Kevin Landolfo

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.

Randomized, multicenter trial comparing sternotomy closure with rigid plate fixation to wire cerclage

Objective: To evaluate sternal healing, complications, and costs after sternotomy closure with rigid plate fixation or wire cerclage. Methods: This prospective, single‐blinded, multicenter trial randomized 236 patients at 12 US centers at the time of sternal closure to either rigid plate fixation (n = 116) or wire cerclage (n = 120). The primary endpoint, sternal healing at 6 months, was evaluated by a core laboratory using computed tomography and a 6‐point scale (greater scores represent greater healing). Secondary endpoints included sternal complications and costs from the time of sternal closure through 6 months. Results: Rigid plate fixation resulted in better sternal healing scores at 3 (2.6 ± 1.1 vs 1.8 ± 1.0; P < .0001) and 6 months (3.8 ± 1.0 vs 3.3 ± 1.1; P = .0007) and greater sternal union rates at 3 (41% [42/103] vs 16% [16/102]; P < .0001) and 6 months (80% [81/101] vs 67% [67/100]; P = .03) compared with wire cerclage. There were fewer sternal complications through 6 months with rigid plate fixation (0% [0/116] vs 5% [6/120]; P = .03) and a trend towards fewer sternal wound infections (0% [0/116] vs 4.2% [5/120]; P = .06) compared with wire cerclage. Although rigid plate fixation was associated with a trend toward greater index hospitalization costs (

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

23,437 vs

Mycobacterium infection from a cardiopulmonary bypass heater-cooler unit in a patient with steroid-induced immunosuppression

20,574; P = .11), 6‐month follow‐up costs tended to be lower (

Retained cardiac implantable electronic device fragments are not associated with magnetic resonance imaging safety issues, morbidity, or mortality after orthotopic heart transplant

9002 vs

Primary pericardial mesothelioma: A rare cause of constrictive pericarditis:

13,511; P = .14). As a result, total costs from randomization through 6 months were similar between groups (

Partial Anomalous Pulmonary Venous Return in a Lung Transplant Recipient

32,439 vs

Mycobacterium infection from a cardiopulmonary bypass heater-cooler unit in a patient with steroid-induced immunosuppression@@@Infection par mycobacterium via un générateur thermique utilisé pendant la circulation extracorporelle chez une patiente immunosupprimée suite à un traitement de stéroïdes

34,085; P = .61). Conclusions: Sternotomy closure with rigid plate fixation resulted in significantly better sternal healing, fewer sternal complications, and no additional cost compared with wire cerclage at 6 months after surgery.

Infection par mycobacterium via un générateur thermique utilisé pendant la circulation extracorporelle chez une patiente immunosupprimée suite à un traitement de stéroïdes

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.

Survival After Lung Retransplantation in the United States in the Current Era (2004 to 2013): Better or Worse?

PurposeTo present a case of mycobacterium infection transmitted through a heater-cooler unit during cardiac bypass surgery.Clinical featuresA 63-yr-old woman with a past medical history of aortic coarctation repair in 1963 and a mechanical aortic valve replacement in 2010 was prescribed antibiotics and steroids at an outpatient care facility in September 2015 for symptoms of an upper respiratory tract infection. Four months later, she developed malaise and intermittent fever with anemia and acute kidney dysfunction. Extensive evaluation revealed negative blood cultures but was suggestive of amyloidosis. The patient was therefore started on systemic steroids prior to being referred to us.At our institution, transesophageal echocardiography and cardiac magnetic resonance imaging revealed a normal mechanical aortic prosthesis with an aortic root abscess. The patient was started on empiric antibiotics for endocarditis. Renal biopsy revealed interstitial nephritis with one granuloma for which she was again started on high-dose steroids. The patient continued to deteriorate, with worsening renal function and pancytopenia that required daily red blood cell and platelet transfusions.Three weeks into this hospitalization, her blood cultures were reported to be positive for Mycobacterium chimera, and she was started on a four-drug regimen of rifampin, rifabutin, ethambutol, and clarithromycin, with dramatic clinical improvement.ConclusionHeater-cooler units manufactured by LivaNova prior to September 2014 and used during cardiopulmonary bypass have been linked to M. chimera, which causes a latent infection that may be activated and become disseminated in cases of immunosuppression related to steroid use.RésuméObjectifPrésenter un cas de mycobacterium transmis par un générateur thermique pendant une chirurgie de pontage coronarien.Éléments cliniquesUne femme de 63 ans ayant subi une réparation d’une coarctation de l’aorte en 1963 et un remplacement valvulaire aortique mécanique en 2010 a reçu une prescription pour des antibiotiques et des stéroïdes dans un centre de soins ambulatoires en septembre 2015 en raison de symptômes d’infection des voies respiratoires supérieures. Quatre mois plus tard, elle a eu un malaise et des fièvres intermittentes accompagnées d’anémie et d’insuffisance rénale aiguë. Un examen approfondi a révélé des cultures sanguines négatives mais les symptômes étaient évocateurs d’une amyloïdose, c’est pourquoi un traitement à base de stéroïdes systémiques a été amorcé avant de référer la patiente à notre institution.Dans notre centre, une échocardiographie transœsophagienne et une imagerie par résonance magnétique cardiaque ont révélé une prothèse aortique mécanique normale accompagnée d’un abcès au niveau de l’anneau aortique. Un traitement empirique d’antibiotiques a été amorcé chez la patiente pour traiter une endocardite. Une biopsie rénale a révélé une néphrite interstitielle avec un granulome, et on lui a à nouveau prescrit des stéroïdes à fortes doses. L’état de la patiente a continué à se détériorer et sa fonction rénale à empirer, et une pancytopénie est apparue, laquelle a nécessité des transfusions quotidiennes d’érythrocytes et de plaquettes.Trois semaines après son hospitalisation, ses cultures sanguines étaient positives pour le Mycobacterium chimera et un régime posologique de quatre médicaments, soit la rifampicine, la rifabutine, l’éthambutol et la clarithromycine a été mis en place. Ce traitement a entraîné des améliorations cliniques spectaculaires.ConclusionLes générateurs thermiques utilisés pendant la circulation extracorporelle fabriqués par LivaNova (Munich, Allemagne) avant septembre 2014 ont été associés à la M. Chimera, une infection latente qui peut être précipitée et devenir une infection disséminée dans les cas d’immunosuppression liée à l’utilisation de stéroïdes.