S. Scheinin

Combined lung and liver transplantation: Analysis of a single-center experience

Patients with end‐stage lung disease complicated by cirrhosis are not expected to survive lung transplantation alone. Such patients are potential candidates for combined lung‐liver transplantation (CLLT), however few reports document the indications and outcomes after CLLT. This is a review of a large single‐center CLLT series. Eight consecutive CLLT performed during 2009‐2012 were retrospectively reviewed. One patient received a third simultaneous heart transplant. Mean age was 42.5 ± 11.5 years. Pulmonary indications included cystic fibrosis (CF) (n = 3), idiopathic pulmonary fibrosis (n = 2), α1‐antitrypsin deficiency (AATD) (n = 1) and pulmonary hypertension (n = 2). Liver indications were CF (n = 3), hepatitis C (n = 2), AATD (n = 1), cryptogenic (n = 1), and cardiac/congestive (n = 1). Urgency was reflected by median lung allocation score (LAS) of 41 (36.0‐89.0) and median predicted FEV1 of 25.7%. Median donor age was 25 (20‐58) years with median cold ischemia times of 147 minutes and 6.1 hours for lung and liver, respectively. Overall patient survival at 30 days, 90 days and 1 year was 87.5%, 75.0% and 71.4% respectively. One patient had evidence of acute lung rejection, and no patients had liver allograft rejection. Early postoperative mortalities (90 days) were caused by sepsis in 2 recipients who exhibited the highest LAS of 69.9 and 89.0. The remaining recipients had a median LAS of 39.5 and 100% survival at 1‐year. Median length of stay was 25 days (7‐181). Complications requiring operative intervention included bile duct ischemia (n = 1) and bile leak (n = 1), ischemia of the bronchial anastomosis (n = 1), and necrotizing pancreatitis with duodenal perforation (n = 1). This series reflects a large single‐center CLLT experience. Sepsis is the most common cause of death. The procedure should be considered for candidates with LAS < 50. Liver Transpl 20:46–53, 2014.

Combined lung and liver transplantation

Patients with end‐stage lung disease complicated by cirrhosis are not expected to survive lung transplantation alone. Such patients are potential candidates for combined lung‐liver transplantation (CLLT), however few reports document the indications and outcomes after CLLT. This is a review of a large single‐center CLLT series. Eight consecutive CLLT performed during 2009‐2012 were retrospectively reviewed. One patient received a third simultaneous heart transplant. Mean age was 42.5 ± 11.5 years. Pulmonary indications included cystic fibrosis (CF) (n = 3), idiopathic pulmonary fibrosis (n = 2), α1‐antitrypsin deficiency (AATD) (n = 1) and pulmonary hypertension (n = 2). Liver indications were CF (n = 3), hepatitis C (n = 2), AATD (n = 1), cryptogenic (n = 1), and cardiac/congestive (n = 1). Urgency was reflected by median lung allocation score (LAS) of 41 (36.0‐89.0) and median predicted FEV1 of 25.7%. Median donor age was 25 (20‐58) years with median cold ischemia times of 147 minutes and 6.1 hours for lung and liver, respectively. Overall patient survival at 30 days, 90 days and 1 year was 87.5%, 75.0% and 71.4% respectively. One patient had evidence of acute lung rejection, and no patients had liver allograft rejection. Early postoperative mortalities (90 days) were caused by sepsis in 2 recipients who exhibited the highest LAS of 69.9 and 89.0. The remaining recipients had a median LAS of 39.5 and 100% survival at 1‐year. Median length of stay was 25 days (7‐181). Complications requiring operative intervention included bile duct ischemia (n = 1) and bile leak (n = 1), ischemia of the bronchial anastomosis (n = 1), and necrotizing pancreatitis with duodenal perforation (n = 1). This series reflects a large single‐center CLLT experience. Sepsis is the most common cause of death. The procedure should be considered for candidates with LAS < 50. Liver Transpl 20:46–53, 2014.

Atrial arrhythmias after lung transplant: Underlying mechanisms, risk factors, and prognosis

BACKGROUND Atrial arrhythmias (AAs) early after lung transplant are frequent and have a significant impact on morbidity and mortality. However, the pathogenesis of AAs after lung transplant remains incompletely understood. In this study we aimed to determine the prevalence of atrial fibrillation (AF) and other AAs, as well as risk factors, clinical outcomes and possible underlying mechanisms associated with AAs after lung transplant. METHODS A retrospective analysis was performed on 382 patients who underwent lung transplantation from 2000 to 2010. A 12-lead electrocardiogram (ECG) was obtained and AAs classified as AF and other AAs (atrial flutter [AFL] and supraventricular tachycardia [SVT]). Multivariate logistic regression analysis was performed to determine predictors, and Kaplan-Meier survival curves were constructed. RESULTS The incidence of AAs was 25%; 17.8% developed AF and 7.6% other AAs (AFL/SVT). The major indication for transplant was idiopathic pulmonary fibrosis (IPF, 35%). Significant predictors of AF were as follows: age; IPF; left atrial enlargement; diastolic dysfunction; and history of coronary artery disease (CAD). Risk factors for other AAs (AFL/SVT) were: age; right ventricle dysfunction; right ventricular enlargement; and elevated right atrial pressure (RAP). One-year mortality was higher in the arrhythmia group (21.5% arrhythmia vs 15.7% no-arrhythmia group; p < 0.05). In addition, patients treated with anti-arrhythmic medications had higher mortality (p < 0.05). CONCLUSIONS AAs are common after lung transplantation. Risk factors for developing either AF or other AAs (AFL/SVT) are different. The development of early AAs post-transplant is associated with prolonged post-operative stay and increased mortality. A rate-control strategy should be used as first-line therapy and anti-arrhythmic agents reserved for those patients who do not respond to the initial treatment.

The Feasibility of Lung Transplantation in HIV-Seropositive Patients

RATIONALE HIV seropositivity has long been considered a contraindication to lung transplantation, primarily because of the potential risks of added immunosuppression. In the past decade, however, experience with kidney and liver transplantation in the setting of HIV infection, with achievement of satisfactory outcomes, has grown considerably. This promising development has created a need to reconsider this contraindication to lung transplantation. OBJECTIVES There is presently limited evidence upon which to base medical decision-making regarding lung transplantation in individuals with HIV infection. In our present study, we wished to extend the existing literature by reporting the outcomes of three individuals with HIV infection who underwent lung transplantation at two centers. METHODS We compiled data for a case series of three HIV-infected subjects undergoing lung transplantation at two centers. MEASUREMENTS AND MAIN RESULTS We reviewed medical records to investigate the effects of lung transplantation on the course of HIV infection, the development of HIV-related opportunistic infections or malignancies, the occurrence of lung transplant and HIV drug interactions, and the extent of acute rejection. Subject 1, who underwent transplantation for HIV-associated pulmonary arterial hypertension, experienced recalcitrant acute rejection requiring a lymphocyte-depleting agent with subsequent rapid development of bronchiolitis obliterans syndrome. Subjects 2 and 3, who underwent transplantation for idiopathic pulmonary fibrosis, experienced mild acute rejection but remain free from chronic rejection at 4 and 2 years after transplant, respectively. CONCLUSIONS Lung transplantation may be feasible for carefully selected patients in the setting of controlled HIV infection. On the basis of our experience with three patients, we caution that acute graft rejection may be more common in such patients.

Impact of pre-operative coronary artery disease on cardiovascular events following lung transplantation

BACKGROUND This study examined the correlation between pre-operative coronary artery disease (CAD) and post-operative cardiovascular events in lung transplant recipients. METHODS Consecutive isolated lung transplant recipients from 2007 to 2013 in our institution were identified and categorized as having significant CAD (≥ 50% coronary stenosis in at least 1 artery or history of coronary revascularization) or no-mild CAD. Patient records and death index data were analyzed for a median of 2 years for death or cardiovascular events, including coronary, cerebrovascular, and peripheral artery events. RESULTS The study comprised 280 patients (62% male) with mean age of 60 ± 10 years. Cardiovascular events occurred in 5.7% (16 of 280) of the entire cohort. Patients with significant CAD had a higher annualized rate of cardiovascular events than those with no-mild CAD (11.9% vs 0.6%; p < 0.001). Significant CAD was an independent predictor of cardiovascular events (hazard ratio, 20.32; 95% confidence interval, 5.79-71.26; p < 0.001) but not all-cause mortality (log-rank p = 0.66). Adding significant CAD to clinical risk factors gave incremental prognostic performance compared with clinical risk factors alone (p < 0.001 for increase in global chi-square). CONCLUSION Selected lung transplant candidates with significant CAD can undergo transplantation with equal mortality risk to those without CAD but are at a higher risk of non-fatal cardiovascular events. These data support the current practice of accepting a selected group of patients with CAD for lung transplantation and suggest that they should be monitored early and treated to prevent cardiovascular complications.

Bloodless Lung Transplantation in Jehovah's Witnesses: Impact on Perioperative Parameters and Outcome Compared With a Matched Control Group

BACKGROUND Jehovahs Witnesses (JW) refuse to receive blood products due to their religious beliefs. Bloodless transplantation programs have made the successful transplantation of solid organs like heart, liver, kidney, and pancreas in JW feasible. In this study we present the third and fourth case of a successful bloodless lung transplantation and analyze perioperative parameters and outcome with a strictly selected matched control group (CG). METHODS Two JW patients suffering from idiopathic pulmonary fibrosis had single lung transplantation in the transfusion-free program. Ten of 113 patients (8.8%) undergoing lung transplantation fulfilled the matching criteria and served as CG. Perioperative parameters including blood loss and transfusions were collected from the charts. Regarding outcome parameters arterial blood gas, lung function testing, length of stay, and survival were analyzed. RESULTS Concerning perioperative parameters no significant differences could be found between both groups except for the creatinine level, which was significantly lower in the JW group on postoperative day 0 (P = .037), and the hemoglobin and hematocrit levels, which were significantly higher in the JW group on postoperative day 3 (P = .032 and P = .041, respectively). The analysis of the outcome parameters revealed significantly higher postoperative lung functional testing values forced expiratory volume after 1 second (FEV1) and forced vital capacity (FVC) in the JW group compared with the CG (P = .037 and P = .036, respectively). CONCLUSION Bloodless lung transplantation is feasible in carefully selected JW recipients. Comparing JW to CG, no statistically significant difference in the perioperative course and a trend towards a favorable postoperative lung function outcome were detected.

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