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Purpose Chronic lung allograft dysfunction (CLAD) limits long term survival after lung transplantation (LTx). Distinction of CLAD subtypes relies on total lung capaciy (TLC) testing which is more cumbersome and less frequently performed compared to FEV1. Also, diagnosing CLAD is more difficult in single compared to double LTx patients due to the contribution of both the native lung and the allograft to FEV1 changes. CT can evaluate the lungs individually and could represent an alternative to TLC testing. Our aim was to investigate the utility of quantitative CT (QCT) in CLAD single LTx patients. Methods Of 138 patients who underwent single LTx 2006-2014, 35 (16 right, 19 left) developed CLAD, were followed for at least 1 year after CLAD onset, and had CT scans at baseline and at CLAD onset. CT lung volume (total volume of both native and allograft lungs) was compared with TLC values. The area under the ROC curve (AUC) was used to compare patients with shorter survial (< 1 year) to those with longer survival (≥ 1 year) after CLAD onset using QCT analysis of allograft lung: volume as a % of baseline, functional principal component analysis (FPCA) using hounsfield units (HU) density histogram at CLAD onset, mean HU at CLAD onset, and HU as a % of baseline. FPCA is a statistical approach that was used for dimension reduction of HU density histogram from QCT data. Results 31 patients had TLC at baseline and 29 at CLAD onset. CT volumes were highly correlated with TLC at both time points (p < 0.0001). Average FEV1(% of baseline) for shorter survival patients (n=12) and longer survival patients (n=23) was similar (74±5%, 75±5%, p=0.67). AUC for differentiating between the 2 groups using QCT on the allograft lung were FPCA = 0.69[95% CI0.51-0.83], p=0.047, mean HU = 0.67[0.50-0.82], p=0.11, volume (% of baseline) = 0.64[0.46-0.80], p=0.24, and HU (% of baseline) = 0.61[0.43-0.77], p=0.33. Conclusion QCT may be a useful radiologic tool for discriminating CLAD prognosis not only for double LTx but also for single LTx. [ABSTRACT FROM AUTHOR]

Mechanical circulatory support for acute biventricular failure is challenging. Given that durable VAD is available only for LV support as bridge-to-transplantation in Japan, the treatment options for this pathology are limited to extracorporeal biventricular assist device (BiVAD) support first, which can be subsequently upgraded to durable LVAD in cases having recovery of RV function and transplant candidacy. The purpose of this study was to review the outcomes of extracorporeal BiVAD and to explore factors associated with the outcomes. This study enrolled an institutional consecutive series of 39 cases who underwent extracorporeal BiVADs implantation for acute biventricular failure between April 2014 and October 2020. The etiological diagnosis was myocarditis in 27 cases, acute MI in 6 cases, and dilated cardiomyopathy (DCM) in 6 cases. The cases were assigned into the two groups according to the BiVAD support less than 7 days (n=18, Short group) or 7 days or more (n=21, Long group). The Long group consisted of 6 cases of acute MI (100%), 13 cases (48%) of myocarditis, two cases of DCM (33%). There was no case who deceased within 7 days after BiVAD implantation. In the Short group, extracorporeal LVAD was weaned-off in 11 cases (61%) or upgraded to durable LVAD in 6 cases after withdrawal of RV support within 7 days. The remaining one case deceased under extracorporeal LVAD. In the Long group, RV support was discontinued in 10 cases in the median support of 60 days (IQR; 24.2-76.8), while two cases were on BiVAD support at October 2020. The remaining nine cases (43%) deceased under BiVAD support in-hospital. Survival and VAD-free survival at 1 year were 79% and 56% in the Short group versus 48% and 20% in the Long group, respectively. Outcomes of extracorporeal BiVAD support for acute biventricular failure were dependent on recovery of RV function. Targeting approach for RV function would be warranted for poor biventricular function. [ABSTRACT FROM AUTHOR]

An extracorporeal centrifugal-flow left ventricular assist device (CF-E-LVAD) system (BR16010) was newly developed. Since implantation of the durable implantable LVAD (I-LVAD) is still controversial in patients with cardiogenic shock or refractory heart failure because of its significant inferiority of outcomes as compared with higher INTERMACS profile patients, short-term E-LVADs have been still clinically important for bridging strategy for the next definitive treatment. Our aim of this study was to evaluate the influence of the novel developed CF-E-LVAD on the clinical prognosis in patients with bridging strategy, as compared with conventional extracorporeal pulsatile flow LVAD (PF-E-LVAD). We retrospectively reviewed the medical records of 62 patients who were implanted E-LVAD as bridging strategy from April 2011 to January 2019. Six patients (9.7%) were implanted CF-E-LVAD. The clinical prognosis until 30 days after E-LVAD implantation, and the change of cardiac function and laboratory data at the early follow up were evaluated. Improvement of left ventricular ejection fraction was significantly greater in the CF-E-LVAD group than in the PF-E-LVAD group (217.9 [147.8 to 335.3] vs 38.3 [-21.7 to 128.8] %, P=0.010). Serum total bilirubin level significantly improved in CF-E-LVAD group than in the PF-E-LVAD group (-7.9 [-33.3 to 82.4] vs 68.8 [10.0 to 202.1] %, P=0.041). Although clinical courses, including death, cerebrovascular accidents and re-thoracotomy due to removal of mediastinal hematoma, were no significant difference between two groups, almost half (54.5%) in the PF-E-LVAD group was still ongoing the E-LVAD support at the 30 days post-E-LVAD implantation while only one patient (16.7%) was supported with E-LVAD in the CF-E-LVAD group. The novel developed CF-E-LVAD system might influence on the earlier recovery of cardiac function and the multiple organ failure, and lead to the earlier decision for next definitive strategy. [ABSTRACT FROM AUTHOR]

Heparin-induced thrombocytopenia (HIT) is an immune-mediated condition associated with thrombocytopenia and thrombotic complications. The condition is increasingly recognized in hospitalized patients including severely injured trauma patients. Because these patients may eventually be considered for organ donation, management of the HIT screen positive donor has become an important issue in transplant surgery. We describe the recent management of 2 cardiac allograft donors with HIT. At organ recovery, both male adult donors were hemodynamically stable with a normal appearing heart and no evidence of thrombosis. The donor underwent a routine multiple organ allograft recovery with argatroban infused over 15 minutes immediately before aortic cross-clamping after confirming activated clotting time (ACT) of greater than 400 sec. The cardiac allograft was flushed in the donor operating room with a total of 4 liters of cold Celsior solution. These hearts were transplanted in patients with dilated cardiomyopathy and cardiac sarcoidosis by modified bicaval anastomosis technique using heparin for anticoagulation therapy during cardiopulmonary support. Both were bridged with implantable left ventricular assist device (Heart Mate II and Jarvik 2000, respectively). This management strategy resulted in successful multiple organ transplants (Case 1: heart, two single lungs, liver, 2 kidney, case 2: heart, bilateral lung, liver, pancreas, 2 kidneys). Neither of the heart and other recipients demonstrated signs or symptoms of HIT, or neither had any postoperative thrombotic complications.. Based on this experience, a treatment algorithm for managing HIT donors using argatroban is proposed for heart donors as well as other organ donors [ABSTRACT FROM AUTHOR]

Purpose Chronic lung allograft dysfunction (CLAD) remains the main impediment to long-term survival after lung transplantation. Club cell secretory protein (CCSP), is an abundant protein secreted from non-ciliated bronchial epithelial cells with both antioxidative and anti-inflammatory properties. BAL CCSP levels were previously shown to be lower in patients who later developed CLAD. We aimed to examine whether levels of CCSP in BAL obtained early after CLAD diagnosis are associated with the major CLAD subtypes: bronchiolitis obliterans syndrome (BOS) and restrictive allograft syndrome (RAS). Methods Among all adult, first, bilateral, lung transplants, between 2004-2013, CLAD status was retrospectively determined as a sustained irreversible drop in FEV 1 , and patients were classified into BOS and RAS (based on 10% reduction in TLC), and long-term (>4 years) CLAD-free. First BAL available after CLAD diagnosis not associated with concurrent infection or acute rejection was chosen for this study. Protein levels were measured by ELISA. Log transformed CCSP levels were compared using linear regression models. Association of CCSP levels with post-CLAD survival was assessed using Cox PH models. Results BALs were obtained from 26 patients with established CLAD (10 RAS, 16 BOS) and 19 CLAD-free controls. CCSP levels were significantly lower in CLAD compared to CLAD-free controls (P =0.019) but did not differ between CLAD subgroups RAS and BOS (P =0.57). CCSP level was not associated with post-CLAD survival (HR 1.05, CI (0.72, 1.56), P =0.78). Conclusion We confirm that BAL CCSP levels are reduced in lung transplant recipients with CLAD. However, CCSP levels do not differ between BOS and RAS, possibly since airways are similarly affected in both conditions. Further investigation of other types of epithelial injury may provide insight into the pathogenesis of CLAD and its subtypes. [ABSTRACT FROM AUTHOR]