Philippe Puyo

Lung transplantation from initially rejected donors after ex vivo lung reconditioning: the French experience

OBJECTIVES Only 15% of brain death donors are considered suitable for lung transplantation (LTx). The normothermic ex vivo lung perfusion technique is used to potentially increase the availability of high-risk lung donors. We report our experience of LTx with initially rejected donors after ex vivo lung reconditioning (EVLR). METHODS From April 2011 to May 2013, we performed EVLR for 32 pairs of donor lungs deemed unsuitable for transplantation and rejected by the 11 French lung transplant teams. After EVLR, lungs with acceptable function were transplanted. During the same period, 81 double-lung transplantations (DLTx) were used as controls. RESULTS During EVLR, 31 of 32 donor lungs recovered physiological function with a median PO2/FiO2 ratio increasing from 274 (range 162-404) mmHg to 511 (378-668) mmHg at the end of EVLR (P < 0.0001). Thirty-one DLTx were performed. The incidence of primary graft dysfunction 72 h after LTx was 9.5% in the EVLR group and 8.5% in the control group (P = 1). The median time of extubation, intensive care unit and hospital lengths of stay were 1, 9 and 37 days in the EVLR group and 1 (P = 0.17), 6 (P = 0.06) and 28 days (P = 0.09) in the control group, respectively. Thirty-day mortality rates were 3.3% (n = 1) in the EVLR group and 3.7% (n = 3) in the control group (P = 0.69). One-year survival rates were 93% in the EVLR group and 91% in the control group. CONCLUSIONS EVLR is a reliable and repeatable technique that offers a significant increase of available donors. The results of LTx with EVLR lungs are similar to those obtained with conventional donors.

Techniques and results of lobar lung transplantations

OBJECTIVES We report our experience of lobar lung transplantations (LLTs) in patients with small thoracic volume. METHODS Since 1988, 50 LLTs were done for cystic fibrosis (n=35), fibrosis (n=7), bronchiectasis (n=3), emphysema (n=3) and lymphangiomyomatosis (n=2). There were 44 females and 6 males (mean age 31±13 years, mean size 155±5.5 cm and mean predicted total lung capacity (TLC) 4463±598 ml). Mean ratio between donor and recipient-predicted TLC was 1.65±0.26. Six patients were listed in high emergency, 2 of them on ECMO as a bridge to transplantation. Forty middle/lower right lobe with left lower LLT, four bilateral lower LLT and six split left lung LLT were performed through a clamshell incision (n=12) or a bilateral antero-lateral thoracotomy (n=38), with epidural analgesia in 17 cases. Thirty-two patients were transplanted under circulatory support (CPB n=16, veno-arterial ECMO n=16). In 11 cases, the right venous anastomosis was enlarged by a pericardial cuff. Ischaemic time was 4.4±1.2 h for the first lobe and 6.1±1.3 h for the second. RESULTS Median mechanical ventilation weaning time was 10.5 (1-136) days. Four patients were extubated in the operating room. Ten patients needed ECMO for primary graft dysfunction. In-hospital mortality was 28% related to sepsis (n=6), PGD (n=3), haemorrhage (n=2), broncho-vascular fistula (n=1), and multiorgan failure (n=2). Eight patients required endoscopic treatments for airway complications. Mean best FEV1 was 72±16% of the theoretical value. The actuarial 3-year and 5-year survival rates were 60 and 46%, respectively. CONCLUSIONS LLTs are a reliable solution and can be performed with satisfactory functional results and survival rates.

Advances in lung transplantation for cystic fibrosis that may improve outcome

OBJECTIVE To study the advances in the management of lung-transplanted patients for cystic fibrosis in our centre and their impact on the outcome. METHODS A retrospective study has included 100 patients who underwent lung transplantation for cystic fibrosis between 1 January 1990 and 15 January 2007. There were 78 sequential double-lung transplantations and 22 lobar transplantations. This series has been equally divided in two groups according to the date of transplantation: group I, before September 2003 and, group II, after September 2003. RESULTS Recipient characteristics were similar in both groups. In group II, donors were older (40 vs 33 years, respectively, P=0.013), with lower partial pressure of oxygen in arterial blood (PaO(2))/fractional inspired oxygen (FiO(2)) ratios (372 vs 427 mmHg, P=0.022). In group II, recipients received, more often, thoracic epidural analgesia (n=35 vs n=13, P<0.001), the surgical approach was mostly a sternum-sparing bilateral anterior thoracotomy (n=42 vs n=9, P<0.001), and lobar transplantations were performed more frequently (n=15 vs n=7, P=0.30). Early tracheal extubation was more frequent in group II (P=0.005). The overall median survival time was 52 months. In the first group, 1-, 2- and 3-year survival rates were 75%, 65% and 55%, respectively, whereas in the second group, these survival rates were 88%, 78% and 69%, respectively (P=0.09). CONCLUSIONS The acceptance of marginal donors and the frequent practice of lobar transplantations allowed an increasing number of lung transplantations for cystic fibrosis over time. Concomitantly, the extensive use of thoracic epidural analgesia has increased the rate of early extubation and contributed to a trend towards a survival improvement.

The Wire-Guided Endobronchial Blocker as a Solution To Provide One-Lung Ventilation When a Double-Lumen Endotracheal Tube Is Malpositioned

DOUBLE-LUMEN endotracheal tubes are the most commonly used tubes for lung isolation. The indications for use of bronchial blockers, such as the Univent single-lumen endotracheal tube with enclosed bronchial blocker (Fuji Systems Corporation, Tokyo, Japan),1 or the wire-guided endobronchial blocker (Cook Critical Care, Bloomington, IN)2, are debatable.3,4 The use of the wire-guided endobronchial blocker is reported for rescue in a patient who presented for thoracoscopy and for whom surgery was difficult because of an improperly positioned left-sided double-lumen endotracheal tube.

High Emergency Lung Transplantation: dramatic decrease of waiting list death rate without relevant higher post-transplant mortality

Many candidates for lung transplantation (LT) die on the waiting list, raising the question of graft availability and strategy for organ allocation. We report the experience of the new organ allocation program, “High Emergency Lung Transplantation” (HELT), since its implementation in our center in 2007. Retrospective analysis of 201 lung transplant patients, of whom 37 received HELT from 1st July 2007 to 31th May 2012. HELT candidates had a higher impairment grade on respiratory status and higher Lung Allocation Score (LAS). HELT patients had increased incidence of perioperative complications (e.g., perioperative bleeding) and extracorporeal circulatory assistance (75% vs. 36.6%, P = 0.0005). No significant difference was observed between HELT and non‐HELT patients in mechanical ventilation duration (15.5 days vs. 11 days, P = 0.27), intensive care unit length of stay (15 days vs. 10 days, P = 0.22) or survival rate at 12 (81% vs. 80%), and 24 months post‐LT (72.9% vs. 75.0%). Lastly, mortality on the waiting list was spectacularly reduced from 19% to 2% when compared to the non‐HELT 2004–2007 group. Despite a more severe clinical status of patients on the waiting list, HELT provided similar results to conventional LT. These results were associated with a dramatic reduction in the mortality rate of patients on the waiting list.

Intraoperative occurrence of a pneumopericardium during double-lung transplantation.

Pneumopericardium is rare and has been reported secondary to chest trauma. We report a case of tension pneumopericardium occurring during double-lung transplantation, where intraoperative transoesophageal echocardiography first showed a hypokinetic left ventricle and a few minutes later a compression of its anterolateral portion due to pneumopericardium. Although the pericardium was opened, left ventricular function remained depressed, necessitating extracorporeal membrane oxygenation, which was withdrawn after 48 h of assistance when left ventricular function had recovered. The patient was extubated on the seventh postoperative day but died of multiorgan failure on the 64 th postoperative day.

Giant Pulmonary Arteriovenous Fistula

2010 by The Society of Thoracic Surgeons ublished by Elsevier Inc stula (9 7.5 6 cm). On a 3-dimensional CT scan Fig 2, Fig 3), a 1.6 cm-diameter-dystrophic arterial (DA) ranch of the middle lobe artery and a 2 cm-diameterystrophic venous (DV) branch of the middle lobe vein ere well identified. Laboratory studies showed partial pressure of arterial xygen of 46 mm Hg, partial pressure of arterial carbon ioxide of 40 mm Hg, arterial oxygen saturation of 73%, nd hemoglobinemia (22 g/dL). Neither pulmonary hyertension nor a second vascular malformation was ound. There was a clear indication for treatment [1]. Howver, artery embolization was contraindicated because he coil would have migrated into the systemic circulaion. A middle lobectomy was performed, and as the ystrophic artery was ligated, digital pulse oximetry mmediately rose to 100%.

ASSESSMENT OF LUNG EDEMA DURING EX-VIVO LUNG PERFUSION BY SINGLE TRANSPULMONARY THERMODILUTION: A PRELIMINARY STUDY IN HUMANS

BACKGROUND Single transpulmonary thermodilution (SD) with extravascular lung water index (EVLWI) could become a new tool to better assess lung graft edema during ex-vivo lung perfusion (EVLP). In this study we compare EVLWI with conventional methods to better select lungs during EVLP and to predict post-transplant primary graft dysfunction (PGD). METHODS We measured EVLWI, arterial oxygen/fraction of inspired oxygen (P/F) ratio, and static lung compliance (SLC) during EVLP in an observational study. At the end of EVLP, grafts were accepted or rejected according to a standardized protocol blinded to EVLWI results. We compared the respective ability of EVLWI, P/F, and SLC to predict PGD. Mann-Whitney U-test, Fishers exact test, and receiver-operating characteristic (ROC) curve data were used for analysis. p < 0.05 was considered statistically significant. RESULTS Thirty-five lungs were evaluated by SD during EVLP. Three lungs were rejected for pulmonary edema. Thirty-two patients were transplanted, 8 patients developed Grade 2 or 3 PGD, and 24 patients developed Grade 0 or 1 PGD. In contrast to P/F ratio, SLC, and pulmonary artery pressure, EVLWI differed between these 2 populations (p < 0.001). The area under the ROC for EVLWI assessing Grade 2 or 3 PGD at the end of EVLP was 0.93. Donor lungs with EVLWI >7.5 ml/kg were more likely associated with a higher incidence of Grade 2 or 3 PGD at Day 3. CONCLUSIONS Increased EVLWI during EVLP was associated with PGD in recipients.

Lung cancer in renal transplant recipients: A case-control study

INTRODUCTION Solid organ transplant patients are at heightened risk of several cancers compared to the general population. Secondary to a higher number of procedures and better survival after transplantation, cancer is a rising health concern in this situation. Limited data exist for lung cancer (LC) after renal transplantation. We report here the most important series of renal transplant recipients with lung cancer. METHODS Retrospective study of all cases of LC diagnosed in three French Renal Transplant Units from 2003 to 2012. A control group consisted of non-transplant patients with LC matched with the cases for age (<30; 30-50; 50-65; >65 years), gender and diagnosis date. We recruited two controls for each case. RESULTS Thirty patients (median age 60 years; range 29-85; male/female ratio 80/20%) with LC were analysed. LC incidence was 1.89/1000 person-years over the period 2008-2012. All patients were former or active smokers (median 30 pack-years). Transplanted patients had significantly more comorbidities, mainly cardiovascular disease. The median interval of time from kidney transplantation (KT) to diagnosis of LC was 7 years (range 0.5-47 years). LC was incidentally diagnosed in 40%. Most patients (70%) had advanced LC (stage III or IV) disease. Stage of LC at diagnosis was similar in cases and controls. Surgery and chemotherapy were proposed to the same proportion of patients. In cases, mortality was cancer related in 87% and median survival time after diagnosis was 24 months. Survival was not significantly different between the 2 groups. CONCLUSION Despite frequent medical and radiological examinations, diagnosis of LC is usually made at an advanced stage and the overall prognosis remains poor.