Ramesh Kesavan

Emerging drugs in lung transplantation.

The balance between immunosuppression to ensure graft tolerance while preventing emergence of infectious complications is key in lung transplantation. Although opportunistic infection may appear to be the most important of these complications, malignancies and severe drug toxicities significantly affect the short- and long-term outcomes of the patients. The present practice is combination therapy using drugs with complementary immunosuppressive action, to achieve synergistic immunosuppression with the lowest possible toxicity. Components of immunosuppression include induction and maintenance regimens. Primary graft failure remains an important cause of mortality and morbidity in the immediate post-transplant period. Acute rejection is a common complication after lung transplant, but responds well to augmented immunosuppression and immunomodulation. Chronic rejection still is the major cause of mortality in patients who survive the initial year post-transplantation. Several new drugs have shown promise in decreasing the rate of loss of graft function. This review discusses the current and emerging therapeutic regimens.

Utility of CMR in monitoring of lung transplant recipients

Methods We enrolled 16 consecutive lung transplant recipients who were referred for CMR evaluation at The Methodist DeBakey Heart & Vascular Center (The Methodist Hospital, Houston, TX). Eight subjects were men and eight women; mean age 59.1 ± 9.2 years, 12 Caucasians, 2 Hispanic, 1 African American and 1 Asian. Six subjects had underlying restrictive (IPF), five had obstructive (COPD/ Emphysema/Cystic fibrosis), and three had other (BOOP/ hypersensitivity pneumonitis) disorders. Nine subjects had undergone double lung transplant while 7 subjects had single lung transplant, a mean of 17.9 ± 18.8 months prior to undergoing CMR imaging. The CMR protocol included complete short and long axis cine imaging using SSFP pulse sequences, spin echo imaging to assess pericardial thickness, contrast enhanced MRA of the pulmonary arterial and venous systems, phase contrast velocity flow mapping [for main, right and left pulmonary artery (PA) flows, and PA anastomotic site peak velocities]. All subjects underwent echocardiography, chest CTA, LPI and RHC as deemed necessary by their transplant pulmonologist. The records of all diagnostic tests were reviewed and compared with CMR findings.

EVALUATION OF VENOUS THROMBOEMBOLIC EVENTS IN LUNG TRANSPLANT RECIPIENTS

PURPOSE: The incidence of venous thromboembolisms (VTE) remains high after lung transplant (LT) . The purpose of this study was to identify the incidence and potential risk factors of VTE in LT patients at a single center. METHODS: A retrospective analysis was conducted on 52 recipients between January and December 2008. Post-operative VTEs were identified based upon radiographic scans, venous doppler reports, and lung biopsies during the transplant admission. The following risk factors were assessed: pre-transplant diagnosis, functional status, cardiopulmonary bypass use, intraoperative or perioperative factor VII administration,post operative Extra Corporeal membrane Oxygenator (ECMO), use of deep vein thrombosis (DVT) prophylaxis, body mass index, and type of transplant(single vs double). RESULTS: Patients were primarily male (71%) and Caucasian (56%) with a mean age of 56.3 ± 11.4 years. The most common pre transplant diagnoses were pulmonary fibrosis (PF) (46%) and chronic obstructive pulmonary disease (29%). The overall incidence of patients developing a VTE was 19.2% (n = 10). Four patients had a DVT alone (2 upper extremity/body), 3 patients had both a DVT and a pulmonary embolism (PE), and 3 patients had a PE alone. Of the 3 patients who had PE alone their postoperative course was complicated by lobar torsion, pulmonary venous anastamotic stenosis and Primary Graft Dysfunction requiring ECMO support.Patients with upper extremity/body DVT were associated with jugular triple lumen catheters or peripherally inserted central catheter placement. Mean time to development of a DVT was 7.7 ± 4.4 days. Of the variables assessed only pre-transplant diagnosis of PF was independently associated with VTE (p = 0.0164) while lack of DVT prophylaxis did not reach significance. CONCLUSION: The incidence of VTE (19.2%)is high in LT population. Pre-transplant diagnosis of PF was identified as a risk factor for VTE. A larger sample size may be needed to validate these and other findings. CLINICAL IMPLICATIONS: Patients with PF are at high risk for VTE. Surveillance for DVT prophylaxis,early ambulation and avoidance of procoagulant clotting factors like factor VII may prevent VTE. DISCLOSURE: Erin Elliott, No Financial Disclosure Information; No Product/Research Disclosure Information Tuesday, November 3, 2009