Clinical course and predictors of pericardial effusion following cardiac transplantation.

OBJECTIVE: Pericardial effusions occur frequently after orthotopic heart transplantation. There have been conflicting reports describing etiology, prognosis, and outcomes associated with these early postoperative effusions. METHODS: A retrospective review of 91 patients transplanted between January 2001 and September 2004 was performed. Pericardial effusion was defined by serial echocardiography and graded as none, small, moderate, or large. A total of 1088 echocardiograms were evaluated during the first posttransplant year. Perioperative variables were evaluated by logistic regression analysis to define predictors for occurrence of effusions. RESULTS: Echocardiographic data were available for 88 patients. Thirty-one patients (35%) developed moderate to large effusion in the immediate postoperative period. Three patients developed hemodynamic compromise that required immediate intervention. All other effusions resolved within 3 months of heart transplantation without any specific intervention. Only prolonged donor ischemic time was associated with higher risk of occurrence of moderate to large pericardial effusions (odds ratio 1.012, 95% confidence interval 1.001 to 1.019, P = .033). There was no difference in morbidity or early mortality between patients with and without pericardial effusions. CONCLUSION: Moderate to large pericardial effusions occur frequently after heart transplantation. In a vast majority, these effusions are not associated with any adverse clinical outcomes and resolve within 3 months postoperatively. Early postoperative close monitoring is still required to evaluate for tamponade.

Potential renal protective benefits of intra-operative BNP infusion during cardiac transplantation.

BACKGROUND: Recombinant BNP (nesiritide) is known to reduce endothelin levels, cause afferent arteriole vasodilation, and increase natriuresis and diuresis. We hypothesized that intraoperative infusion of BNP may benefit renal function in cardiac transplant patients. METHODS: From June 2003 to September 2005, 22 consecutive heart transplant patients received BNP at a dose of 0.01 microg/kg/min before initiation of cardiopulmonary bypass (group A). BNP infusion was continued for a mean of 3.3 +/- 1.9 days. Hemodynamics, urine output, and serum creatinine levels were prospectively collected and compared with 22 consecutive patients who underwent heart transplantation between May 2002 and June 2003 following the identical transplant protocol, but without BNP infusion (group B). RESULTS: At 24 hours postoperatively, mean blood pressure was comparable between groups (87 +/- 11 mm Hg vs 89 +/- 17 mm Hg, P = .7), but pulmonary artery pressure (18 +/- 5 mm Hg vs 24 +/- 5 mm Hg, P = .001) and central venous pressure (12 +/- 5 mm Hg vs 16 +/- 4 mm Hg, P = .01) were lower with BNP infusion, whereas cardiac index was augmented (2.8 +/- 0.5 vs 2.4 +/- 0.6, P = .03). Requirement of low-dose inotropic and vasopressor support was equally distributed between groups (P > or = .72). Postoperative urine output for the initial 24 hours was higher in group A (84 +/- 15 vs 55 +/- 36 mL/h, P = .01). None of the patients with BNP infusion required additional diuretics or renal replacement therapy during the first week after transplantation. Mean postoperative serum creatinine levels as compared with preoperative values remained unchanged within group A (P = .12), but increased significantly in group B (P < .001). CONCLUSIONS: Intraoperative BNP infusion in heart transplant recipients was associated with favorable postoperative hemodynamics, significantly improved urine output, and stable serum creatinine levels. A prospective, randomized, multicenter trial is warranted to evaluate the potential renal protective benefits of intraoperative BNP infusion in this patient population.

Outcome of bilateral lung volume reduction in patients with emphysema potentially eligible for lung transplantation.

OBJECTIVE: Between January 1993 and May 1998, we performed 200 consecutive bilateral lung volume reduction operations. After initial assessment, 99 of these patients were eligible for lung volume reduction and potentially eligible for immediate or eventual lung transplantation on the basis of age and absence of contraindications. All chose to proceed with lung volume reduction surgery. The outcomes of these 99 patients are reviewed to assess the consequences of proceeding with lung volume reduction surgery on patients potentially eligible for lung transplantation. METHODS: A retrospective study was performed with the use of a prospectively assembled computer database. RESULTS: The 61 men and 38 women were 55 +/- 7 years old at evaluation for lung volume reduction. Mean values for first second expired volume, total lung capacity, and residual volume were 24% +/- 8%, 141% +/- 19%, and 294% +/- 54% predicted. There were 4 operative deaths and 17 late deaths. Two-year and 5-year survival after evaluation for lung volume reduction are 92% and 75%. The 32 patients who have been listed for transplantation after lung volume reduction include 15 who have undergone transplantation, 14 who remain on the list, and 3 who have been removed from the list. All 15 transplant recipients survived transplantation and 3 have subsequently died of rejection or late infection. The 12 living recipients have a median post-transplantation follow-up of 1.7 years. The age at transplantation was 58 +/- 5 years with transplantation occurring 3.8 +/- 1.1 years after lung volume reduction. Sixteen of 99 patients underwent lower lobe volume reduction with an increased rate of listing (63%, P =.008) and transplantation (38%, P =.003) compared with patients undergoing upper lobe volume reduction. Patients listed for transplantation were younger, more impaired, and experienced less benefit from lung volume reduction than patients not yet listed for transplantation. CONCLUSIONS: The preliminary use of lung volume reduction in patients potentially suitable for transplantation does not appear to jeopardize the chances for subsequent successful transplantation.

Lung transplantation is warranted for stable, ventilator-dependent recipients.

BACKGROUND: Lung transplantation for patients on ventilators is a controversial use of scarce donor lungs. We have performed 500 lung transplants in 12 years and 21 of these have been in ventilator-dependent patients. METHODS: A retrospective review of patient records and computerized database was performed. Living patients were contacted to confirm their health and functional status. RESULTS: Patients included 13 men and 8 women with a mean age of 43 years. Sixteen patients were considered stable awaiting lung transplant, whereas 5 patients were unstable with acute graft failure after prior lung transplantation. Stable patients had been ventilated for a mean of 57 +/- 46 days whereas unstable patients had been supported for 10 +/- 9 days. Half of the patients required cardiopulmonary bypass support during the transplant, and there was no statistical difference in the frequency of CPB in stable and unstable patients (p = 0.61). Three hospital deaths included 0 of 16 of the stable patients and 3 of 5 of the unstable patients (p = 0.01). Long-term actuarial survival was significantly better in stable versus unstable patients (p = 0.02), with 5-year survival 40% for stable patients and 0% for unstable patients. CONCLUSIONS: Lung transplantation can be successfully conducted in stable patients who have become ventilator dependent after listing for transplantation. Acute retransplantation for early lung dysfunction is high risk and has produced poor long-term results.

Perioperative complications after living donor lobectomy.

OBJECTIVE: Clinical lung transplantation has been limited by availability of suitable cadaveric donor lungs. Living donor lobectomy provides right and left lower lobes from a pair of living donors for each recipient. We reviewed our experience with living donor lobectomy from July 1994 to February 2000. METHODS: Sixty-two donor lobectomies were performed. The hospital and outpatient records of these 62 donors were retrospectively analyzed to examine the incidence of perioperative complications. RESULTS: Twenty-four (38.7%) of 62 donors had no perioperative complications and had a median length of hospital stay of 5.0 days. Thirty-eight (61.3%) of 62 donors had postoperative complications. Twelve major complications occurred in 10 patients and included pleural effusions necessitating drainage (n = 4), bronchial stump fistulas (n = 3), bilobectomy (n = 1), hemorrhage necessitating red cell transfusion (n = 1), phrenic nerve injury (n = 1), atrial flutter ultimately necessitating electrophysiologic ablation (n = 1), and bronchial stricture necessitating dilatation (n = 1). These 38 donors had 55 minor complications including persistent air leaks (n = 9), pericarditis (n = 9), pneumonia (n = 8), arrhythmia (n = 7), transient hypotension necessitating fluid resuscitation (n = 4), atelectasis (n = 3), ileus (n = 3), subcutaneous emphysema (n = 3), urinary tract infections (n = 2), loculated pleural effusions (n = 2), transfusion (n = 2), Clostridium difficile colitis (n = 1), puncture of a saline breast implant (n = 1), and severe contact dermatitis secondary to adhesive tape (n = 1). There were no postoperative deaths and only 1 donor required surgical re-exploration. CONCLUSIONS: Living donor lobectomy can be performed with low mortality and remains an important alternative for potential recipients unable to wait for cadaveric lung allografts. However, morbidity is high and must be considered when potential living donors are being counseled.

The current role of mediastinoscopy in the evaluation of thoracic disease.

OBJECTIVE: Mediastinoscopy is a common procedure used for the diagnosis of thoracic disease and the staging of lung cancer. We sought to determine the current role of mediastinoscopy in the evaluation of thoracic disease. METHODS: We conducted a retrospective review of all mediastinoscopies performed by members of our service between January 1988 and September 1998. RESULTS: We performed mediastinoscopies on 2137 patients. A total of 1745 patients underwent mediastinoscopy for known or suspected lung cancer. In 422 of these procedures, N2 or N3 disease was identified; only 28 of these patients underwent resection. The remaining 1323 had no evidence of metastatic disease. In these patients 947 had lung cancer. Only 76 of the patients with lung cancer were found to have N2 disease at exploration. Among the 1323 patients with a negative mediastinoscopy result, 52 underwent resection of a nonbronchogenic malignancy, and 217 had resection of a benign lesion. A total of 392 patients underwent mediastinoscopy for the evaluation of mediastinal adenopathy in the absence of any identifiable pulmonary lesion. Of these, 161 had a nonbronchogenic malignancy, 209 had benign disease, and 25 had no diagnosis established; mediastinoscopy established a definitive diagnosis in 93.6% of patients. In the entire group of 2137 patients, there were 4 perioperative deaths and 12 complications. Only one death was directly attributed to mediastinoscopy. No deaths or complications occurred in patients undergoing mediastinoscopy for benign disease. CONCLUSIONS: Mediastinoscopy is a highly effective and safe procedure. We believe that mediastinoscopy should currently be used routinely in the diagnosis and staging of thoracic diseases.

Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients.

OBJECTIVE: To review the results of the authors' most recent 100 consecutive cases of transcervical thymectomy for myasthenia gravis (MG) in terms of complications and outcome in comparison with other reported techniques. SUMMARY BACKGROUND DATA: Myasthenia gravis is believed to be an autoimmune disorder characterized by increasing fatigue with exertion. The role of thymectomy in the management of the disease remains unproven, but there is widespread acceptance of the notion that complete thymectomy improves the course of the disease. Complete excision of the thymus is the goal in all cases; however, the best technique to achieve complete thymectomy remains controversial. The authors favor a transcervical approach through a small collar incision aided by a specially designed sternal retractor. Others prefer a transsternal, a combined transcervical and transsternal ("maximal"), or a video-assisted thoracoscopic surgical approach. METHODS: A retrospective review of the authors' most recent 100 consecutive transcervical thymectomies for nonthymoma-associated MG was performed using medical records and telephone interviews. Patients' symptoms were graded before surgery and at the most recent (within the last 6 months) postoperative time point, using the modified Osserman classification: 0 = asymptomatic, 1 = ocular signs and symptoms, 2 = mild generalized weakness, 3 = moderate generalized weakness, bulbar dysfunction, or both, and 4 = severe generalized weakness, respiratory dysfunction, or both. RESULTS: There were 61 female patients and 39 male patients with a mean age of 38 years (range, 14 to 84). The median hospital stay was 1 day. There were no deaths and no significant complications. Seventy-eight patients who had undergone surgery >12 months ago were available for analysis. In these patients, with a mean follow-up time of 5 years (median 5.3; range, 12 months to 10 years), the median preoperative Osserman grade improved from 3.0 (mean 2.73) before surgery to 1.0 after surgery (mean 0.94). CONCLUSIONS: The transcervical approach for thymectomy for the treatment of MG produces results similar to those of other surgical approaches, with the added benefits of shortened hospital stay, decreased complications, reduced cost, and broader physician and patient acceptance of surgical treatment.

Lung transplantation: a decade of experience.

OBJECTIVE: To review the 10-year clinical experience of a single institution's adult lung transplant program. METHODS: Since July 1988, 450 lung transplants have been performed in 443 patients. Recipient diagnoses included emphysema in 229 patients, cystic fibrosis in 70 patients, pulmonary fibrosis in 48 patients, pulmonary hypertension in 49 patients, and miscellaneous end-stage lung diseases in 47 patients. Single-lung transplant was performed in 157 cases, bilateral sequential lung transplant in 283 cases, en bloc double-lung transplant in 8 cases, and heart-lung transplant in 2 cases. Graft lungs were obtained from local donors in 24% of cases and from distant donors in 76% of cases. Ideal donors were used in 74% of cases; in 26%, the donor was classified as marginal based on objective criteria. RESULTS: Four hundred six (91.6%) lung transplant recipients survived to hospital discharge. There were 37 hospital deaths from cardiac events (n = 8), primary graft failure (n = 8), sepsis (n = 6), anastomotic dehiscence (n = 6), and other causes (n = 9). A diagnosis of chronic rejection (bronchiolitis obliterans syndrome [BOS]) was made in 191 patients (42.5%). BOS has not been improved by any specific therapy. Rates of freedom from BOS at 1, 3, and 5 years after the transplant are 82%, 42%, and 25%. One-, 3-, and 5-year actuarial survival rate for the entire group are 83%, 70%, and 54%. There is no statistical difference in survival according to diagnosis or type of lung transplant. Recipient waiting time was 116 days in the first 90 patients and 634 days in the most recent 90 patients. CONCLUSIONS: Lung transplantation offers patients with end-stage lung disease acceptable prospects for 5-year survival. Chronic rejection and long waiting lists for donor lungs continue to be major problems facing lung transplant programs. The use of marginal and distant donors is a successful strategy in improving donor availability.