Julian A. Smith

Bilateral sequential single lung transplantation for pulmonary hypertension and Eisenmenger's syndrome

BACKGROUNDnLung transplantation, with and without intracardiac repair for pulmonary hypertension (PH) and Eisenmengers syndrome (EIS), has become an alternative transplant strategy to combined heart and lung transplantation (HLT).nnnMETHODSnThirty-five patients with PH or EIS underwent either bilateral sequential single lung transplantation (BSSLT, group I, n = 13) or HLT (group II, n = 22). Another 74 patients, who underwent BSSLT for other indications, served as controls (group III). Immediate allograft function, early and medium-term outcomes, lung function, and 2-year survival were compared between the groups.nnnRESULTSnComparisons between groups I and II showed no significant difference in any variables except percent predicted forced vital capacity. Immediate allograft function was significantly inferior (p < 0.05) and the blood loss was greater (p < 0.01) in group I when compared with those in group III. However, this resulted in no significant difference in early and medium-term outcomes, and 2-year survival between the 2 groups.nnnCONCLUSIONSnBSSLT for PH and EIS can be performed as an alternative procedure to HLT without an increase in early and medium-term morbidity and mortality. Results are comparable with BSSLT performed for other indications.

Lung volume reduction surgery in emphysema: a systematic review

The aim of this study was to systematically review the literature regarding the safety and efficacy of lung volume reduction surgery (LVRS) in patients with emphysema. Studies on LVRS to August 2000 were identified using MEDLINE, Embase, Current Contents, and the Cochrane Library. Human studies of patients with upper, lower or diffuse distributions of emphysema were included. All types of bullous emphysema were excluded. A surgeon and researcher independently assessed the retrieved articles for their inclusion in the review. When LVRS was compared with medical management, at 2 years LVRS was associated with a higher FEV1 and at least equivalent survival. The use of staple excision of selected areas of lung appeared to be more efficacious than laser ablation. There is insufficient evidence to show preference for median sternotomy or videoscopically assisted thoracotomy, as the more safe and efficacious procedure. In highly selected patients with emphysema LVRS is deemed an acceptable treatment. To fully evaluate the safety and efficacy of LVRS, outcomes beyond 2 years must be included. The results of prospective randomized trials between medical management and LVRS, now in progress, are essential before a final assessment can be made.

Impact of graft ischemic time on outcomes after bilateral sequential single-lung transplantation

BACKGROUNDnGraft ischemic time (GIT) is a potential limiting factor in lung transplantation.nnnMETHODSnSeventy-four patients who underwent bilateral sequential single-lung transplantation were divided into three groups: group I, GIT less than 5 hours (n = 20); group II, GIT between 5 and 8 hours (n = 39); and group III, GIT more than 8 hours (n = 15). We compared early allograft function (ratio of arterial oxygen tension to inspired oxygen fraction and alveolar-arterial oxygen gradient), blood loss, the need for tracheostomy, the duration of ventilation, intensive care unit stay, and hospital stay. We also compared prevalences of acute and chronic rejection, airway complications, lung function test, and 2-year survival.nnnRESULTSnEarly allograft function in group III was significantly worse than those in groups I and II. However, there was no significant difference in any other variables of early and medium-term outcomes among the three groups. No significant correlation was detected between GIT and duration of intensive care unit stay or hospital stay.nnnCONCLUSIONSnThe limitation of acceptable GIT could be extended from the traditionally approved 4 to 5 hours, to 5 to 8 hours or even longer.

Saphenous vein graft pseudoaneurysm formation after postoperative mediastinitis

Pseudoaneurysm formation involving the body of an aortocoronary saphenous vein graft is a rare event. True aneurysmal dilatation of the graft and anastomotic pseudoaneurysm formation occur more commonly. We present the case of a 73-year-old woman in whom a pseudoaneurysm communicating with the body of a posterior descending coronary artery saphenous vein graft developed, presumably after a postoperative sternal wound infection. The aneurysm was excised and the defect within the saphenous vein graft repaired using hypothermia and circulatory arrest.

Predictors of perioperative morbidity and mortality in lung volume reduction surgery

BACKGROUNDnSelection criteria for lung volume reduction surgery are still being refined. We sought to determine whether preoperative features could be used to predict early morbidity or mortality.nnnMETHODSnWe reviewed preoperative characteristics of the first 89 patients who underwent lung volume reduction surgery at the Alfred Hospital. Data included arterial blood gases, prednisolone use, pulmonary function tests, 6-minute walk test, and anesthetic time. Length of stay and reintubation for respiratory failure were used as markers of morbidity.nnnRESULTSnFindings included PaCO2 of 43 +/- 0.7 mm Hg, PaO2 70 +/- 1.1 mm Hg, percent predicted values for forced expiratory volume in 1 second 29.6% +/- 0.8%, TLCO% predicted 35.2 +/- 1.4%, and 6-minute walk test of 315 +/- 10.6 m (mean +/- SEM). Mean length of stay was 19 +/- 2 days, with 17 (19%) patients reintubated for respiratory failure. Mortality rate was 5.6% at 1 year post surgery, with no deaths in patients less than 65 years old. Multivariate analysis revealed that length of stay, reintubation and mortality were predicted by age and surgical time (p < 0.05), with no correlation with any other variables tested. Age greater than 70 years was associated with a significant risk of mortality (OR 9.0; p = 0.04).nnnCONCLUSIONSnAge greater than 70 years and anesthetic time greater than 210 minutes predict both perioperative morbidity and mortality.

Sonne Dysentery in Aberdeen.

1. In the absence of the epidemic prevalence of the dysenteries over a period of 30 months it is found that cases of the various forms of dysentery as occurring in Aberdeen have been in the proportion of 1 amoebic, to 3 Flexner, to 6 Sonne dysenteries, and it is concluded that B. dysenteriae Sonne is the most frequent cause of dysenteric outbreaks in Aberdeen in non-epidemic times. 2. A description of the clinical and bacteriological features of Sonne dysentery is submitted. 3. Preliminary experiments, undertaken with a view to ascertaining whether B. dysenteriae Sonne produces a true exo-toxin, are described.

Technique and Results of Cardiac Transplantation Using “Domino‐Donor” Hearts

Abstract Heart‐lung transplantation is now well established for treatment of patients with terminal cardiopulmonary disease. More than 50% of heart‐lung transplant recipients have normal or near normal hearts, with the majority having some degree of right ventricular hypertrophy. This potential source of “prepared” cardiac allografts remained untapped until the introduction of the “domino‐donor” operation, a procedure in which the heart‐lung recipient serves as a cardiac donor. The implantation of these available allografts contributes to the alleviation of the short supply of donor organs for cardiac transplantation. Aspects of the surgical technique, results, and potential benefits of this procedure are presented.

Massive hyperkalemia during combined heart-lung transplantation: inadvertent contamination with modified Euro-Collins solution

C OMBINED HEART-LUNG transplantation (HLTX) is an accepted form of treatment for selected patients with end-stage cardiopulmonary failure. More than 500 procedures have been performed since its inception in 1981, with some 150 cases performed annually worldwide. Pneumoplegic preservation of the donor lungs and storage during transport involve the use of specialized solutions. At this hospital, 130 transplantation procedures have been performed, 19 of which have been combined HLTXs (13 “domino” donor operations). Modified Euro-Collins solution* (60 mL/kg) has been used as a pneumoplegic solution, preceded by prostacyclin infusion (5 to 20 ng/kg/ min for 5 minutes) into the pulmonary artery.’

Bronchoscopic lung volume reduction (BLVR) using bronchial prostheses: a pilot safety and efficacy study

Lung volume reduction surgery(LVRS) can provide symptomatic improvement in patients with advanced emphysema. Both the open and video-assisted approaches to LVRS are associated with significant morbidity and mortality. Selective bronchoscopic placement of prostheses into segmental bronchi has the potential to achieve LVRS by promoting absorption atelectasis without an incision or intercostal drainage. Aim: this phase 1 study reports the safety and efficacy of BLVR. Methods: following successful sheep experiments, patients with apical emphysema and hyperinflation (otherwise acceptable for standard approach LVR) had apical bronchoscopic segmental airway placement of one-way valves under general anesthesia. The 4 or 6mm valves were silicone based and mounted in a Nitinol bronchial stent (Emphasys Medical Inc, CA, USA). Placement was over a guidewire under bronchoscopic and fluoroscopic control. Results: 5 patients(2M,3F, age 57-69yrs)underwent BLVR. Mean preoperative FEV1 was 0.72L(0.38-1.02L, 23-34% predicted)with a 6minute walk of 354m(315-402m).6-11 prostheses per patient took 90-135 minutes to obstruct most or all upper lobe segments bilaterally. Inpatient stay was 2-8 days. Relatively minor complications seen include minor exacerabtion of COPD(n 3), hemoptysis, pneumothorax(managed with aspiration only) and lower lobe pneumonia(n 1 for each). Symptomatic improvement is noted in 3 of 5 and the other 2 are currently stable. At 1 month lung function is unchanged in 4 patients and imaging shows collapse in only 1 patient. Conclusion: BLVR is a potentially useful novel therapy for emphysema. This pilot study shows that BLVR protheses can be safely placed into the human lung. The absence of xray lung reduction or spirometric improvement likely indicates significant collateral ventilation is occurring, possibly from previously undescribed interlobar collaterals. Alternatively, valve leakage remains possible. Extended followup studies, with active attempts to collapse the obstructed segments are pending.

Early hemodynamic effects of left atrial administration of epinephrine after cardiac transplantation.

We studied the hemodynamic effects of left atrial (LA) administration of epinephrine in 10 patients after cardiac transplantation, using a prospective, randomized, double-blind, cross-over design. After allograft implantation, a LA catheter was inserted and epinephrine infusion commenced at 100 ng [centered dot] kg-1 [centered dot] min-1. Each trial period consisted of 20 min, with the LA and right atrial (RA) lines switched over between each period; hemodynamic measurements were taken after each time period. Whether epinephrine was administered via the RA or LA did not significantly alter hemodynamics (RA versus LA): mean (SD) arterial blood pressure 67 (7.5) vs 64 (9.5) mm Hg (P = 0.16), mean pulmonary artery pressure 22 (4.0) vs 21 (9.4) mm Hg (P = 0.67), cardiac index 3.2 (1.1) vs 3.2 (1.1) L [centered dot] min-1 [centered dot] m-2 (P = 0.83), pulmonary vascular resistance index 308 (157) vs 345 (157) dynes [centered dot] s [centered dot] cm-5/m-2 (P = 0.30) or right ventricular ejection fraction 35% (11%) vs 32% (9.8%) (P = 0.23). Arterial epinephrine plasma levels were similar (P = 0.16). There was no significant pulmonary extraction of measured catecholamines. We observed no hemodynamic benefit of LA epinephrine administration. It may be that the cardiac transplantation population reacts differently compared with other cardiac surgical patients (possibly because pulmonary extraction of catecholamines is reduced). Because we did not observe a hemodynamic advantage in patients immediately after cardiac transplantation, we would not recommend the use of LA epinephrine at the dose studied. (Anesth Analg 1997;84:976-81)