Keiji Goto

Living-donor lobar lung transplantation for various lung diseases

OBJECTIVE We report on our early experience in living-donor lobar lung transplantation for patients with various lung diseases including restrictive, obstructive, septic, and hypertensive lung diseases. METHODS From October 1998 to March 2002, living-donor lobar lung transplantation was performed in 14 patients with end-stage lung diseases. There were 11 female patients and 3 male patients, with ages ranging from 8 to 53 years, including 4 children and 10 adults. Diagnoses included primary pulmonary hypertension (n = 6), idiopathic interstitial pneumonia (n = 2), bronchiolitis obliterans (n = 2), bronchiectasis (n = 2), lymphangioleiomyomatosis (n = 1), and cystic fibrosis (n = 1). Bilateral living-donor lobar lung transplantation was performed in 13 patients and right single living-donor lobar lung transplantation was performed for a 10-year-old boy with primary pulmonary hypertension. RESULTS All the 14 patients are currently alive with a follow-up period of 4 to 45 months. Although their forced vital capacity (1327 +/- 78 mL, 50.2% of predicted) was limited at discharge, arterial oxygen tension on room air (98.5 +/- 1.8 mm Hg) and systolic pulmonary artery pressure (24.8 +/- 1.6 mm Hg) were excellent. Forced vital capacity improved gradually and reached 1894 +/- 99 mL, 67.4% of predicted, at 1 year. All donors have returned to their previous lifestyles. CONCLUSIONS Living-donor lobar lung transplantation can be applied to restrictive, obstructive, septic, and hypertensive lung diseases. This type of procedure can be an alternative to conventional cadaveric lung transplantation for both pediatric and adult patients who would die soon otherwise.

Transcatheter closure of atrial septal defect in a geriatric population

Objectives: To evaluate the efficacy and safety of transcatheter closure of atrial septal defects (ASD) in patients over 70 years of age. Background: Transcatheter closure of ASD is an established procedure in children and young adults, but the benefits of this procedure in geriatric patients are still unclear. Methods: Between 2005 and 2010, 430 patients with ASD underwent transcatheter closure in our hospital. Among those patients, 30 consecutive patients older than 70 years of age were prospectively evaluated. Results: Mean age at procedure was 75.8 ± 3.8 years (range: 70–85 years). Mean Qp/Qs was 2.4 ± 0.7 and mean ASD diameter was 20.3 ± 6.4 mm. Nine patients (30%) had a history of hospitalization due to heart failure. ASD closure was successfully performed in 28 patients (93%) without significant complications. During the follow‐up period (mean period of 19.1 ± 11.3 months), New York Heart Association (NYHA) functional class was significantly improved in 20 patients (74%). Significant improvements of plasma BNP level, resting heart rate, and systolic pulmonary artery pressure were also observed. Improvement of tricuspid regurgitation was observed in 11 of 17 patients with moderate or severe regurgitation during the follow‐up period. Conversely, worsening of mitral regurgitation was observed in 10 of the 27 patients. Conclusion: Transcatheter closure of ASD in geriatric patients can be performed safely. This procedure contributes to significant improvement of symptoms and positive cardiac remodeling. Long‐term follow‐up is mandatory, especially for patients with mitral regurgitation.

Bilateral Lung Volume Reduction Surgery via Median Sternotomy for Severe Pulmonary Emphysema

BACKGROUND Lung volume reduction surgery either via sternotomy or by thoracoscopy has been demonstrated to be effective for selected emphysema patients in North America and Europe. The present study summarizes short-term results of bilateral lung volume reduction performed via median sternotomy for the first consecutive 39 patients with severe diffuse emphysema in Okayama, Japan, from July 1995 to February 1997. METHODS There were 35 men and 4 women, and the age range was 54 to 74 years with a mean age of 65 years. All were former heavy smokers and none of them had alpha1-antitrypsin deficiency. Only 9 patients (23%) showed a bilateral upper lobe pattern of emphysema. The operation was done through a median sternotomy, and the most emphysematous portions were excised bilaterally with a linear stapling device fitted with strips of bovine pericardium to prevent air leakage. RESULTS No operative death was encountered. The first 33 patients completed 3-month follow-up assessment, and their mean forced expiratory volume in 1 second had improved by 41% from 735 mL to 1,037 mL. Other parameters of pulmonary function tests, arterial blood gas analysis, 6-minute walking distance, and dyspnea scale also had improved significantly. These improvements lasted for at least a year. CONCLUSIONS Bilateral lung volume reduction surgery via median sternotomy is a safe and effective procedure for selected severe emphysema patients. Although the pattern of emphysema might be different between countries, the results in Japanese patients were similar to those previously reported in North American and European patients.

Right but not left ventricular function recovers early after living-donor lobar lung transplantation in patients with pulmonary arterial hypertension

OBJECTIVE The aim of this study was to evaluate right and left ventricular functions in patients with pulmonary arterial hypertension after living-donor lobar lung transplantation compared with those without hypertension. METHODS Thirty-three recipients of living-donor lobar lung transplantation were divided into two groups: those with pulmonary arterial hypertension (PAH group; n = 12) and those without (non-PAH group; n = 21). Their systolic pulmonary artery pressure was 93.1 +/- 6.7 mm Hg versus 31.4 +/- 2.9 mm Hg, respectively. Right and left ventricular ejection fractions, systolic pulmonary artery pressure, and cardiac index were serially measured by radionuclide ventriculography and right heart catheterization, respectively. RESULTS Pretransplant right and left ventricular ejection fractions were lower in the PAH group (29.8% +/- 7.0%, 49.9% +/- 6.6%) than in the non-PAH group (49.7% +/- 3.3%, 65.2% +/- 1.9%) (P = .010, .068). Two months after living-donor lobar lung transplantation, right ventricular ejection fraction and systolic pulmonary artery pressure in the PAH group (57.3% +/- 5.1%, 25.7 +/- 1.8 mm Hg) improved dramatically, equal to those in the non-PAH group. In contrast, left ventricular ejection fraction and cardiac index in the PAH group (50.9% +/- 3.7%, 2.66 +/- 0.12 L x min(-1) x m(-2)) were still significantly lower than in the non-PAH group (65.4% +/- 2.8%, 3.13 +/- 0.15 L x min(-1) x m(-2)) (P = .0038, .037). At 6 to 12 months, the PAH group demonstrated a significant rise in left ventricular ejection fraction and cardiac index that reached similar values in the non-PAH group measured at 2 months. These values were stable for up to 3 years. CONCLUSIONS Right ventricular function recovered early after living-donor lobar lung transplantation in the PAH group. In contrast, recovery of left ventricular function required 6 to 12 months. Improved cardiac function was sustained for up to 3 years, suggesting long-term durability of cardiac function recovery after living-donor lobar lung transplantation.

Calcineurin Inhibitor-Related Cholestasis Complicating Lung Transplantation

Hepatotoxicity, including cholestasis, is a rare but significant complication of treatment with calcineurin inhibitors. Timely life-saving therapy with revision of immunosuppression is mandatory. A 43-year-old woman with pulmonary hypertension was found to have severe cholestasis (serum bilirubin up to 35 mg/dL) after a living-donor lobar lung transplantation. Calcineurin-inhibitor cholestasis markedly improved after withdrawal of the calcineurin inhibitor, initiation of sirolimus, and interleukin-2 receptor blockade. Awareness of the diagnostic criteria of this rare posttransplant complication is important to initiate timely therapy.

Successful Lung Transplantation in a Case With Diffuse Pulmonary Arteriovenous Malformations and Hereditary Hemorrhagic Telangiectasia

Diffuse pulmonary arteriovenous malformations (AVMs) are associated with a poor prognosis and the therapeutic strategy remains controversial. We describe a pediatric patient with diffuse pulmonary AVMs associated with hereditary hemorrhagic telangiectasia (HHT), who presented with two cerebral AVMs in the parietal and occipital lobes as well. Of note, successful bilateral lung transplantation not only improved the hypoxemia but also resulted in size reduction of the cerebral AVMs. Although it is essential to consider involvements other than pulmonary AVMs, especially brain AVMs, to decide the indication, lung transplantation can be a viable therapeutic option for patients with diffuse pulmonary AVMs and HHT.

Extracorporeal Membrane Oxygenation Bridging to Living-Donor Lobar Lung Transplantation

A 21-year-old man with pulmonary fibrosis and a 27-year-old woman with idiopathic pulmonary hypertension, who were in pulmonary hypertensive crisis, were successfully treated by using venoarterial extracorporeal membrane oxygenation, followed by living-donor lobar lung transplantation. In both of the patients, bridging time of extracorporeal membrane oxygenation to lung transplantation was 2 days, and both could be weaned from cardiopulmonary support immediately after transplantation in the operating room. No major complications were seen, including primary graft dysfunction. The cardiopulmonary functions of these patients markedly improved after living-donor lobar lung transplantation.

Rapid development of severe interstitial pneumonia caused by epoprostenol in a patient with primary pulmonary hypertension

A young woman with primary pulmonary hypertension developed severe interstitial pneumonia (IP) 5 days after induction of epoprostenol infusion. Although the pathogen involved was not identified, her IP was initially responsive to steroids, and discontinuation of steroid therapy caused the redevelopment of IP. After intensive treatment, including steroid therapy and inhaled nitric oxide, epoprostenol was successfully switched to prostaglandin E(1) infusion and she recovered. Epoprostenol infusion can cause a rapid severe IP, even soon after the induction of therapy. Clinicians should keep this syndrome in mind, especially when treating a severe case of IP.

Favorable outcomes after living-donor lobar lung transplantation in ventilator-dependent patients

PurposeLiving-donor lobar lung transplantation (LDLLT) is performed in critically ill patients, although the outcome is generally expected to be poor for those who are ventilator dependent. The aim of this study was to compare the outcomes of LDLLT in ventilator-dependent patients compared with those in ventilator-independent patients.MethodsWe reviewed 31 consecutive patients who received LDLLT between October 1998 and May 2004.ResultsFive patients were ventilator dependent and 26 were ventilator independent. All five ventilator-dependent patients were female, with a mean age of 29.6 years. The duration of preoperative ventilation was 23.4 ± 5.7 days. The underlying diagnoses in the ventilator-dependent patients included only obstructive (n = 3) and infectious lung diseases (n = 2), whereas those in the ventilator-independent patients included hypertensive and restrictive diseases (P = 0.004). There were no significant differences between the groups in early postoperative clinical values. The incidences of acute rejection and bronchiolitis obliterans syndrome (BOS) were comparable. The 5-year survival rates were 100% for the ventilator-dependent patients and 92.3% for the ventilator-independent patients (P = 0.45).ConclusionOur findings suggest that LDLLT can have a favorable outcome in selected ventilator-dependent patients.

An adult with ARDS managed with high-frequency oscillatory ventilation and prone position

tion. The preoperative chemotherapy had been started 11 days before the operation and had finished 9 days before the operation. On the first postoperative day, a chest radiograph revealed bilateral infiltrates, and he was diagnosed as having acute lung injury (ALI), or ARDS, according to the definition of the American-European consensus conference on ARDS [7]. On the second postoperative day, marked neutropenia was observed (neutrophils, 200/μl; leukocytes, 1800/μl), and granulocyte colonystimulating factor (G-CSF; 75μg/day) was administered subcutaneously for 2 days. On the third postoperative day, oxygenation and hemodynamics deteriorated after the second administration of G-CSF. One hour before the second administration of G-CSF, arterial oxygen tension (PaO2) was 73.3mmHg and arterial carbon dioxide tension (PaCO2) was 39.6 mmHg with pressure support ventilation; fractional inspired oxygen (FIO2) was 0.7, positive end-expiratory pressure (PEEP) was 7cmH2O, and pressure support, 18cmH2O (PaO2/FIO2 (P/F) ratio, 104.7). Two hours after the second G-CSF, PaO2 was 47.6mmHg and PaCO2 was 36.4mmHg with the same ventilator settings (P/F ratio, 68.0). Arterial blood pressure was 75/45mmHg, and central venous pressure was 15mmHg with dopamine, 5μg·kg 1·min 1 and dobutamine, 4 μg·kg 1·min 1. Although his hemodynamics improved with norepinephrine, 0.2μg·kg 1·min 1 and dopamine, 10μg·kg 1·min 1, urine output transiently decreased and continuous hemodiafiltration (CHDF) was started. Oxygenation did not improve and ventilation worsened in spite of the use of aggressive ventilator settings under conditions of sedation (continuous infusion of fentanyl and propofol) and muscle relaxation. PaO2 was 62.6 mmHg and PaCO2 was 52.4mmHg (pH 7.28) with pressure-controlled ventilation (PCV); FIO2, 1.0; PEEP, 10 cmH2O; distending pressure, 25 cmH2O; respiratory frequency, 30/min. This resulted in a tidal volume of 0.35 l, minute volume of 10.5 l/min, mean airway pressure (MAP) of 22.5 cmH2O,