Charles Poirier

Transesophageal echocardiography monitoring in the intensive care department: the management of hemodynamic instability secondary to thoracic tamponade after single lung transplantation

A 65-year-old woman with pulmonary fibrosis had hemodynamic instability develop after single lung transplantation. Transesophageal echocardiography was useful in determining the cause of hemodynamic instability, which was secondary to thoracic tamponade. Furthermore, transesophageal echocardiography monitoring was important in the decision to initiate extracorporeal membrane oxygenation to evaluate adequate positioning of the cannula and in the extracorporeal membrane oxygenation weaning process.

Late retrograde perfusion of donor lungs does not decrease the severity of primary graft dysfunction.

BACKGROUND The ideal preservation strategy has yet to be established in lung transplantation. This clinical study compares primary graft dysfunction using antegrade and retrograde perfusion of donor lungs. METHODS Over a 6-year period, 153 consecutive patients underwent lung transplantation in our institution. Group I consists of 65 patients who received lungs preserved with an antegrade flush of modified Euro-Collins solution. Group II includes 65 patients who received lungs preserved with an antegrade flush of low-potassium dextran (LPD) solution. Group III consists of 23 patients who received lungs preserved with an antegrade and a preimplantation retrograde flush of LPD solution. Endpoints evaluated were the following: acute lung injury (ALI) score, time to achieve a fraction of inspired oxygen (Fio2) of 40% and a positive end-expiratory pressure (PEEP) of 5, length of ventilation, length of intensive care unit (ICU) stay, 90-day operative mortality, and patient survival rates. RESULTS The patient demographic data, underlying diagnosis, number of single and double lung transplants, use of cardiopulmonary bypass, and mean ischemic times were similar in all 3 groups. The mean ALI score (6.2, 5.8, and 6.0) and the median length of ventilation (23.5, 24.0, and 27.0 hours) in groups I, II, and III, respectively, were not significantly different. The length of ICU stay, the 90-day operative mortality, and the survival rates were not significantly different in the 3 groups. CONCLUSIONS Our results suggest that late retrograde perfusion of donor lungs does not decrease the severity of primary graft dysfunction when compared with standard antegrade techniques.

Endobronchial Dilation for the Management of Bronchial Stenosis in Patients after Lung Transplantation: Effect of Stent Placement on Survival

PURPOSE To compare the outcome of patients treated with balloon dilation and stent placement in the management of bronchial strictures after lung transplantation. MATERIALS AND METHODS Forty-one lung recipients were treated with balloon dilation or stent placement between January 1997 and July 2005. Stent placement was reserved for cases of bronchoplasty technical failure or restenosis. Clinical files and results of pulmonary function tests and bronchoscopic evaluation were reviewed. Dyspnea and cough were defined according to the Breathlessness, Cough, and Sputum Scale. Patient survival and bronchial patency after bronchial intervention were estimated with the Kaplan-Meier method and Cox proportional hazards regression with analysis of stent implantation as a cofactor. RESULTS Twenty-three of the 41 patients (56%) received a stent because of balloon dilation failure or stenosis recurrence. A total of 243 procedures were performed in 106 strictures (205 bronchoplasties and 38 stent insertions). At the first session, primary patency was higher in patients treated with stents (71%) than in those who underwent bronchoplasty (19%) (P = .037). Mean survival in patients with stents was longer than that in those who underwent bronchoplasty (82 vs 22 months, respectively), and stent insertion was associated with a 66% reduction in the risk of death (P < .02). Primary patency was 40 months for stented strictures versus 10 months for strictures treated with bronchoplasty (P < .02). Dyspnea and cough were improved after intervention (P < .001), and the forced expiratory volume in 1 second (FEV(1)) was ameliorated by 17% (P < .00003) at last follow-up. CONCLUSIONS Clinical outcome and FEV(1) were improved after bronchoplasty and stent placement. Longer patient survival and bronchial patency were observed after stent insertion.

Postoperative imaging after lung transplantation.

Lung transplantation (LT) is an established procedure for chronic end-stage lung diseases. Complications are frequent and diverse and are the consequence of the complex surgical technique, the severity of the initial pathology, and the deep state of posttransplantation immunosuppression. Complications following LT include primary graft dysfunction, rejection (hyperacute, acute, and chronic), infections, posttransplantation lymphoproliferative disease, pleural and airway complications, native lung complications, and recurrence of primary disease. An understanding of these complications, their temporal evolution, and the role of radiology and other diagnostic methods in their diagnosis and management will help reduce the morbidity and mortality associated with LT.

Rapid progression of Barrett's esophagus into adenocarcinoma in a combined lung and kidney transplant recipient

The incidence of cancer in solid organ transplant recipients is significantly greater than that of the general population. This increase is related to the intensity and duration of the immunosuppressive therapy. We herein present a rare case in which Barrett’s esophagus (BE) rapidly progressed into invasive adenocarcinoma after a patient with scleroderma underwent combined lung and kidney transplantation.

Double lung transplantation in an HIV-positive patient with Mycobacterium kansasii infection

Good outcomes with kidney and liver transplantation in HIV‐positive patients have led clinicians to recommend lung transplantation in HIV‐positive patients based on extrapolated data. Pre‐transplant mycobacterial infection is associated with an increased risk of developing new infection or aggravating existing infection, though it does not contraindicate transplantation in non‐HIV–infected patients. However, no data exists regarding the outcome of HIV‐positive patients with pre‐transplant mycobacterial infection. We report a case of double lung transplantation in a 50‐year‐old HIV‐positive patient with alpha‐1 antitrypsin deficiency. Prior to transplantation, Mycobacterium kansasii was isolated in one sputum culture and the patient was considered merely colonized as no clinical evidence of pulmonary or disseminated disease was present. The patient successfully underwent a double lung transplantation. Nontuberculous mycobacterial infection was diagnosed histologically on examination of native lungs. Surveillance and watchful waiting were chosen over treatment of the infection. HIV remained under control post‐transplantation with no AIDS‐defining illnesses throughout the follow‐up. A minimal acute rejection that responded to increased corticosteroids was reported. At 12 months post‐transplant, a bronchiolitis obliterans syndrome was diagnosed after a drop in FEV1. No evidence of isolation nor recurrence of nontuberculous mycobacteria was reported post‐transplantation. At 15 months post‐transplant, the patient remained stable with an FEV1 of 30%. The presence of pre‐transplant nontuberculous mycobacterial infection did not translate into recurrence of nontuberculous mycobacterial infection post‐transplant. Whether it contributed to bronchiolitis obliterans syndrome remains unknown.