Caroline Van De Wauwer

The use of non-heart-beating lung donors category III can increase the donor pool

OBJECTIVE The use of non-heart-beating (NHB) lung donors has been propagated as an alternative besides heart-beating (HB) lung donors to overcome organ shortage. We evaluated the effectiveness of NHB lung transplantation. METHODS The donor and recipient data of all 35 NHB category III lung transplantations (LTx) between January 2005 and December 2009 were reviewed. For comparison, we collected recipient and donor data of a cohort of 77 HB lung transplantations. In both groups, we assessed survival, primary graft dysfunction (PGD), forced expiratory volume in 1s (FEV(1)), acute rejection, and bronchiolitis obliterans syndrome (BOS). RESULTS Thirty-five NHB lung transplantations were performed, five single LTx and 30 bilateral LTx in 12 male and 23 female patients. The donor oxygenation capacity was 61 kPa (interquartile range (IQR), 56-64). Warm ischemia time in the donor was 29 min (IQR, 24-30). Cold ischemic time of the last implanted lung was 458 min (IQR, 392-522). Cardiopulmonary bypass was used 13 times. PGD (1-3) was observed in 45% of the patients at T0, in 42% at T24, in 53% at T48, and in 50% at T72. PGD 3 decreased from 24% at T0 to 6% at T72. The use of nitric oxide (NO) within 24h after transplantation was necessary in three patients with successful weaning in all. There was no significant difference for donor and recipient characteristics between NHB and HB lung transplantations. Survival, occurrence of PGD, and acute rejection was equal to the HB cohort. The incidence of BOS was lower in the NHB group. The measured FEV(1) tended to be better in the NHB group. CONCLUSION Lungs from nonheparinized category III NHB donors are well suited for transplantation and can safely increase the donor pool.

The mode of death in the non-heart-beating donor has an impact on lung graft quality

OBJECTIVE We hypothesised that the agonal phase prior to cardiac death may negatively influence the quality of the pulmonary graft recovered from non-heart-beating donors (NHBDs). Different modes of death were compared in an experimental model. METHODS Non-heparinised pigs were divided into three groups (n=6 per group). Animals in group I [FIB] were sacrificed by ventricular fibrillation resulting in immediate circulatory arrest. In group II [EXS], animals were exsanguinated (45+/-11 min). In group III [HYP], hypoxic cardiac arrest (13+/-3 min) was induced by disconnecting the animal from the ventilator. Blood samples were taken pre-mortem in HYP and EXS for measurement of catecholamine levels. After 1 h of in situ warm ischaemia, unflushed lungs were explanted and stored for 3 h (4 degrees C). Left lung performance was then tested during 60 min in our ex vivo reperfusion model. Total protein concentration in bronchial lavage fluid was measured at the end of reperfusion. RESULTS Pre-mortem noradrenalin (mcg l(-1)) concentration (baseline: 0.03+/-0) increased to a higher level in HYP (50+/-8) vs EXS (15+/-3); p=0.0074. PO(2) (mmHg) at 60 min of reperfusion was significantly worse in HYP compared to FIB (445+/-64 vs 621+/-25; p<0.05), but not to EXS (563+/-51). Pulmonary vascular resistance (dynes s cm(-5)) was initially higher in EXS (p<0.001) and HYP (NS) vs FIB (15824+/-5052 and 8557+/-4933 vs 1482+/-61, respectively) but normalised thereafter. Wet-to-dry weight ratio was higher in HYP compared to FIB (5.2+/-0.3 vs 4.7+/-0.2, p=0.041), but not to EXS (4.9+/-0.2). Total protein (g l(-1)) concentration was higher, although not significant in HYP and EXS vs FIB (18+/-6 and 13+/-4 vs 4.5+/-1.3, respectively). CONCLUSION Pre-mortem agonal phase in the NHBD induces a sympathetic storm leading to capillary leak with pulmonary oedema and reduced oxygenation upon reperfusion. Graft quality appears inferior in NHBD lungs when recovered in controlled (HYP) vs uncontrolled (EXS and FIB) setting.

Retrograde Flush Following Warm Ischemia in the Non-Heart-Beating Donor Results in Superior Graft Performance at Reperfusion

BACKGROUND The use of non-heart-beating donors (NHBD) has been propagated as an alternative to overcome the scarcity of pulmonary grafts. The presence of postmortem thrombi, however, is a concern for the development of primary graft dysfunction. In this isolated lung reperfusion study, we looked at the need and the best route of preharvest pulmonary flush. METHODS Domestic pigs were sacrificed by ventricular fibrillation and divided in 3 groups (n = 6 per group). After 1 h of in situ warm ischemia, lungs in group I were retrieved unflushed (NF). In group II, lungs were explanted after an anterograde flush (AF) through the pulmonary artery. Finally, in group III, lungs were explanted after a retrograde flush (RF) via the left atrium. After 3 h of cold storage, the left lung was assessed for 60 min in our ex vivo reperfusion model. Wet-to-dry weight ratio (W/D) was calculated after reperfusion. RESULTS Pulmonary vascular resistance (dynes x sec x cm(-5)) was 1145 +/- 56 (RF) versus 1560 +/- 123 (AF) and 1435 +/- 95 (NF) at 60 min of reperfusion (P < 0.05). Oxygenation and compliance were higher and plateau airway pressure was lower in RF versus AF and NF, although the difference did not reach statistical significance. No differences in W/D were observed between groups after reperfusion. Histological examination revealed fewer microthrombi in the left lung in RF compared with AF and NF. CONCLUSION RF of lungs from NHBD improves graft function by elimination of microthrombi from the pulmonary vasculature, resulting in lower pulmonary vascular resistance upon reperfusion.

Azithromycin reduces airway inflammation in a murine model of lung ischaemia reperfusion injury

Clinical studies revealed that azithromycin reduces airway neutrophilia during chronic rejection after lung transplantation. Our aim was to investigate the possible effect of azithromycin on ischaemia‐reperfusion injury. Azithromycin or water was administered to mice every other day during 2 weeks (n = 6/group). On the 14th day, the left lung was clamped to induce ischaemia (90 min). In two additional groups, animals underwent the same protocol, followed by 4 h of reperfusion. Two control groups were included with thoracotomy only. Inflammatory parameters and oxidative stress were measured in broncho‐alveolar lavage of the left lung. Leukocytes, lymphocytes, neutrophils, 8‐isoprostane and IL‐1β levels after ischaemia and reperfusion were significantly reduced in mice treated with azithromycin. There was a trend towards lower IL‐6 and KC levels. A significant correlation was seen between 8‐isoprostanes and neutrophils (Pearson r = 0.72; P = 0.0086), IL‐6 (Pearson r = 0.84; P = 0.0006), KC (Pearson r = 0.88; P = 0.0002) and IL‐1β (Pearson r = 0.62; P = 0.0326). We conclude (i) that azithromycin reduces inflammation and oxidative stress in our IRI model, and (ii) that oxidative stress is correlated with the number of neutrophils and IL‐6, KC and IL‐1β levels after ischaemia and reperfusion. Azithromycin should be further investigated as a novel drug to prevent lung ischaemia‐reperfusion injury.

CT-guided percutaneous hookwire localization increases the efficacy and safety of VATS for pulmonary nodules

The diagnosis of pulmonary nodules of unknown origin is challenging, and such nodules are not always suitable for transthoracic needle biopsy. With the advent of video assisted thoracic surgery (VATS) and CT‐guided percutaneous hookwire localization (CT‐PHL) we hypothesized that the combination of these two procedures will improve early diagnosis.

In situ lung perfusion is a valuable tool to assess lungs from donation after circulatory death donors category I–II

Donations after circulatory death (DCD) lung grafts are an alternative to extend the donor pool in lung transplantation. This study investigates the use of an in situ lung perfusion system (ISLP) in the donor to evaluate category I–II lungs. Pigs were sacrificed by ventricular fibrillation. All animals underwent 20 min of cardiopulmonary resuscitation and 5 min hands‐off period after which heparin was administered. In group [WI‐1], this was followed by 1 h of warm ischemia (WI) and 2 h of topical cooling (TC). In group [WI‐2], 2 h of WI was followed by 1 h of TC. In group [WI‐0], there was a minimal period of WI and no TC. In all three groups, the lungs were then evaluated during 60 min with ISLP. [WI‐0] lungs showed a significantly higher compliance and Δ PO2/FiO2 compared with [WI‐1] and [WI‐2]. PaCO2 and lactate production were higher in [WI‐2] versus [WI‐0]. Wet/Dry weight ratio was significantly higher in [WI‐2] compared with [WI‐0] in two lung biopsy locations. A high W/D weight ratio was correlated with a lower compliance, higher lactate production, and a higher PaCO2. ISLP is an effective way to assess the quality of lungs from category I–II DCD donors.

A staged approach for a lung-liver transplant patient using ex vivo reconditioned lungs first followed by an urgent liver transplantation

Combined lung–liver transplantation is a logistically challenging procedure hampered by shortage of organ donors. We describe the case of a young patient with end‐stage lung disease due to of cystic fibrosis and liver cirrhosis who needed combined lung–liver transplantation. The long waiting for this caused an interesting clinical dilemma. We decided to change our policy in this situation by listing him only for the lung transplantation and to apply for a high urgent liver transplantation if the liver failed after the lung transplantation. This strategy enabled us to use lungs treated with ex vivo lung perfusion (EVLP) from an unsuitable donor after circulatory death. After conditioning for 4 h via EVLP, the pO2 was 59.7 kPa. The lungs were transplanted successfully. He developed an acute‐on‐chronic liver failure for which he received a successful liver transplantation 19 days after the lung transplantation.

Robot-assisted thoracoscopic lobectomy as treatment of a giant bulla

BackgroundA bulla is a marked enlarged space within the parenchyma of the lung. Bullae may cause dyspnea by compressing healthy lung parenchyma and can cause a pneumothorax. Also, bullae are associated with malignancy, therefore surgical bullectomy is indicated on preventive basis. This case is unique and therefore valuable because of the remarkable presentation, innovative treatment and the spectacular improvement of lung function and socio-economic performance of the patient.Case presentationIn this case report we describe the presentation, minimally invasive surgical treatment by means of a robot-assisted lobectomy and postoperative outcome of a young patient with a giant congenital bulla of the left upper lobe.ConclusionsIn this case robot-assisted lobectomy has shown spectacular improvement of lung function and fast-track recovery with beneficial socio-economic performance in a young patient with a giant congenital bulla.