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We hypothesized that outcomes after 2 staged, contralateral single lung transplantation procedures (SSLTs) may be equivalent to those of double lung transplantation (DLT) by capitalizing on the known long-term survival advantages of DLT. Using the United Network for Organ Sharing data set (1987-2018), the largest national data set available, the outcomes of 278 SSLTs were retrospectively analyzed and compared with the outcomes of 21,121 standard DLTs. During SSLT, the median interval between the 2 transplants was 960 days, and the indication for the second transplant was most often chronic lung allograft dysfunction (n = 148; 53.2%) or the same disease that necessitated the first transplant (n = 81; 29.1%). The patients who underwent SSLT were significantly older and had a higher baseline creatinine level than the patients who underwent DLT. Most posttransplantation short-term outcomes were equivalent between the second stage of SSLT and DLT, but renal insufficiency requiring hemodialysis was notably higher after SSLT. There were no differences in long-term survival. In multivariate analysis, baseline creatinine, O 2 support at rest, ventilator support at the time of the second transplantation, and posttransplantation renal insufficiency requiring dialysis were independent predictors of 1-year mortality after SSLT. Over a study period of 30 years, long-term survival after SSLT was comparable with survival after DLT. With further analysis of individual risk profiles, including the contributions of preoperative renal function and functional status, SSLT can be a valuable option for patients who would have undergone single lung transplantation to reap the long-term benefits of a second transplant. [Display omitted] [ABSTRACT FROM AUTHOR]

Donors with characteristics that increase risk of hepatitis B virus, hepatitis C virus, and HIV transmission are deemed increased-risk donors (IRDs) per Public Health Service guidelines. Compared with organs from standard-risk donors (SRDs), IRD organs are more frequently declined. We sought to investigate the outcomes of IRD lung transplant recipients following the 2013 guideline change. We retrospectively identified lung transplant recipients using the United Network of Organ Sharing registry (February 2014 to March 2020). Patients were divided into 2 cohorts, based on Centers for Disease Control and Prevention risk status of the donor: SRD or IRD. Demographics and clinical parameters were compared across groups. Survival was compared using Kaplan–Meier curves and log-rank tests. Cox proportional hazard model was performed to identify variables associated with survival outcome. We identified 13,205 lung transplant recipients, 9963 who received allografts from SRDs and 3242 who received allografts from IRDs. In both groups, most donors were White, male, and <30 years old. IRDs demonstrated greater rates of heavy alcohol, cigarette, and cocaine use. SRDs had greater rates of cancer, hypertension, previous myocardial infarction, and diabetes. Survival analysis demonstrated no significant difference in 90-day, 1-year, 3-year, or 5-year survival outcome between SRD and IRD recipients (P =.34, P =.67, P =.40, P =.52, respectively). Cox regression demonstrated that double-lung transplants were associated with 13% decreased mortality risk compared with single-lung (P =.0009). IRD and SRD recipients demonstrated equivalent survival outcomes. Our study suggests that IRDs offer a safe approach to expand the donor pool and increase availability of lungs for transplantation. [Display omitted] [ABSTRACT FROM AUTHOR]

Postoperative bronchial anastomotic complications are not uncommon in lung transplant recipients. We investigated 2 surgical techniques (continuous and interrupted sutures) during bronchial anastomosis, comparing survival and postoperative bronchial complications. We retrospectively analyzed 421 patients who were transplanted in our center (February 2012 to March 2018). Patients were divided according to bronchial anastomotic technique (continuous or interrupted). Demographics and clinical parameters were compared for significance (P <.05). Comparison of postoperative morbidity included bronchial complications, venovenous extracorporeal membrane oxygenation support, and intervention requirements. Survival was assessed using Kaplan-Meier curve and log-rank tests (P <.05). Of the 421 patients, 290 underwent bronchial anastomoses with continuous suture; 44 of these patients had postoperative bronchial complications (15.2%). Contrarily, 131 patients underwent the interrupted suture technique; 9 patients in this group had postoperative bronchial complications (6.9%). Demographics and clinical parameters included age, sex, ethnicity, etiology, lung allocation score, body mass index, donor age, lung transplant type, cardiopulmonary bypass usage, surgical approaches, and median length of stay. Postoperative complications (continuous vs interrupted) were bronchial complications (P =.017), venovenous extracorporeal membrane oxygenation support (P =.41), venoarterial extracorporeal membrane oxygenation support (P =.38), and complications requiring dilatation with stent placement (P =.09). Kaplan-Meier curve showed better survival in the interrupted group (P =.0002). Our study demonstrated the comparable postoperative results between the continuous and interrupted technique. [ABSTRACT FROM AUTHOR]

Coronary artery disease is common in lung transplant patients and has historically been viewed as a contraindication to the procedure. Although this mindset is changing, the effect of prior or perioperative revascularization on lung transplant survival outcomes is not adequately established. We performed a single-center retrospective analysis of all single and double lung transplant patients from 2012 to 2018 (n = 468). Patients were split into 4 groups: (1) patients who received a preoperative percutaneous coronary intervention (n = 34), (2) those who received coronary artery bypass grafting (CABG) before transplantation (n = 25), (3) those that received concomitant CABG during transplantation (n = 29), and (4) those who had lung transplantation with no need for revascularization (n = 380). Groups were compared for demographics, surgical procedure, and survival outcomes. The no-revascularization group was statistically younger than the rest (P =.001). The lung allocation score trended toward being higher in the concomitant coronary artery bypass group (P =.03). All groups were predominantly diagnosed with idiopathic pulmonary fibrosis. The proportion of patients with chronic obstructive pulmonary disease was greatest in the group not requiring revascularization (P =.001). Patients with previous CABG were more likely to receive a single lung transplant than a double one (21 versus 4; P =.054). Length of stay, posttransplant survival, and postoperative adverse events were similar among all groups. Results suggest that preoperative or intraoperative revascularization does not negatively affect survival in lung transplant patients; lung recipients with coronary artery disease have comparable survival when adequately revascularized. [ABSTRACT FROM AUTHOR]

Background There is little in the literature pertaining to cost associated with the use of extracorporeal membrane oxygenation (ECMO) in lung transplantation. We sought to evaluate charges associated with the index hospitalization among recipients of a lung transplant who required ECMO to identify factors that increase hospital charges in these patients. Methods With the use of the Nationwide Inpatient Sample, we reviewed data pertaining to patients who received a lung transplant between 2000 and 2011 and stratified them into ECMO and non-ECMO groups based on use of ECMO. Regression modeling was used to identify differences in charges. Results Data pertaining to 15,596 recipients of a lung transplant were evaluated, 658 (4.2%) of whom required ECMO. ECMO recipients were more likely to have a diagnosis of idiopathic pulmonary fibrosis (3.5% versus 1.3%, p = 0.007) or pulmonary hypertension (PH) (9.1% versus 3.0%, p < 0.001). Patients who received a bilateral lung transplant had 32.1% (95% confidence interval [CI]: 26.2% to 37.9%, p < 0.001) higher charges. Recipients with PH had 28.7% (95% CI: 14.9% to 42.4%, p = 0.001) higher charges. Median charges for recipients of a lung transplant who required ECMO were $780,391.50 versus $324,279.80 for non-ECMO recipients of a lung transplant and were 50.3% (95% CI: 33.0% to 67.5%, p < 0.001) higher. Hospital charges among Medicare enrollees were 6.6% (95% CI: 0.7% to 12.5%, p = 0.028) higher than privately insured recipients of a lung transplant. Black recipients had approximately 34.2% (95% CI: 3.2% to 65.0%, p = 0.030) higher charges. The ECMO group had longer median length of stay (LOS) (25 versus 15 days, p < 0.001). Conclusions Recipients of a lung transplant who required ECMO support had longer LOS and higher hospital charges, specifically among black recipients, recipients with PH, and Medicare enrollees. [ABSTRACT FROM AUTHOR]

Background Dysphagia, aspiration, and potential pneumonia represent a major source of morbidity in patients undergoing lung transplantation. Conditions that potentiate dysphagia and aspiration include frailty and prolonged intubation. Our group of speech-language pathologists has been actively involved in performance of a bedside evaluation of swallowing, and instrumental evaluation of swallowing with modified barium swallow, and postoperative management in patients undergoing lung transplantation. Methods All lung transplant patients from April 2009 to September 2012 were evaluated retrospectively. A clinical bedside examination was performed by the speech-language pathology team, followed by a modified barium swallow or fiberoptic endoscopic evaluation of swallowing. Results A total of 321 patients were referred for evaluation. Twenty-four patients were unable to complete the evaluation. Clinical signs of aspiration were apparent in 160 patients (54%). Deep laryngeal penetration or aspiration were identified in 198 (67%) patients during instrumental testing. A group of 81 patients (27%) had an entirely normal clinical examination, but were found to have either deep penetration or aspiration. Conclusions The majority of patients aspirate after lung transplantation. Clinical bedside examination is not sensitive enough and will fail to identify patients with silent aspiration. A standard of practice following lung transplantation has been established that helps avoid postoperative aspiration associated with complications. [ABSTRACT FROM AUTHOR]

Objective To identify preoperative predictors of extracorporeal support in patients with pulmonary hypertension (PH) undergoing bilateral sequential lung transplantation (LTx), and to examine outcomes associated with the use of extracorporeal support. Design Retrospective, observational study. Setting Single organ transplantation and tertiary care university medical center. Participants Adults with PH (preoperative mean pulmonary artery pressure (mPAP)≥25 mmHg) who underwent primary bilateral sequential LTx during 2007 to 2013. Measurements and Main Results Of 262 patients with PH undergoing LTx, extracorporeal support was initiated intraoperatively in 149 (57%). Preoperative severe right ventricle (RV) dysfunction and moderate or severe tricuspid regurgitation (TR) were associated with extracorporeal support. In the remaining 208 patients without those factors, increasing preoperative oxygen requirement (odds ratio [OR] 1.30 per 1 L/min, 95% confidence intervals [CI] 1.11-1.52, p = 0.001), presence of RV dilation (OR 2.77, 95% CI 1.28-6.02, p = 0.010), and mPAP (OR 1.33 per 5-mmHg increase in mPAP, 95% CI 1.04-1.70, p = 0.021) were associated independently with extracorporeal support in the multivariable model. Analysis of 49 propensity-matched pairs showed longer intensive care unit (5 v 14 days, p = 0.006) and hospital stays (27 v 39 days, p = 0.016) and increased need for tracheostomy (16% v 41%, p = 0.017) in patients exposed to extracorporeal support but no differences in 30-day mortality, stroke, myocardial infarction, or dialysis. Conclusions Severity of RV dysfunction, TR, RV dilatation, increasing oxygen requirement, and increasing mPAP showed significant associations with the need for extracorporeal support during LTX in patients with PH. Extracorporeal support was associated with increased length of stay and tracheostomy but not with mortality or other complications. © 2016 Elsevier Inc. All rights reserved. [ABSTRACT FROM AUTHOR]

Objectives Atrial arrhythmia (AA) after lung transplantation (LTx) is a potentially morbid event often associated with increased length of hospital stay. Predictors of postsurgical AA, however, are incompletely understood. We characterized the incidence and predisposing risk factors for AA in patients undergoing LTx. Methods A retrospective analysis of prospectively collected data was conducted to identify LTx recipients between January 2008 and October 2013. Patients were divided into 2 groups on the basis of postoperative AA development. Univariable and multivariable analyses were performed to define differences between groups and identify factors associated with AA. Survival differences were assessed by the use of competing risks methodology. Results A total of 198 of 652 (30.4%) patients developed AA at a median onset of 5 days after transplant. Increasing age (hazard ratio [HR] 1.03 per additional year, P < .001) and previous coronary artery bypass grafting (HR 2.77, P = .002) were found to be independent risk factors. Counterintuitively, patients with a medical history of AA before LTx had a lower incidence of postoperative AA. Preoperative beta-blocker usage was not a significant predictor of postoperative AA. Postoperative AA was a significant predictor of long-term mortality (HR 1.63, P = .007) when we adjusted for other risk factors. Conclusions AA is a common occurrence after LTx, occurring with greatest frequency in the first postoperative week, and results in a significant reduction in long-term survival. Increasing age and before coronary artery bypass grafting were identified as independent risk factors for AA development. Better understanding of these risk factors may improve identification of patients at heightened risk after transplantation. [ABSTRACT FROM AUTHOR]

Objective Lung transplantation is a life-saving procedure for patients who have end-stage lung disease. The frequency and severity of complications have not been fully characterized. We hypothesized that early in-hospital, postoperative complications decrease long-term survival. Methods We retrospectively identified in-hospital complications in lung transplant recipients, from the period January 2007 to October 2013. Complications were graded using the extended Accordion Severity Grading System (ASGS). Complications were categorized by event and organ system. Survival analysis was performed ( P < .05) using a time-dependent model. Results Among 748 eligible patients, 3381 independent in-hospital, postoperative complications occurred in 92.78% of patients. Median follow-up was 5.4 years. Complications associated with significant decrease in 5-year survival were: renal (hazard ratio [HR] 2.58, 95% confidence interval [CI] 1.40-4.48); hepatic (HR 4.08, 95% CI 2.86-5.82); cardiac (HR 1.95, 95% CI 1.56-2.45). The maximum ASGS of ≥5 (18.5% vs 73.8%), and the weighted ASGS sum >10 (2.5% vs 73.8%), were found to be significant predictors of long-term survival. Multivariate analysis identified a weighted ASGS sum of >10, and renal, cardiac, and vascular complications as predictors of decreased long-term survival. Conclusions Rigorous delineation of complications after lung transplantation showed that grade 5 ASGS in-hospital postoperative complications, and a weighted ASGS sum >10, were independent predictors of decreased long-term survival well beyond the initial perioperative period. These results may identify important targets for best practice guidelines and quality-of-care measures after lung transplantation. [ABSTRACT FROM AUTHOR]

Objective Improvements in technology have led to a resurgence in the use of extracorporeal membrane oxygenation as a bridge to lung transplantation. By using a national registry, we sought to evaluate how short-term survival has evolved using this strategy. Methods With the use of the United Network for Organ Sharing database, we analyzed data from 12,458 adults who underwent lung transplantation between 2000 and 2011. Patients were categorized into 2 cohorts: 119 patients who were bridged to transplantation using extracorporeal membrane oxygenation and 12,339 patients who were not. The study period was divided into four 3-year intervals: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. With Kaplan-Meier analysis, 1-year survival was compared for the 2 cohorts of patients in each of the time periods. A propensity score--adjusted Cox regression model was used to estimate the risk of 1-year mortality. Results Of the total number of recipients, 4 (3.4%) were bridged between 2000 and 2002, 17 (14.3%) were bridged between 2003 and 2005, 31 (26.1%) were bridged between 2006 and 2008, and 67 were bridged (56.3%) between 2009 and 2011. Recipients bridged using extracorporeal membrane oxygenation were more likely to be younger and diabetic and to have higher serum creatinine and bilirubin levels. The 1-year survival for those bridged with extracorporeal membrane oxygenation was significantly lower in subsequent periods: 25.0% versus 81.0% (2000-2002), 47.1% versus 84.2% (2006-2008), and 74.4% versus 85.7% (2009-2011). However, this survival progressively increased with each period, as did the number of patients bridged using extracorporeal membrane oxygenation. Conclusions Short-term survival with the use of extracorporeal membrane oxygenation as a bridge to lung transplantation has significantly improved over the past few years. [ABSTRACT FROM AUTHOR]

Background The intraoperative use of cardiopulmonary bypass (CPB) in lung transplantation has been associated with increased rates of pulmonary dysfunction and bleeding complications. More recently, extracorporeal membrane oxygenation (ECMO) has emerged as a valid alternative method of support and has been our preferred method of support since March 2012. We compared early and midterm outcomes of these 2 support methods. Methods Between July 2007 and April 2013, 271 consecutive patients underwent lung transplant using CPB (n = 222) or ECMO (n = 49). We retrospectively reviewed the outcomes of these patients requiring CPB or ECMO during lung transplant. Results The CPB and ECMO groups had comparable demographic and operative characteristics; however, the ECMO group had higher mean lung allocation scores (73 vs 52, p < 0.001). In the CPB group, more patients required reintubation (35.6% vs 20.4%, p = 0.04) or temporary tracheostomy (44.6% vs 28.6%, p = 0.05). Patients in the CPB group had a higher rate of renal failure requiring dialysis than the ECMO group (22.1% vs 8.2 %, p = 0.028). There were no differences in severe PGD requiring postoperative circulatory support ( p = 0.83) or the need for perioperative red blood cell transfusions ( p = 0.64) between the groups. No differences in 30-day (5% CPB vs 4.1% ECMO) or 6-month mortality (14.4% CPB vs 14.3% ECMO) were noted. Conclusions The use of ECMO in lung transplant is safe and in our experience was associated with decreased rates of pulmonary and renal complications, as compared with CPB. Extracorporeal membrane oxygenation has become our preferred method of intraoperative support during lung transplantation. [ABSTRACT FROM AUTHOR]

Background The relative paucity of donors heightens the debate and scrutiny surrounding retransplantation. To date, risk factors associated with retransplantation are poorly characterized in the literature. We sought to identify those risk factors that may independently serve to predict lung retransplantation. Methods We performed a retrospective evaluation of the United Network for Organ Sharing data over 25 years from 1987 to 2012. Competing risk analysis was used to evaluate the cohort for cumulative incidence of retransplantation. Recipient-related, donor-related, and transplant-related characteristics were assessed using Cox regression to identify risk factors associated with lung retransplantation. Results We identified 23,180 adult lung transplant recipients, of which 791 (3.4%) had also undergone retransplantation. Factors associated with lung retransplantation at 1 year included recipient age (hazard ratio [HR], 0.97; p = 0.005), admission to the intensive care unit (HR, 2.89; p = 0.002), donor age (HR, 1.02; p = 0.004), and bilateral lung transplantation (HR, 0.41; p < 0.001). Moreover, predictors of 5-year risk of retransplantation included recipient age (HR, 0.95; p < 0.001), intensive care unit hospitalization (HR, 1.87; p = 0.005), and bilateral lung transplant (HR, 0.46; p < 0.001), as well as recipient body mass index of 25 to 29 kg/m 2 (HR, 1.29; p = 0.04) and a diagnosis of chronic obstructive pulmonary disease (HR, 0.68; p = 0.008). Conclusions We identified factors associated with retransplantation that may afford a better prediction of graft failure and need for retransplantation. These may further serve to better guide donor selection and assist in the development and validation of a risk-scoring model to further guide preoperative counseling. [ABSTRACT FROM AUTHOR]

Background: With the implementation of the lung allocation score (LAS) system, an increased number of critically ill patients are considered for transplantation. However, LAS does not take size matching between donor and recipient lungs into consideration. Mortality on the waiting list is high (as high as 25%) for short-stature patients and for patients with restrictive lung disease. Here, we review our experience using cadaveric lobar lung transplantation as a surgical option in an attempt to decrease mortality while waiting. Methods: We retrospectively reviewed patients with end-stage lung diseases and an LAS greater than 70 who underwent cadaveric lobar lung transplantation between 2010 and 2012 (n = 25) at our institution, a high-volume lung transplant center. Anatomic lobectomy was performed on all donor lungs before double lung transplantation. Results: Median LAS was 85.6 (range, 72 to 94). Average waiting time after the patients’ LAS was updated to greater than 70 was 10 days (range, 1 to 41). There were 2 in-hospital deaths. The 90-day and 1-year survivals were 88% and 76%, respectively. Patient major comorbidities included severe primary graft dysfunction requiring postoperative extracorporeal membrane oxygenation (7 patients), acute renal insufficiency (4 patients), and bleeding requiring reoperation (4 patients). No technical problems were identified, and repeated bronchoscopy demonstrated satisfactory healing of the bronchial stump after lobectomy. The average posttransplant peak for forced expiratory volume in 1 second was 85%. Conclusions: Our initial experience supports the option of lobar lung transplantation for critically ill patients whose opportunities for transplant are limited by their stature. Long-term functional studies are warranted. [Copyright &y& Elsevier]

Background: Preoperative extracorporeal membrane oxygenation (ECMO) is a risk factor for poor outcome and currently considered a contraindication to lung transplantation. The lung allocation score system was introduced in May 2005 and prioritizes lung allocation to those with the greatest respiratory impairment. The purpose of this study is to determine whether ECMO as a bridge to lung transplantation is an acceptable option to support those in respiratory failure until donor lungs become available in the lung allocation score era. Method: A retrospective review of 715 consecutive lung transplants performed between May 2005 and September 2011 was conducted using a prospectively collected institutional registry database. Twenty-four lung transplants (3.4%) were performed in the 31 patients with attempted pretransplant ECMO; 7 patients who received ECMO patients did not survive or were deemed unfit for transplantation. These patients were compared with a control group of 691 patients who did not receive pretransplant ECMO. Results: The duration of pretransplant ECMO was 171 ± 242 hours (median, 91 hours). Venovenous ECMO was used for respiratory failure in 15 patients, whereas venoarterial ECMO was used for circulatory collapse due to pulmonary hypertension in 9 patients. Patients in the retransplant ECMO group were younger (46 ± 15 years vs 57 ± 14 years, P < .01) compared with the control group, with no difference in recipient gender (male/female: 10/14 vs 380/311), donor age (33 ± 14 years vs 36 ± 15 years), or donor gender (male/female: 10/14 vs 352/339). Emphysema was less common (1, 4% vs 260, 38%, P < .01), and cystic fibrosis (5, 21% vs 72, 10%, P = .09), redo lung transplant (3, 13% vs 28, 4%, P = .08), and bronchiectasis (2, 8% vs 6, 1%, P = .03) were more common in the pretransplant ECMO group. Patients in the pretransplant ECMO group had a significantly higher lung allocation score (87 ± 9 vs 44 ± 15, P < .01). All patients in the pretransplant ECMO group underwent double lung transplants on pump (cardiopulmonary bypass/ECMO), and single lung transplants were performed in 171 patients (25%) and pump was used in 243 patients (35%) in the control group. The cardiopulmonary bypass time was longer in the pretransplant ECMO group (277 ± 69 minutes vs 225 ± 89 minutes, P = .02), with no difference in ischemic time (343 ± 93 minutes vs 330 ± 98 minutes, P = .54). Cadaveric lobar lung transplants were performed because of the urgency to overcome size mismatch with an oversized donor more frequently in 25% (n = 6, no mortality with the longest follow-up at 6 years) of patients in the pretransplant ECMO group versus 0.3% (n = 2) of patients in the control group (P < .01). Post-transplant ECMO was used for primary graft dysfunction in 13 patients (54%) in the pretransplant ECMO group and 41 patients (6%) in the control group (P < .01). The median hospital stay was 46 days in the pretransplant ECMO group versus 27 days in the control group (P = .16). The actuarial survivals after lung transplants at 1, 3, 6, 12, and 24 months were 96%, 88%, 83%, 74%, and 74%, respectively, in the pretransplant ECMO group, and 97%, 94%, 90%, 83%, and 74%, respectively, in the control group (P = .787). Conclusions: Although the incidence of primary graft dysfunction requiring post-transplant ECMO is higher and the hospital stay is longer in patients receiving pretransplant ECMO, the graft survival is good (2-year survival, 74%). ECMO is efficacious as a bridge to lung transplantation with good post-lung transplant outcomes. [Copyright &y& Elsevier]

Background: The lung allocation score (LAS) assigns organ allocation priority based on medical urgency and the likelihood of posttransplant survival. This study is a review of a single institutional experience for lung transplantation in the era of LAS. Methods: We performed a retrospective review of 527 consecutive patients, from May 2005 to February 2010, who underwent lung transplant at our institution, comprising a high LAS group (LAS ≥ 50, n = 108) and a low LAS group (LAS < 50, n = 419). Kaplan-Meier and univariate analyses were performed to assess postoperative mortality as a primary outcome, and length of ventilator support and intensive care unit stay as secondary outcomes. Risk factors, including demographics, pulmonary status, and surgical and donor variables, were compared. Predictors of mortality were determined using a Cox proportional hazard model. Results: Survivals after 30 days, 90 days, 1 year, and 3 years were 92.6%, 87.8%, 71.5%, and 52.0%, respectively, in the high LAS group, and 96.9%, 93.5%, 83.2%, and 73.9% in the low LAS group (p < 0.001). The incidence of prolonged ventilator support and the need for tracheostomy were higher, and intensive care unit stay was longer in the high LAS group. In the high LAS group, ischemic time greater than 8 hours was an independent predictor for mortality (hazard ratio: 3.080; 95% confidence interval 1.101 to 8.161, p = 0.032). Conclusions: Lung transplant in patients with high a LAS is associated with significantly decreased survival and increased complications compared with patients with a low LAS. Ischemic time greater than 8 hours is a significant predictor of death in patients with a high LAS. [ABSTRACT FROM AUTHOR]

Background: Extracorporeal membrane oxygenation (ECMO) is used occasionally as a bridge to lung transplantation. The impact on mid-term survival is unknown. We analyzed outcomes after lung transplant over a 19-year period in patients who received ECMO support. Methods: From March 1991 to October 2010, 1,305 lung transplants were performed at our institution. Seventeen patients (1.3%) were supported with ECMO before lung transplant. Diagnoses included retransplantation (n = 6), pulmonary fibrosis (n = 6), cystic fibrosis (n = 4), and chronic obstructive pulmonary disease (n = 1). Fifteen patients underwent double lung transplant, one patient had single left lung transplant and one patient had a heart-lung transplant. Venovenous and venoarterial ECMO were implanted in eight and nine cases, respectively. Median duration of support was 3.2 days (range, 1 to 49 days). Mean patient follow-up was 2.3 years. Results: Thirty-day, 1-year, and 3-year survivals were 81%, 74%, and 65%, respectively, for the supported patients and 93%, 78%, and 62% in the control group (p = 0.56). Two-year survival was not affected by ECMO type, with survival of five out of nine patients supported by venoarterial ECMO vs seven out of eight patients supported by venovenous ECMO (p = 0.17). At 1- year follow-up, allograft function for the ECMO-supported patients did not differ from the control group (forced expiratory volume in one second, 2.35 L vs 2.09 L, p = 0.39) (forced vital capacity, 3.06 L vs 2.71 L, p = 0.34). Conclusions: Extracorporeal membrane oxygenation as a bridge to lung transplantation is associated with higher perioperative mortality but acceptable mid-term survival in carefully selected patients. Late allograft function did not differ in patients who received ECMO support before lung transplant from those who did not receive ECMO. [ABSTRACT FROM AUTHOR]

Background: Because inhaled hydrogen provides potent anti-inflammatory and antiapoptotic effects against acute lung injury, we hypothesized that treatment of organ donors with inhaled hydrogen during mechanical ventilation would decrease graft injury after lung transplantation. Methods: Orthotopic left lung transplants were performed using a fully allogeneic Lewis to Brown Norway rat model. The donors were exposed to mechanical ventilation with 98% oxygen plus 2% nitrogen or 2% hydrogen for 3 h prior to harvest, and the lung grafts underwent 4 h of cold storage in Perfadex (Vitrolife, Göteborg, Sweden). The graft function, histomorphologic changes, and inflammatory reactions were assessed. Results: The combination of mechanical ventilation and prolonged cold ischemia resulted in marked deterioration of gas exchange when the donors were ventilated with 2% nitrogen/98% oxygen, which was accompanied by upregulation of proinflammatory cytokines and proapoptotic molecules. These lung injuries were attenuated significantly by ventilation with 2% hydrogen. Inhaled hydrogen induced heme oxygenase-1, an antioxidant enzyme, in the lung grafts prior to implantation, which might contribute to protective effects afforded by hydrogen. Conclusion: Preloaded hydrogen gas during ventilation prior to organ procurement protected lung grafts effectively from ischemia/reperfusion-induced injury in a rat lung transplantation model. [ABSTRACT FROM AUTHOR]

Background: The growing number of patients awaiting heart transplantation, coupled with the worldwide donor shortage, has led to increased use of marginal organs, specifically hearts from older donors. This study compared the protective effects of two widely used preservation solutions, histidine-tryptophan-ketoglutarate (HTK) and Celsior (CEL; Sangstat Medical, Menlo Park, CA), for ischemia-reperfusion injury using a rat heterotopic heart transplantation model with older donors. Methods: The hearts were excised from 16- and 80-week-old Lewis donor rats, stored in HTK, CEL, or saline for 6 hours and heterotopically transplanted into syngenic young Lewis recipients. Serum troponin I and creatine phosphokinase, graft infiltrating cells, graft apoptosis, graft proinflammatory messenger ribonucleic acid levels, and adenosine monophosphate-activated protein kinase phosphorylation were analyzed 3, 6, and 12 hours after reperfusion as markers of graft injury. Tissue adenosine triphosphate levels were measured after cold storage for 0, 6, 12, and 18 hours. Results: The HTK and CEL reduced injury comparably in grafts from young donors. The recipients of grafts from older donors and stored in HTK for 6 hours had lower levels of serum troponin I and creatine phosphokinase, less upregulation of the messenger ribonucleic acid for interleukin-6, intercellular adhesion molecule-1, and tumor necrosis factor-α, fewer infiltrating cells, less apoptosis, and less phosphorylated adenosine monophosphate-activated protein kinase than recipients of grafts stored in CEL. Adenosine triphosphate levels in the hearts stored in HTK were significantly higher than those stored in CEL or saline. Conclusions: Cold storage in HTK exhibited superior protective effects against ischemia-reperfusion injury of hearts from older donors in this rat transplantation model. [ABSTRACT FROM AUTHOR]

Background: Increasing allograft ischemic time is a significant risk factor for mortality following heart transplantation (HTx). The purpose of this study was to evaluate the protective effects of histidine-tryptophan-ketoglutarate (HTK) and Celsior (CEL) using a rat HTx model with prolonged cold storage. Methods: The hearts were excised from donor rats, stored in cold preservation solution for either 6 or 18 hours, and heterotopically transplanted into syngeneic recipients. Serum creatine phosphokinase (CPK), serum troponin I, graft-infiltrating cells, graft mRNA levels for inflammatory mediators, and tissue adenosine triphosphate (ATP) levels were analyzed, as markers of graft injury. Results: The recipients of grafts stored in HTK for 18 hours of prolonged cold ischemia had lower levels of serum CPK and tissue malondialdehyde, less upregulation of the mRNAs for IL-6 and inducible nitric oxide synthase, less apoptosis, and higher ATP levels than those receiving grafts stored in CEL and Saline. Cardiac contraction 3 hours after reperfusion was observed in 43% of the cardiac grafts stored in HTK for 18 hours, while no cardiac wall movement was seen in grafts stored in either saline or CEL. Conclusion: Cold storage in HTK exhibited superior protective effects against prolonged cold ischemia in a syngeneic rat transplantation model. [Copyright &y& Elsevier]

Lung transplantation has emerged as a viable treatment option for patients with end-stage lymphangioleiomyomatosis (LAM), and therapeutic outcome results reported thus far have been satisfactory. However, persisting chylothorax after transplantation for LAM remains a challenging problem, and the optimal management has not been decided. We present the case with persistent chylothorax after lung transplantation for LAM, in which the intravenous administration of a tissue repair factor (human factor XIII) resulted in complete resolution of chylous effusion without performing additional invasive treatments, leading to a successful transplant outcome. [Copyright &y& Elsevier]

Objective: The current trend in lung transplantation has led to liberalized lung donor selection criteria and use of marginal donors, with a corresponding requirement for improved procurement techniques to obtain high-quality donor grafts. Few reports, however, have provided recommendations for successful lung procurement procedures. Methods: We retrospectively studied 47 lung procurements performed by the University of Pittsburgh Medical Center team from January 2007 to December 2007. From those findings, we compared outcomes, as well as technical errors encountered, between procurements performed by trainees with limited transplant experience and by experienced transplant surgeons. Results: Twenty-two of the procurements (47%) were performed by experienced transplant surgeons and 25 (53%) by supervised trainees. Patient characteristics and technical difficulties were comparable between the two groups. The trainees took more time to complete the procedure than did the experienced surgeons, although the difference was not significant. Furthermore, 21 of the cases performed by trainees (84%) had one or more technical errors in the sequential steps of the procurement, including inadequate placement of the perfusion cannula in the main pulmonary artery (60%), insufficient topical cooling (56%), and inadequate timing of the start of pulmonary artery perfusion (44%). Conclusion: Donor lung procurements performed by beginners with limited transplant experience included frequent technical errors with regard to adequate graft preservation, which may lead to serious complications after transplant. Sequential steps in lung procurement techniques and better understanding of organ preservation should be an integral part of a lung transplant training program. [Copyright &y& Elsevier]

Background: Life-threatening massive hemoptysis requires prompt action and thoracic surgical input. Although there are a number of reports regarding each therapeutic modality for medical or surgical treatment, the significance of a multidisciplinary strategy remains undetermined. Methods: From January 1995 to December 2005, 120 patients were referred to our cardiothoracic center with massive hemoptysis. We retrospectively reviewed and compared the outcomes of a recent 5-year period (2000 to 2005) with those from the previous 5 years (1995 to 1999), as we made major changes in our practice in 2000. We currently try to avoid surgery within 48 hours after onset of active hemoptysis and adopt bronchial artery embolization as a first-line therapy. Treatment decisions are made after discussions among intensive care unit physicians, thoracic surgeons, and interventional radiologists. Results: The former group had 49 patients (57.9 ± 14.1 years old, 41 males), and the recent group, 71 (62.2 ± 23.5 years old, 52 males). There were no significant differences for any characteristics studied between the groups. In analyses of short-term complications after surgery, the former had a higher in-hospital mortality rate than the recent group (15% versus 0%). Furthermore, postoperative complications were seen in 8 patients (30%) in the former, whereas those occurred in 3 patients (18%) in the recent group. Conclusion: Bronchial artery embolization is an effective therapeutic tool and plays a pivotal role in management of life-threatening massive hemoptysis. Surgery is indicated when bronchial artery embolization is not suitable and can be safely performed in combination with a rigid bronchoscopy or bronchial artery embolization procedure. Our results indicate that a multidisciplinary approach should be adopted for management of life-threatening massive hemoptysis. [Copyright &y& Elsevier]

Background: Although video-assisted thoracic surgery (VATS) has been in use for more than a decade, its application to major lung resection for lung cancer is still not widely practiced. The success of a cancer operation is judged by the long-term survival of the treated patients. Therefore, the goal of the present study was to evaluate long-term outcomes associated with various video-assisted lobectomy techniques and conventional surgery in patients with peripheral non–small cell lung cancer less than or equal to 2 cm in diameter (stage IA). Methods: A multi-institutional, retrospective review was performed in 145 consecutive patients. Patients with clinical stage IA disease, with tumor size less than or equal to 2 cm in diameter, from three institutions underwent a complete VATS (c-VATS, n = 56), an assisted VATS (a-VATS, n = 34), or a conventional open (open, n = 55) approach for pulmonary lobectomy and lymph node dissection. Results: Patients undergoing lobectomy and lymph node dissection with c-VATS had less blood loss, faster recovery, shorter hospitalization, and longer operating times than did patients undergoing the lobectomy with the a-VATS and open approaches. At a mean follow-up of 38.8 months, Kaplan-Meier probabilities of survival at 5 years were as follows: c-VATS, 96.7%; a-VATS, 95.2%; open, 97.2%. There was no significant difference in the rate of recurrence among the 3 different procedures. Conclusion: VATS lobectomy, a safe procedure with earlier return to normal activities, can be regarded as an acceptable cancer operation for the patients with peripheral non–small cell lung cancer less than or equal to 2 cm in diameter (clinical stage IA) with the same long-term survivals as open surgery. [Copyright &y& Elsevier]

: PurposeWe present our initial evaluation of a new surgical technique of lung tissue sealing for nonanatomical pulmonary resection composed of sutureless and stapleless thoracoscopic surgery.: DescriptionTwelve patients who required therapeutic thoracoscopic pulmonary resection from April 2001 to April 2002 were recruited for this study. Resection of lung parenchyma was performed with an ultrasound-driven scalpel, and the cut end was sealed using LigaSure, a new bipolar system. Measurement of the cut surface after resection during the surgery and assessment of LigaSure sealing strength was performed.: EvaluationThere were no deaths or major intraoperative complications. The mean operation time was 65 minutes, and mean hemorrhage volume was 46 mL. Average chest drain duration was 3 days, and average hospital stay was 6 days. One patient with a giant bulla and cut surface diameter of 50 mm experienced persistent air leak for 1 week. Late complications did not occur over the 8-month follow-up period.: ConclusionsVideo-assisted thoracoscopic surgery pulmonary resection using LigaSure instead of staplers appears technically feasible and easy, and produces satisfactory preliminary results. Although further studies are required to confirm the sealing strength and reliability of LigaSure, this technique should be considered for use in nonanatomical pulmonary resections. [Copyright &y& Elsevier]

: BackgroundWe conducted a trial of a new less invasive, locoregional modality for lung cancer with pleural spread. This study was planned to investigate the feasibility, safety, and pharmacokinetics of pleural perfusion thermochemotherapy (PPTC) under video-assisted thoracoscopic surgery (VATS) and its modified method with a short perfusion time for preventing heat damage to the lung during the procedure.: MethodsSeventeen patients, 59 to 79 years old, underwent surgical resection of the primary lesions and PPTC under VATS without thoracotomy. All had pleural spread with malignant effusion due to lung cancer proven before the treatment. PPTC consists of irrigating the pleural space with 42°C saline solution containing cisplatin (200 mg/m2) using a devised circuit. The time for perfusion was two hours in 10 patients (group L), and one hour in 7 patients (group S).: ResultsAll patients successfully completed this treatment with acceptable toxicities. The pharmacokinetic analysis showed that high platinum levels for the regional pleural exposure, which was 20- to 40-fold greater than those for the plasma in both groups. These values were equivalent between the groups, although the levels for the plasma were higher in group L than in group S. Postoperative lung damage was seen in 4 patients with no serious conditions in group L, and none in group S. The median survival for the L and S groups was 17 and 19 months, respectively.: ConclusionsThis less invasive modality seems to offer a safe, feasible, and pharmacokinetically advantageous procedure to have excellent local control for lung cancer with pleural spread. [Copyright &y& Elsevier]