Omeros Artemiou

Accuracy of echocardiographic right ventricular parameters in patients with different end-stage lung diseases prior to lung transplantation.

BACKGROUND Because there are few data available on the accuracy of 2D-echocardiography to assess right ventricular (RV) size and function in patients with far-advanced lung disease, in this prospective study, we compared various echocardiographic RV parameters with RV volumes derived from magnetic resonance imaging (MRI). METHODS In 32 patients (18 male, 17 female) presenting for lung transplantation, we measured RV end-diastolic and end-systolic area as well as derived RV fractional area change, long-axis diameter, short-axis diameter, tricuspid valve anulus diameter (using 2D apical or sub-costal 4-chamber view), and RV end-diastolic diameter (using M-mode in the parasternal short-axis view). These values were compared with RV end-diastolic and end-systolic volumes derived by MRI, serving as the gold standard. RESULTS Right ventricular end-diastolic area was the most accurate echocardiographic parameter of RV size (correlation to MRI: r = 0.88, p < 0.001), followed by RV end-diastolic short-axis diameter (r = 0.75, p < 0.001), long axis diameter (r = 0.66, p < 0.001), and tricuspid valve anulus diameter (r = 0.63, p < 0.001). In contrast, M-mode measurement of RV end-diastolic diameter was possible in only 24/35 (68%) patients and showed a weak correlation to MRI-derived RV end-diastolic volume (r = 0.56, p = 0.004). Right ventricular fractional area change correlated well with MRI-derived RV ejection fraction (r = 0.84, p < 0.0001). In a sub-group analysis, patients with vascular lung disease showed best agreement between both methods for RV end-diastolic area and RV fractional area change compared with patients with restrictive or obstructive lung disease. CONCLUSION This study shows that in patients with far-advanced lung diseases, RV end-diastolic area demonstrated the best correlation with MRI-derived measurement of RV end-diastolic volume, and RV fractional area change compared favorably with MRI-derived ejection fraction. Despite reduced image quality, especially in patients with obstructive lung disease, these parameters can yield clinically valuable information.

Comparison between mycophenolate mofetil- and azathioprine-based immunosuppressions in clinical lung transplantation.

BACKGROUND The aim of the study was to assess the impact of mycophenolate mofetil (MMF) on the early phase after lung transplantation. PATIENTS AND METHODS Thirty-eight consecutive patients between November 1994 and January 1997 were treated with cyclosporine, prednisolone, antithymocyte globuline induction therapy, and either MMF (n = 21) or azathioprine (Aza) (n = 17). Four patients from the MMF group and 2 patients from the Aza group were intubated and in the ICU prior to transplantation. Demographic data and primary diagnosis were comparable. MMF was administered at a dosage of 2 gm/day whereas Aza was initiated at 2 mg/kg/day and adapted by leukocyte count. Three-month survival and incidence of rejections and infections were compared. RESULTS Six-month survival in the MMF group was 76% compared to 65% in the Aza group (n.s.). The mean number of acute rejection episodes in the MMF and Aza group were 0.29+/-0.10 and 1.53+/-0.29 (p<0.01) respectively. Transbronchial biopsy (TBB) results > or =grade 2 ISHLT were seen in 10% of MMF and in 43% of Aza-treated patients; completely free from rejection were 17 MMF and 3 Aza patients. The mean number of infections per patient in the MMF and Aza group were 1.57+/-0.29 and 2.29+/-0.40 respectively, bacterial (1.10 vs. 1.71), viral (0.35 vs. 0.33), and fungal (0.14 vs. 0.24) infections were the same in both groups. CONCLUSIONS These data result suggest that mycophenolate mofetil therapy is more effective in preventing rejection episodes in patients early after lung transplantation than therapy with azathioprine. We therefore conclude that MMF is a safe and effective drug to optimize immunosuppressive therapy in the early phase after lung transplantation.

Impact of different coverage techniques on incidence of postpneumonectomy stump fistula

OBJECTIVE Postpneumonectomy bronchial stump fistula (PBSF) is a serious complication with a reported incidence between 0 and 12%. The aim of this retrospective study was to investigate the effectiveness of different coverage techniques of the bronchial stump applied in a consecutive series of pneumonectomies in avoiding this particular problem. METHODS Between 1/87 and 10/97, 129 patients (90 male, 39 female, mean age 57.8 years, range: 15-78 years) underwent pneumonectomy by one surgeon (W.K.). In 14 patients, additional resection procedures were performed (aorta n = 6, vena cava n = 5, thoracic wall n = 3). In all patients with malignancies (n = 123), mediastinal lymphadenectomy was routinely added to the procedure. Bronchial stump closure was performed by means of stapling devices in all patients. Coverage of the bronchial stump was performed with a generous pedicled pericardial flap and concomitant reconstruction of the pericardium with Vicryl mesh (n = 50), with a portion of the posterior pericardium (n = 16), with the azygos vein (n = 12), with surrounding mediastinal tissue (n = 25), with pleura (n = 16), or with intercostal muscle flap (n = 3); no coverage at all was performed in seven patients. In all patients with high risk for development of PBSF, i.e. patients who received any form of neoadjuvant therapy or had extended resections, the pericardial flap technique was used. RESULTS Perioperative mortality was 5.4% (n = 7) and five patients (3.9%) experienced significant perioperative complications, with one of them directly related to the method of bronchial stump coverage (cardiac tamponade due to the use of a too small Vicryl mesh for reconstruction of the pericardium). Follow-up was 96.1% complete (five patients were lost to follow-up). Fourty-seven patients (36.4%) died late after operation (mean 19+/-13 months, median 17 months), mainly due to recurrence of their underlying malignant disease. PBSF occurred in one patient only (0.8%), 2 weeks after operation (coverage with pleura). No PBSF was seen in the long term follow-up period. CONCLUSION Coverage of the bronchial stump contributes to a low incidence of PBSF. In view of the fact, that this serious complication was completely avoided in the pericardial flap group (used in patients with expected higher risk for PBSF), this particular technique seems to offer the best results.

Transient left ventricular failure following bilateral lung transplantation for pulmonary hypertension

BACKGROUND Bilateral lung transplantation is an established therapy for end-stage pulmonary hypertension. Its early postoperative outcome may be biased by various complications resulting in unexpected deterioration of the patient in terms of hemodynamics and blood gases. METHODS We have reviewed the early postoperative course of patients who underwent bilateral lung transplantation for pulmonary hypertension at our institution and analyzed all available data, especially hemodynamic measurements, echocardiographic documentation and therapeutical strategies, in those cases where cardiac dysfunction was found to be responsible for clinical deterioration. RESULTS Three out of 20 lung transplant recipients operated for pulmonary hypertension experienced severe respiratory insufficiency accompanied by hemodynamic decompensation during the first days after surgery. Clinical and laboratory findings together with results of echocardiography and pulmonary artery catheterism helped establish the diagnosis of left ventricular failure. This proved to be transitory, but the response to therapy (inotropic drugs, afterload reduction and eventually prostaglandins) was very variable. Adequately treated, this complication did not preclude the outcome of transplantation by itself. CONCLUSION Left ventricular failure is a possible complication after lung transplantation for pulmonary hypertension. Echocardiography and pulmonary artery catheterism may be useful adjuvant diagnostic tools, beside routine physical examination, chest X-ray, and laboratory analysis. Therapy of this complication must be adapted individually and may be complex.

Pleurovenous shunting in the treatment of nonmalignant pleural effusion

BACKGROUND The goals of treatment of chronic nonmalignant pleural effusion are relief of dyspnea and improved quality of life. Treatment options include needle thoracentesis, tube thoracostomy chemical pleurodesis, and pleurectomy. Pleurovenous shunting (PVS) represents an alternative, minimally invasive method. METHODS Since 1999, 12 patients underwent pleurovenous shunting for right-sided pleural effusion in our center. Indications were hepatic hydrothorax (n = 6, one as bridging to liver transplantation), nephrotic syndrome (n = 4), and chylothorax (n = 2, one as bridging to lung transplantation). All patients received Denver shunt systems from the pleural cavity to either the subclavian or jugular vein. RESULTS Shunt occlusion was observed in one case (chylothorax) 4 weeks after implantation. There was one early death, which was not related to the procedure (hepatic failure). No air embolism or infection was observed. All systems were patent throughout the observation period of 1 to 40 months (mean = 13.3 months), and none of the patients required further treatment for pleural effusion. CONCLUSION Pleurovenous shunting offers an efficient, minimally invasive alternative to other surgical methods for treatment of recurrent nonmalignant pleural effusion.

Incidence and outcome of major non-pulmonary surgical procedures in lung transplant recipients

OBJECTIVE Pulmonary transplant recipients are at high risk from various conditions requiring surgical intervention. As little is known about their exact incidence and course, we examined such procedures in detail. METHODS AND PATIENTS We have retrospectively analyzed major nonpulmonary surgical procedures performed in 124 consecutive patients who received an isolated lung transplant at the University of Vienna between 1989 and December 1995. Twenty-two patients underwent a total of 28 major interventions (22/124 = 17.7%), resulting in an incidence of one procedure every 5.8 patient years of follow-up. The mean interval between transplantation and intervention was 17.9 months (range 3 days to 62 months) with six interventions being carried out during the first month after transplantation. Fourteen emergency operations were performed, the remaining 14 procedures were carried out electively. Overall, 15 abdominal procedures, four thoracic, four orthopedic, two gynecological, one neurosurgical, one urological and one plastic surgery were performed. RESULTS There was no intraoperative death. Perioperatively, five surgery related deaths were observed (5/28, related mortality 17.9%) with multiple organ failure as the cause of death in all cases. All of these deaths followed emergency operations (5/14 = 35.7%) and all were observed in patients with septic abdominal complications. In contrast, even very extensive procedures were performed electively without related mortality (0/14, P = 0.02). During the first month after transplantation, major surgery was associated with a 50% (3/6) mortality, for late interventions mortality was 9.1% (2/22; P = 0.047). CONCLUSIONS Pulmonary transplant recipients showed a high incidence of conditions requiring surgical intervention. As expected, septic complications, especially during the immediate post transplant period, carried a very poor prognosis. However, it was reassuring to observe that even extensive surgical procedures could be performed safely without associated mortality in the elective setting.

Transperitoneale Unterbindung des Ductus thoracicus zur Behandlung eines Chylothorax nach Lungentransplantation

ZusammenfassungGrundlagen: Chylothorax stellt eine seltene Komplikation nach thoraxchirurgischen Eingriffen dar. Falls die Beherrschung über diätetische Maßnahmen nicht gelingt, ist ein chirurgischer Eingriff nicht zu umgehen. Dabei kann das Risiko einer thorakalen Reintervention beträchtlich sein. Die transperitoneale Unterbindung des Ductus thoracicus im Bereich des Hiatus diaphragmaticus stellt eine alternative Eingriffsmöglichkeit dar.Methodik: Wir berichten über einen 41jährigen männlichen Patienten, bei dem unmittelbar nach unilateraler Lungentransplantation eine Chylusfistel auftrat. Nachdem die diätetische Fettrestriktion keinen Erfolg erbracht hatte, wurde eine offene parietale Pleurektomie durchgeführt. Da auch nach diesem Eingriff der Chylothorax persistierte und mittels Lymphographie eine hoch gelegene Chylusfistel dargestellt werden konnte, wurde die Indikation zur Reoperation gestellt. Um das Risiko eines dritten thorakalen Eingriffes zu vermeiden, wurden über eine mediane Laparotomie die Lymphbahnen im Bereich des Hiatus diaphragmaticus unterbunden.Ergebnisse: Es kam zu keinem weiteren Chylothorax und der Patient konnte in gutem Zustand entlassen werden.Schlußfolgerungen: Um das Risiko einer thorakalen Reinter-vention nach extensiven thoraxchirurgischen Eingriffen zu minimieren, ist die transperitoneale Unterbindung des Ductus thoracicus eine alternative Behandlungsmöglichkeit für Chylothorax.SummaryBackground: Chylothorax is an unfrequent complication after thoracic surgery. If conservative therapy fails, surgical treatment is indicated. The risk of a thoracic reintervention may be high in this setting. Transperitoneal ligation of the thoracic duct represents an alternative therapeutical strategy.Methods: We report about a 41 year old male patient who presented with a chylothorax immediately after right single lung transplantation. After dietary fat restriction had failed, an open pleurectomy was performed. Chylothorax still persisted, and a chylous fistula was detected by lymphography. In an attempt to minimize the risk of a third thoracic operation, a ligature of the lymph vessels at the level of the diaphragmatic hiatus was performed through a median laparotomy.Results: Chylothorax did not reoccur and the patient was finally discharged.Conclusions: Transperitoneal ligation of the thoracic duct is an alternative therapeutical strategy with little operative risk for chylothorax after extensive thoracic surgery.

Right ventricle lipoma with pseudoaneurysmatic appearance

The case of a 78-year-old female patient, with a large lipoma (13 x 17 x 10 cm) of the right ventricle, appearing pseudoaneurysmatic, is presented. Radical resection left a considerable right ventricle wall and interventricular septum defect which was reconstructed with a bovine pericardium patch.

Single versus bilateral lung transplantation

Following the initial success with heart/lung transplantation in Stanford (8), the first successful single lung transplant was accomplished by the Toronto team in 1983 (9). In recent years phenomenal progress has been made in the application of lung transplantation for patients with end-stage pulmonary disease. Experiences of individual groups have challenged old dogmas and led to new approaches in all facets of lung transplantation. However, it still remains in debate which form of lung transplantation represents the optimal treatment for the specific indications. Despite the clinical acceptance of both, single and double lung transplantation, their role and potential has still to be determined. This refers to the clarification of the ideal indications, to the functional benefit, as well as to the long-term outcome that can be reached with each technique. In this chapter, the various aspects of single and double lung transplantation are discussed.