Combined Heart Lung Research Articles

PERIOPERATIVE OUTCOMES OF COMBINED HEART SURGERY AND LUNG TUMOR RESECTION : A SYSTEMATIC REVIEW

Background: Cancer and cardiovascular disease are the leading causes of death in both men and women worldwide. There are concerns regarding the potentially increased mortality and complication rates of simultaneous surgery and the adequacy of lung exposure during heart surgery. Methods: By comparing itself to the standards set by the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020, this study was able to show that it met all of cthe requirements. So, the experts were able to make sure that the study was as up-to-date as it was possible to be. For this search approach, publications that came out between 2013 and 2023 were taken into account. Several different online reference sources, like Pubmed and SagePub, were used to do this. It was decided not to take into account review pieces, works that had already been published, or works that were only half done. Result: In the PubMed database, the results of our search brought up 14 articles, whereas the results of our search on SagePub brought up 91 articles. The results of the search conducted for the last year of 2013 yielded a total 9 articles for PubMed and 23 articles for SagePub. In the end, we compiled a total of 5 papers, 4 of which came from PubMed and 1 of which came from SagePub. We included five research that met the criteria. Conclusion: In summary, combined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate. Subgroup analyses revealed that most patients with lung cancer underwent uncompromised anatomical resection and mediastinal lymph node sampling or dissection during combined cardiothoracic surgery, and showed off-pump CABG may reduce the complication rate compared with on-pump CABG. Further researches are still needed to verify these findings.

Should there be an age limit for advanced therapies?

Combined heart lung transplant has become a rare procedure. However, there is a significant number of patients potentially benefitting from replacement of both heart and lungs. This represents a quite diverse patient population. Decisions in patient selection have to be adjusted to individual needs and distinct constellation of the patient. Age may be a risk factor, but should be carefully integrated into the evaluation of perioperative and long term risks.

Fungi between Immunostimulatory and Immunosuppressive

Microbes in general and fungi especially are promising biotechnological tools that are used for green synthesis of numerous products. Fungi in particular are potent producers of many industrially important compounds. β-Glucans are a group of biologically-active fibres or polysaccharides from natural sources with proven medical significance. β-Glucans are known to have antitumor, anti-inflammatory, anti-obesity, anti-allergic, anti-osteoporotic, and immunomodulating activities. On the other hand, cyclosporin is a cyclic undecapeptide with a variety of biological activities including immunosuppressive, antiinflammatory, antifungal, and antiparasitic properties. It is an extremely powerful immunosuppressant and is approved for the use in organ transplantation to prevent graft rejection in kidney, liver, heart, lung, and combined heart–lung transplants. Hence, this review aims to focus on β-glucan as immunostimulatory and Cyclosporine A as Immunosuppressants

German Heart Surgery Report 2021: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery.

Based on a longtime voluntary registry, founded by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) in 1980, well-defined data of all cardiac, thoracic and vascular surgery procedures performed in 78 German heart surgery departments during the year 2021 are analyzed. Under more than extraordinary conditions of the further ongoing worldwide coronavirus disease 2019 (COVID-19) pandemic, a total of 161,261 procedures were submitted to the registry. In total, 92,838 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 27,947 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.2:1) was 97.3%. For the 36,714 isolated heart valve procedures (19,242 transcatheter interventions included) it was 96.7 and 99.0% for the registered pacemaker and International Classification of Diseases (ICD) procedures (19,490), respectively. Concerning short- and long-term circulatory support, a total of 3,404 ECLS/ECMO implantations and 750 assist device implantations (L-/ R-/ BVAD, TAH), respectively were registered. In 2021 329 isolated heart transplantations, 254 isolated lung transplantations, and one combined heart-lung transplantations were performed.This annually updated registry of the GSTCVS represents voluntary public reporting by accumulating actual information for nearly all heart surgical procedures in Germany, constitutes advancements in heart medicine and represents a basis for quality management for all participating institutions. In addition, the registry demonstrates that the provision of cardiac surgery in Germany is up to date, appropriate, and nationwide patient treatment is guaranteed all the time.

Outcomes After Lung or Combined Heart Lung Transplantation for PAH and CTEPH According to Baseline Kidney Function

<h3>Purpose</h3> Decreased renal function is often considered as a contraindication for lung (LTX) or combined heart-lung (HLTX) transplantation due to poorer prognosis and risk of further decline due to nephrotoxic medication. Severe pulmonary hypertension (PH) may decrease renal function because of low cardiac output and renal congestion, which may be reversible with transplantation. We aimed to assess whether pre-transplant kidney function is a predictor for mortality or need for renal replacement therapy (RRT) and evaluated the evolution of renal function after LTX or HLTX in PH patients. <h3>Methods</h3> We conducted a retrospective study in 68 consecutive patients diagnosed with PAH, chronic thromboembolic pulmonary hypertension (CTEPH) or PAH due to congenital heart disease who had undergone LTX or HLTX in our center between 1996 and 2019. 3 year survival according to pre-transplant kidney function was evaluated using the Kaplan-Meier method and by log-rank test. The evolution of eGFR according to pre-transplant kidney function was evaluated using mixed model effect test. Predictors of the need for RRT in the first 90 days and mortality after 1 year were identified by univariate analysis. <h3>Results</h3> 35 of 68 patients had an abnormal pre-transplant creatinine (cut off >1.15mg/dL for males, >0.95mg/dL for females). eGFR range was 38-121 ml/min/1.73m². 3 year survival was similar in both groups (67% versus 69%). In all patients, there was a trend to an improvement of kidney function at one month (eGFR +11.5 ml/min, P=0.055). At 6 months there was no longer a significant difference between the eGFR of both groups. A pre-transplant right atrial pressure of >15 mmHg was predictive for the need of RRT in the first 90 days, a baseline abnormal creatinine was not. The need for RRT in the first 90 days was predictive for mortality in the first year. <h3>Conclusion</h3> In patients with PAH, CTEPH or PAH related to congenital heart disease, a mild abnormal kidney function does not correlate with a higher risk of RRT or mortality after LTX or HLTX. eGFR may improve at one month suggesting an impairment due to hemodynamic status pre-transplant. At 6 months, there was no difference in eGFR according to the baseline kidney function. This suggests that pre-transplant kidney dysfunction is mostly determined by a hemodynamic factor and that it should only be considered as a relative contraindication for transplantation.

Novel Use of Pulmonary Artery Pressure Monitoring After a Total Artificial Heart Implantation

<h3>Introduction</h3> The use of total artificial heart (TAH) implantation remains of limited use in the United States for patients with biventricular heart failure. One subgroup of patients that have been supported by TAH include patients with pulmonary hypertension that are not candidates for combined heart lung transplantation. These patients are difficult to manage after TAH implantation, as right heart catheterization cannot be performed to guide post surgical therapy. <h3>Case Report</h3> GF is a 49 year old male with ischemic cardiomyopathy on a home milrinone infusion with a left ventricular thrombus, pulmonary embolism, and pulmonary sarcoidosis. He presented with shortness of breath and fatigue. Right heart catheterization demonstrated severely decreased cardiac index (1.59L/min/m2 on thermodilution and 1.68 L/min/m2 on Fick) and severe pulmonary hypertension (transpulmonary gradient 36 mmHg, pulmonary vascular resistance 10.6 Woods Units, pulmonary artery (PA) pulsatility index 1.88). Intra-aortic balloon pump was placed for support and a PA catheter was left in place for continuous hemodynamic monitoring. He continued to decline and required escalation to extracorporeal membrane oxygenation support. He was listed for a heart transplant, but due to persistent severe pulmonary hypertension and new onset bacteremia he was made inactive and the decision was made to pursue alternative mechanical support with a TAH. Since right heart catheterization cannot be performed on patients with a TAH, a pulmonary artery sensor was placed in the left pulmonary artery one day prior to TAH implantation. Postoperatively, the TAH functioned well and the PA pressures were monitored easily with a bedside sensor. Initially, PA pressures ranged from 61-70/36-47 mmHg, but with medical optimization they improved to 37-48/20-27 mmHg by postoperative week 7 and he was relisted for transplant. <h3>Summary</h3> We identified a novel use for a pulmonary artery pressure sensor in a total artificial heart patient to help guide post implantation strategies. Our patient successfully had decreased pulmonary artery pressures and advanced to heart transplant listing.

Perioperative outcomes of combined heart surgery and lung tumor resection: a systematic review and meta-analysis

ObjectiveThe prevalence of patients with concomitant heart and lung lesions requiring surgical intervention is increasing. Simultaneous cardiac surgery and pulmonary resection avoids the need for a second operation. However, there are concerns regarding the potentially increased mortality and complication rates of simultaneous surgery and the adequacy of lung exposure during heart surgery. Therefore, we performed a meta-analysis to evaluate the perioperative mortality and complication rates of combined heart surgery and lung tumor resection.MethodsA comprehensive literature search was performed in July 2020. The PubMed, Embase, and Web of Science databases were searched to identify studies that reported the perioperative outcomes of combined heart surgery and lung tumor resection. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias of included studies. Pooled proportions and 95% confidence intervals (95% CI) were calculated by R version 3.6.1 using the meta package.ResultsA total of 536 patients from 29 studies were included. Overall, the pooled proportion of operative mortality was 0.01 (95% CI: 0.00, 0.03) and the pooled proportion of postoperative complications was 0.40 (95% CI: 0.24, 0.57) for patients who underwent combined cardiothoracic surgery. Subgroup analysis by lung pathology revealed that, for patients with lung cancer, the pooled proportion of anatomical lung resection was 0.99 (95% CI: 0.95, 1.00) and the pooled proportion of systematic lymph node dissection or sampling was 1.00 (95% CI: 1.00, 1.00). Subgroup analysis by heart surgery procedure found that the pooled proportion of postoperative complications of patients who underwent coronary artery bypass grafting (CABG) patients using the off-pump method was 0.17 (95% CI: 0.01, 0.43), while the pooled proportion of complications after CABG using the on-pump method was 0.61 (95% CI: 0.38, 0.82).ConclusionCombined heart surgery and lung tumor resection had a low mortality rate and an acceptable complication rate. Subgroup analyses revealed that most patients with lung cancer underwent uncompromised anatomical resection and mediastinal lymph node sampling or dissection during combined cardiothoracic surgery, and showed off-pump CABG may reduce the complication rate compared with on-pump CABG. Further researches are still needed to verify these findings.

Heart transplant recipients with confirmed 2019 novel coronavirus infection: The Detroit experience.

A chronic immunosuppressed state as in solid organ transplant recipients is a reported risk factor for the novel 2019 coronavirus infection. Patients with a history of orthotopic heart transplant (OHT) at a tertiary care transplant center in Detroit, Michigan were retrospectively reviewed from March until May 2020. Clinical parameters and outcomes of 5 OHT recipients and one combined heart-lung recipient with confirmed SARS-CoV-2 were obtained. The cohort was predominately African American males with median age of 59years (interquartile range, 48.25-73.25). All patients were classified as having mild-moderate disease; none required intubation or ICU admission with no deaths. The most common presenting symptoms were fever and shortness of breath 83% (n=5), followed by cough and chills 67% (n=4). All admitted patients (n=5) received hydroxychloroquine and 3 received high-dose steroids. Antimetabolites were held for 2 patients (33.3%). The calcineurin inhibitor trough goal was decreased in only 1 patient; 3 other patients, without change in goal, required calcineurin inhibitor dosage reduction. Two patients requiring readmission presented 7 and 23days after initial symptoms onset. In conclusion, our experience with OHT patients infected by the SARS-CoV-2 virus did not have an elevated risk of severe infection. Impact of modifying immunosuppression remains unclear.

Combined heart–lung transplantation from a donation after circulatory death donor

Combined heart-lung transplantation is the optimal treatment option for many patients with end-stage heart failure and fixed severe pulmonary hypertension. It offers the only possibility of long-term survival and a return to a normal quality of life. Unfortunately, it is rarely performed because of donor organ allocation policies. We present the case of a critically ill 24-year-old man, who after waiting for >100 days in-hospital on the urgent transplant list, deteriorated further and underwent the first successful heart-lung transplant with organs from a donation after circulatory death.

Successful Combined Heart-Lung Transplant from a Donation after Circulatory Determined Death (DCD) Donor

For patients with end stage heart failure and fixed pulmonary hypertension, combined heart-lung transplantation offers the only possibility of survival with a return to a normal quality of life. Unfortunately, due to the severe scarcity of donation after brain death (DBD) organs it is rarely performed. We present the first successful combined heart lung transplant from a DCD donor. A 24-year-old male born with transposition of the great arteries, pulmonary stenosis and a ventricular septal defect (VSD) was operated in childhood with the arterial switch operation and closure of VSD. He continued to suffer with pulmonary hypertension in childhood treated with pulmonary vasodilators. He was referred to our institute in decompensated heart failure and listed for combined heart and lung transplantation, (table 1). After 3 months on the urgent list with no suitable DBD donor offers, the possibility of DCD transplantation was discussed. He matched for a DCD heart-lung bloc 109 days after his original listing and 17 days after listing for a DCD organ. The donor was a 29 year old male motorcyclist who suffered a 30 minute hypoxic cardiac arrest following a road traffic accident (table 1). The potential donor was treated for Staphylococcus aureus pneumonia and was ventilated for 12 days in ITU until futility was declared. Death was declared 219 minutes following withdrawal with a functional warm ischaemic time of 41 minutes. The heart heart and lungs were removed en bloc and perfused together on an in house modified Transmedics OCS lung device for 8 hours 2 minutes. Post transplant the recipient weaned off cardiopulmonary bypass without difficulty. He was discharged home in the 7th post-operative week and remains well at home 3 months following his transplant. DCD heart-lung transplantation has the potential for the increasing number of young adult congenital heart failure patients bridged through childhood with palliative surgical procedures in urgent need of transplantation.

First Series of Combined Heart & Lung Transplantation from India

This study analyses the data of patients undergoing Combined heart and lung transplant(CHLTx) with primary pulmonary hypertension(PPH),advanced lung diseases with right ventricular failure and uncorrected congenital heart diseases which are not uncommon in India unlike the developed countries. Single centre retrospective study of patients who underwent thoracic organ transplantation from April 2017 to October 2019. 107 patients underwent CHLTX,double lung and single lung transplantation. 17 patients underwent CHLTx . Primary etiology was congenital heart disease in 6 (35.3 %), PPH in 6(35.3 %), followed by Group III PH, in 5 (29.4 %) {ILD with severe PH in 4 (30%) and bronchiectasis with severe PH in 1 (7%)}. Post operatively primary graft dysfunction(PGD) was observed in 5 (29.4 %) patients. 2 (11.76 %) had Grade 3 and 3 (17.64 %) had Grade 2 PGD. Post-op ECMO was used in 4 (23.5%) cases. 30 day mortality was observed at n = 3 (17.64 %). 4 (23.5 %) had gram negative sepsis of which 3 (17.64%) expired. For CHLTx in Eisenmenger syndrome with no clear guidelines about the timing,often patient's symptoms and degree of cyanosis are the deciding factors. With well developed congenital cardiac surgery services in developed countries, patients requiring CHLTx for Eisenmenger are rare. However, in India it's not uncommon. The criteria to decide between double lung transplantation vs CHTLX in the other two groups were made with ECHO and right heart catheterisation results. In cases where the results were ambiguous, Cardiac MRI was used to decide between CHTLX vs only lung transplantation. Patients with Right ventricular EF < 25% on Cardiac MRI were advised to undergo CHLTx. Our early experience in CHLTx proves encouraging for patients with end stage cardiopulmonary disorders in India. Cardiac MRI plays a vital role in deciding between CHLTx vs only lung transplantation. Further follow up of the patients is required to establish long term outcomes and complications following combined heart lung transplant.

Lung Transplantation: The Indian Experience and Suggested Guidelines Part II A: The Technique of Lung Transplantation

Background: A series of lectures and workshop on lung and heart–lung transplantation were organized by the Departments of Cardiology and Cardiothoracic Surgery at All India Institute of Medical Sciences, New Delhi, and the Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai. The 1st day workshop on preoperative workup part was published as Part-I in this journal in August 2018. The hands-on cadaveric workshop conducted on May 20, 2018, forms the basis of the first section of the second part (Part II a) which deals with the technique of lung transplantation. The techniques of lung transplantation and Indian scenario are also reviewed. Methodology: The technique practiced by the transplant team at Apollo Hospitals, Chennai, was used for the demonstration of donor lung, heart–lung block harvest and implanting lungs, heart–lung block, while also discussing other possible techniques. Human cadavers were used, and live high-definition audio–video transmission to the lecture hall was made. Results: Accurate figures regarding lung transplantation in India are still not available. However, as per the Indian Society for Heart and Lung Transplantation, current data suggest that overall, about 1050 heart transplants and 310 lung transplants have been done in India. Of these, it is anticipated that national data regarding number of single-lung transplants, double-lung transplants, and heart–lung transplants will be available soon. The Department of Heart and Lung Transplantation at Apollo Hospitals, Chennai, has performed a total of 69 hearts and 149 lungs in 119 patients in various combinations: isolated heart transplants (40 patients), double-lung transplantation (DLT) (43 patients), single-lung transplantation (7 patients), heart and DLT (27 patients), en bloc heart and liver transplantation (1 patient), and combined heart–lung and kidney transplantation (1 patient). While the survival data for India are not currently available, our 3-year survival for DLT is 76.2%. Conclusions: While the surgical technique demonstrated is used in most of our cases, at times, different techniques have had to be adopted based on challenges confronted on the operating table. However, we have found that developing surgical protocols and maintaining consistency in the operative techniques translates into good surgical outcomes.

Welcome Address

Welcome Address

MON-378 Somatic HIF2α Mutation and Pheochromocytoma in a Patient with Cyanotic Congenital Heart Disease

Background: Pheochromocytoma and paraganglioma (PPGL) prevalence is increased in cyanotic congenital heart disease relative to the unaffected population. Chronic hypoxemia promotes stabilization of hypoxia inducible factors (HIFs), which activate downstream hypoxia responsive genes. Somatic mutations in EPAS1 (HIF2α) distort the conformational properties of HIF2α, allowing for avoidance of normally rapid oxygen-dependent enzymatic degradation. EPAS1 mutations have been implicated in PPGL and have recently been proposed to mediate the increased rates of PPGL observed in patients with cyanotic congenital heart disease. Clinical Case: A 48 year old woman with Eisenmenger’s syndrome secondary to congenital ventricular septal defect was admitted to hospital for combined heart and bilateral lung transplantation. Severe pulmonary hypertension with hypoxic respiratory failure had been present for >15 years pre-transplant, and during the 12 months directly preceding admission oxygen saturations routinely measured below 80%. Surgery was complicated by major bleeding and prolonged intraoperative hypotension necessitating initiation of extracorporeal membranous oxygenation to achieve hemodynamic stability. The patient was admitted to the intensive care unit for post-surgical management and within hours of arrival developed paroxysms of pronounced hypertension during which the systolic blood pressure repeatedly exceeded 230 mmHg. On each occasion the hypertensive episode was self-limiting and followed by a period of marked hypotension requiring maximal inotropic support. Plasma metanephrine and normetanephrine concentrations were elevated at 1.00 nmol/L (NR <0.4) and 8.00 nmol/L (NR <0.9) respectively. Computed tomography demonstrated adrenal lesions measuring 18x22x21 mm on the right and 39x38x42 mm on the left. Both adrenal masses were gallium-68 DOTATATE PET-CT avid and pathologic extra-adrenal DOTATATE avidity was not present. The left adrenal tumour was histologically confirmed as PPGL. Histology of the right adrenal gland was unremarkable, but pathologic examination of an extra-adrenal mass identified during surgery was consistent with PPGL. Immunohistochemistry was positive for synaptophysin, chromogranin, CD56 and SDHB in both tumours. Germline mutation screening was negative for pathologic variants in the known PPGL susceptibility genes, but tumour DNA isolated from formalin-fixed paraffin embedded sections identified a pathogenic HIF2α mutation (c.1589C>T, p.Ala530Val) in the left phaeochromocytoma. This variant was not observed in the right PPGL and both PPGL were negative for other known PPGL gene mutations. Conclusions: Chronic hypoxia associated with cyanotic heart conditions may be a risk factor for development of PPGL. Increased risk appears to be mediated, at least in part, through somatic gain of function mutations in the HIF2α gene.

An Eye on Necrosis

We present a case of acute esophageal necrosis (black esophagus) caused by iron pill esophagitis in a patient thirteen days status post combined heart and bilateral lung transplant who was supplemented with oral iron for anemia due to intraoperative blood loss. This case illustrates an unusual cause of acute esophageal necrosis and should be on the differential for patients with unexplained findings of esophageal necrosis who are also on iron supplementation. Case A 52 year old man with chronic right ventricular failure due to class I pulmonary hypertension and unrepaired total anomalous pulmonary venous return with Eisenmenger physiology underwent combined heart and bilateral lung transplantation. He received standard infectious prophylaxis, and started oral ferrous sulfate for anemia after passing a swallow evaluation. On postoperative day (POD) 11, he developed dysphagia and odynophagia. Esophagogastroduodenoscopy (EGD) performed on POD 13 showed circumferential necrosis of the esophagus with tongues of esophagitis proximally (Figure 1), and a stricture with luminal diameter of 6mm. Biopsies revealed necrotic tissue and brown pigment/crystalline material consistent with iron pill-induced esophageal necrosis (supported by positive iron stain) (Figure 2). Ischemia and infection were ruled out. Four months after discharge, EGD showed a 3 cm long fibrotic stricture 25 cm from the incisors 6 mm in diameter. There was mild erythema adjacent to the stricture with otherwise normal esophageal mucosa. Biopsies demonstrated normal squamous mucosa. He will undergo temporary esophageal stenting to treat the stricture. Discussion Ferrous sulfate was first reported to cause ulcerations of the hypopharynx and cervical esophagus in 1976. Severe gastrointestinal necrosis has been seen with iron overdose, however, not with therapeutic doses. In one series of 33 patients with iron pill induced upper gastrointestinal injury, 83% of biopsies contained ulcerative or erosive mucosal injury, but none contained necrosis. Acute esophageal necrosis remains a rare entity with well characterized clinical manifestations but poorly understood pathophysiology. It is suspected to result from ischemia and decreased mucosal defenses. Currently there are no reported cases of iron pill induced acute esophageal necrosis in the literature. This was a surprising finding and should be considered in patient with severe esophagitis or acute esophageal necrosis taking oral iron supplements.1770_A Figure 1 No Caption available.1770_B Figure 2 No Caption available.

017 Combined heart lung MRI protocol for simultaneous interrogation of heart and lung structure

Introduction Many conditions considered to be primary lung diseases are independently associated with adverse cardiovascular outcome. Systemic inflammation and subsequent fibrosis are hypothesised mechanisms. However, beyond the mechanical impact on right heart, characterisation of myocardial involvement in lung disease remains limited. We present a combined heart-lung MRI protocol which allows simultaneous interrogation of heart and lung structure and function. Methods Protocol (1.5T Siemens Avanto) includes steady state free precession (SSFP) cine imaging of the heart (standard long and short axis views), followed by inspiration and expiration cine lung imaging (sagittal planes). T2 prepared SFFP and T1 MOLLIE images are acquired in standard cardiac planes and left and right lungs. Dynamic contrast enhanced MRI (DCE-MRI) sequences are performed using free breathing 2D saturation-recovery FLASH dynamic acquisitions in four planes (two LV short axis slices, left and right lung sagittal slices) with temporal resolution equal to 50% of patient’s heart rate. Three boluses of gadolinium contrast (dotarem) are administered: 0.005 mmol/kg, followed by 2 min of dynamic acquisitions; 0.05 mmol/kg followed by 6 min of dynamics; final dose of 0.1 mmol/kg. Finally, late enhancement imaging and post-contrast T1 mapping are performed. Overall each scan protocol lasted for approximately 60 min. Results Parametric mapping and LGE imaging provides direct tissue characterisation. Myocardial and lung contrast agent kinetics are modelled from the DCE images in matlab (Extended Kety Model) to determine heart and lung capillary permeability (Ktrans), extracellular volume (ECV) and plasma volume fraction (vp). Regions of interest are drawn in the LV and RV cavities to obtain arterial input functions (AIF). The low dose AIF is multiplied by a factor of ten and the first pass peak is combined with the high dose AIF curve in order to correct for saturation effects (Figure 1). Examples of ECV maps are shown in Figure 2 and 3. Conclusions This combined heart lung protocol is an efficient and comprehensive imaging tool for simultaneous myocardial and pulmonary assessment. It has a potential to help elucidate complex links between pulmonary and myocardial pathologies, and is a model for other dual organ parametric MR imaging.

Examining Mortality and Rejection in Combined Heart-Lung Transplantations.

Background There is a paucity of data on outcomes related to combined heart-lung transplantations (HLTs). Our objective was to identify variables associated with mortality and rejection in HLT. Methods The United Network for Organ Sharing database was reviewed for HLT performed between 1993 and 2008. Long-term survivors (survival > 5 years) were compared with short-term survivors (survival < 5 years). Factors associated with rejection were examined. Risk-adjusted multivariable Cox's proportional hazards regression analysis was performed to examine variables associated with mortality and rejection. Results Multivariable analysis revealed that recipient male gender was associated with mortality at 1 year (hazard ratio [HR]: 1.68, 95% confidence interval [CI]: 1.11-2.54, p = 0.01) and 5 years (HR: 1.41, 95% CI: 1.05-1.89, p = 0.02). Preoperative extracorporeal membrane oxygenation (ECMO) was associated with mortality at 1 year (HR: 7.55, 95% CI: 2.55-22.30, p < 0.01) and 5 years (HR: 3.14, 95% CI: 1.19-8.32, p = 0.02). Preoperative mechanical ventilation (MV) was associated with mortality at 1 year (HR: 3.51, 95% CI: 1.77-6.98, p < 0.01) and at 5 years (HR: 2.70, 95% CI: 1.51-4.85, p < 0.01). Multivariable analysis showed that male gender (HR: 1.78, 95% CI: 1.03-3.09, p = 0.04) and cytomegalovirus (CMV) positivity in the recipient and donor (HR: 3.09, 95% CI: 1.59-6.01, p < 0.01) were associated with rejection. Clinical infection in the donor (HR: 2.05, 95% CI: 1.16-3.61, p = 0.01) was also associated with rejection. Conclusion Survival was affected by recipient male sex and need for preoperative ECMO or MV. Risk factors for rejection included male sex, CMV positivity in the donor and recipient, and donor with clinical infection.

Induction immunosuppression for combined heart–lung transplantation

Research on induction immunosuppression in patients undergoing combined heart-lung transplantation (HLTx) is limited. The United Network for Organ Sharing database was queried from 2000 to 2013 to examine the influence of induction immunosuppression for combined HLTx in adult (≥18years) and adolescent (≥12 and <18years) recipients. Of 394 eligible combined HLTx cases (361 adults, 33 adolescents), 384 were included in univariate Cox analysis and 116 in the multivariate Cox model. Univariate analysis demonstrated no differences in survival by induction medication and no difference among the most common maintenance immunosuppression regimens. Adjusting for use of corticosteroids, multivariate analysis demonstrated no benefit of basiliximab (HR=3.582; 95% CI: 0.966, 13.279; P=.056), thymoglobulin/antilymphocyte globulin (ALG)/antithymocyte globulin (ATG) (HR=0.808; 95% CI: 0.134, 4.888; P=.817), alemtuzumab (HR=0.369; 95% CI: 0.087, 1.563; P=.176), or other induction medications (HR=1.511; 95% CI: 0.146, 15.610; P=.729), compared to no induction medication, with respect to mortality hazard post-HLTx. There were also no differences in treated acute rejection episodes by type of induction immunosuppression. Induction immunosuppression with contemporary agents does not improve survival after combined HLTx.

The history of organ transplantation in Austria

In 1902, the first successful kidney transplant ever was performed by E. Ullmann in Vienna. Also, the first clinical renal transplant in Austria was performed on June 17, 1965, by F. Piza in the same city. The first combined pancreas–kidney transplant was performed by R. Margreiter in 1979 in Innsbruck. H.J. Bohmig did the first liver transplant in 1972 in Vienna. The world’s first combined liver–kidney transplant was carried out by R. Margreiter in 1983 in Innsbruck. The same year as the first heart transplant, in 1985 the first combined heart–lung transplant and in 1986 the first double lung transplant were performed in Innsbruck by R. Margreiter and F. Gschnitzer, respectively. In 1989, for the first time, a single lung was transplanted in Vienna by W. Klepetko and E. Wolner. In 1989, the first successful multivisceral transplant including the entire small bowel worldwide took place in Innsbruck, with R. Margreiter and A. Konigsrainer being the surgeons. An isolated bowel transplant was performed in Vienna by F. Muhlbacher in 1983. The world’s second double-hand transplant was performed in Innsbruck in 2000 by a team led by H. Piza and R. Margreiter. These pioneering transplants led to three multiorgan- and two kidney-transplant programs in Austria and generated activities that are among the best worldwide in terms of volume, and also quality.

Increasing Creatine Phosphokinase and Myglobine Levels Predict the Development of Acute Renal Failure Immediately after Combined Heart-Lung Transplantation

Purpose Combined heart–lung transplantation (HLTx) is a therapeutic option for both adult and pediatric patients since the early 1980s. The leading indications for HLTx are congenital heart disease with Eisenmenger’s syndrome and, historically idiopathic pulmonary arterial hypertension. HLTx is plagued by frequent postoperative acute renal failure (ARF) requiring hemodialysis (up to 80%), by far not always explained by perioperative hemodynamic instability and other well-known risk factors. Here, we hypothesized that high levels of creatine phosphokinase (CPK) or myoglobine would predict acute renal failure after combined heart lung transplantation. Methods and Materials In this study, we present a cohort of 75 patients, who received combined heart and lung transplantation between 2002 and 2012 at Hanover Medical School. In this cohort we defined 2 groups according to the development of ARF requiring hemodialysis after transplant. In both groups CK, CKMB and myoglobin were measured preoperative and at the time of 6h, 12h, POD 1, POD 2, POD 3, POD 4, POD 5, POD 6 and once weekly up to 8 weeks after transplantation. We also assessed at which time after transplant the patients received the first course of hemodialysis. Results Of a total of 75 patients included into this study, 42 developed ARF after transplant und needed hemodialysis. The first course of hemodialysis was necessary on POD 2 (mean). 33 patients showed sufficient renal function. We detected a statistically significant positive correlation between CPK and myglobine levels in blood during the first 48 hours preceeding initiation of hemodialsis and the development of ARF (p Conclusions High CPK and myglobine levels in peripheral blood predict (and might even cause) the development of acute kidney injury immediately after combined heart lung transplantation.