Th. Wahlers

Lung transplantation for cystic fibrosis – a single center experience over 8 years

OBJECTIVE Colonization of the lung and mediastinal lymph nodes with multi-resistant bacteria, diabetes and malnutrition represent potential risk factors for lung transplantation in cystic fibrosis. We therefore reviewed our experience in this patient population. METHODS Between December 1988 and March 1997, 219 lung and heart-lung transplantations were performed at our institution. Of these, 39 procedures were done in 35 patients with cystic fibrosis. All candidates (mean age 26 years) were oxygen dependent (preoperative mean PO2: 44.8 +/- 9.1 Torr, preoperative mean PCO2: 53.4 +/- 10.5 Torr, one patient on respirator). Of the primary operations, 34 were performed as bilateral sequential lung transplants, one as a heart-lung transplantation. RESULTS Mean duration on respirator for survivors was 3.1 (1-12) days, mean ICU and hospital stay were 4.7 (1-13) and 28 (12-79) days, respectively. The 3-month mortality rate was 5.7% (two patients died due to acute graft failure on days 36 and 73). Other causes of death in the follow-up were cerebral bleeding (one patient) and chronic graft failure (three patients). The survival rates were 91% at 1 year, 83% at 3 years and 76% at 5 years. In eight patients, a bronchiolitis obliterans syndrome (BOS) developed (in four cases grade 3). The freedom of BOS (grade 1 or more) at 1, 3 and 5 years was 87, 79 and 55%, respectively. Four retransplantations were performed. Of the 29 patients alive, only seven are physically limited. CONCLUSION Bilateral lung transplantation for cystic fibrosis allows for acceptable early- and long-term results. Postoperative survival is not impaired by infection, diabetes and malnutrition. Long-term functional outcome seems to be comparable to lung transplantation in patients without infectious pulmonary disease.

Valve reconstruction or replacement for long-term biopsy-induced tricuspid regurgitation following heart transplantation

Abstract  Tricuspid regurgitation following heart transplantation can become a severe problem in a subset of patients, where medical therapy fails. Operative findings are described and results of subsequent results with surgical intervention including repair and replacement are analysed. Although follow‐up is short, tricuspid replacement seems superior to reconstruction following heart transplantation. Best results are obtained, if replacement is performed, before right ventricular function deterioates.

Cytolytic Induction Therapy in Heart and Lung Transplantation: The Protagonist Opinion

From the studies analysed as well as based on our own experience, induction therapy mainly with polyclonal cytolytic agents represents a helpful tool in the individualised immunosuppressive approach, whereas monoclonal induction therapies have to be discussed carefully. Although transplantation is also feasible without cytolytic agents, certain patients at risk will further encourage the need for this valuable therapy also in the future, where new immunosuppressants are available. However, it is anticipated that the application should be conducted on an individual patient basis to achieve optimal individual benefit.

Results of orthotopic heart transplantation for ischaemic cardiomyopathy

From July 1983 to May 1987, 172 orthotopic heart transplantations were performed in 165 patients. Of these, 46 recipients (39 male, 7 female), aged between 26 and 56 years (mean age 47), suffered from ischaemic cardiomyopathy. Postoperative immunosuppression consisted of a triple drug regimen of cyclosporine A, azathioprine and, in the last 31 patients, low-dose steroids. The actuarial survival in this group of patients at 1 year and at 2 years was 71.9%. There were five early deaths: three due to acute rejection and two from multiple-organ failure and sepsis. Of the eight late deaths, two could be attributed to acute cardiac rejection and four to bacterial infections. In two patients, sudden death occurred in the presence of accelerated graft atherosclerosis. Mild-to-moderate coronary artery lesions were seen in five other patients undergoing angiography one year after transplantation. Apart from the well-known postoperative risk factors in cardiac transplant recipients, accelerated graft atherosclerosis appears to be an additional hazard in the subgroup surgically treated for ischaemic cardiomyopathy.

Influence of dextrans on cardiac preservation in an extracorporeal rat heart model.

Despite advances in preservation techniques for thoracic organs, the ischemic tolerance of the donor heart is still limited. Recently, a beneficial effect of oncotic substances such as dextran was shown in lung transplantation. Clinically, only in the University of Wisconsin (UW) solution oncotic substances for the prevention of cellular edema are used. Since little is known about the perspective value of dextrans in cardiac preservation, we investigated dextrans with different molecular weights added to the St. Thomas Hospital solution in an experimental working rat heart Langendorff model for functional and histological aspects. By comparison of various dextrans with molecular weights of 40,000, 70,000 and 160,000 daltons, best results were achieved by the addition of 5% dextran with the highest molecular weight.

Antagonisation of platelet activating factor — a new therapeutic concept for improvement of organ quality in lung preservation

The release of platelet activating factor (PAF) is thought to be one of the most important pathophysiological pathways in the development of ischemic lung injury. We investigated the use of a PAF antagonist (PAF-a) in a canine model in reducing PAF-mediated pulmonary dysfunction following lung preservation and transplantation. Twelve combined heterotopic heart and orthotopic left lung allotransplantations were performed after 6 h of cold ischemia. Following administration of prostacyclin (PGI2), Euro-Collins solution (EC) was used for pulmonary artery flush in all donors, while in six animals the PAF-a, WEB 2170 BS, was administered to the donor (0.15 mg/kg for 30 min), to the storage solution (0.3 mg/kg) and to the recipient during reperfusion for a total of 6 h (0.3 mg/kg per h) EC/PAF-a). In all donors myocardial preservation was achieved using St. Thomas Hospital solution. Postoperatively, cardiorespiratory function was evaluated separately for donor and recipient organs at an FiO2 of 0.4 for a maximum of 12 h. The quality of lung preservation was assessed by means of postoperative oxygenation (pO2), pulmonary artery pressure (PAP) and pulmonary vascular resistance index (PVRI). In the EC/PAF-a group, pO2 of the donor lung was significantly elevated (P < 0.01) and PVRI was significantly lower (P < 0.05) when compared to the EC group, while PAP showed no significant differences between both groups and throughout the entire postoperative course. We concluded that a significant improvement in the current clinical standard for lung preservation could be obtained by the application of WEB 2170 BS in combination with EC flush as demonstrated by improved oxygenation and lower PVRI of the transplantated organs.