Isolated Lung Transplantation Research Articles

Outcomes after lung transplantation performed using elective cardiopulmonary bypass: A single-center experience

PurposeThere remains significant variability in the use of intraoperative mechanical circulatory support in lung transplantation. This report details our outcomes using elective CPB in lung transplantation. MethodsWe performed a single institution analysis of consecutively enrolled patients who underwent isolated lung transplantation between August 2020 and April 2023. Primary outcomes included rates of grade 3 PGD and one-year survival. Results40 consecutive lung transplants were performed on CBP over the study period. The average PaO2/FiO2 at 72 hours was 369.7+121.4, with grade 3 PGD occurring in two patients (5%). The median intra-operative packed red blood cell transfusion requirement was 300 (93.75-727.5) mL. Freedom from non-elective re-operation was 82.5% (n=33). Mortality was 0% at 90-days, and one-year survival was 90.5%. ConclusionLung transplantation can be safely performed with elective CPB support.

Impact of Early Tracheostomy After Lung Transplantation: A National Analysis

BackgroundProlonged mechanical ventilation is common among lung transplant recipients, affecting nearly one-third of patients. Tracheostomy has been shown as a beneficial alternative to endotracheal intubation, but delays in tracheostomy tube placement persist. To date, no large-scale study has investigated the effect of tracheostomy timing on posttransplant outcomes. MethodsAll adults receiving tracheostomy after primary, isolated lung transplantation were identified in the 2016 to 2020 Nationwide Readmissions Database. Early tracheostomy was defined as placement before postoperative day 8 based on exploratory cohort analysis. Multivariable regression was used to evaluate the association of early tracheostomy with in-hospital mortality, select posttransplant complications, and resource utilization. ResultsOf an estimated 11,048 patients undergoing first-time lung transplantation, 1509 required a tracheostomy in the postoperative period, with 783 (51.9%) comprising the early cohort. After entropy balancing and risk adjustment, early tracheostomy placement was associated with reduced odds of death (adjusted odds ratio, 0.59; 95% CI, 0.36-0.97) and posttransplant infection (adjusted odds ratio, 0.54; 95% CI, 0.35-0.82). Further, tracheostomy within 1 week of transplantation was associated with decreased length of stay (β-coefficient, −16.5 days; 95% CI, −25.3 to −7.6 days) and index hospitalization costs (β-coefficient, −$97,600; 95% CI, −$153,000 to −$42,100). ConclusionsThe present study supports the safety of early tracheostomy among lung transplant recipients and highlights several potential benefits. Among appropriately selected patients, tracheostomy placement before postoperative day 8 may facilitate early discharge, lower costs, and reduced odds of posttransplant infection.

Development of an experimental technique for orthotopic left lung transplantation in a rabbit model

Objective: to develop, master and evaluate the efficiency of an isolated lung transplantation (LT) technique on a rabbit animal model using Perfadex Plus® solution for cold static storage. Materials and methods. Scottish Giant rabbits (n = 20) were used in this study and divided into two groups: donors and recipients. Donor lungs were preserved with Perfadex Plus® solution and stored for 6 hours at 4 °C. Recipient animals underwent unilateral orthotopic left LT. The postoperative follow-up period was 24 hours. Laboratory and instrumental control with assessment of blood gas composition, lactate level, ventilation parameters, and central hemodynamic parameters, was performed during the follow-up. Chest X-ray in direct projection was performed twice, and at the end of follow-up, material was taken for histologic examination. Results. We obtained a high oxygenation index in the post-transplant period (>350 at p < 0.023), as well as physiological indicators of lactate (3 ± 0.3 mmol/L at p < 0.002) and peak inspiratory pressure (15 ± 1 cmH2O, p < 0.001). Radiological examination showed no radiological signs of severe primary graft dysfunction in all cases (mean RALE score 1), which was confirmed by histological studies. Conclusion. Left LT in rabbits is possible, the LT technique on a biological rabbit model using Perfadex Plus® solution is valid and efficient with the achievement of satisfactory gas exchange, ventilation and metabolism parameters.

Racial and Gender Disparities in Transplantation of Hepatitis C+ Hearts and Lungs

BackgroundTransplanting organs from hepatitis c virus (HCV) infected donors into HCV-negative recipients has led to thousands of more transplants in the US since 2016. Studies have demonstrated disparities in utilization of kidneys from these donors due to gender and education. It is still unknown, however, if the same disparities are seen in heart and lung transplantation. MethodsWe used Organ Procurement and Transplantation (OPTN)/United Network for Organ Sharing (UNOS) data on all isolated heart and lung transplants from 11/01/2018- 03/31/2023, classifying donors based on their HCV nucleic acid test (NAT) result: HCV NAT- vs HCV NAT+. We fit separate mixed effects logistic regression models (outcome: HCV-NAT+ donor) for heart and lung transplants. Primary covariates included: 1) race/ethnicity; 2) sex; 3) education level; 4) insurance type; and 5) transplant year. ResultsThe study included 26,108 adults (14,189 isolated heart transplant recipients and 11,919 isolated lung transplant recipients). 993 (7.0%) heart transplants involved an HCV-NAT+ donor, compared to 457 (3.8%) lung transplants. In multivariable models among all isolated heart transplant recipients, women were significantly less likely to receive an HCV-NAT+ donor heart (OR: 0.79, 95% CI: 0.67-0.92, P=0.003), as were Asian patients (OR: 0.52, 95% CI: 0.31=0.86, P= 0.01). In multivariable models among all isolated lung transplant recipients, Asians were significantly less likely to receive HCV-NAT+ transplants (OR: 0.31, 95% CI: 0.12-0.77, P= 0.01). ConclusionThere are disparities in utilization of heart and lungs from HCV NAT+ donors, with women and Asian patients being significantly less likely to receive these transplants.

Lung Transplantation from hepatitis C+ donor lungs: Reassuring midterm outcomes

The development of modern antiviral therapy for hepatitis C virus (HCV) has allowed for the transplantation of HCV nucleic acid amplification testing positive (NAT+) donor lungs with acceptable short-term outcomes. We sought to evaluate trends and mid-term outcomes of lung transplant recipients of HCV NAT+ donor allografts. All adults undergoing isolated lung transplantation in the United Network for Organ Sharing database from January 2016 to December 2022 were included in the study. Lung transplant recipients were stratified based on donor HCV status (HCV NAT+ vs NAT-). Propensity-score matching was used to adjust for differences between groups. Several outcomes, including acute rejection by one year, early (30-day and in-hospital) mortality and both 1- and 3-year survival were compared between matched groups. A total of 16,725 patients underwent lung transplantation during the study period, with 489 (3%) receiving HCV NAT+ donor lungs. Regions 1 (18%), and 6/8 (both 0%) had the highest and lowest proportions, respectively, of HCV NAT+ donor transplants. Utilization of HCV NAT+ donors increased throughout the study period from 2 (0.1%) in 2016 to a peak of 117 (5%) in 2019. Donors who were HCV NAT+ were younger (34 vs 36 years, P<0.001), more often female (44% vs 39%, P<0.01) and more commonly died due to drug intoxication (56% vs 15%, P<0.001). Recipients of HCV NAT+ donor lungs were similar in age (62 vs 62 years, P=0.69) and female gender (43% vs 39%, P=0.15) but had lower lung allocation scores (38 vs 41, P<0.001) compared to others. Rates of acute rejection (13% vs 17%, P=0.09), early mortality (30-day: 2% vs 1%, P=0.59, in-hospital: 3% vs 4%, P=0.38) as well as 1- (90% vs 92%, P=0.29) and 3-year survival (69% vs 75%, P=0.13) were not significantly different between matched groups. Lung transplant recipients of HCV NAT+ donor allografts experience similar rates of acute rejection, early mortality and 3-year survival compared to all other lung recipients. Increased use of HCV NAT+ donor allografts may help to expand the donor pool and alleviate donor shortages.

Extracorporeal membrane oxygenation as a bridge to lung transplantation: Practice patterns and patient outcomes

Extracorporeal membrane oxygenation (ECMO) is increasingly relied on to bridge patients with respiratory failure to lung transplantation despite limited evidence for its use in this setting. This study evaluated longitudinal trends in practice patterns, patient characteristics, and outcomes in patients bridged with ECMO to lung transplant. A retrospective review of all adult isolated lung transplant patients in the United Network for Organ Sharing database between 2000 and 2019 was performed. Patients were classified as "ECMO" if supported with ECMO at the time of listing or transplantation and "non-ECMO" otherwise. Linear regression was used to evaluate trends in patient demographics during the study period. Trends in mortality were evaluated using Cox proportional hazards modeling, with time period as the primary covariate (2000-2004, 2005-2009, 2010-2014, or 2015-2019) and age, time on the waitlist, and underlying diagnosis as covariates. The number of patients included were 40,866, of whom 1,387 (3.4%) were classified as ECMO and 39,479 (96.6%) as no ECMO. Average age and initial Lung Allocation Score increased significantly during the study period in both cohorts, but occurred at a slower rate in the ECMO population. The hazard of death was significantly lower in more recent years (2015-2019) for both the ECMO and non-ECMO cohorts (aHR (adjusted hazards ratio) 0.59, 95% confidence interval (CI) 0.37-0.96 and aHR 0.74, 95% CI 0.70-0.79) when compared to the early years (2000-2004) of the study period. Post-transplantation survival for patients bridged to transplantation with ECMO demonstrates ongoing improvement despite cannulation of progressively older and sicker patients.

German Heart Surgery Report 2022: 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/DGTHG) in 1980, well-defined data of all cardiac, thoracic, and vascular surgery procedures performed in 78 German heart surgery departments during the year 2022 are analyzed. Under the decreasing interference of the worldwide coronavirus disease 2019 pandemic, a total of 162,167 procedures were submitted to the registry. A total of 93,913 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 27,994 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.2:1) was 97.5%. For the 38,492 isolated heart valve procedures (20,272 transcatheter interventions included) it was 96.9%, and for the registered pacemaker/implantable cardioverter-defibrillator procedures (19,531) 99.1%, respectively. Concerning short- and long-term circulatory support, a total of 2,737 extracorporeal life support/extracorporeal membrane oxygenation implantations, respectively 672 assist device implantations (L-/ R-/ BVAD, TAH) were registered. In 2022, 356 isolated heart transplantations, 228 isolated lung transplantations, and 5 combined heart-lung transplantations were performed. This annually updated registry of the GSTCVS/DGTHG 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 always available.

(925) Combined Lung-Kidney Transplantation Yields Better Survival Than Isolated Lung Transplantation in Recipients with Underlying Renal Failure

(925) Combined Lung-Kidney Transplantation Yields Better Survival Than Isolated Lung Transplantation in Recipients with Underlying Renal Failure

Trends, Outcomes, and Predictors of Acute In-hospital Stroke after Lung Transplantation: An Analysis of the United Network for Organ Sharing Database

INTRODUCTION: Lung transplantation is the gold standard treatment for end-stage lung failure. We sought to characterize the impact of strokes on mortality and identify factors which were associated with stroke. METHODS: We identified adult (≥18 years old) first-time, isolated lung transplant (LTx) recipients from the United Network for Organ Sharing database between 5/2005 and 12/2020. Stroke was defined as occurring at any time after LTx but prior to discharge. Cox proportional hazards analysis was used to identify predictors of death at 24 months. Freedom from death in stroke vs non-stroke was evaluated with Kaplan-Meier analysis. Multivariable logistic regression was used to identify risk factors for stroke. RESULTS: Of 28,564 patients (median age = 60, 60% male), 653 (2.3%) experienced an acute in-hospital stroke after LTx. Median follow-up was 1.2 (stroke) and 3.0 years (non-stroke). Annual incidence of stroke increased (1.5% in 2005 to 2.4% in 2020, p-trend = 0.007), as did lung allocation score (LAS) and utilization of post-LTx extracorporeal membrane oxygenation (postLTX-ECMO) (p = 0.01 and p < 0.001, respectively). Those with stroke had lower survival at 1-month (84% vs 98%) and 12-months (61% vs 88%) compared to those without (p < 0.001; Figure). In Cox analysis, stroke had the highest hazard of death (HR = 3.05, 95% CI = 2.70-3.44). PostLTx-ECMO was the strongest risk factor of stroke (adjusted odds ratio = 2.76, 95% CI = 2.07-3.68).FigureCONCLUSION: Strokes after LTx have increased over time; this likely corresponds to the transplantation of patients with increasingly higher LAS. Strokes were associated with significant short- and long-term mortality in patients after LTx and postLTx-ECMO was a strong risk factor.

Do older surgeons have safer hands? A retrospective cohort study

BackgroundFor complex surgical procedures a volume-outcome relationship can often be demonstrated implicating multiple factors at a unit and surgeon specific level. This study aims to investigate this phenomenon in lung transplantation over a 30-year period with particular reference to surgeon age and experience, cumulative unit activity and time/day of transplant.MethodsProspective databases identified adult patients undergoing isolated lung transplantation at a single UK centre between June 1987 and October 2017. Mortality data was acquired from NHS Spine. Individual surgeon demographics were obtained from the General Medical Council. Student t-test, Pearson’s Chi-squared, Logistic Regression, and Kaplan–Meier Survival analyses were performed using Analyse-it package for MicrosoftExcel and STATA/IC.Results954 transplants (55.9% male, age 44.4 ± 13.8 years, 67.9% bilateral lung) were performed, with a median survival to follow-up of 4.37 years. There was no difference in survival by recipient gender (p = 0.661), between individual surgeons (p = 0.224), or between weekday/weekend procedures (p = 0.327).Increasing centre experience with lung transplantation (OR1.001, 95%CI: 1.000–1.001, p = 0.03) and successive calendar years (OR1.028, 95%CI: 1.005–1.052, p = 0.017) was associated with improved 5-year survival.Advancing surgeon age at the time of transplant (mean, 48.8 ± 6.6 years) was associated with improved 30-day survival (OR1.062, 95%CI: 1.019 to1.106, p = 0.003), which persisted 5 years post-transplant (OR1.043, 95%CI: 1.014–1.073, p = 0.003).Individual surgeon experience, measured by the number of previous lung transplants performed, showed a trend towards improved outcomes at 30 days (p = 0.0413) with no difference in 5-year survival (p = 0.192).ConclusionsOur study demonstrates a relationship between unit volume, increasing surgeon age and survival after lung transplantation. A transplant volume: outcome relationship was not seen for individual surgeons.

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.

The United States Experience of Lung Transplantation in Recipients with COVID-19 Fibrosis: A UNOS/OPTN Analysis

PurposeCoronavirus Disease 19 (COVID-19) is a novel cause of end-stage fibrotic lung disease. Data has been limited to case series and single center reports with regards to outcomes in this unique cohort of patients. We sought to investigate the largest experience to date in patients with COVID-19 fibrosis (CVF) who underwent lung transplantation.MethodsThe United Network for Organ Sharing (UNOS) database was queried for all adult patients (≥18 years old) who underwent isolated lung transplantation between 2018 and July 2021. Recipients diagnosed with CVF were identified and compared to those with idiopathic pulmonary fibrosis (IPF). The IPF cohort included recipients from 2018, in the pre-COVID era. Baseline demographics, perioperative factors, and 30-day outcomes were examined.ResultsA total of 931 recipients were included in this study, 868 (93.2%) and 63 (6.8%) were IPF and CVF, respectively. IPF recipients were on average older (65 vs. 56 years, p<0.001), white race (83% vs. 51%, p<0.001), and less likely to be male (73% vs. 86%, p=0.04). BMI was similar between the IPF and CVF, 27.6 and 27.2 kg/m2, as was the mean PAP 24 and 21 mmHg. The CVF cohort had lower predicted FVC (32% vs. 47%, p=0.01), and had less tobacco use (36% vs 61%, p<0.001). Mean creatinine level was clinically similar, though statistically higher in the IPF cohort, (0.83 vs 0.64, p<0.001). CVF recipients were on the waitlist for a shorter median duration (10 vs 32 days, p<0.001) with a higher LAS (85 vs 41, p<0.001). Notably, more CVF recipient were be on ECMO at time of listing (29% vs 2%, p<0.001) and require ventilatory support (27% vs. 2%, p<0.001). CVF recipients were more likely to receive a double lung transplantation compared to IPF (83% vs 64%, p=0.002), with similar ischemia times, 5.5 vs 5.1 hrs (p=0.17). Mortality at 30 days was comparable between CVF and IPF (7.0% vs. 2.3%, p=0.09), though 20 patients in the CVF cohort had missing data.ConclusionPatients with end-stage lung disease secondary to CVF are higher acuity, and more likely to require ECMO and ventilatory support as a bridge to lung transplantation. Early mortality, while comparable to non-COVID related fibrotic lung disease, remains almost 3 times higher with CVF. In the era of publicly reported survival outcomes, the transplant community may need to reconsider how we approach this new and devastating diagnosis of CVF.

Adult Lung Transplantation from Donation After Circulatory Death Donors: Safety and Outcomes Utilizing the UNOS / OPTN Registry

<h3>Purpose</h3> Donation after circulatory death (DCD) has been described in abdominal transplantation but has not been thoroughly evaluated in lung transplantation. The aim of this retrospective study was to describe and compare DCD utilization with donation after brain death (DBD). <h3>Methods</h3> The United Network for Organ Sharing (UNOS) database was reviewed for all adult patients who underwent lung transplant between 2016 and 2020. Baseline features and post-transplant outcomes were reviewed using descriptive and survival analyses by the Kaplan-Meier and Cox regression method. <h3>Results</h3> A total of 11,837 isolated lung transplant recipients met criteria for analysis. DCD utilization increased over time, from 92/2198 (14.7%) in 2016 to 180/2376 (28.8%) recipients in 2020 (p<0.001 for trend). DCD patients were more likely double lung recipients (79.9 vs 74.6%), had longer ischemia times (7.6 vs. 5.5 h), and were more commonly intubated (42.8 vs. 29.9%) and required extracorporeal support (12.5 vs 7.2%) up to 72 h following surgery (Table 1). Unadjusted overall survival was worse for DCD vs DBD patients (log rank, p<0.001). When stratified by transplant type, there was no survival difference between DCD and DBD single lung recipients (log rank, p=0.322); however, survival among double lung recipients was worse for DCD vs DBD patients (log rank, p<0.001). After adjustment for statistically significant covariates (Table 1), DCD status was not associated with mortality for double lung recipients (HR: 1.189, 95% CI [0.985 - 1.435]; p=0.071). Ischemia time (HR: 1.029, 95% CI [1.007 - 1.052]; p=0.010) and extracorporeal support (HR: 2.862, 95% CI [2.512 - 3.260]; p<0.001) after transplant were more common in DCD patients and strongly associated with mortality up to 5 years. <h3>Conclusion</h3> DCD status was associated with worse survival in double lung transplant recipients, which may be attributed to longer ischemia times. Additional efforts will be required to characterize and mitigate these effects.

Double Trouble: Ischemic Time is Associated with Worse Outcomes After Double Lung but Not Single Lung Transplantation

Purpose Currently accepted clinical guidelines recommend ischemic times of no longer than four to six hours. To maximize organ supply, ischemic times beyond this are sometimes necessitated. We sought to determine whether graft ischemic time is independently associated with all-cause survival in a large, contemporary cohort of single and double lung transplant recipients. Methods Data from adults undergoing initial isolated lung transplantation in the UNOS (United Nation for Organ Sharing) registry from January 2010 to December 2017 were included and compared for all-cause mortality at 1 year. Within single lung transplants, patients were further stratified into 3 ischemic time groups: <3 hours (17%), 3-4.5 hours (45%), 4.5-6 hours (28%), and >6 hours (10%). Meanwhile, in the double lung transplant cohort, ischemic time subgroups were as follows: <4.5 hours (26%), 4.5-6 hours (39%), and >6 hours (35%). Results Ischemic time had no impact on survival following single lung transplantation whether defined categorically (P=0.546) or continuously (HR, 0.986; 95% CI, 0.960-1.011; P=0.272). However, ischemic time was associated with significantly reduced survival following DLT in both definitions (P<0.001). After adjustment for potential confounders, the difference remained significant (HR, 1.041; 95% CI, 1.023-1.059; P<0.001). Conclusion The results of this large contemporary cohort suggest that the relationship between graft ischemic time and 1 year all-cause survival is not uniform across lung transplant types. Ischemic time was significantly associated with risk of reduced survival in double lung but not single lung transplant recipients. Both graft type and ischemic time should be incorporated in the decision-making process. Currently accepted clinical guidelines recommend ischemic times of no longer than four to six hours. To maximize organ supply, ischemic times beyond this are sometimes necessitated. We sought to determine whether graft ischemic time is independently associated with all-cause survival in a large, contemporary cohort of single and double lung transplant recipients. Data from adults undergoing initial isolated lung transplantation in the UNOS (United Nation for Organ Sharing) registry from January 2010 to December 2017 were included and compared for all-cause mortality at 1 year. Within single lung transplants, patients were further stratified into 3 ischemic time groups: <3 hours (17%), 3-4.5 hours (45%), 4.5-6 hours (28%), and >6 hours (10%). Meanwhile, in the double lung transplant cohort, ischemic time subgroups were as follows: <4.5 hours (26%), 4.5-6 hours (39%), and >6 hours (35%). Ischemic time had no impact on survival following single lung transplantation whether defined categorically (P=0.546) or continuously (HR, 0.986; 95% CI, 0.960-1.011; P=0.272). However, ischemic time was associated with significantly reduced survival following DLT in both definitions (P<0.001). After adjustment for potential confounders, the difference remained significant (HR, 1.041; 95% CI, 1.023-1.059; P<0.001). The results of this large contemporary cohort suggest that the relationship between graft ischemic time and 1 year all-cause survival is not uniform across lung transplant types. Ischemic time was significantly associated with risk of reduced survival in double lung but not single lung transplant recipients. Both graft type and ischemic time should be incorporated in the decision-making process.

German Heart Surgery Report 2020: 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 2020 are analyzed. Under the more than extraordinary conditions of the ongoing worldwide coronavirus disease 2019 pandemic, a total of 161,817 procedures were submitted to the registry. A total of 92,809 of these operations are summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 29,444 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.6:1) was 97.2%. For the 35,469 isolated heart valve procedures, (17,471 transcatheter interventions included), the survival rate was 96.7%. Concerning short- and long-term circulatory support, a total of 2,852 extracorporeal life support/extracorporeal membrane oxygenation implantations, respectively, 843 assist device implantations (left/right/biventricular assist device, total artificial device), were registered. In 2020, the number of isolated heart transplantations increased to 340, a rise of 2.1% compared with the previous year. The isolated lung transplantations amounted to 291, a decrease of 6.4%.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.

A review of liver dysfunction in the lung transplant patient.

Liver dysfunction is an increasingly common finding in patients evaluated for lung transplantation. New or worsening dysfunction in the perioperative period, defined by presence of clinical ascites/encephalopathy, high model for end-stage liver disease (MELD) score, and/or independent diagnostic criteria, is associated with high short- and long-term mortality. Therefore, a thorough liver function assessment is necessary prior to listing for lung transplant. Unfortunately, identification and intraoperative monitoring remain the only options for prevention of disease progression with isolated lung transplantation. Combined lung and liver transplantation may provide an option for definitive long-term management in selecting patients with known liver disease at high risk for postoperative progression. However, experience with the combined operation is extremely limited and indications for combined lung and liver transplant remain unclear. Herein, we present a comprehensive literature review of patients with liver dysfunction undergoing lung transplantation with and without concurrent liver transplant in an effort to illuminate the risks, benefits, and clinical judgement surrounding decision to pursue combined lung-liver transplantation (CLLT). We also argue description of liver function is currently a weakness of the current lung allocation scoring system. Additional algorithms incorporating liver function may aid in risk stratification and decision to pursue combined transplantation.

Panel Reactive Antibody and Donor-Recipient Sex Differences Do Not Affect Long-Term Lung Transplant Outcomes

PurposePatients with elevated panel reactive antibody (PRA) experience delayed transplant and higher waitlist mortality than minimally sensitized patients. If transplanted, the importance of elevated PRA observed with donor-recipient sex differences on long-term outcomes remain unknown.MethodsThe United Network for Organ Sharing database was reviewed for all adult patients who underwent isolated lung transplantation between 2005 and 2015. All patients without known BOS status on follow up were excluded. The date of first BOS diagnosis, if present, was used for analysis. All remaining patients were censored at time of last follow up in absence of BOS, graft dysfunction, or death. Baseline and post-transplant outcomes were reviewed using descriptive and Kaplan-Meier analyses.ResultsBetween 2005 and 2015, 15596 lung transplant recipients with known BOS status were included in analysis and divided into donor-recipient subgroups: male to male (M-M; n=6846, 44%), male to female (M-F: n=2581, 16%), female to male (F-M: n=2347, 15%), and female to female (F-F: n=3822, 25%) - Table 1. The time between listing and transplant was highest among M-F, 263 (95% CI [246-280]), and F-F, 275 days (95% CI [261-289]), subgroups. Female recipients also had higher pre-transplant PRA%, 13.7 (F-F) and 15.0 (M-F), compared to males (p < 0.001 between groups). Overall, there were no differences in freedom from BOS (p=0.282) or graft dysfunction (p=0.602) when adjusted for single or double transplant and donor-recipient subgroup. Composite survival differed between groups (p < 0.001 by log rank test); however, this was unaffected by subgroup PRA% when analyzed continuously or stratified by quartiles.ConclusionDonor-recipient sex differences are associated with elevated pre-transplant PRA levels in female recipients; however, pre-transplant PRA had no observed impact on graft and survival outcomes in all disease groups. The clinical significance of PRA after transplant selection, if any, remains unclear. Patients with elevated panel reactive antibody (PRA) experience delayed transplant and higher waitlist mortality than minimally sensitized patients. If transplanted, the importance of elevated PRA observed with donor-recipient sex differences on long-term outcomes remain unknown. The United Network for Organ Sharing database was reviewed for all adult patients who underwent isolated lung transplantation between 2005 and 2015. All patients without known BOS status on follow up were excluded. The date of first BOS diagnosis, if present, was used for analysis. All remaining patients were censored at time of last follow up in absence of BOS, graft dysfunction, or death. Baseline and post-transplant outcomes were reviewed using descriptive and Kaplan-Meier analyses. Between 2005 and 2015, 15596 lung transplant recipients with known BOS status were included in analysis and divided into donor-recipient subgroups: male to male (M-M; n=6846, 44%), male to female (M-F: n=2581, 16%), female to male (F-M: n=2347, 15%), and female to female (F-F: n=3822, 25%) - Table 1. The time between listing and transplant was highest among M-F, 263 (95% CI [246-280]), and F-F, 275 days (95% CI [261-289]), subgroups. Female recipients also had higher pre-transplant PRA%, 13.7 (F-F) and 15.0 (M-F), compared to males (p < 0.001 between groups). Overall, there were no differences in freedom from BOS (p=0.282) or graft dysfunction (p=0.602) when adjusted for single or double transplant and donor-recipient subgroup. Composite survival differed between groups (p < 0.001 by log rank test); however, this was unaffected by subgroup PRA% when analyzed continuously or stratified by quartiles. Donor-recipient sex differences are associated with elevated pre-transplant PRA levels in female recipients; however, pre-transplant PRA had no observed impact on graft and survival outcomes in all disease groups. The clinical significance of PRA after transplant selection, if any, remains unclear.

Factors Related to Survival in Low–Glomerular Filtration Rate Cohorts Undergoing Lung Transplant

BackgroundHistorically, a glomerular filtration rate (GFR) of less than 50 mL/min per 1.73 m2 has been considered a contraindication to lung transplantation. Combined or sequential lung–kidney transplantation is an option for those with a GFR less than 30 mL/min per 1.73 m2. Patients with a GFR of 30 to 50 mL/min per 1.73 m2 are provided with no options for transplantation. This study explores factors associated with improved survival in patients who undergo isolated lung transplantation with a GFR of 30 to 50 mL/min per 1.73 m2. MethodsThe United Network for Organ Sharing database was queried for adult patients undergoing primary isolated lung transplantation between January 2007 and March 2018. Regression models were used to identify factors associated with improved survival in lung recipients with a preoperative GFR of 30 to 50 mL/min per 1.73 m2. The propensity score method was used to match highly performing patients (outpatient recipients aged less than 60 years) with a GFR of 30 to 50 mL/min per 1.73 m2 with patients who had a GFR greater than 50 mL/min per 1.73 m2. Kaplan-Meier, Cox, and logistic regression analyses compared outcomes in matched populations. ResultsA total of 21,282 lung transplantations were performed during the study period. Compared with patients with a GFR greater than 50 mL/min per 1.73 m2, survival was significantly worse for patients with a GFR of 30 to 50 mL/min per 1.73 m2. Multivariate analysis of patients with a GFR of 30 to 50 mL/min per 1.73 m2 demonstrated outpatient status and age less than 60 years to be predictive of superior survival. After propensity matching, survival of this highly performing subset with a GFR of 30 to 50 mL/min per 1.73 m2 was no different from that of patients with a normal GFR. ConclusionsOutpatient recipients aged less than 60 years represent an optimal subset of patients with a GFR of 30 to 50 mL/min per 1.73 m2. Lung transplant listing should not be declined based only on a GFR less than 50 mL/min per 1.73 m2.

Factors associated with short- versus long-term survival after lung transplant

ObjectiveA small but growing proportion of lung transplant recipients survive longer than a decade post-transplant. The aim of this study was to identify factors associated with survival beyond a decade after lung transplant. MethodsWe queried the United Network for Organ Sharing registry for adult (age ≥18 years) recipients undergoing first-time isolated lung transplantation between the introduction of the Lung Allocation Score in 2005 and 2009. Recipients were stratified into 3 cohorts: those who survived less than 1 year, 1 to 10 years, and greater than 10 years. Multivariable logistic regression was used to identify factors independently associated with early mortality (<1 year) and long-term (>10 years) survival. ResultsA total of 5171 lung transplant recipients and their associated donors met inclusion criteria, including 964 (18.6%) with early mortality, 2843 (55.0%) with intermediate survival, and 1364 (26.3%) long-term survivors. Factors independently associated with early mortality included donor Black race, cigarette use, arterial oxygen partial pressure/fractional inspired oxygen ratio, diabetes, recipient Lung Allocation Score, total bilirubin, extracorporeal membrane oxygenation bridge requirement, single lung transplantation, and annual lung transplant center volume. The only factors independently associated with long-term survival among those who survived at least 1 year was donor age and single lung transplantation. ConclusionsOf patients undergoing lung transplantation after the implementation of the Lung Allocation Score, approximately one-quarter survived 10 years post-transplant. There was minimal overlap between the factors associated with 1-year and 10-year survival. Of note, the Lung Allocation Score was not associated with long-term survival. Further research is needed to better refine patient selection and optimize management strategies to increase the number of long-term survivors.

German Heart Surgery Report 2019: 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 2019 are analyzed. For this period, a total of 175,705 procedures were submitted to the registry, 100,446 summarized as heart surgery procedures in a classical sense. The unadjusted in-hospital survival rate for the 34,224 isolated coronary artery bypass grafting procedures (relationship on-/off-pump 3.8:1) was 97.3%. For the 36,650 isolated heart valve procedures (16,625 transcatheter interventions included), it was 96.4%. Concerning short- and long-term circulatory support, a total of 2,716 extracorporeal life support/extracorporeal membrane oxygenation implantations, resp. 953 assist device implantations (L-/ R-/ BVAD, TAH) were registered. In 2019, the number of isolated heart transplantations increased to 333, a rise of 6.7% compared to the previous year. The isolated lung transplantations amounted to 311, a decrease of 8.5%. 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.