Julie Prenovault

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.

Pericardial Fat Necrosis Presenting as Acute Pleuritic Chest Pain

A 58-year-old man presented to the Emergency Department with a 4-day history of acute and progressive left pleuritic chest pain. The chest pain appeared suddenly, awakening the patient in the middle of the night. There was no history of trauma or associated dyspnea. Pain was not entirely relieved by non-steroidal anti-inflammatory drugs (NSAIDS). Prior medical history was relevant for diabetes, hypertension, and dyslipidemia. There were no risk factors for pulmonary embolus. On examination, the patient was cooperative and alert. Vitals signs were normal. Physical examination revealed decreased air entry in the left lower lung. Calves were non-tender and not swollen. The initial chest X-ray study showed a rise of the left hemidiaphragm and small left pleural effusion (Figure 1). Laboratory values were normal, with negative cardiac enzyme levels and D-dimers. The electrocardiogram (ECG) showed a normal sinus rhythm with a right bundle branch block, the exact same result as an ECG done 5 years prior (Figure 2). The patient’s pain was relieved by morphine. Probability for pulmonary embolus was intermediate at ventilation-perfusion scintigraphy, which demonstrated a ventilation-perfusion mismatch in the lateral basal segment of the left lower lobe. Intravenous heparin was started. Due to the result of lung scintigraphy, a pulmonary computed tomography (CT) angiography was requested. CT angiography did not show any signs of pulmonary embolism, although distal vascular evaluation at both lung bases was limited due to respiratory artifacts.

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.

Comparison of the effect of low- and iso-osmolar contrast agents on heart rate during chest CT angiography: Results of a prospective randomized multicenter study

PURPOSE To prospectively compare the effect of intravenous injection of low-osmolar iopamidol with that of intravenous injection of iso-osmolar iodixanol on heart rate (HR) during nongated chest computed tomographic (CT) angiography. MATERIALS AND METHODS This multicenter study was approved by local institutional review boards, and patients provided written informed consent. Patient enrollment and examination at centers in the United States complied with HIPAA regulations. One hundred and thirty patients (54 male; mean age, 52 years) clinically suspected of having pulmonary embolism were referred for pulmonary CT angiography and were randomly assigned to receive 80 mL of either iopamidol (370 mg of iodine per milliliter, n = 63) or iodixanol (320 mg of iodine per milliliter, n = 67) at a rate of 4 mL/sec. HR (measured in beats per minute) was monitored from 5 minutes before the start of injection to the end of imaging, and precontrast HR and maximum postcontrast HR were recorded. Student t and χ(2) tests were used for continuous and categorical variables, respectively. RESULTS Precontrast HR in patients who received iopamidol (mean, 81 beats per minute ± 18 [standard deviation]) was similar to that in patients who received iodixanol (mean, 77 beats per minute ± 17) (P = .16). Mean postcontrast HR was 87 beats per minute ± 17 and 82 beats per minute ± 18 (P = .16) in the iopamidol and iodixanol groups, respectively. Mean increase from precontrast HR to postcontrast HR was 5 beats per minute ± 9 and 5 beats per minute ± 7 (P = .72) in the iopamidol and iodixanol groups, respectively. Thirty-five (56%) of the 63 patients who received iopamidol and 33 (49%) of the 67 patients who received iodixanol had an HR increase of fewer than 5 beats per minute, 15 (24%) and 18 (27%) patients, respectively, had an increase of 5-9 beats per minute, and four (6%) and three (4%) patients, respectively, had an increase of more than 20 beats per minute. These proportions were not significantly different between the groups (P = .51, χ(2) test). CONCLUSION High-rate intravenous administration of 80 mL of iopamidol and iodixanol during pulmonary CT angiography slightly increased HR; there was no difference in HR between the contrast agent groups.

Chest Computed Tomography Screening in Colorectal Cancer Patients

We read with interest the article ‘‘Clinical usefulness of chest radiography in detection of pulmonary metastases after curative resection for colorectal cancer’’ that was published in the July 2007 issue of World Journal of Surgery [1]. In a retrospective analysis of patients after curative resection for colorectal cancer, the authors showed that the sensitivity of abdominal computed tomography (CT) with lower thorax images was superior to chest radiography for lung metastasis detection. They concluded that elevating the upper level of the scan during abdominal CT or performing chest CT could result in higher detection of lung metastases. As Lee et al. noted, reports evaluating CT versus radiography for detecting pulmonary metastases in the context of colorectal cancer have been few and somewhat inconsistent [2, 3]. In our center, we did a prospective study in a selected subset of 96 patients undergoing preoperative evaluation for liver metastases resection, 90% of which were from colorectal cancer, with intrapatient comparison of chest radiography and whole-chest CT for the detection of lung metastases. Neoplastic confirmation of lung lesions was done either by lung biopsy or evidence of growth on follow-up. Lung metastases were present in 13 patients (13.5%). Chest CT was more sensitive than radiography and alone prevented unnecessary liver surgery in three patients (3.1%) in whom chest radiography was normal. Four other chest CT-positive/chest radiography-negative patients were not operated on based on the nonresectability of liver lesions demonstrated by abdominal CT. In six patients, lung metastases were demonstrated by both chest CT and radiography. Incidental CT visualization of indeterminate small lung nodules (too small for characterization with biopsy or positron emission tomography) remains a potential drawback of routine chest CT for colorectal cancer in a small number of patients. Those patients require follow-up chest CT [4]. Since our prospective study, we have included chest CT in the preoperative evaluation of our patients for colorectal liver metastases resection. This is especially valuable with the wider indications of surgical resection of liver metastases allowed by the use of improved combination chemotherapy regimens [5].

Percutaneous CT-guided lung interventions-local pleural anesthesia.

Local pleural anesthesia during percutaneous lung interventions is an important part of the procedure that has not been standardized in the literature. Significant pain can be experienced during lung biopsies, which may affect the outcome of intervention. We describe a step-by-step method of anesthesia targeting the most sensitive anatomical structure involved: the parietal pleura.