Lung Transplant Group Research Articles

Management of airway complications following lung transplantation: first interventional bronchoscopy report from Türkiye.

Lung transplantation is the treatment of last resort for many chronic lung diseases. Airway complications (AC) following lung transplantation, such as bronchial stenosis, dehiscence, malacia, and fistula, account for frequent hospital admissions, additional treatment costs, decreased quality of life, and reduced survival rates. Beyond surgical and medical preventive efforts, interventional bronchoscopy (IB) can be used in the management of these complications. The aim of the study is to evaluate the efficacy of IB on the management of AC following lung transplantation. A retrospective analysis was done using the data of lung transplant patients with AC referred to the interventional pulmonology unit between December 2012 and December 2019. From a total of 116 lung transplants, the data of 14/116 (12%) patients and 14/220 (6.3%) anastomoses in the same lung transplant group with AC requiring IB were analyzed. In these 14 patients, the diseases leading to lung transplantation were interstitial lung diseases (ILD) (50.0%), bronchiectasis (28.6%), pulmonary arterial hypertension (PAH) (7.1%), chronic obstructive pulmonary disease (COPD) (7.1%), and COPD + bronchiectasis (7.1%). Airway stenosis was the most common airway complication, and it developed mostly in the right bronchial system.The 14 patients underwent 27 total sessions of IB with an average of 2-3 per patient. Airway patency was successfully achieved in 74.1% of the procedures. Mechanical dilatation with a balloon and/or a rigid tube was the most preferred procedure (81.5%). Permanent airway patency was achieved in eight (57.4%) patients. No early complications were encountered (0%). The late complication rate was 48.1%. The most frequent late complication was restenosis, which cannot be directly attributed to IB. IB is safe to perform on lung transplant patients with AC. It has low procedural complication rates and can be performed repeatedly. Because of the high rate of restenosis, interventional pulmonologists should find out treatment modalities with lower rates of restenosis.

#2487 Deleterious renal outcome in patients with thrombotic microangiopathy after lung transplantation: the lung TMA trial

Abstract Background and Aims Thrombotic microangiopathy (TMA) is a rare but severe complication following lung transplantation. The pathogenesis is poorly understood, involving endothelial damage and various risk factors, including calcineurin inhibitor (CNI) toxicity. We aimed to evaluate diagnostic accuracy, identify risk factors for and assess the renal and overall survival of TMA in this patient group. Method We performed a retrospective study of patients with TMA after lung transplant between 01/01/2000-01/01/2021. Matching controls were selected based on underlying lung disease, age, gender, CMV risk, and immunosuppressive regimen. Overall survival and baseline data (age, gender) were collected for the whole lung transplant group. Results A total of 29 TMA cases (2.9%) were identified out of 1025 lung transplantations. 48% of patients had a complete hematological assessment with Coombs testing as the most frequent (52%) missing test. The median time from transplantation to TMA was 5.9 months. 76% of the episodes occurred before 12 months. 77% of patients had organ damage with acute kidney injury in 72%. At the time of TMA 38% of patients had a cytomegalovirus (CMV) infection. Arterial hypertension was found in 31% and acute rejection in 11%. The immunosuppressive scheme consisted of tacrolimus/mycophenolate mofetil and corticosteroids in the majority of cases (56%). Tacrolimus (n = 22) and cyclosporine (n = 7) trough levels were respectively 11.8 and 207 µg/l at the time of TMA. Treatment consisted of change in immunosuppressive regimen (72%), 31% received plasmapheresis. When comparing the TMA patients with the control group a higher rate of donor specific antibodies were found (11% vs 1%), a lower median time till chronic lung allograft dysfunction (37 m vs 91 m) and a higher prevalence of end-stage renal disease (24% vs 6%) and overall death (97% vs 44%) with mortality being significantly higher (p < 0.01). Fig. 1 illustrates the overall outcome. Conclusion This study illustrates the clinical characteristics and outcomes of TMA after lung transplantation. Even though the prevalence is low the effects are deleterious with acute kidney injury in the majority of cases and higher risk of end-stage renal disease and mortality. Our study emphasizes the need for higher further research into risk factors, and therapeutic strategies to prevent and improve patient outcomes. Furthermore, the findings underscore the importance of vigilant monitoring and tailored interventions for TMA in lung transplant patients.

(633) - Comparison Between Waiting List Diagnosis for Lung Transplantation for Pulmonary Interstitial Disease and Explant Analysis from the Largest Lung Transplantation Group of Brazil

(633) - Comparison Between Waiting List Diagnosis for Lung Transplantation for Pulmonary Interstitial Disease and Explant Analysis from the Largest Lung Transplantation Group of Brazil

Impact of the COVID-19 pandemic on lung transplant patients and on a cohort of patients with rare lung disease: A single-center study

IntroductionDue to the COVID-19 pandemic, France underwent several lockdown periods during 2020. Our aim was to evaluate its clinical and social impact on lung transplant (LT) patients treated at Strasbourg University Hospital, by comparing three periods: first lockdown (T1: March-May 2020), end of the first lockdown (T2: May-October 2020), and second lockdown (T3: November-December 2020) and the incidence of COVID-19 infections. A cohort of patients with rare lung disease (RLD) was also studied during T2. MethodsWe used clinical and paraclinical data collected during routine follow-up. A questionnaire was submitted to each patient at each period to assess their lifestyle, adherence to protective measures against COVID-19, contacts with their family and friends, and contagion risk. The incidence of new COVID-19 cases was also assessed. ResultsOverall, 283 LT and 57 RLD patients were included. We observed only eight COVID-19 cases over the three periods (n = 4 during T1, n = 0 during T2, and n = 4 during T3) in LT patients, with 37.5 % of patients hospitalized, no ICU transfers, and 100 % favorable outcomes. No case of COVID-19 was diagnosed in the RLD cohort. When comparing the three periods in the LT group, fewer patients limited their out-of-home activities during T2 (p < 0.0001). The frequency of these activities increased after the first lockdown, for the purchase of basic necessities (p < 0.0001), and professional activity continued (p = 0.008). We observed a significant increase in unscheduled medical consultations and in the prescription of anti-infective treatments during the end of the lockdown (p = 0.0002 and p = 0.005, respectively). Adherence to lockdown and to protective measures was high in both groups of patients. ConclusionCOVID-19 incidence remained low in both groups and there were significant lifestyle evolutions in LT patients and in those with RLD between first and second lockdown.

Esophageal Motility Abnormalities in Lung Transplant Recipients With Esophageal Acid Reflux Are Different From Matched Controls.

There is an increased incidence of gastroesophageal reflux disease (GERD) after lung transplantation (LT) that can be associated with graft dysfunction. It is unclear if the underlying esophageal motility changes in GERD are different following LT. This study aimed to use esophageal high-resolution manometry (HRM) to explore GERD mechanisms in LT recipients compared to matched controls. This was a retrospective study including patients with pathologic acid reflux who underwent HRM and pH testing at our healthcare facility July 2012 to October 2019. The study included 12 LT recipients and 36 controls. Controls were matched in a 1:3 ratio for age, gender, and acid exposure time (AET). LT recipients had less hypotensive esophagogastric junction (EGJ) (mean EGJ-contractile integral 89.2 mmHg/cm in LT vs 33.9 mmHg/cm in controls, P < 0.001). AET correlated with distal contractile integral and total EGJ-contractile integral only in LT group (r = -0.79, P = 0.002 and r = -0.57, P = 0.051, respectively). Following LT, acid reflux is characterized by a less hypotensive EGJ compared to controls with similar AET. The strongest correlation with AET after LT was found to be esophageal peristaltic vigor. These results add to the understanding of reflux after LT and may help tailor an individualized treatment plan.

FRI677 Analysis Of Characteristics Associated With Osteoporosis In Solid Organ Transplant Recipients - Results Of Phoenix VA Based Quality Improvement Project

Abstract Disclosure: T. Shah: None. K. Vinales: None. Introduction: Solid organ transplants are increasingly performed for multiple end-stage organ failures, that increase longevity and quality of life, but can be complicated with osteoporosis, which is associated with increased morbidity and mortality. Determining the risk factors, diagnostic and treatment related characteristics will facilitate improvement in care of patients with this condition. Design: This was part of a quality improvement project at single institution to identify male veterans, 65 years and older, who were at risk for or osteoporosis. In this analysis, we focused on those with solid-organ transplant who developed post-transplant osteoporosis over the past 10 years. Various parameters were obtained, along with the most recent DXA scan, quantifying the T-scores at various sites, trabecular bone score (TBS) and treatment modalities. Results: From initial cohort of male veterans at risk for osteoporosis (n=1676), 26 (1.5%) were identified as post-transplant osteoporosis. Baseline characteristics (mean±SD) included: age = 72.9±3.0 years-old, BMI =26.0±3 kg/m2. 26.9% patients were noted to have history of smoking, while 7.6% had rheumatoid arthritis, 65% had history of diabetes mellitus, 54% were noted to be on prednisone as part of post-transplant immunosuppression regimen with dosages varying between 5-10mg daily. 61.5% of patients had GERD, whereas 57.1% were treated with proton pump inhibitors and H2-blockers. Analysis of DXA parameters revealed the lowest T-score average to be -1.88±0.5 with 88% having low BMD at the femoral neck site. Average TBS in the group was noted to be 1.37±0.1, while vertebral compression fractures were noted in 21% of these patients. Only 76% of patients were on osteoporosis treatment, where 65% were treated with Alendronate, 25% were treated with Denosumab and 20% with Zolendronic acid. Sub group analysis based on the solid organ transplanted reported liver transplant in 46%, renal transplant in 30%, lung transplant in 15%, heart transplant in 7% of the patients. Patients in the liver transplant group had a lower TBS of 1.26 (vs. 1.46 in the renal, 1.45 in the heart and 1.33 in the lung transplant groups). Incidence of vertebral compression fractures was highest in this subgroup and noted in 27% patients. Notably 25% of liver transplant were diagnosed with osteoporosis solely based on presence of vertebral compression fractures. Conclusion: Our quality improvement study highlights the fact that lowest DEXA scan T-scores are most commonly found at the femoral neck site in solid organ transplant recipients and high incidence of fragility fractures. Thorough assessment for vertebral fractures should be routinely incorporated while evaluating DXA scans in post-transplant osteoporosis cases, especially recipients of liver transplants as vertebral compression fractures can be the sole determinant of osteoporosis in this group of patients. Presentation: Friday, June 16, 2023

Aspergillus Galactomannan Titer as a Diagnostic Marker of Invasive Pulmonary Aspergillosis in Lung Transplant Recipients: A Single-Center Retrospective Cohort Study

Invasive pulmonary aspergillosis (IPA) can occur in immunocompromised patients, and an early detection and intensive treatment are crucial. We sought to determine the potential of Aspergillus galactomannan antigen titer (AGT) in serum and bronchoalveolar lavage fluid (BALF) and serum titers of beta-D-glucan (BDG) to predict IPA in lung transplantation recipients, as opposed to pneumonia unrelated to IPA. We retrospectively reviewed the medical records of 192 lung transplant recipients. Overall, 26 recipients had been diagnosed with proven IPA, 40 recipients with probable IPA, and 75 recipients with pneumonia unrelated to IPA. We analyzed AGT levels in IPA and non-IPA pneumonia patients and used ROC curves to determine the diagnostic cutoff value. The Serum AGT cutoff value was 0.560 (index level), with a sensitivity of 50%, specificity of 91%, and AUC of 0.724, and the BALF AGT cutoff value was 0.600, with a sensitivity of 85%, specificity of 85%, and AUC of 0.895. Revised EORTC suggests a diagnostic cutoff value of 1.0 in both serum and BALF AGT when IPA is highly suspicious. In our group, serum AGT of 1.0 showed a sensitivity of 27% and a specificity of 97%, and BALF AGT of 1.0 showed a sensitivity of 60% and a specificity of 95%. The result suggested that a lower cutoff could be beneficial in the lung transplant group. In multivariable analysis, serum and BALF AGT, with a minimal correlation between the two, showed a correlation with a history of diabetes mellitus.

National Trends in Transplantation-Associated Intensive Care Unit Admission in South Korea From 2010 to 2019

We aimed to investigate the mortality and associated factors among patients admitted to the intensive care unit (ICU) after transplantation in South Korea. The South Korean National Health Insurance Service database was used as the data source. All adult patients (age ≥18 years) who were admitted to the ICU for organ transplantation-related causes from January 1, 2010 to December 31, 2019 (10 years) were included. Transplantation-associated ICU admissions were defined as admissions to the ward and ICU after transplantation or to the ICU before transplantation. A total of 23,994 ICU admissions after transplantation were included in the analysis (mean [SD] age: 52.7 [10.7] years; men: 67.0%; kidney transplantation: n=9638; liver transplantation: n=12,196; heart and/or lung transplantation: n=1829; pancreas or small bowel transplantation: n=331). Transplantation-associated ICU admissions gradually increased from 1666 in 2010 to 3014 in 2019. The 1-year mortality rates were 21.2%, 12.3%, 4.2%, and 3.0% after heart and/or lung, liver, pancreas or small bowel, and kidney transplantation, respectively. Invasive life support procedures during ICU stay, comorbidities, and older age were potential risk factors for 1-year mortality after transplantation. Transplantation-associated ICU admissions gradually increased from 2010 to 2019 in South Korea. The 1-year mortality rate after transplantation was the highest in the heart and/or lung transplantation group, followed by those of the liver, pancreas or small bowel, and kidney transplantation groups.

The ratio of TAPSE to PASP predicts prognosis in lung transplant candidates with pulmonary arterial hypertension

Lung transplantation (LT) is the only option for patients with pulmonary arterial hypertension (PAH) refractory to maximal medical therapy. However, some patients referred for LT could survive without LT, and its determinants remain unclear. This study aimed to elucidate prognostic factors of severe PAH at the referral time. We retrospectively analyzed 34 patients referred for LT evaluation. The primary outcome was a composite of death or LT. Over a median follow-up period of 2.56 years, eight patients received LT and eight died. Compared with LT-free survival group, pulmonary arterial systolic pressure (PASP) was higher (p = 0.042), and the ratio of tricuspid annular plane systolic excursion (TAPSE) to PASP (TAPSE/PASP) was lower (p = 0.01) in LT or death group. In receiver operating characteristic analysis, the area under the curve was 0.759 (95% confidence interval 0.589–0.929) for TAPSE/PASP to predict primary outcome, and the optimal cut-off value was 0.30 mm/mmHg (sensitivity 0.875 and specificity 0.667). In a multivariate analysis, TAPSE/PASP was independently associated with death or LT. Kaplan–Meier analysis showed a better LT-free survival in patients with TAPSE/PASP ≧0.30 mm/mmHg than in those with < 0.30 mm/mmHg (p = 0.001). Low-level TAPSE/PASP could be a poor prognostic factor in PAH patients referred for LT evaluation.

Clinical characteristics of patients requiring lung transplantation referral in national cystic fibrosis registry data.

We aimed to determine the number of cystic fibrosis (CF) patients recorded in the Cystic Fibrosis Registry of Türkiye (CFRT) who were in need of lung transplantation (LT) referral and examine clinical differences between patients who were LT candidates due to rapid forced expiratory volume in one second (FEV₁) decline and LT candidates without rapid FEV₁ decline in the last year to identify a preventable cause in patients with such rapid FEV₁ decline. All CF patients recorded in the CFRT in 2018 were evaluated in terms of LT. Patients were divided into those with FEV₁ below 50% and in need of LT due to a decrease of 20% or more in the previous year (Group 1) and those who did not have FEV₁ decline of more than 20% in the previous year but had other indications for LT (Group 2). Demographic and clinical features were compared between the two groups. Of 1488 patients registered in CFRT, 58 had a need for LT. Twenty patients were included in Group 1 and others in Group 2. Our findings did not reveal any significant variations in treatment, chronic infection status, or complications between the two groups. The average weight z-score was significantly higher in Group 1. Positive correlations were detected between weight z-score and FEV₁ in 2017 in Group 1 and between FEV₁ values in 2017 and 2018 in Group 2. There appears to be a relationship between the nutritional status and weight z-scores of CF patients and pulmonary function, which may indirectly affect the need for lung transplantation referral.

Current perspective of immunomodulators for lung transplant.

Lung transplantation is an effective treatment option for selected patients suffering from end-stage lung disease. More intensive immunosuppression is enforced after lung transplants owing to a greater risk of rejection than after any other solid organ transplants. The commencing of lung transplantation in the modern era was in 1983 when the Toronto Lung Transplant Group executed the first successful lung transplant. A total of 43,785 lung transplants and 1365 heart-lung transplants have been performed from 1 Jan 1988 until 31 Jan 2021. The aim of this review article is to discuss the existing immunosuppressive strategies and emerging agents to prevent acute and chronic rejection in lung transplantation.

Lobar size reduction in lung transplantation: A propensity score study.

For small-sized recipients of lung transplantation, the time span for organ reception from standard donors is generally longer than for normal-sized patients. Despite its underuse, lobar reduction may be a concrete option for these patients. This study aims to assess early and long-term outcomes associated with lobar reduction in lung transplantation. A retrospective study was performed on 608 consecutive lung transplantations at 2 centers between January 2005 and August 2019 (559 standard lung transplantations [standard transplantation] and 49 with lobar reduction [lung transplantation group]). A propensity-score weighting approach was used to account for potential confounding related to patients' nonrandom allocation to the 2 intervention groups. The effects of the intervention on postoperative outcomes were assessed with a weighted regression approach. The propensity score was estimated on 571 patients (522 in standard transplantation group and 49 in lung transplantation group). In terms of early outcomes, the lung transplantation group showed a higher percentage of severe primary graft dysfunction at 0hours and reported longer intensive care unit stay than the standard transplantation group. No other differences in terms of morbidity, mortality, mechanical ventilation time, hospital stay, and anastomotic complications were observed. Although the lung transplantation group showed worse long-term pulmonary function, the 2 populations had comparable survival outcomes. The use of lobar reduction showed early and long-term results comparable to those after standard lung transplantation. Although a higher rate of early severe primary graft dysfunction and slightly reduced respiratory function were detected in the lobar group, these did not affect patients' morbidity and survival.

Outcomes in Post Lung Transplant Patients Diagnosed with COVID 19

PurposeThe manifestations and complications of SARS-CoV-2 infection in solid organ transplant are poorly known. Lung Transplant group is an immunocompromised group with a shock organ of COVID-19. For this, we analyze the possible risk factors associated with an unfavorable outcomeMethodsRetrospective study between the period march 2020 until june 2021. We analysed the database of Lung Transplant and medical records. It included all patients with a confirmed diagnosis of COVID-19 in our cohort with RT-PCR SARS-COV-2 or rapid test and chest computed tomography compatible. We analyzed demographic features and outcomes: sex; type of transplant (unilateral or bilateral); presence of chronic graft dysfunction; transplant time; confirmed prior rejections; history of SAH and/or DM; nosocomial transmission infection; report of fever and/or dyspnea; need for hospitalization and/or ICU; use of an O2 nasal catheter and/or mechanical ventilation; need of dyalisis; associated bronchopneumonia (confirmed by culture); and previous use of 2 or more immunosuppressants. Statistical analysis was performed and multivariate analysisResultsIn our cohort, we had 213 patients in follow-up (March 2020) and during this period 29 (13.6%) patients with COVID-19 were evaluated. These 23 with diagnosis and supervised treatment in our service and 6 patients in external follow-up of the infectious condition. Overall death was 31% (9).The mean age of patients is 46 years (±15.66), being 51.8% male and 48.2% female. A multivariate analysis, only dialysis (HR 9.186 - CI 1.804-46.758 - p=0.008) and bronchopneumonia (HR 7.554 - CI 1.510-37.790 - p=0.014) are associated with a negative outcome.ConclusionThe lethality is high in this group of patients. Our data was shown that dialysis and bronchopneumonia are associated with a higher risk of death in this group of patients infected with COVID-19. We emphasize that the limitation of this work is mainly due to the small sample analyzed. We suggest more studies are necessary.

Right lung transplantation with a left-to-right inverted anastomosis in a rat model

ObjectiveRight lung transplantation in rats has been attempted occasionally, but the technical complexity makes it challenging to apply routinely. Additionally, basic research on inverted lobar lung transplantation is scarce because of the lack of a cost-effective experimental model. We first reported right lung transplantation in a rat model using left-to-right inverted anastomosis to imitate the principle of clinically inverted lung transplantation. MethodsRight lung transplantation was performed in 10 consecutive rats. By using a 3-cuff technique, the left lung of the donor rat was implanted into the right thoracic cavity of the recipient rat. The rat lung graft was rotated 180° along the vertical axis to achieve anatomic matching of right hilar structures. Another 10 consecutive rats had received orthotopic left lung transplantation as a control. ResultsAll lung transplantation procedures were technically successful without intraoperative failure. One rat (10%) died of full pulmonary atelectasis after right lung transplantation, whereas all rats survived after left lung transplantation. No significant difference was observed in heart-lung block retrieval (8.6 ± 0.8 vs 8.4 ± 0.9 minutes), cuff preparation (8.3 ± 0.9 vs 8.7 ± 0.9 minutes), or total procedure time (58.2 ± 2.6 vs 56.6 ± 2.1 minutes) between the right lung transplantation and standard left lung transplantation groups (P > .05), although the cold ischemia time (14.2 ± 0.9 vs 25.5 ± 1.7 minutes) and warm ischemia time (19.8 ± 1.5 vs 13.7 ± 1.8 minutes) were different (P < .001). ConclusionsRight lung transplantation with a left-to-right inverted anastomosis in a rat model is technically easy to master, expeditious, and reproducible. It can potentially imitate the principle of clinically inverted lung transplantation and become an alternative to standard left lung transplantation.

Pre-transplant vaccination compliance in adult heart and lung transplant recipients.

Vaccine preventable diseases can affect solid organ transplant recipients post-transplant. Therefore, the administration of vaccines and assessment of serologic response should be prioritized in the pre-transplant period. This single-center, retrospective study included 349 adult heart or lung transplant candidates between December 1, 2017 and November 30, 2019. We describe vaccination or serologic status for hepatitis A, hepatitis B, tetanus, pneumococcal, influenza, and other recommended vaccinations among heart or lung transplant candidates. Eighty-two heart transplant candidates (91%) and 77 lung transplant candidates (30%) received an ID consult prior to transplant. More patients completed the pneumococcal series (66.7%vs. 28.6%, P=.045) in the heart transplant group that received an ID consult. In the lung transplant group, patients with an ID consult demonstrated higher rates of immunity to hepatitis A (84.4% vs. 72.9%, P=.047), hepatitis B (75.3% vs. 56.9%, P=.005), and measles (71.4%vs. 52.5%, P=.005) compared to those without. Our results demonstrate the value of consulting ID and administering vaccinations in the early evaluation phase, prior to transplant listing. Opportunities remain to better optimize vaccination rates prior to transplant in heart and lung transplant candidates.

The association of lung function changes with outcomes in children with bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation.

Bronchiolitis obliterans syndrome (BOS) is a life-threatening respiratory complication of allogeneic hematopoietic stem cell transplantation (HSCT). Although pulmonary function testing is crucial for monitoring BOS, little information exists on the association of these test results with outcomes in children with BOS. The purpose of this study was to determine the correlation between changes in lung function after BOS diagnosis and long-term outcomes. A total of 428 children underwent allogeneic HSCT from January 2006 to December 2017 at Asan Medical Center. Twenty-three (5.4%) were diagnosed with BOS after allogeneic HSCT, and their clinical data were reviewed. Twenty-one subjects underwent regular pulmonary function testing for 24 months after BOS diagnosis. Among the 21 children with BOS, 8 died, 5 underwent lung transplantation (TPL), and 15 required oxygen (O2 ) therapy. The FEV1 % predicted (pred), FVC% pred, and FEF25%-75% pred were 37.8 ± 12.7% (mean ± SD), 62.2 ± 16.2%, and 16.4 ± 9.6%, respectively, at the time of BOS diagnosis. Changes in the FEV1 % pred were greater in the death and lung TPL groups (-24.8 ± 22.3%) than in the survival without lung TPL group (5.7 ± 21.8%) and greater in the O2 therapy (-19.4 ± 23.4%) group than in the group without O2 therapy (14.2 ± 20.0%) during the first 3 months after BOS diagnosis. The change in FEV1 during the first 3 months after BOS diagnosis correlated with outcomes including survival, lung TPL, and O2 therapy. These results suggest that more active intervention in the first 3 months after BOS diagnosis may be needed to improve prognosis.

Graft reduction surgery is associated with poorer outcome after lung transplantation: a single-centre propensity score-matched analysis.

Implanted lung volume-reduction surgery due to donor/recipient size mismatch could affect both lung function and survival. We examined the outcomes of lung volume-reduction procedures post-lung transplant. We retrospectively reviewed 366 consecutive adult lung transplants carried out between January 2014 and December 2018 at one single centre. Patients were divided into either a non-reduced-size lung transplant or a reduced-size lung transplant (RT) group. To adjust for covariates, a propensity score analysis was performed. Survival was estimated using the Kaplan-Meier method. Differences were considered significant with P-values <0.05. In the RT group, 45 patients (12.3%) had some type of graft reduction surgery: 31 (68.9%) patients had pulmonary lobectomies and 14 (31.1%) wedge resections. Of the total cohort, 30 patients (8.2%) were prioritized, 23% of whom required graft reduction surgery. The propensity score analysis matched 41 patients in each group. In the RT group, there was an increased need for cardiopulmonary bypass (P = 0.017) during surgery and extracorporeal membrane oxygenation (P = 0.025) after lung transplant. Furthermore, the median length of mechanical ventilation was higher (P = 0.008), and lung function at discharge, 3 and 6 months post-lung transplant was significantly lower in the RT group (P < 0.05). Survival analysis demonstrated a significantly poorer overall outcome at 1, 3 and 5 years post-lung transplantation in patients with a reduced graft (P = 0.007), while the 1-year conditional survival was also worse in this group (P = 0.025). Graft reduction surgery in lung transplant recipients is associated with lower pulmonary function and poorer overall survival. However, it does allow transplantation in prioritized recipients for whom it might otherwise be impossible to find an organ of suitable size.

Epidemiology of Infections in Adult Heart and Lung Transplant Recipients: A Single Center Experience

<h3>Purpose</h3> Infectious complications are a common cause of morbidity and mortality among solid organ transplant (SOT) recipients. Understanding their epidemiology and outcomes is vital when planning preventative strategies. <h3>Methods</h3> We conducted a retrospective study of selected infections diagnosed in patients receiving heart (HT) or lung transplantation (LT) from January 2013 to June 2018. We examined the incidence of infections and outcomes one-year post-transplant. <h3>Results</h3> We reviewed 217 patients that underwent heart or lung transplantation (109 HT, 108 LT) at our center over a five-year period. Median follow-up was 2.5 years, median age was 51, 68% were males, and 75%-white. Indication for transplant in HT recipients was predominantly idiopathic dilated cardiomyopathy (22%) and ischemic dilated cardiomyopathy (11%). Indications for lung transplants included idiopathic pulmonary fibrosis (19%), chronic obstructive pulmonary disease (9%), and cystic fibrosis (7%). Within the first year post-transplant, 46% of transplant recipients had defined infections (56% LT, 35% HT)(Table). In the HT group, CMV (14%) respiratory viruses (9%), aspergillosis (6%), and <i>Clostridioides difficile</i> infection (6%) were most common. In the LT group, respiratory viruses (39%), aspergillosis (21%), <i>Clostridioides difficile</i> (14%), and extended-spectrum beta-lactamase producing bacteria (9%) were most common. All-cause mortality at one year was 5% and 10% in the HT and LT recipients, respectively. There was no infection-related mortality at one year in both groups. <h3>Conclusion</h3> Despite standard infection prevention strategies, nearly half of all HT and LT recipients had identified infections at the end of one year. The most frequent infectious process was respiratory viral infections, particularly in the LT group. Further studies identifying associated risk factors and additional preventative measures may be needed to reduce these infections.

Frailty and aging-associated syndromes in lung transplant candidates and recipients.

Many lung transplant candidates and recipients are older and frailer compared to previous eras. Older patients are at increased risk for pre- and posttransplant mortality, but this risk is not explained by numerical age alone. This manuscript represents the product of the American Society of Transplantation (AST) conference on frailty. Experts in the field reviewed the latest published research on assessment of elderly and frail lung transplant candidates. Physical frailty, often defined as slowness, weakness, low physical activity, shrinking, and exhaustion, and frailty evaluation is an important tool for evaluation of age-associated dysfunction. Another approach is assessment by cumulative deficits, and both types of frailty are common in lung transplant candidates. Frailty is associated with death or delisting before transplant, and may be associated with posttransplant mortality. Sarcopenia, cognitive dysfunction, depression, and nutrition are other important components for patient evaluation. Aging-associated inflammation, telomere dysfunction, and adaptive immune system senescence may also contribute to frailty. Developing tools for frailty assessment and interventions holds promise for improving patient outcomes before and after lung transplantation.

Oxy Right Ventricular Assist Device Using Extracoporeal Membrane Oxygenation as a Bridge to Lung Transplant for Right Ventricular Failure

Patients with IPF and cardiopulmonary failure caused by secondary pulmonary hypertension have poor prognoses. If lung oxygen exchange capacity is completely lost and secondary heart failure caused by pulmonary exacerbation was appeared, it is difficult to maintain survival via conventional peripheral ECMO alone. We used Oxy-RVAD(RA-PA ECMO) as novel configuration delivered via anterior thoracotomy to treat end-stage IPF patients with RHF. Patients with RHF caused by secondary pulmonary hypertension, who had a bridge to LT, were indicated for Oxy-RVAD placement. After ECMO initiation, echoic findings were used to diagnose RHF, and Oxy-RVAD was inserted when the hemodynamic status was unstable or laboratory data on other organs were abnormal. We chose the cannulation and Oxy-RVAD incision sites (left fourth anterior thoracotomy) considering the fact that LT was planned. Two purse-string sutures were placed more than 1 cm above the pulmonary valve to allow return cannula insertion using the Seldinger technique. After MPA cannulation, the inflow cannula in the jugular vein was converted into a drainage cannula. To decompress the right heart, double drainage was enforced. A total of eleven patients underwent conversion from peripheral ECMO to Oxy-RVAD between September 2018 and September 2019. Eight patients successfully underwent LT. The remaining three patients survived for 9, 14 and 23 days under Oxy-RVAD, respectively. Hospital stay of all patients was 73.0 ± 55.4. 30 days mortality and In hospital mortality in LT group was 0 and 2 (25%). In conclusion, Oxy-RVAD can be reduced the signs of multiple organ failures that can be caused by RVF by decompressing the right ventricle. In the successful lung transplant group that waited for lung transplant under RVAD, they had satisfactory survival result. Oxy-RVAD is useful option in Patients with RHF caused by secondary pulmonary hypertension, who were on ECMO support as a bridge to LT.