combined Heart-Lung Transplant in Patients With Eisenmenger Syndrome in the United States.

BACKGROUND: Thoracic transplantation is considered for patients with Eisenmenger syndrome (ES) who have refractory right ventricular failure despite optimal therapy for pulmonary arterial hypertension. This study compared the outcomes of bilateral lung transplantation (BLT) with cardiac defect repair vs combined heart-lung transplantation (HLT). RESEARCH QUESTION: This study presents an updated analysis using a US national registry to evaluate the outcomes of patients diagnosed with ES who underwent HLT or BLT with repair of cardiac defects. STUDY DESIGN AND METHODS: This study identified patients with ES who underwent thoracic transplantation from 1987 to 2018 from the United Network for Organ Sharing database. Survival curves were estimated by using the Kaplan-Meier method and were compared by using the log-rank test. RESULTS: During the study period, 442 adults with ES underwent thoracic transplantation (316 HLTs and 126 BLTs). Following BLT, overall survival 1, 5, and 10 years' posttransplant was 63.1%, 38.5%, and 30.2%, respectively. Following HLT, overall survival 1, 5, and 10 years' posttransplant was 68.0%, 47.3%, and 30.5% (P = .6). When survival analysis was stratified according to type of defect, patients with an atrial septal defect had better survival following BLT than following HLT (88.3% vs 63.2% 1 year posttransplant, P < .01; 71.1% vs 49.8% 3 years' posttransplant, P < .01; and 37.4% vs 29.9% 10 years' posttransplant, P = .08). Patients with a ventricular septal defect (VSD) exhibited better survival following HLT than following BLT (78.2% vs 49.6% 1 year posttransplant, P < .01; 55.6% vs 34.3% 5 years' posttransplant, P < .01; and 35.7% vs 26.5% 10 years' posttransplant, P = .03). The most common cause of mortality in patients with VSD undergoing BLT was cardiac ventricular failure. INTERPRETATION: This study suggests that the best transplant option for patients with VSD remains HLT, which prevents subsequent development of ventricular failure. BLT with cardiac defect repair should be considered as the first-line treatment option in patients with ES due to an uncorrected atrial septal defect. These patients can be considered to have isolated and reversible right ventricular failure akin to patients with advanced pulmonary arterial hypertension.

[The heart-lung transplant. Initial clinical experience]. / Transplante cardiopulmonar. Experiência clínica inicial.

PURPOSE: To assess this initial clinical experience with heart-lung transplantation in Brazil. METHODS: Four patients underwent heart-lung transplantation from December 1988 to March 1990, one patient with cardiomyopathy and high pulmonary resistance, two patients with primary pulmonary hypertension and another with pulmonary silicosis. The heart lung blocks were harvested from the donor using cardiopulmonary bypass and deep hypothermia. They were transplanted to the recipient by anastomosing the trachea, right atrium or venae cavae, and the ascending aorta. RESULTS: The second patient died on the 5th postoperative day due to respiratory insufficiency with consequent brain lesions. The first and third patients had survived nine months and 42 days respectively. The 4th patients is asymptomatic eight months after the operation. The main complications were bleeding in two patients, acute pulmonary rejection in three of them and obliterans bronchiolitis in one patients. CONCLUSION: The heart lung transplantation is a challenging procedure which results are progressively improving with the development of better surgical technique and clinical concepts.

Heart and unilateral lung transplantation for cardiomyopathy with high pulmonary vascular resistance.

Heart and left lung (en bloc) transplantation was used as an approach to end-stage cardiomyopathy with very high pulmonary vascular resistance. This surgical method was applied to a 13-year-old girl who did very well initially, but died 5 months later of severe pulmonary and cardiac rejection. The pulmonary perfusion scintigraphy showed equalization of the blood flow in both lungs after 42 days, and complete reversal of the pulmonary vascular changes in the opposite lung was observed at autopsy.

Transplante de pulmón: experiencia del Hospital Xavier Arnozan / Lung transplantation: experience at the Xavier Arnozan Hospital

Se analizan los primeros 38 transplantes pulmonares realizados en Bordeaux, entre enero de 1988 y julio de 1990. En 27 pacientes se realizó un transplante cardiopulmonar, en 5 un transplante unipulmonar, en 5 un bipulmonar y en uno un transplante cardiounipulmonar. Los transplantes fueron motivados por patología pulmonar o cardiopulmonar terminal: enfisema 19, fibrosis pulmonar 6, hipertensión arterial pulmonar primitiva 4, mucoviscidosis 3, silicosis 1 y 1 intoxicación por paraquat. De un modo general, se indicó un transplante cardiopulmonar en las insuficiencias cardiorrespiratorias, bipulmonar en la patología pulmonar bilateral con función cardíaca conservada o recuperable y un transplante unipulmonar en las fibrosis. Se detallan los criterios de aceptación de dadores así como las exigencias de compatibilidad (morfológica, hematológica y serológica) entre dador y receptor. La sobrevida global luego de dos años y medio de comenzado el programa es de 66 por ciento. Dos pacientes fallecieron en el postoperatorio inmediato y otros 11 luego del segundo mes. La infección viral, sobre todo a citomegalovirus y el rechazo, han sido la causa de muerte más importante en el primer semestre. Los trastornos de la cicatrización traqueal o brónquica, presentes en 11 enfermos, contribuyeron a la muerte en 4. Los resultados funcionales, para pacientes considerados terminales, son de muy buenos a excelentes (AU)

Transplante de pulmäo / Lung transplantation

O transplante de pulmäo teve início em 1950 quando foi realizado pela primeira vez por Metras em animais, seguido pela primeira experiência clínica por Hardy em 1963 sem sobrevida e Cooper em 1983 que realizou com sucesso um transplante pulmonar direito. O pulmäo doador deve ser de um indivíduo sem edema pulmonar ou trauma torácico recente, näo ter sido submetido a massagem cardíaca aberta e näo ter doença pulmonar crónica. Além disso a radiografia do tórax deve ser normal, cultura do escarro negativa. PaO2 acima de 300 nmHg com FiO2=1.0 e PEEP de 5 cm H2O. Uma vez declarado o doador morto cerebral, deve ser realizado um esforço conjunto para a remoçäo simultânea de diversos órgäos para transplantaçäo, incluindo, fígado, rins, pâncreas, coraçäo, pulmöes, pele, ossos, além de vasos e válvulas cardíacas. O transplante pulmonar pode ser único, direito ou esquerdo, bilateral seqüencial simultâneo ou cardiopulmonar, ou ainda lobar. Os critérios para seleçäo do receptor, incluem, expectativa de vida menor do que 18 meses, idade abaixo de 50 anos, inexistência de doença sistêmica com lesäo de órgäos salvo, excetuando o pulmäo; fraçäo de ejeçäo ventricular direita acima de 25%, nemhuma dependência de corticóide, nutriçäo adequada e nenhuma violaçäo do espaço pleural. A avaliaçäo prê-operatória deve incluir a funçäo pulmonar, cardíaca, hematológica, renal, hepática e nutricional. Das três soluçöes usadas para irrigaçäo (flushing) pulmonar, EuroCollins, Papworth e Wisconsin, a primeira é a mais utilizada. O esquema de imunosupressäo mais usado é na base de metilprednisolona (01 grama), ciclosporina (17mg/Kg) e azatioprina (2 a 3 mg/Kg). Os fenômenos indicativos de rejeiçäo säo dispnéia, mal estar, febre baixa, diminuiçäo da PaO2 arterial, infiltrado mal definido perihilar. A distinçäo entre ejeiçäo e infecçäo é às vezes difícil. A bronquiolite obliterante é o achado histológico mais comum após biópsia transbrônquica. O tratamento consiste no uso de um "bolo" de corticóide na dose de 500 mg a 1 gr, além das drogas imunosupressoras

The question of FK 506 nephrotoxicity after liver transplantation.

Formal studies have not been published on the nephrotoxicity of FK 506 when the drug was used from the outset. This kind of information was sought in 101 recipients of primary livers, 24 hearts, and 3 double lungs or heart-lung. Perioperative renal dysfunction was commonly seen, which appeared to be related to FK 506 doses and plasma levels, particularly when the drug was given IV. This was reversible. Late renal function has been generally satisfactory in all three cohorts of patients, and the incidence of hypertension has been low. The therapeutic index of FK 506 is a good one, as revealed by these observations in patients whose most notable achievement was a low mortality.