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Objective Primary graft dysfunction, a severe form of lung injury that occurs in the first 72 hours after lung transplant, is associated with morbidity and mortality. We sought to assess the impact of an evidence-based guideline as a protocol for respiratory and hemodynamic management. Methods Preoperative and postoperative data for patients treated per the guideline (n = 56) were compared with those of a historical control group (n = 53). Patient data such as ratio of arterial Po 2 to inspired oxygen fraction, central venous pressure, cumulative fluid balance, vasopressor dose, and serum urea and creatinine were measured and documented at specific times. Primary outcome was severity of primary graft dysfunction within the first 72 hours. Results Primary graft dysfunction grade was progressively lower in patients treated after introduction of the guideline ( P = .01). Lower postoperative fluid balances ( P = .01) and vasopressor doses ( P = .007) were seen, with no associated renal dysfunction. There were no differences in duration of mechanical ventilation or mortality. Nonadherence to the guideline occurred in 10 cases (18%). Conclusions Implementation of an evidence-based guideline for managing respiratory and hemodynamic status is feasible and safe and was associated with reduction in severity of primary graft dysfunction. Further studies are required to determine whether such a guideline would lead to a consistent reduction in severity of primary graft dysfunction at other institutions. Creation of a protocol for postoperative care provides a template for further studies of novel therapies or management strategies for primary graft dysfunction.

Objective To assess the safety and early clinical results of a multicenter evaluation of airway bypass with paclitaxel-eluting stents for selected patients with severe emphysema. Methods Airway bypass was performed with a fiberoptic bronchoscope in three steps: identification of a blood vessel–free location with a Doppler probe at the level of segmental bronchi, fenestration of the bronchial wall, and placement of a paclitaxel-eluting stent to expand and maintain the new passage between the airway and adjacent lung tissue. All adverse events were recorded, as well as 1- and 6-month pulmonary function tests and dyspnea index. Results Thirty-five patients received the airway bypass procedure with a median of 8 stents implanted per patient. At 1-month follow-up, statistically significant differences in residual volume, total lung capacity, forced vital capacity, forced expiratory volume, modified Medical Research Council scale, 6-minute walk, and St George's Respiratory Questionnaire were observed. At the 6-month follow-up, statistically significant improvements in residual volume and dyspnea were demonstrated. One death occurred after bleeding during the procedure. Retrospective analysis revealed that the degree of pretreatment hyperinflation may be an important indicator of which patients achieve the best short- and long-term results. Conclusions The airway bypass procedure reduces hyperinflation and improves pulmonary function and dyspnea in selected patients with severe emphysema. Duration of benefit appears to correlate with the degree of pretreatment hyperinflation. These preliminary clinical results support further evaluation of the procedure.

ObjectivesUnilateral infiltrates on chest x-ray films are occasionally seen after bilateral lung transplantation. In the primary graft dysfunction grading system, the presence or absence of a radiographic abnormality is crucial in determining the incidence and severity of primary graft dysfunction. However, no consideration is given as to whether unilateral infiltrates have the same impact and relevance as bilateral infiltrates. This study aims to describe the incidence, features, and outcomes of posttransplant unilateral infiltrates and their effect on the novel primary graft dysfunction grading system.MethodsDepending on posttransplant radiographic appearance, 144 patients who underwent bilateral lung transplantation were divided into 3 groups: no infiltrates (clear), unilateral infiltrates (unilateral), or bilateral infiltrates (bilateral).ResultsRadiographic abnormalities were seen in 43% of donors and 61% of posttransplant recipients (sensitivity = 76%, specificity = 50%). The percentage of recipients in the unilateral, clear, and bilateral groups was 26%, 39%, and 35%, respectively. Lower posttransplant oxygenation (P < .05), longer intubation hours, and more intensive care unit days (P < .0001) were seen in the bilateral compared with the unilateral and the clear groups. A significant difference in the prevalence of primary graft dysfunction (P < .0001) was seen, depending on whether unilateral infiltrates were included or excluded from the primary graft dysfunction grading.ConclusionsThe incidence of unilateral infiltrates is relatively high after bilateral lung transplantation. The early posttransplant outcome of the unilateral infiltrates is similar to that in the group having a clear chest x-ray film and significantly better than that in those with bilateral infiltrates. In bilateral lung transplantation, only bilateral infiltrates should be used as part of the definition of primary graft dysfunction.

Objective Despite the clinical importance of early graft dysfunction, no standardized definition is available. We hypothesized that the arterial blood gas oxygen tension/fraction of inspired oxygen ratio (Pao 2 /Fio 2 ) would prove to be a useful marker for predicting subsequent outcomes of early graft dysfunction. The aims of this study were to define the prevalence of various ranges of Pao 2 /Fio 2 over the first 48 hours after lung transplantation and to evaluate which measurement using the Pao 2 /Fio 2 best correlates with the duration of intubation, the length of stay in the intensive care unit, and 30-day mortality, which are important alternative indicators of early graft performance. Methods A retrospective study was performed that included all 68 bilateral single-lung transplantations at The Alfred Hospital from January 2000 to December 2002. Results Pao 2 /Fio 2 at 6 and 12 hours after admission to the intensive care unit was significantly associated with the duration of intubation ( r = −0.44; P r = −0.48; P 2 /Fio 2 at 6 and 24 hours was also significantly associated with the length of intensive care unit stay ( r = −0.38; P = .002 and r = −0.44; P = .001, respectively). Thirty-day mortality was significantly associated with a lower Pao 2 /Fio 2 at 6 hours (219 ± 93 vs 306 ± 101; P = .03). Conclusions Pao 2 /Fio 2 taken between 6 and 12 hours after transplantation is a useful marker associated with lung transplantation outcomes. There is the potential for therapeutic interventions during this time that may be able to enhance Pao 2 /Fio 2 by 12 hours and improve subsequent outcomes.

not to place the LVAD using bivalirudin or any other direct thrombin inhibitors because this is associated with potentially lethal bleeding complications. Some centers have reported the use of unfractionated heparin and concomitant potent platelet inhibitors for CPB in the setting of HIT. However, this approach has not been adopted at our institution. The use of plasmapheresis for HIT is not a novel conception. Few studies have reported using plasma exchange in the management of HIT with thrombosis. However, the surgical literature contains only 1 case report in which plasmapheresis was successfully used preoperatively in a HIT-positive patient who required coronary artery bypass grafting under CPB with heparin. To our knowledge, this is the first reported case of plasmapheresis for a HIT-positive patient requiring an LVAD. This isolated experience suggests that plasmapheresis may be used successfully to seroconvert a patient to

ObjectiveLungs from non–heart-beating donors for transplantation require protection against warm ischemic damage. Minimally invasive techniques are required to reduce organ damage during the warm ischemic period because invasive surgical procedures are often not feasible at this time. This study investigated the preservative effect of high-flow endobronchial cooled humidified air during warm ischemia in non–heart-beating donor rat lungs.MethodsFourteen animals were divided into a Cooling group (n = 7), which received cooled air/saline spray during a 2-hour warm ischemic period, and a Control group (n = 7), which received no cooling. After ischemia the lungs were reperfused on an isolated lung perfusion apparatus.ResultsEndobronchial temperatures in the Cooling and Control groups were 8°C and 36°C at 10 minutes, and 5°C and 35°C at 20 minutes, respectively (P < .0001). Lung core and surface temperatures in the Cooling group were also lower than those in the corresponding Control group (P < .0001). After reperfusion, pulmonary arterial pressure (P = .003) and peak airway pressure (P = .002) were lower in the Cooling group than in the Control group. Higher pulmonary venous Po2 (P = .02), higher adenosine triphosphate levels (P = .01), and lower wet/dry lung weight ratio (P = .003) were seen in the Cooling group compared with the Control group.ConclusionsHigh-flow endobronchial cooled humidified air can decrease lung temperature and improve post-ischemic pulmonary function and adenosine triphosphate levels in non–heart-beating donor lungs.

Objective Single-lung transplantation for chronic obstructive pulmonary disease can cause unique postoperative problems that might require independent lung ventilation. We evaluated preoperative and immediate postoperative factors to predict the need for independent lung ventilation. Methods We retrospectively studied 170 patients who received a single-lung transplant over a 15-year period, 20 (12%) of whom required independent lung ventilation. Results Patients requiring independent lung ventilation were similar in age, sex, ischemic time, and donor characteristics to those who required conventional ventilation. Patients receiving independent lung ventilation had a greater degree of preoperative airflow limitation, more hyperinflation, lower postoperative Pao 2 /fraction of inspired oxygen ratios, more radiologic mediastinal shift, and more transplant lung infiltrate on the postoperative chest radiograph. Multivariate logistic regression analysis showed that independent lung ventilation was associated with increasing levels of recipient hyperinflation (percentage total lung capacity compared with predicted value; odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .032) and reduced early postoperative Pao 2 /fraction of inspired oxygen ratio (odds ratio, 0.97; 95% confidence interval, 0.95-0.99; P = .005). Length of ventilation and intensive care unit stay and mortality were higher in the independent lung ventilation group. Among patients who survived to hospital discharge, there were no differences in long-term mortality between the 2 groups. Conclusions The need for independent lung ventilation in patients undergoing single-lung transplantation for obstructive lung disease is predicted by the combination of increased hyperinflation measured on recipients' preoperative lung function tests and a low Pao 2 /fraction of inspired oxygen ratio, indicating graft dysfunction in the immediate postoperative period.

ObjectivePrimary graft failure remains a significant cause of morbidity and mortality after lung transplantation, and its mechanism is not understood. Previously 2 case reports described fatal primary graft failure due to donor-related unexpected pulmonary embolism. This study investigated the incidence, early outcome, and risk factors of unexpected pulmonary embolism in lung transplantation.MethodsAn exploratory retrograde donor lung flush before implantation to diagnose pulmonary embolism (emboli group) or no pulmonary embolism (no-emboli group) was performed in 74 of 122 consecutive lung transplantations.ResultsThe incidence of macroscopic unexpected pulmonary embolism was 38% (28% clot and 9% fat). In the emboli group, significantly decreased oxygenation (P < .05), increased pulmonary vascular resistance (P < .001), an increased proportion of opacity on chest radiograph (P = .03), prolonged intubation (P < .001) and intensive care unit stay (P < .01), and decreased 1-year survival (P = .03) were seen after transplantation. In multivariate analysis, pulmonary embolism was an independent risk factor for prolonged intubation (hazard ratio, 2.42; P < .01). In logistic regression, death due to trauma with fracture and a smoking history of more than 20 pack-years were significant donor risk factors for pulmonary embolism (adjusted odds ratio, 8.77 and 5.64; P = .02 and .04, respectively). No deleterious effects of the exploratory flush were seen.ConclusionsUnexpected pulmonary embolism is relatively common, is potentially predicted by donor history (but not by arterial blood gas analysis or chest radiograph), and is associated with primary graft failure. Donor lungs with risk factors of pulmonary embolism should undergo an exploratory flush. When pulmonary embolism is diagnosed, further therapeutic strategies must be considered.