Reply to the Editor

Abstract

The aims of our study were to describe the difference of unilateral and bilateral radiographic infiltrates on early posttransplant outcomes, including primary graft dysfunction (PGD) grade.1Oto T. Griffiths A.P. Levvey B.J. Williams T.J. Snell G.I. Unilateral radiographic abnormalities following bilateral lung transplantation: exclusion from the definition of primary graft dysfunction?.J Thorac Cardiovasc Surg. 2006; 132: 1441-1446Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 2Christie J.D. Carby M. Bag R. Corris P. Hertz M. Well D. Report of the ISHLT working group on primary lung graft dysfunction part II: definition A consensus statement of the International Society for Heart and Lung Transplantation.J Heart Lung Transplant. 2005; 24: 1454-1459Abstract Full Text Full Text PDF PubMed Scopus (576) Google Scholar As Shuhaiber states, a perioperative bronchoscopy protocol could influence radiographic findings. In our protocol, inspection and toileting bronchoscopy was routinely performed before donor lung procurement, immediately after implantation, and within 6 hours after admission to the intensive care unit. Therefore, significant airway secretions or mucus plugging were unlikely to be present in the early postoperative period. Moreover, for the purpose of PGD grading, only radiographic infiltrates, consistent with pulmonary edema rather than atelectasis, were assessed (as per the International Society for Heart and Lung Transplantation PGD grading guideline.2Christie J.D. Carby M. Bag R. Corris P. Hertz M. Well D. Report of the ISHLT working group on primary lung graft dysfunction part II: definition A consensus statement of the International Society for Heart and Lung Transplantation.J Heart Lung Transplant. 2005; 24: 1454-1459Abstract Full Text Full Text PDF PubMed Scopus (576) Google Scholar). Notwithstanding, mucus plugging, clot, or extubation itself3Oto T. Levvey B.J. Snell G.I. Potential refinements of the International Society for Heart and Lung Transplantation primary graft dysfunction grading system.J Heart Lung Transplant. 2007; 26: 431-436Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar could cause a temporary reduction of arterial oxygen tension/fraction of inspired oxygen (Pao2/Fio2) ratio. Therefore, the worst Pao2/Fio2 ratio might not represent true graft function4Oto T. Levvey B. Pilcher D.V. Bailey M.J. Snell G.I. Evaluation of the oxygenation ratio in the definition of early graft dysfunction post lung transplantation.J Thorac Cardiovasc Surg. 2005; 130: 180-186Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar and should not be used for PGD grading. Pulmonary hypertension (PH) is a significant risk factor for posttransplant radiographic infiltrates. In our study, the number of patients with PH was small; thus, the majority of bilateral infiltrates were seen in the non-PH patient group. Moreover, the official PGD grading system applies to both PH and non-PH recipients. Antifibrinolytic agents were used for patients having a higher risk of bleeding (eg, cardiopulmonary bypass, previous thoracic operation), patients already at increased risk of postoperative pulmonary infiltrates. Therefore, in this circumstance, the radiographic infiltrates are potentially multifactorial. Although further study including multivariate analysis is needed, our study clearly showed that the early posttransplant outcome of the unilateral infiltrates was similar to that in the group having a clear chest x-ray film and significantly better than that in those with bilateral infiltrates. Therefore, we believe that in bilateral lung transplantation, only bilateral infiltrates should be used as part of the definition of PGD. Unilateral as well as bilateral infiltrates should remain part of the definition of pulmonary graft dysfunctionThe Journal of Thoracic and Cardiovascular SurgeryVol. 134Issue 1PreviewWe read with interest the article by Oto and associates1 in the December 2006 issue of the Journal. The authors underestimate the importance of unilateral infiltrates. We disagree with the statement, “only bilateral infiltrates should be used as part of the definition of primary graft dysfunction” despite their convincing statistical methods. We explain why. Full-Text PDF