Jasmine Huang

Extracorporeal membrane oxygenation as a bridge to lung transplantation: A single-center experience in the present era

Objective: Extracorporeal membrane oxygenation has been used as a bridge to lung transplantation in patients with rapid pulmonary function deterioration. The reported success of this modality and perioperative and functional outcomes are varied. Methods: We retrospectively reviewed all patients who underwent lung transplantation at our institution over 1 year (January 1, 2015, to December 31, 2015). Patients were divided into 2 groups depending on whether they required extracorporeal membrane oxygenation support as a bridge to transplant; preoperative characteristics, lung transplantation outcomes, and survival were compared between groups. Results: Of the 93 patients, 12 (13%) received bridge to transplant, and 81 (87%) did not. Patients receiving bridge to transplant were younger, had higher lung allocation scores, had lower functional status, and were more often on mechanical ventilation at listing. Most patients who received bridge to transplant (n = 10, 83.3%) had pulmonary fibrosis. Mean pretransplant extracorporeal membrane oxygenation support was 103.6 hours in duration (range, 16‐395 hours). All patients who received bridge to transplant were decannulated immediately after lung transplantation but were more likely to return to the operating room for secondary chest closure or rethoracotomy. Grade 3 primary graft dysfunction within 72 hours was similar between groups. Lung transplantation success and hospital discharge were 100% in the bridge to transplant group; however, these patients experienced longer hospital stays and higher rates of discharge to acute rehabilitation. The 1‐year survival was 100% in the bridge to transplant group and 91% in the non–bridge to transplant group (log‐rank, P = .24). The 1‐year functional status was excellent in both groups. Conclusions: Extracorporeal membrane oxygenation can be used to safely bridge high‐acuity patients with end‐stage lung disease to lung transplantation with good 30‐day, 90‐day, and 1‐year survival and excellent 1‐year functional status. Long‐term outcomes are being studied.

Gastroparesis is common after lung transplantation and may be ameliorated by botulinum toxin-A injection of the pylorus

aPTT may be falsely elevated and may lead to insufficient anticoagulation if dosing UFH from aPTT levels. This is a preliminary report in a small number of patients. However, the incidence of thrombosis is high in LVAD patients and all potential causes need to be reported quickly so that they can be investigated in larger numbers and at multiple institutions. Several hypotheses need to be tested in LVAD patients, including: exclusive monitoring of anti-Xa levels (or a combination of anti-Xa and aPTT) and the increased risk of bleeding when monitoring anti-Xa levels. Our results suggest that aPTT levels underestimate anti-coagulation in LVAD patients and monitoring UFH with anti-Xa levels more accurately reflects the level of anti-coagulation.

Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease

Objectives: Gastroesophageal reflux disease (GERD) is prevalent after lung transplantation. Fundoplication slows lung function decline in patients with GERD, but the optimal timing of fundoplication is unknown. Methods: We retrospectively reviewed patients who underwent fundoplication after lung transplantion at our center from April 2007 to July 2014. Patients were divided into 2 groups: early fundoplication (<6 months after lung transplantation) and late fundoplication (≥6 months after lung transplantation). Annual decline in percent predicted forced expiratory volume in 1 second (FEV1) was analyzed. Results: Of the 251 patients who underwent lung transplantation during the study period with available pH data, 86 (34.3%) underwent post‐transplantation fundoplication for GERD. Thirty of 86 (34.9%) had early fundoplication and 56 of 86 (65.1%) had late fundoplication. Median time from lung transplantation to fundoplication was 4.6 months (interquartile range, 2.0–5.2) and 13.8 months (interquartile range, 9.0–16.1) for the early and late groups, respectively. The median DeMeester score was comparable between groups. One‐, 3‐, and 5‐year actuarial survival rates in the early group were 90%, 70%, and 70%, respectively; in the late group, these rates were 91%, 66%, and 66% (log rank P = .60). Three‐ and 5‐year percent predicted FEV1 was lower in the late group by 8.9% (95% confidence interval, −30.2 to 12.38; P = .46) and 40.7% (95% confidence interval, −73.66 to −7.69; P = .019). A linear mixed model showed a 5.7% lower percent predicted FEV1 over time in the late fundoplication group (P < .001). Conclusions: In this study, patients with early fundoplication had a higher FEV1 5 years after lung transplantation. Early fundoplication might protect against GERD‐induced lung damage in lung transplant recipients with GERD.

Coexistent Non–Small Cell Carcinoma and Small Cell Carcinoma in a Patient Presenting with Hyponatremia

Despite recent advances in screening methods, lung cancer remains the leading cause of cancer-related deaths worldwide. By the time lung cancer becomes symptomatic and patients seek treatment, it is often too advanced for curative measures. Low-dose computed tomography (CT) screening has been shown to reduce mortality in patients at high risk of lung cancer. We present a 66-year-old man with a 50-pack-year smoking history who had a right upper lobe (RUL) pulmonary nodule and left lower lobe (LLL) consolidation on a screening CT. He reported a weight loss of 45 pounds over 3 months, had recently been hospitalized for hyponatremia, and was notably cachectic. A CT of the chest showed a stable LLL mass-like consolidation and a 9 × 21 mm subsolid lesion in the RUL. Navigational bronchoscopy biopsy of the RUL lesion revealed squamous non–small cell lung cancer (NSCLC). Endobronchial ultrasound-guided transbronchial needle aspiration of the LLL lesion revealed small cell lung cancer (SCLC). The final diagnosis was a right-sided Stage I NSCLC (squamous) and a left-sided limited SCLC. The RUL NSCLC was treated with stereotactic radiation; the LLL SCLC was treated with concurrent chemotherapy and radiation. In patients with multiple lung nodules, a diagnosis of synchronous multiple primary lung cancers (MPLCs) is crucial, as inadvertent upstaging of patients with MPLC (to T3 and/or T4 tumors) can lead to erroneous staging, inaccurate prognosis, and improper treatment. Recent advances in the diagnosis of small pulmonary nodules via navigational bronchoscopy and management of these lesions dramatically affect a patients overall prognosis.

Outcomes of lung transplant recipients with preoperative atrial fibrillation

Background Preoperative atrial fibrillation is associated with poor outcomes after cardiac surgery, but its effect on lung transplantation outcomes remains unknown. Methods We retrospectively reviewed the charts of 235 patients who underwent lung transplantation in our institution from 2013 to 2015, analyzing demographics, length of stay, survival, readmissions, and cardiac events. Mean recipient age was 59 ± 11 years, and 142 (60.4%) were men. Patients were grouped according to pre-transplantation atrial fibrillation status (atrial fibrillation/no atrial fibrillation). Results The atrial fibrillation group (n = 38; 16.2%) was significantly older with a longer ischemic time, more postoperative atrial arrhythmias (73.7% vs. 20.8%, p = 0.01), and a longer median postoperative length of stay (16 vs. 13 days, p = 0.02). The median total hospital stay in the first postoperative year was also higher in the atrial fibrillation group (27 vs. 21 days, p = 0.25). Short-term survival and survival during follow-up did not differ significantly between groups. Conclusions Lung transplant recipients with preoperative atrial fibrillation are at increased risk of adverse cardiovascular outcomes and longer hospital stay. Preoperative atrial fibrillation may portend adverse events after lung transplantation.