Erol V. Belli

Lung cancer following lung transplant: Single institution 10 year experience

BACKGROUND Lung cancer following lung transplantation is an infrequent occurrence of post-transplant neoplasia. Tumors are classified based on donor or recipient origin. Recipient tumors can be diagnosed in explanted specimens or found in contralateral native lungs which remain in place during single lung transplant (SLTx). The aim of our study was to review our institutions incidence of post lung transplant lung cancer, describe tumor histology, and review our experience with their outcomes. METHODS A total of 335 lung transplants from 2001 to 2010 were reviewed. Patients were identified with a post-transplant diagnosis of lung cancer, neoplasia, or mass. Fifteen patients were identified; two were excluded due to concomitant cancers with which the lung cancer would represent a metastasis. Retrospective chart review was undertaken for thirteen patients for descriptive statistics, tumor characteristics and overall survival. RESULTS Overall incidence of lung cancer following transplant was 13 cases (3.88%). Six tumors were found in native explanted lungs and six developed subsequently in native lungs. One tumor was confirmed to be of donor origin. Histology included squamous cell in five (38.4%), adenocarcinoma in four (30.7%), and one patient each with adenosquamous (7.6%), carcinoid (7.6%), small cell (7.6%), or malignant solitary fibrous tumor (7.6%). Mean age at transplant was 65 ± 3 years. Mean time from transplant to diagnosis is reported as 241 ± 7 days (range 1-1170). Each patient had at least a 20 pack year smoking history with a mean of 45 ± 3 years. One-year survival for those with lung cancer following transplant was 42.8% while 1 year survival of all lung transplants at our institution is 85.7%. CONCLUSION Lung cancer incidentally found at the time of transplant or following transplantation is a serious complication with a noted effect on overall survival. The infrequent occurrence of donor tumors represents an adequate screening process of potential young donor lungs. The recognition of cancers in explanted specimens brings to question policies regarding screening of potential recipients with extensive smoking history. A high index of suspicion for native tumors is needed when conducting post-transplant surveillance as these tumors tend to be stage 4 at time diagnosis.

Preoperative risk factors predict survival following cardiac retransplantation: Analysis of the United Network for Organ Sharing database

BACKGROUND The aim of our study was to identify preoperative risk factors affecting overall survival after cardiac retransplantation (ReTX) in a contemporary era. METHODS The United Network for Organ Sharing database was used to identify patients undergoing ReTX between 1995 and 2012. Of the total 28,464 primary transplants performed, 987 (3.5%) were retransplants. The primary outcome investigated was overall survival. The influence of preoperative donor and recipient characteristics on survival were then tested with univariate logistic regression and multivariate Cox regression models. RESULTS Of 987 patients who underwent ReTX, median survival was 9 years. Estimated survival at 1, 3, 5, 10, and 15 years following retransplant was 80% (95% confidence interval [CI], 78%-83%), 70% (95% CI, 67%-73%), 64% (95% CI, 61%-67%), 47% (95% CI, 43%-51%), and 30% (95% CI, 25%-37%), respectively. Clinical predictors of survival using multivariable analysis included donor age (relative risk [RR], 1.14; P = .004), ischemic time > 4 hours (RR, 1.48; P = .004); preoperative support with extracorporeal membrane oxygenator (RR, 3.91; P < .001), and the time between previous and current transplant (P = .004). Patients with ReTX have 1.27 times higher relative risk of death compared with patients undergoing primary transplant only (RR, 1.27; 95% CI, 1.13-1.42; P < .001). CONCLUSIONS Patients who undergo cardiac ReTX can expect to have a 1-year survival less than a patient undergoing primary transplant with an acceptable median overall survival. Both donor and recipient preoperative factors contribute to overall survival following cardiac ReTx. Donor characteristics include age of the donor and ischemic time. Recipient factors include the need for extracorporeal membrane oxygenator and the number of days between the first and second transplant. Optimal survival following cardiac ReTX can best be predicted by choosing patients who are farther out from their initial transplant, not dependent upon preoperative extracorporeal support, and by choosing donor hearts younger in age and those likely to have shorter ischemic times.

Treatment of a mycotic descending thoracic aortic aneurysm using endovascular stent-graft placement and rifampin infusion with postoperative aspiration of the aneurysm sac

Purpose: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. Case report: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. Conclusion: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.

Primary pericardial mesothelioma: A rare cause of constrictive pericarditis:

A 42-year-old man presented with relapsing acute pericarditis. He had a remote history of Hodgkin’s lymphoma, diagnosed at the age of 17 years, and treated with external beam radiation. Examination showed jugular venous distention, muffled heart sounds, and grade Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 599–600 The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313517384 aan.sagepub.com

Partial Anomalous Pulmonary Venous Return in a Lung Transplant Recipient

Partial anomalous pulmonary venous return (PAPVR) is a rare condition in which some of the pulmonary veins empty into the systemic venous system. The presence of PAPVR in a lung transplant recipient may cause technical challenges during transplantation. We present a technique for left atrial reconstruction when faced with a recipient with PAPVR. The patient had a left superior pulmonary vein that emptied into the brachiocephalic vein without a left atrial connection. Because of the discrepancy in size of the 2 donor and the single recipient pulmonary veins, left atrial reconstruction was performed before venous anastomosis.

Electric Shock–Induced Coronary Artery Thrombosis and Dissection

Electric shock-induced myocardial infarction is rare. Shock-induced coronary artery thrombosis and dissection in multiple distributions have not been reported. After shock, coronary thrombosis may cause anginal symptoms, and any coronary artery may be damaged. A 32-year-old man presented with angina and ischemia-related symptoms after 6,000-V electric shock. He reported occasional exertional angina; the stress echocardiography result was positive for ischemia. Cardiac catheterization showed severe multivessel disease, an occluded left anterior descending coronary artery, and an occluded circumflex artery with collateralization to the distal left anterior descending coronary artery. Surgical intervention detected global coronary dissection and thrombosis. Bypass grafting achieved complete revascularization. The patient was successfully discharged home.