Heart-lung Transplant Recipients Research Articles

(994) - A Tight Squeeze: Endobronchial Mucormycosis in a Heart-Lung Transplant Recipient

(994) - A Tight Squeeze: Endobronchial Mucormycosis in a Heart-Lung Transplant Recipient

Four decades of progress in heart-lung transplantation: Two hundred seventy-one cases at a single institution

ObjectiveThe objective of this study is to evaluate survival for combined heart-lung transplant (HLTx) recipients across 4 decades at a single institution. We aim to summarize our contemporary practice based on more than 271 HLTx procedures over 40 years. MethodsData were collected from a departmental database and the United Network for Organ Sharing. Recipients younger than age 18 years, those undergoing redo HLTx, or triple-organ system transplantation were excluded, leaving 271 patients for analysis. The pioneering era was defined by date of transplant between 1981 and 2000 (n = 155), and the modern era between 2001 and 2022 (n = 116). Survival analysis was performed using cardinality matching of populations based on donor and recipient age, donor and recipient sex, ischemic time, and sex matching. ResultsBetween 1981 and 2022, 271 HLTx were performed at a single institution. Recipients in the modern era were older (age 42 vs 34 y; P < .001) and had shorter waitlist times (78 vs 234 days; P < .001). Allografts from female donors were more common in the modern era (59% vs 39%; P = .002). In the matched survival analysis, 30-day survival (97% vs 84%; P = .005), 1-year survival (89% vs 77%; P = .041), and 10-year survival (53% vs 26%; P = .012) significantly improved in the modern era relative to the pioneering era, respectively. ConclusionsLong-term survival in HLTx is achievable with institutional experience and may continue to improve in the coming decades. Advances in mechanical circulatory support, improved maintenance immunosuppression, and early recognition and management of acute complications such as primary graft dysfunction and acute rejection have dramatically improved the prognosis for recipients of HLTx in our contemporary institutional experience.

Revised Heart Allocation Policy Improved Waitlist Mortality and Waiting Time With Maintained Outcomes in En-Bloc Heart-Lung Transplant Candidates and Recipients.

The revised United Network for Organ Sharing heart allocation policy was implemented in October 2018. Using a national transplant database, this study evaluated the transplant rate, waitlist mortality, waiting time, and other outcomes of en-bloc heart-lung transplantation recipients. Adult patients registered on the national database for heart-lung transplants before and after the policy update were selected as cohorts. Baseline characteristics, transplant rates, waitlist mortality, waiting times, and other outcomes were compared between the two periods. In total, 370 patients were registered for heart-lung transplants during the pre- and post-periods. There were significantly higher transplant rates, shorter waitlist times, and substantially reduced waitlist mortality in the post-period. Registered patients waitlisted in the post-period had significantly higher utilization of intra-aortic balloon pumps, extracorporeal membrane oxygenation, and overall life support, including ventricular assist devices. Transplant recipients had significantly longer ischemic times, increased transport distances, and shorter waiting times before transplantation in the post-policy period. Transplant recipients held similar short-term survival before and after the policy change (log-rank test, p = 0.4357). Therefore, the revised policy significantly improved access to en-bloc heart-lung allografts compared with the prior policy, with better waitlist outcomes and similar post-transplant outcomes.

Extended criteria donor organ use for heart-lung transplantation in the modern era

BackgroundDemand for donor hearts and lungs exceeds their supply. Extended Criteria Donor (ECD) organs are used to help meet this demand, but their impact on heart-lung transplantation outcomes is poorly characterized. Methods and results: The United Network for Organ Sharing was queried for data on adult heart-lung transplantation recipients (n = 447) from 2005‒2021. Recipients were stratified based on whether they received ECD hearts and/or lungs. Morbidity was analyzed using Kruskal-Wallis, chi-square, and Fisher's exact tests. Mortality was analyzed using Kaplan-Meier estimation, log-rank tests and Cox regression. Sixty-five (14.5%) patients received two ECD organs, 134 (30.0%) received only an ECD lung, and 65 (14.5%) only an ECD heart. Recipients of two ECD organs were older, more likely to have diabetes, and more likely transplanted from 2015‒2021 (p < 0.05). Groups did not differ by pre-transplant diagnosis, intensive care unit disposition, life support use, or hemodynamics. Group five-year survival rates ranged from 54.5% to 63.2% (p = 0.428). Groups did not differ by 30-day mortality, strokes, graft rejection, or hospital length of stay. Conclusions: Using ECD hearts and/or lungs for heart-lung transplantation is not associated with increased mortality and is a safe strategy for increasing donor organ supply in this complex patient population.

Comprehensive Review of Pulmonary Hypertension and Treatment Options in the Paediatric Population

Pulmonary hypertension (PH) is a complex condition that can occur as a result of a wide range of disorders, including left heart disease, lung disease, and chronic pulmonary thromboembolism. Multiple improvements have been made in the diagnosis and treatment of pulmonary arterial hypertension (PAH)including a greater understanding of the involvement of extrapulmonary vascular organ systems, validated point of care, clinical assessment tools, and a focus on the initial exposure of numerous pharmacotherapeutics in the appropriate level of care. To achieve a minimal symptom burden, improve the patient's biochemical, hemodynamic, and functional profile, and reduce adverse impact, early diagnosis of PAH is a key objective today. The preferred method of management for thromboembolic PH, which is chronic, is pulmonary endarterectomysince the majority of affected patients are operable. The timing of pulmonary endarterectomy should never be delayed for medical reasons, and risk stratification can enable us to select patients who have a high chance of success. Patients who are not qualified for endarterectomy should be referred for drug trials. Even though there are more effective ways to guarantee a sufficient, long-lasting septostomy, atrial septostomy is promising but undervalued. The procedure's indications remain the sameand needto be taken into account more frequently. Class III or IV patients who are not improving need to be consulted at a transplant centre as soon as possible as they may be candidates for potential recipients of bilateral sequential lung or heart-lung transplants, which is a significant choice for some people. PH is rarely linked to other conditions like connective tissue or thromboembolic disease. It is either idiopathic or linked to congenital heart disease. Infants and children with PH are more frequently recognised in conjunction with a congenital diaphragmatic hernia and developmental lung diseases like bronchopulmonary dysplasia. Although the underlying disease has not yet been treated and advanced structural changes have not yet been reversed, the value of natural life and survival have suggestively increased. Children's haemodynamic and functional outcomes have improved as a result of endothelin receptor antagonists, prostacyclin analogues, and phosphodiesterase type 5 inhibitors, which are examples of targeted pulmonary vasodilator therapies. The health maintenance of paediatric PH is still difficult because treatment decisions are largely based on the findings of adult studies that have been supported by evidence and the clinical expertise of paediatric specialists.

Combined Heart-Lung Transplantation Outcomes in Asian Populations: National Database Analysis.

Heart-lung transplantation (HLTx) is a definitive surgical procedure for end-stage cardiopulmonary failure. Studies to understand the relationship between ethnicity and race and outcomes after HLTx are needed to uphold equitable HLTx access to the increasingly diverse U.S. population facing advanced cardiopulmonary failure. This study sought to examine the outcomes of HLTx recipients of Asian origin, with emphasis on the ethnic and racial disparities in the outcomes. We analyzed data from the United Network for Organ Sharing (UNOS) for patients of≥18 years of age who underwent HLTx between 1987 and 2021. Propensity-score matching was performed between Asian and non-Hispanic Whites (NHWs), with a 1:3 matching ratio based on the propensity score of each patient estimated by multivariable logistic regression. We identified 42 Asian and Asian American heart-lung transplant recipients and 834 NHW recipients. In the pre-matched cohort, the median survival was 1,459days (IQR: 1,080-2,692days) in Asian recipients after transplantation, whereas it was 1,521days (IQR: 1,262-1,841days) in White recipients. Of the 876 recipients, 156 transplants were successfully matched (Asian, n=36; NHW, n=108). Among the post-transplantation outcomes, there were no significant differences in morbidity and mortality between Asian and NHW cohorts. This large-scale analysis in Asian patients will have important implications in Asian countries that have relatively fewer HLTx surgeries. An outcome equivalent to NHW in Asian patients, as demonstrated in our study, could be the driving force for further expansion of HLTx surgeries in Asian countries.

SARS-CoV-2 Vaccination Efficacy & Safety in Lung Transplantation Recipients: A Single Centre Study

PurposeSolid Organ Transplant recipients (SOT) are at higher risk of SARS-CoV-2 infection. Mortality rates reported between 13 to over 30% in SOT recipients. SARS‐CoV‐2 vaccination may help reduce the morbidity and mortality of COVID‐19 among SOT. There is paucity of literature of SARS-CoV-2 vaccination efficacy in lung transplantation recipients . The purpose of the study was 1) to evaluate SARS-CoV-2 vaccination efficacy & safety in lung transplantation recipients and 2) to assess the need for 3rd booster dose.MethodsA retrospective study (from Jan 2021 till Oct 2021) of lung transplantation recipients receiving 2 doses of SARS-CoV-2 vaccination available in India i.e. ChAdOx1 nCoV- 19 Corona Virus Vaccine (Recombinant) or Whole-Virion Inactivated Vero Cell vaccine, was done to evaluate vaccination efficacy and safety. SARS-CoV-2 spike COVID antibodies levels were checked 4 weeks after 2nd dose of vaccination. Local and Systemic reactions to vaccination were notedResults11 Bilateral lung transplantation recipients and 4 Combined Heart-Lung transplantation recipients received SARS-CoV-2 vaccination. Out of 15 recipients, 11 recipients received ChAdOx1 nCoV- 19 Corona Virus Vaccine (Recombinant) and 4 recipients received Whole-Virion Inactivated Vero Cell vaccine. 12 recipients developed mild pain at vaccination site, 2 recipients developed local tenderness and 1 recipient developed redness at vaccination site as part of local reaction . 5 recipients developed fever, 5 recipients experienced fatigue/bodypain, 2 recipients had vomiting, 2 recipients experienced headache & 1 recipient developed abdominal pain as part of systemic reactions. 8 (53.3%) out of 15 recipients developed significant SARS-CoV-2 spike antibodies level demonstrating vaccination efficacy. 7 (46.6%) recipients demonstrated lower SARS-CoV-2 antibodies titre (Less than cut off values) indicating no significant vaccination efficacy. 1 recipient developed vaccine breakthrough mild infection after 2nd dose.ConclusionOur experience has shown that SARS-CoV-2 vaccination efficacy was demonstrated in nearly 50 % of lung transplantation recipients. The study also showed safety of SARS-CoV-2 vaccines in such immunocompromised subset. However, for those recipients with no vaccination efficacy, utility of 3rd booster dose and at what interval needs more research.

Results of Heart Transplants from Donation After Circulatory Death (DCD) Donors Using Thoraco-Abdominal Normothermic Regional Perfusion (TA-NRP) Compared to Donation After Brain Death (DBD)

<h3>Purpose</h3> In the U.S., heart transplantation from donation after circulatory death (DCD) is increasing. We present our institutional experience of DCD transplantation by using a thoracoabdominal-normothermic regional perfusion (TA-NRP) protocol and compare the results to a cohort concomitantly transplanted, from standard brain death (DBD) donation. <h3>Methods</h3> For TA-NRP protocol, suitable local DCD donors were transferred to our institution and co-located with the recipient in proximate operating rooms. Standard DCD procurement involved resuscitation of the donor on cardiopulmonary bypass after declaration of death and assessment for suitability by echocardiogram and hemodynamic data. Heart transplant from DBD was performed per standard protocol. Immunosuppression and management followed the same standardized protocol for all recipients. <h3>Results</h3> Between January 2020 and October 2021, we performed 10 DCD transplantations with TA-NRP protocol (7 isolated heart, 2 heart-lung and 1 heart-kidney). The median age was 54 years (44-72), and 70% were male. One heart-lung transplant recipient required VA ECMO post-op, for 3 days. During the same period, 70 patients received heart transplant from a DBD donor (71.4% isolated heart, 7.1% heart-lung, 21.4% heart-kidney). The median age was 56 years (24-77) - p=0.916, 84.% were male p=0.27. At mean follow-up of 397.6 days (DCD recipients) and 305.9 days (DBD recipients), there were no significant differences in acute cellular, antibody mediated rejection, cardiac allograft vasculopathy, heart graft function, and survival. Compared to DBD recipients, DCD recipients received transplant at lower listed statuses. <h3>Conclusion</h3> Short-term results suggest that transplant outcomes from DCD TA-NRP are comparable to recipients from DBD. Expanding heart transplantation by using DCD is a viable option for lower-status listed patients and wide adoption should be considered.

Cross-Organ Survival in Patients Undergoing Multi-Organ Cardiac Transplantation

<h3>Purpose</h3> Multi-organ cardiac (i.e., heart-X) transplantation indications have increased as analyses suggest comparable outcomes to patients undergoing single-organ procedures. Here, we present a comparison between survival outcomes in three of the most prevalent multi-organ procedures: heart-lung, heart-kidney, and heart-liver transplantation. <h3>Methods</h3> Using the United Network for Organ Sharing (UNOS) Standard Transplant Analysis and Research Database, we retrospectively reviewed heart transplants performed from January 1988 to September 2020. Heart-pancreas and triple-organ transplants were excluded due to insufficient sample size. Survival was assessed with Kaplan-Meier method and compared by log-rank test. Univariate and multivariate cox regression analyses were performed to assess hazard ratios. <h3>Results</h3> A total of 80,058 patients were included in this study. Heart-lung transplant recipients experienced significantly worse survival compared to those receiving heart-kidney, heart-liver, or heart-only transplants (p <0.0001). Cox regression analyses found an increased risk for mortality in heart-lung transplants, HR 1.91 (95% CI 1.79-2.04, p <0.001). Multivariate analysis adjusting for donor age, recipient age, and ethnicity found increased risk for mortality in heart-lung transplants and reduced risk in heart-kidney transplants, HR 2.15 (95% CI 2.01-2.29, p <0.001) and HR 0.86 (95% CI 0.8-0.93, p <0.001), respectively. Higher donor or recipient age and African American ethnicity were associated with worse outcomes. <h3>Conclusion</h3> Patients undergoing heart-lung transplantation have poorer outcomes, while heart-liver and heart-kidney transplants display improved rates of survival relative to heart-only transplants. Further research should be performed to validate these findings prospectively and account for confounding.

Two consecutive major lower limb operations in a heart-lung transplant recipient during COVID pandemic: A case report and literature review

Introduction: Combined heart and lung transplant is a rare procedure performed for patients with congenital heart disease and end stage pulmonary disease. Due to improvement in survival, non-cardiac surgeries are frequently performed in these patients and anaesthetists are involved in their perioperative management. Apart from increasing the physical and mental health risks, COVID-19 pandemic has posed an additional challenge to health care providers in the management of these immunosuppressed patients. Case presentation: We report a case of a 64-year-old female patient with a previous combined heart and lung transplant who underwent two consecutive lower limb surgeries during COVID pandemic.Conclusion: Meticulous preoperative assessment involving multidisciplinary team, knowledge of the pathophysiology of heart–lung transplant patients, choosing appropriate anaesthetic technique is vital in successful management of these patients. Psychological implications of COVID-19 pandemic in immunosuppressed patients should be considered.

Endoscopic pyloromyotomy is feasible and effective in improving post–lung transplant gastroparesis

ObjectivesGastroparesis is a debilitating and difficult to manage problem that has been reported in 20% to 90% of lung and heart-lung transplant recipients. The primary objective was to evaluate the safety and clinical effectiveness of per-oral endoscopic pyloromyotomy in relieving gastroparesis after lung transplant. Secondary objectives evaluated the effect of per-oral endoscopic pyloromyotomy on gastroesophageal reflux and allograft function. MethodsFifty-two lung transplant recipients underwent per-oral endoscopic pyloromyotomy for refractory gastroparesis. Gastroparesis was assessed by a pre–per-oral endoscopic pyloromyotomy and post–per-oral endoscopic pyloromyotomy radionuclide gastric emptying test and Gastroparesis Cardinal Symptom Index. Secondary outcomes included 90-day complications, gastroesophageal reflux as measured by pH testing, and longitudinal spirometry measurements. ResultsMedian time from lung transplant to per-oral endoscopic pyloromyotomy was 10.5 months. Twenty-eight patients had prior pyloric botulinum injection with either no improvement or relapse of symptoms. Post–per-oral endoscopic pyloromyotomy gastric emptying tests were available for 32 patients and showed a decrease in median gastric retention at 4 hours from 63.5% pre–per-oral endoscopic pyloromyotomy to 5.5% post–per-oral endoscopic pyloromyotomy (P < .0001). Complete normalization of gastric emptying time was noted in 19 patients. Gastroparesis Cardinal Symptom Index score significantly improved after per-oral endoscopic pyloromyotomy (median, 23-3.5; P < .0001). Post–per-oral endoscopic pyloromyotomy pH testing showed improved or stable DeMeester score in all patients except 1. Graft function (forced expiratory volume in 1 second) remained stable 1 year after per-oral endoscopic pyloromyotomy. ConclusionsThe improvements in symptom score and radionuclide imaging observed in this uncontrolled study suggest that per-oral endoscopic pyloromyotomy is an effective strategy in the lung transplant population and can be performed with minimal morbidity.

Early experience with donation after circulatory death heart transplantation using normothermic regional perfusion in the United States

ObjectiveThis pilot study sought to evaluate the feasibility of our donation after circulatory death (DCD) heart transplantation protocol using cardiopulmonary bypass (CPB) for normothermic regional reperfusion (NRP). MethodsSuitable local DCD candidates were transferred to our institution. Life support was withdrawn in the operating room (OR). On declaration of circulatory death, sternotomy was performed, and the aortic arch vessels were ligated. CPB was initiated with left ventricular venting. The heart was reperfused, with correction of any metabolic abnormalities. CPB was weaned, and cardiac function was assessed at 30-minute intervals. If accepted, the heart was procured with cold preservation and transplanted into recipients in a nearby OR. ResultsBetween January 2020 and January 2021, a total of 8 DCD heart transplants were performed: 6 isolated hearts, 1 heart-lung, and 1 combined heart and kidney. All donor hearts were successfully resuscitated and weaned from CPB without inotropic support. Average lactate and potassium levels decreased from 9.39 ± 1.47 mmol/L to 7.20 ± 0.13 mmol/L and 7.49 ± 1.32 mmol/L to 4.36 ± 0.67 mmol/L, respectively. Post-transplantation, the heart-lung transplant recipient required venoarterial extracorporeal membrane oxygenation for primary lung graft dysfunction but was decannulated on postoperative day 3 and recovered uneventfully. All other recipients required minimal inotropic support without mechanical circulatory support. Survival was 100% with a median follow-up of 304 days (interquartile range, 105-371 days). ConclusionsDCD heart transplantation outcomes have been excellent. Our DCD protocol is adoptable for more widespread use and will increase donor heart availability in the United States.

The International Thoracic Organ Transplant Registry of the International Society for Heart and Lung Transplantation: Thirty-eighth adult lung transplantation report — 2021; Focus on recipient characteristics

For over 30 years, the International Society for Heart and Lung Transplantation (ISHLT) International Thoracic Organ Transplant (TTX) Registry has gathered data regarding transplant procedures, donor and recipient characteristics, and outcomes from a global community of transplant centers. Almost 70,000 adult lung transplant procedures have been reported to the Registry since its inception, each one providing an opportunity for a recipient with end-stage lung disease to regain quality of life and longevity. With each year's report, we provide more detailed analyses on a particular focus theme important to recipient outcomes. Since 2013, these have been donor and recipient age; retransplantation; early graft failure; indication for transplant; allograft ischemic time; multiorgan transplantation; and donor and recipient size matching.1-7 In response to a changing regulatory environment, the ISHLT TTX Registry is undergoing an update in data acquisition, and the patient cohort examined in this report is therefore derived from the same data source or datasets as that examined in the 2019 annual reports.2,8-10 We refer the reader to the 2019 and prior reports for a detailed description of the baseline characteristics of the cohort, and additional core analyses not directly related to the focus explored in this year's report. To complement the 2020 report which focussed on donor characteristics, the goal of this year's report was to focus entirely on changes in recipient factors over the past 3 decades and to identify important recipient characteristics and transplant processes that may influence post-transplant outcomes. Due to small numbers, heart-lung transplant recipient characteristics and transplant outcomes have not been included. This 38th annual adult lung transplant report is hence based on data submitted to the ISHLT TTX Registry on 67,493 adult recipients of deceased recipient transplants between January 1, 1992 and June 30, 2018.

Low Rates of Growth in Paediatric Lung and Heart-Lung Transplant Recipients and Effects on Spirometry

Purpose A retrospective study of paediatric lung and heart-lung transplant (LTx) recipients to assess growth and its relationship with spirometric indices. Methods Analyses of relationships between serially assessed age, height, weight, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were undertaken. Serial spirometry at identical heights were analysed as means. Percentile height-for-age was calculated from the CDC 2000 dataset.1 95% confidence intervals are presented in parentheses after values. Results 42 LTx recipients ≤17 years (median at LTx = 13.6 years, 62% female) had spirometry and biometric data available. LTx indications included Cystic Fibrosis (n = 20) and Obliterative Bronchiolitis (n = 6). Median follow-up was 1.24 years (0.13-2.35). There was no significant difference between median biometric or spirometry value changes if recipients with 10cm. The median increase in FVC was 0.94L (0.15-1.72). Median predicted FVC and FEV1 were 67.8% (37.5-98.2) and 58.3% (27.8-88.8) of predicted respectively. Growth was not above expected for age with median change in height for age of -2.9 percentiles (-36.2-30.4). LTx recipients 1year follow-up) had a median height change of 7.5cm (-2.1-17.1 and median age-matched height percentile change of-4.55 percentiles (-22.6-13.47). Conclusion Most paediatric LTx recipients did not significantly change height after LTx. Unlike other solid organ Tx, where growth catch-up is expected, this does not occur.2 Additionally, graft function does not appear to impact growth trajectory. While significant steroid exposure contributes, further research will need to delineate the interplay of LTx on pubertal growth, immunosuppression and the effects of underlying conditions.

Characterization of Mycobacterial Findings before and after Lung and Heart-Lung Transplantation

<h3>Purpose</h3> Lung and heart-lung transplant candidates and recipients are susceptible to mycobacterial infections that can cause morbidity and mortality. We characterized the incidence, clinical characteristics and treatment of mycobacterial findings and assessed their impact on patient outcomes. <h3>Methods</h3> We conducted a retrospective review of patients who underwent lung or heart-lung transplantation in our center between June 1988 and May 2020 and identified patients with mycobacterial findings, in most cases positive sputum or bronchoscopy sample cultures. Pre-transplant patients are screened for mycobacterial infections with bronchoscopy and sputum samples. Post-transplant patients undergo surveillance bronchoscopies several times during the first post-transplant year, annually thereafter, and when clinically warranted. The decision to initiate anti-mycobacterial treatment is based on clinical, radiologic and mycobacterial sample results, with the aim to treat mycobacterial disease and monitor colonization. <h3>Results</h3> In a cohort of 355 patients, 15/355 (4.2%) patients had a pre-transplant mycobacterial finding and 9/15 received anti-mycobacterial treatment. In one patient, mycobacterium tuberculosis infection recurred post-transplant. No deaths were related to mycobacterial infections in patients with a pre-transplant mycobacterial finding. In post-transplant patients, 27/355 (7.6%) patients had a mycobacterial finding and 5/27 received anti-mycobacterial treatment. One patient died due to disseminated mycobacterium abscessus infection. Mycobacterial findings pre- or post-transplant did not affect overall patient survival compared to non-infected patients (Log Rank p = 0.312). <h3>Conclusion</h3> Mycobacterial findings are rare in patients undergoing lung or heart-lung transplantation, and do not seem to affect overall survival of patients. Most post-transplant mycobacterial findings represent colonization, but disseminated mycobacterial infection may be fatal.

A 3-Decade Analysis of Pancreatic Adenocarcinoma After Solid Organ Transplant.

Solid organ transplant (SOT) recipients have moderately increased risk of pancreatic adenocarcinoma (PAC). We evaluated the incidence and survival of PAC in 2 cohorts and aimed to identify potential risk factors. This study performed a retrospective cohort analysis. Cohort A was extracted from the United Network of Organ Sharing data set and cohort B from SOT recipients evaluated at 3 Mayo Clinic transplant centers. The primary outcome was age-adjusted annual incidence of PAC. Descriptive statistics, hazard ratios, and survival rates were compared. Cohort A and cohort B included 617,042 and 29,472 SOT recipients, respectively. In cohort A, the annual incidence rate was 12.78 per 100,000 in kidney-pancreas, 13.34 in liver, and 21.87 in heart-lung transplant recipients. Receiving heart-lung transplant, 50 years or older, and history of cancer (in either recipient or donor) were independent factors associated with PAC. Fifty-two patients developed PAC in cohort B. Despite earlier diagnosis (21.15% with stage I-II), survival rates were similar to those reported for sporadic (non-SOT) patients. We report demographic and clinical risk factors for PAC after SOT, many of which were present before transplant and are common to sporadic pancreatic cancer. Despite the diagnosis at earlier stages, PAC in SOT portends a very poor survival.

Citizenship Status and Cardiothoracic Organ Transplantation in the United States.

Citizenship Status and Cardiothoracic Organ Transplantation in the United States.

The experiences of adult heart, lung, and heart-lung transplantation recipients: A systematic review of qualitative research evidence.

To review evidence about the experience of being the recipient of a donated heart, lungs, or heart and lungs. A systematic review (registered with PROSPERO: CRD42017067218), in accordance with PRISMA guidelines. Seven databases and Google Scholar were searched in May 2017 and July 2019 for papers reporting English-language research that had used qualitative methods to investigate experiences of adult recipients. Quality was assessed and results were analysed thematically. 24 papers (reporting 20 studies) were eligible and included. Their results were organised into three chronological periods: pre-transplant (encompassing the themes of 'dynamic psychosocial impact', 'resources and support'), transplant ('The Call', 'intensive care unit'), and post-transplant ('dynamic psychosocial impact', 'management', 'rejection'). Sub-themes were also identified. It was evident that contemplating and accepting listing for transplantation entailed or amplified realisation of the precipitating illness's existential threat. The period surrounding transplantation surgery was marked by profound, often surreal, experiences. Thereafter, although life usually improved, it incorporated unforeseen challenges. The transplantation clinic remained important to the recipient. The meaning of the clinic and its staff could be both reassuring (providing care and support) and threatening (representing onerous medical requirements and potential organ rejection). This review has implications for the psychosocial care of transplant recipients and indicates the need for further research to gain insight into the experience of receiving a donated heart and/or lung. Medical consequences of heart and lung transplantation are well documented; this is the first systematic review of research using qualitative methods to investigate the experience of heart, lung, and heart-and-lung transplantation. The psychosocial impact of transplantation was found to be dynamic and complex, with notable features evident before, during, and after transplantation. Clinic staff remained significant to recipients. It is clear that recipients need continuing psychosocial as well as medical support.

Travel Practices and Associated Risks in Thoracic Transplant Recipients: A Monocentric Survey

Little is known regarding the travel practices of thoracic organ transplant recipients and their potential associated morbidity. A questionnaire was distributed to thoracic organ transplant recipients in the transplant clinic at a single French center between October, 2015, and October, 2018. Questions addressed demographics, transplant history, current immune suppression, knowledge regarding vaccination status, past history of travel (any destination outside metropolitan France), including pre-travel advice, health issues during travels outside Europe, and travel intentions during the following year. 117 patients completed the survey (82 lung, 14 heart and 21 heart-lung transplant recipients). Mean age was 49.4 years, 61.5% were female. 19 patients (17%) were born outside metropolitan France. At the time of survey completion, 70%, 68%, 96% and 12% of patients were receiving steroids, mycophenolate, calcineurin inhibitors, and mTOR inhibitors, respectively. 36%, 16%, and 10% of respondents considered that being a transplant recipient increased their risk of travel-related health issues mildly, moderately, and greatly, respectively. 58 patients (50%) had traveled outside metropolitan France after transplant (mean number of travels=7; mean number of destinations=3.3). Among 34 subjects who had traveled outside Europe in the last 5 years, 23 had received pre-travel advice, predominantly by their transplant physician. Among 41 respondents having traveled outside metropolitan France, 6 (15%) had experienced health issues (all outside Europe), which led to consultation and hospitalization in 3 and 1 cases, respectively. No immunosuppressives shortage was reported. Among 102 respondents, 61 (60%) intended to travel within the following year, and 50 (82%) to sought medical advice before departure, predominantly from their transplant physician (50 patients, including 17 in combination with a general practitioner or a travel medicine center). These data highlight the significant number of international travels undertaken by thoracic transplant recipients, and a relatively low travel-associated morbidity. As very few patients intend to seek advice from travel medicine specialists, transplant physicians are expected to be the major players of pre-travel counselling in this specific population.

Domino heart transplant following heart-lung transplantation: a systematic review and meta-analysis.

The domino-donor operation occurs when a "conditioned" heart from the heart-lung transplant (HLT) recipient is transplanted into a separate heart transplant (HT) recipient. The purpose of this systematic review was to investigate the indications and outcomes associated with the domino procedure. An electronic search was performed to identify all prospective and retrospective studies on the domino procedure in the English literature. Eight studies reported 183 HLT recipients and 263 HT recipients who were included in the final analysis. HLT indications included cystic fibrosis in 58% (95% CI: 27-84%) of recipients, primary pulmonary hypertension (PPH) in 17% (95% CI: 12-24%), bronchiectasis in 5% (95% CI: 3-10%), emphysema in 5% (95% CI: 0-45%), and Eisenmenger's syndrome in 4% (95% CI: 2-8%). HT indications included ischemic heart disease in 40% (95% CI: 33-47%), non-ischemic disease in 39% (95% CI: 25-56%), and re-transplantation in 10% (95% CI: 1-59%). The pooled mean pulmonary vascular resistance (PVR) in HT recipients was 3.05 Woods units (95% CI: 0.14-5.95). The overall mortality in the HLT group was 28% (95% CI: 18-41%) at an average follow-up of 15.68 months (95% CI: 0.82-30.54), and 35% (95% CI: 17-58%) in the HT group at an average follow-up of 37.26 months (95% CI: 6.68-67.84). Freedom from rejection in HT was 94% (95% CI: 75-99%) at 1 month, 77% (95% CI: 30-96%) at 6 months, and 41% (95% CI: 33-50%) at 1 year. The domino procedure appears to be a viable option in properly selected patients that can be performed safely with acceptable outcomes.