Lung Transplantation Surgery Research Articles

Risk factors for mortality in lung transplant recipients aged ≥65 years: A retrospective cohort study of 5,815 patients in the scientific registry of transplant recipients

Lung transplantation is increasingly performed in recipients aged ≥65 years. However, the risk factors for mortality specific to this population have not been well studied. In lung transplant recipients aged ≥65 years, we sought to determine post-transplant survival and clinical factors associated with post-transplant mortality. We investigated 5,815 adult lung transplants recipients aged ≥65 years in the Scientific Registry of Transplant Recipients. Mortality was defined as a composite of recipient death or retransplantation. The Kaplan-Meier method was used to estimate the median time to mortality. Univariable and multivariable Cox proportional hazards regression models were used to examine the association between time to mortality and 23 donor, recipient, or center characteristics. Median survival in lung transplant recipients aged ≥65 years was 4.41 years (95% CI: 4.21-4.60 years) and significantly worsened by increasing age strata. In the multivariable model, increasing recipient age strata, creatinine level, bilirubin level, hospitalization at the time of transplantation, single lung transplant operation, steroid use at the time of transplantation, donor diabetes, and cytomegalovirus mismatch were independently associated with increased mortality. Among the 8 risk factors we identified, 5 factors are readily available, which can be used to optimize post-transplant survival by informing risk during candidate selection of patients aged ≥65 years. Furthermore, bilateral lung transplantation may confer improved survival in comparison with single lung transplantation. Our results support that after careful consideration of risk factors, lung transplantation can provide life-extending benefits in individuals aged ≥65 years.

Expert recommendations for the diagnosis and treatment of interstitial lung disease caused by novel coronavirus pneumonia

COVID-19 is an acute infectious disease caused by a newly discovered coronavirus (SARS-CoV2). COVID-19 may manifest bilateral interstitial pneumonia on imaging. About 30%-60% of patients present varying degrees of interstitial changes, while most patients have a good prognosis. Since there's little practical instruct on treating interstitial lung disease (ILD) caused by COVID-19, we present this file as references for all the colleagues fighting with this disease. The primary findings on CT are bilateral, peripheral ground-glass opacities (GGO) and consolidation. Inter-/intra-lobular septal thickening are also common. Subpleural lines and traction bronchiectasis can be seen in some cases which indicate the presence of interstitial fibrosis. Images of severe cases are similar with those in advanced stage of nonspecific interstitial pneumonia (NSIP) and organizing pneumonia (OP). COVID-19 could present the typical two phases of diffuse alveolar damage: acute and proliferative phase on pathology. Massive pulmonary interstitial fibrosis may also be present. HRCT is the best radiological approach for the diagnosis and differential diagnosis of COVID-19, and to assess the presence of ILD. Periodical CT following-up is recommended for patients who present interstitial manifestations. Biomarkers such as KL-6, SP-D, RAGE may also helpful on evaluating the severity of interstitial fibrosis and therapeutic response. We do not suggest applying pulmonary function tests and 6-minute walking test on patients in active stage of the disease. The primary treatments in acute phase are antiviral therapy and supportive treatment. We do not suggest routine use of corticosteroids, while on patients with excessive activation of inflammatory response or rapid progression of lung lesions, a low to medium dosage of corticosteroids could be applied for a short course. Pirfenidone and Nintedanib are encouraged to apply on patients in reparative phase with evidence of progressing fibrosis. Low to medium dosage of corticosteroids is also feasible on patients with NSIP or OP manifestation in this phase, with a relatively longer course. Chinese traditional medicine and rehabilitation medicine may also helpful. Lung transplant surgery is an option for severe pulmonary fibrosis patients. Patients should receive CT following-up after be discharged from hospital, especially those whose pulmonary exudation is not well absorbed. We suggest a routine following-up on month 1, 4 and 10 after discharging, and an extended period for those who have developed irreversible interstitial fibrosis.

Nontuberculous mycobacterial infection after lung transplantation: A single-center experience in South Korea.

Nontuberculous mycobacteria (NTM) infection is an important issue after lung transplantation. However, a large-scale epidemiological study on this issue in Korea is lacking. We aimed to evaluate the epidemiology of NTM infection after lung transplant surgery in Korea. Between October 2012 and December 2018, we retrospectively evaluated lung transplant recipients in a referral hospital in South Korea. A total of 215 recipients were enrolled. The median age at transplantation was 56 years (range, 17-75), and 62% were men. Bronchoscopy was performed according to the surveillance protocol and clinical indications. A diagnosis of NTM infection was defined as a positive NTM culture from a bronchial washing, bronchoalveolar lavage sample, or two separate sputum samples. We determined NTM pulmonary disease (NTM-PD) according to the American Thoracic Society/Infectious Disease Society of America 2007 guidelines. The Kaplan-Meier method and log-rank test were used for conditional survival analysis in patients with follow-up of ≥12 months. Fourteen patients (6.5%) were diagnosed with NTM infection at a median of 11.8 months (range, 0.3-51.4) after transplantation. Nine patients (4.2%) were diagnosed with NTM-PD, and the incidence rate was 1980/100,000 person-years. Mycobacterium abscessus was the most common species causing NTM-PD (66%), followed by M. avium complex (33%). The presence of NTM infection did not influence all-cause mortality among those who underwent follow-up for ≥12 months (N=133, log-rank P=0.816). The incidence of NTM-PD was considerably high among lung-transplant recipients. M. abscessus was the most common causative species of NTM-PD after lung transplantation.

Harvesting left internal thoracic artery via clamshell incision for coronary bypass and lung transplant.

Concomitant lung transplantation and coronary artery bypass grafting operation became more prevalent over the last decade due to the advanced age of recipients. Median sternotomy approach is traditionally used when internal thoracic artery is utilized. Here we report a technique of harvesting the left internal thoracic artery via a clamshell incision for a combined coronary artery bypass and bilateral lung transplant operation in a 71-year-old male with terminal respiratory failure and coronary artery disease.

Prognostic Value of Change in Cardiac Index After Prostacyclin Initiation in Pediatric Pulmonary Hypertension

Invasive hemodynamic assessment remains the gold standard for the diagnosis of pediatric pulmonary hypertension and for longitudinal assessment of response to therapy. This analysis sought to describe the changes in hemodynamic variables after initiation of prostacyclin therapy and determine which changes bear predictive power of adverse clinical outcomes. A retrospective chart review of established patients at Cincinnati Children's Hospital with pulmonary arterial hypertension (PAH) who required prostacyclin therapy between 2004 and 2018 was performed. The baseline hemodynamic parameters at diagnosis as well as change in those parameters between initial catheterization and post-prostacyclin initiation catheterization were independent variables. Cox proportional hazard regression and recursive partitioning analysis were used to characterize which hemodynamic factors predicted the composite adverse outcome (CAO) defined as death, lung transplantation, or reverse Pott's shunt surgery. During the study period, 29 patients met inclusion criteria in which there were 7 CAOs: 4 deaths, 3 lung transplants, and 2 reverse Pott's shunts. Median time between catheterizations was 86days and between the initiation of prostacyclin therapy and the second catheterization was 54days. Cox regression revealed that only baseline pulmonary artery pressure (> 51mmHg) and a failure to increase cardiac index illustrated statistically significant hazard for occurrence of the CAO (p < 0.01). These criteria significantly dichotomized the population in a Kaplan-Meier analysis into likelihoods of experiencing the CAO. While controlling for other hemodynamic variables, the absence of augmentation of cardiac index after the initiation of prostacyclin therapy is a valuable prognostic indicator of adverse PAH outcomes in pediatrics.

Dysphagia and medicine regimes in patients following lung transplant surgery: A retrospective review

Purpose Dysphagia is reported following lung transplantation. Characteristics and trajectory for dysphagia are poorly understood. This retrospective study explored dysphagia and medicine regimes in patients following lung transplant. Method Medical records and endoscopic recordings of 101 patients (M:50yrs, range 20–67yrs, SD 13yrs) were reviewed. Standardised endoscopic swallowing measures were reported. Discharge reports were analysed for medicines known to cause dysphagia. Result All patients received bilateral sequential single-lung transplant. Prevalence of referral to speech pathology was 65% with 37 requiring more than one instrumental assessment. Twenty-nine patients were referred to otorhinolaryngology with suspected laryngeal abnormalities. Seventy-five percent of patients (n = 49/65) who received an instrumental assessment aspirated; of whom 63% aspirated silently (31/49). Diet on first day transferred from Intensive Care Unit (ICU) was significantly associated with intubation duration, ICU and hospital length of stay, tracheostomy and vocal fold paralysis (p < 0.001). In contrast, pre-operative reflux was significantly associated with diet on discharge (p < 0.05). Only three patients remained enterally fed on discharge. Polypharmacy (concurrent use of 5+ medicines) was prevalent. Conclusion Endoscopic, radiographic and/or manometric assessment of dysphagia in patients prior to, and following, lung transplant may allow for early management and prevention of secondary complications. Teams must consider pre-surgical reflux, length of stay in ICU and current medicine regimes when managing patients.

Evaluating the Impact of Pulmonary Artery Obstruction After Lung Transplant Surgery: A Systematic Review and Meta-analysis.

Pulmonary artery obstruction is an uncommon but significant complication after lung transplantation. Although numerous reports have documented its occurrence, the hemodynamic parameters associated with its presentation and diagnostic considerations remain ill-defined. This systematic review summarizes evidence in the literature surrounding pulmonary artery obstruction after lung transplantation surgery. Databases were searched for all articles and abstracts reporting on pulmonary artery obstruction. Data collected included the number of patients studied, patient characteristics, incidences of pulmonary artery obstruction, and timing and imaging modality used for diagnosis. Thirty-four full-text citations were included in this review. The point prevalence of pulmonary artery obstruction was 3.66%. The peak pulmonary artery velocity associated with obstruction was found to be 2.60 ± 0.58 m/s. The diameter of the obstructed pulmonary artery predictive of poor outcomes was noted to be 0.78 ± 0.40 cm. The majority of diagnoses were made in the late postoperative period using pulmonary angiogram and transesophageal echocardiography. Overall, 76% of patients (47 of 62) required emergent procedural reintervention, and 23% of patients (14 of 62) diagnosed with pulmonary artery obstruction died during their hospital stay. This systematic review underscores the importance of identifying pulmonary artery obstruction immediately after lung transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for early detection of irregularities in pulmonary artery anastomosis in lung transplant patients.

Ex vivo lung CT findings may predict the outcome of the early phase after lung transplantation.

We developed an ex vivo lung CT (EVL-CT) technique that allows us to obtain detailed CT images and morphologically assess the retrieved lung from a donor for transplantation. After we recovered the lung graft from a brain-dead donor, we transported it to our hospital and CT images were obtained ex vivo before lung transplant surgery. The objective of this study was to investigate the correlation between the EVL-CT findings and post-transplant outcome in patients who underwent bilateral lung transplantation (BLT) or single lung transplantation (SLT). We retrospectively reviewed the records of 70 patients with available EVL-CT data who underwent BLT (34 cases) or SLT (36 cases) in our hospital between October 2007 and September 2017. The recipients were divided into 2 groups (control group, infiltration group) according to the findings of EVL-CT of the lung graft in BLT and SLT, respectively. Recipients in the control group were transplanted lung grafts without any infiltrates (BLT control group, SLT control group). Recipients in the infiltration group received lung grafts with infiltrates (BLT infiltration group, SLT infiltration group). The recipients in the BLT infiltration group showed significantly slower recovery from primary graft dysfunction and a longer mechanical ventilation period and ICU stay period than those in the BLT control group. The mechanical ventilation period was significantly longer in the recipients in the SLT infiltration group than those in the SLT control group. EVL-CT may predict the outcome of the early phase after lung transplantation.

Current trends in thoracic surgery.

ABSTRACTThoracic surgery has evolved drastically in recent years. Although thoracic surgeons mainly deal with tumorous lesion in the lungs, mediastinum, and pleura, they also perform lung transplantation surgery in patients with end-stage lung disease. Herein, we introduce various major current topics in thoracic surgery. Minimally invasive surgical procedures include robot-assisted thoracic surgery and uniportal video-assisted thoracic surgery. Novel techniques for sublobar resection include virtual-assisted lung mapping, image-guided video-assisted thoracic surgery, and segmentectomy using indocyanine green. Three-dimensional (3D) computed tomography (CT) simulation consists of surgeon-friendly 3D-CT image analysis systems and new-generation, dynamic 3D-CT imaging systems. Updates in cadaveric lung transplantation include use of marginal donors, including donation after circulatory death, and ex vivo lung perfusion for such donors. Topics in living donor lobar lung transplantation include size matching, donor issues, and new surgical techniques. During routine clinical practice, thoracic surgeons encounter various pivotal topics related to thoracic surgery, which are described in this report.

Perioperative Characteristics Associated with Transfusion-Free Lung Transplantation

Blood transfusion during lung transplantation (LT) surgery is common. There is little evidence to identify potential candidates for transfusion-free LT surgery. We describe patient and procedural characteristics of LT patients in the era of ECMO and identify predictors of a successful transfusion-free surgery. In this single-center, retrospective analysis, all adult patients undergoing LT between 9/5/2016-2/28/2019 were included. Patients were grouped based on perioperative transfusions received over 72 hours; no products, 1-4 units PRBC, or >4 U PRBC. Donor and recipient characteristics were compared between the three groups by univariate and multivariate analysis. 241 LTs were performed over the time period; 235 were included and 6 multiorgan transplants were excluded. 41 patients (17.4%) received no blood transfusions, while 82.6% (N=194) received transfusions. Most patients (43%, N=101) received >4 U of product. Recipients requiring blood transfusions had associated prolonged ventilation, length of stay, PGD and worsened 1-year graft survival compared to those who did not. Donor characteristics were similar between groups (Fig 1). Older males with obstructive or restrictive lung disease undergoing an off-pump, single lung LT, with lower Lung Allocation Score (LAS), higher starting hemoglobin, shorter ischemic time and case length were associated with a transfusion free LT (Fig 1). In a multivariate analysis, positive predictors for transfusion-free LT included single LT (OR=6.27, p=0.0004), and higher preoperative hemoglobin (OR=1.35 per point, p.0231). Negative predictors included female sex (F v M, OR=0.13, p=0.0005) and higher LAS (OR=0.88 per point, p=0.0002). Predictors of transfusion free LT surgery include older males undergoing a single, off-pump LT procedure, with lower LAS scores and higher starting hemoglobin. This may guide decision making in exploring candidacy for transfusion-free LT or blood refusal patients in the era of ECMO.

Reducing Length of Stay after Lung Transplant through Implementation of Multi-Disciplinary Care Coordination Rounds

Aim of this project was to reduce length of stay (LOS) after lung transplant surgery (LT) by implementing multi-disciplinary care coordination rounds (MDR). We performed a single-center study analyzing efficacy of weekly MDR focused on discharge planning for new LT recipients. Providers involved in MDR included social workers, pharmacists, case managers, physical-, occupational-, and speech-therapists, dietician, nurse coordinators, and nurse practitioners. MDR efficacy was evaluated by comparing a prospective cohort of LT recipients exposed to MDR from January to August 2019, to a retrospective cohort of LT recipients who underwent LT from January to December 2018. Demographic and clinical characteristics: age, sex, days hospitalized prior to LT, mechanical ventilation and/or ECMO support prior to LT were collected from the medical record. Primary outcome was overall length of stay following LT surgery. Secondary outcomes included ICU LOS, <30 days hospital readmission rate and diagnosis. LOS was compared by Mann-Whitney U test. Readmission rates compared by Fisher's Exact Test. Forty subjects underwent LT from January to August 2019 comprising the intervention population (Table). Prior to the intervention, 2018 median hospital LOS was 21 days (14,33), median ICU LOS was 6.5 days (5,21), 4 (7%) <30 days readmission rate. After MDR implementation, 2019 median hospital LOS was 15 days (13,23), a 6 day (29%) reduction (p = 0.04). Median ICU LOS was 5 days (5,12) (p=0.13). 8 (20%) <30 days readmission rate (p=0.12). Discharge barriers identified: patient/caregiver readiness, caregiver support, housing, discharge education, and physical therapy. MDR was implemented to facilitate interprofessional collaboration to minimize barriers to discharge after LT surgery. This reduced post-ICU LOS by 29% while maintaining comparable ICU LOS, an expected finding with similar acuity between cohorts. Further analysis of readmission rate is warranted.

Predictors and Outcomes among Patients with Early Swallow Dysfunction after Lung Transplantation

To evaluate the patient characteristics, associated variables and early and late outcomes among patients with swallow dysfunction on modified barium swallow study (MBSS) after lung transplantation (LT). This was a retrospective study that included patients transplanted between 2012- 2015 (n=257, mean age 58±13 years, M:F 165: 92). We reviewed baseline characteristics, and findings on MBSS done as part of the post-transplant assessment of swallow function. We also reviewed the pre and post LT course including morbidity and mortality endpoints. A completely normal swallow evaluation on MBSS was unusual (n=60, 23.3%) with laryngeal penetration as the most commonly encountered abnormality (n=187, 72.8%) following by oropharyngeal pooling of secretions (n=72, 28%). Aspiration was noted in nearly one-fifth of the study group (50/257). Baseline demographics, co-morbidities, underlying diagnosis, or LAS were not associated with aspiration on post-LT MBSS. Patients bridged to transplant on mechanical ventilation (42.9% vs 17.4%; OR: 3.6, 1.4-9; p=0.005) had increased risk of aspiration. None of the post-operative variables such as primary graft dysfunction, duration of intubation after LT, ICU or hospital length of stay were associated with aspiration. Although patients with aspiration had worse one-yr (16% vs 5.8%; OR,95%CI: 3.1, 1.19-8.06; p=0.016, see Figure) and possibly 3-yr mortality (36% vs 23.7%; OR,95%CI: 1.8, 0.94-1.19; p=0.07), CLAD free survival at 3-yr was similar (48.8% vs 55.3%). Development of swallow dysfunction is common after LT surgery. While mild dysphagia, as reflected by the finding of laryngeal penetration, is the most common abnormality, a significant proportion of patients demonstrate frank aspiration. None of the pre-transplant or peri-transplant variables reliably predict post-LT aspiration risk. Despite similar morbidity outcomes early on, patients with aspiration may experience worse one-year survival.

ATRIAL ARRHYTHMIA COMMON AFTER LUNG TRANSPLANTATION AND REDUCED WITH BETA BLOCKER USE

Atrial fibrillation and flutter (AF/AFL) are common following lung transplant surgery although risk factors for AF/AFL development are controversial. We reevaluated risk factors and the effects of prophylactic beta blocker use on incident AF/AFL. We performed a single-center retrospective study of

POST-OPERATIVE ATRIAL FIBRILLATION AND FLUTTER AFTER LUNG TRANSPLANTATION IS ASSOCIATED WITH INCREASED HOSPITAL LENGTH OF STAY, ICU LENGTH OF STAY, AND RISK OF RE-INTUBATION

Post-operative atrial fibrillation and flutter (AF/AFL) are common following lung transplant surgery and may affect hospital and early clinical outcomes. We performed a single-center retrospective study of consecutive patients undergoing lung transplantation at a tertiary, academic medical center

KNOWING THE LAY OF THE LAND: A CASE OF A RIGHT POSTEPARTERIAL BRONCHUS

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: In an era of increasing advancements in interventional pulmonology, lung transplantation, and robotic thoracic surgery, an awareness and understanding of congenital airway anomalies is vital. CASE PRESENTATION: A 63 year-old woman with a history of rheumatoid arthritis, Sjogren’s syndrome, and latent TB was referred to pulmonary clinic for worsening bronchiectasis and tree-in-bud nodularity seen on a chest CT scan. A bronchoscopy was performed, and during the initial inspection, an unexpected orifice was noted just distal to the right upper lobe takeoff. 3-D reconstruction of her chest radiographs (Fig. 1) revealed an ectopic airway originating from the lateral wall of the bronchus intermedius, consistent with a rare anatomic anomaly called a “right posteparterial bronchus.” DISCUSSION: Over 500,000 bronchoscopies are performed annually in the United States [1], and most of them reveal normal airway anatomy in the classic distribution described by Jackson and Huber in 1943. However, in rare instances, anomalous bronchi may be encountered, which can lead to erroneous reporting and sampling of the wrong lobe. Furthermore, if lung transplantation or surgical resection is planned, an accurate description of the existing airways is crucial. Finally, ectopic tracheal bronchi may be occluded during intubation, which can lead to inadvertent atelectasis, pneumothorax, or respiratory failure [3]. Therefore, it is important for the adult bronchoscopist to be aware of these possible anatomic variants. One of the most common anomalies described in the literature is the tracheal bronchus which arises from the trachea and supplies ventilation to a significant proportion of the upper lobe. It is often times called a “pig bronchus” because the normal anatomy of swine consists of an upper lobe bronchus originating from the trachea. [1] As for the others, naming of an anomalous bronchus depends on the relationship of its origin to the location of the pulmonary artery (PA) and upper lobe (UL) takeoff. An anomalous bronchus arising from the main bronchus above the level of the PA is referred to as eparterial, and those which originate below the level of the PA are termed hyparterial. For a bronchus on the right that arises below the RUL bronchus but is still above the level of the PA, this is termed posteparterial. On the left side, as the origin of the LUL bronchus is below the level of the PA, an anomalous bronchus arising below this is termed posthyparterial, while a bronchus that appears just above it is termed prehyparterial [4]. CONCLUSIONS: In our patient, she had a right posteparterial bronchus which was asymptomatic and incidentally found. This anomaly has an incidence of approximately 0.9%. Although rarely seen, a thorough understanding of congenital airway anomalies should be part of every adult bronchoscopist’s education. Reference #1: Mehta A, et al. Chest 2015; 148: 274-287 Reference #2: Chassagnon G, et al. Radiographics 2016; 36: 358-373 Reference #3: Wooten C, Clinical Anatomy 2014; 27: 1223-1233 DISCLOSURES: No relevant relationships by Ching-Fei Chang, source=Admin input No relevant relationships by Gregory Grandio, source=Web Response No relevant relationships by Christopher Lee, source=Web Response

Pre-operative therapeutic plasma Exchange and intravenous immune globulin for the treatment of heparin induced thrombocytopenia in a lung transplant recipient

Lung transplantation surgery often relies on the use of intraoperative extracorporeal membrane oxygenation (ECMO) and necessitates the need for high dose anticoagulation. Heparin induced thrombocytopenia complicates intraoperative anticoagulation management during lung transplant surgery requiring ECMO. Though other anticoagulants such as argatroban and bivalrudin are utilized for the treatment of Heparin Induced Thrombocytopenia (HIT), the lack of reversal agents makes it difficult to use these agents intraoperatively in cases with high bleeding risk. This is especially true in patients with end stage fibrotic lung disease with calcified mediastinal lymphadenopathy and pulmonary hypertension undergoing lung transplantation. Here we describe a case of HIT in a patient with Sarcoidosis listed for lung transplant who was treated with Therapeutic Plasma Exchange and Intravenous Immune globulin preoperatively and successfully underwent lung transplantation with the use of intraoperative venoarterial ECMO and heparin anticoagulation.

The outcomes of 80 lung transplants in a single center from Saudi Arabia.

ABSTRACTBACKGROUND: Lung transplantation has become a standard of care for a select group of patients with advanced lung diseases. Lung transplantation has undergone rapid growth in the last few years in Saudi Arabia.OBJECTIVE: Describe five years of experience with lung transplantation.DESIGN: Retrospective, descriptive.SETTINGS: Major tertiary care hospital.PATIENTS: All patients who underwent lung transplant surgery between 2010 to 2015.MAIN OUTCOME MEASURES: Indications for lung transplant demographics, body mass index, blood group, type of transplant surgery, morbidity rate using the Clavien-Dindo classification, rate of early- and late-onset bronchiolitis obliterans syndrome (BOS), bronchiolitis obliterans-free survival, 30- and 90-day mortality rate, and survival (30 days, 90 days, 1-year, 3-years and 5-years) for lung transplant recipients. The duration of mechanical ventilation, colonization by bacteria and need for lung volume reduction surgery for lung donors.SAMPLE SIZE: 80, 45% women and 55% men.RESULTS: The most common indication for lung transplant in Saudi Arabia is pulmonary fibrosis (45%), followed by non-cystic fibrosis bronchiectasis (25%) and cystic fibrosis-related bronchiectasis (20%). Only 45% of our lung transplant recipients had a normal BMI (18-28 kg/m2). The most frequent blood group was A (40%), followed by blood group O (32.5%). Most (85%) lung transplants were bilateral while 15% were single lung transplants. Postoperative complications developed in 64 patients, 34 (42.5%) had minor grade 1 complications, while 13 (16.5%) had severe complications leading to death (grade V). Early onset BOS developed in 6 (7.5%) patients while 16 (20%) had late onset BOS. The BOS-free survival rate was 72.5%. The mean duration of mechanical ventilation in lung donors was 9 days and most were infected by bacteria. The majority of recipients required lung volume reduction. The 30-day mortality rate was 12.5% and the 90-day mortality rate was 17.5%. Survival rates at our center were 87.5% at 30 days, 82.5% at 90 days, 81.2% at 1 year, 67.9% at 2 years and 62.1% at 5 years.CONCLUSIONS: Lung transplantation has become an invaluable approach for the treatment of end-stage respiratory disease. Our 5-year experience has shown exciting promises for lung transplantation in Saudi Arabia.LIMITATIONS: Retrospective design, single center experience.CONFLICT OF INTEREST: None.

Epidural Anesthesia Combined with Intravenous Dexmedetomidine Sedation for Elective Ileostomy Closure in a Patient with Bilateral Lung Transplantation: A Case Report

A patient who had undergone bilateral lung transplantation surgery four years ago and had significant residual pulmonary insufficiency was scheduled for elective ileostomy closure. The procedure was performed under epidural anesthesia, intravenous sedation with dexmedetomidine and spontaneous ventilation without tracheal intubation. The combination provided high quality intraoperative analgesia and a moderate level of sedation without causing respiratory depression or excessive hemodynamic instability. The pharmacological properties of dexmedetomidine contributed to make this technique safe and effective.

Diagnostic capabilities of monitoring of redox potential in blood plasma of lung transplant patients

Introduction. Monitoring of redox potential (platinum electrode open circuit potential) in biological media (serum, blood plasma) is one of the promising methods for diagnosing and predicting the development of complications in patients in the early post-transplantation period. The study of the diagnostic capabilities of this technique in patients after lung transplantation is highly relevant.The objective was to assess the diagnostic and prognostic capabilities of monitoring platinum electrode open circuit potential in blood plasma of lung transplant patients.Material and methods. The data obtained at monitoring of platinum electrode open circuit potential in blood plasma and clinical laboratory test results of 14 patients after double lung transplantation surgery were analyzed. The platinum electrode open circuit potential value in the blood plasma was measured by the potentiometric method.Results. The study demonstrated the differences in the dynamics and values of platinum electrode open circuit potential in the blood plasma between the lung transplant patients with a favorable outcome and those with a fatal outcome. Wave-like segments on the relationship curves of the platinum electrode open circuit potential in blood plasma to time coincided with inflammatory markers (C-reactive protein, stab neutrophils, erythrocyte sedimentation rate) activation. Statistically significant correlations between platinum electrode open circuit potential values in blood plasma and clinical laboratory test results were revealed.Conclusion. The informative value and diagnostic capabilities of the technique of the platinum electrode open circuit potential measurement in blood plasma of lung transplant patients have prospects of using its results as a criterion for assessing the patient’s condition and improving the quality of therapy.

Intra-Operative Transfusions are Associated with Worse Outcomes after Lung Transplantation

Purpose Peri-operative blood transfusions are associated with increased pulmonary morbidity and mortality. The impact of blood transfusions during lung transplantation surgery is largely unknown. We investigated the impact of intra-operative blood transfusions on acute rejection, post-transplant lung function and mortality in lung transplant recipients. Methods A retrospective review was conducted on 274 adult patients who underwent bilateral lung transplantation from January 2012 to June 2018. Intra-operative transfusions of red blood cells (RBC), fresh frozen plasma (FFP), platelets and cryoprecipitate were analysed. Logistic regression was used to determine variables predicting higher blood product use. Kaplan-Meier and Cox proportional hazard models were used to analyse time-to-first rejection/death and all-cause mortality. Results 149 men and 125 women (median age 55, range 18 to 69) required a median number of 2 units of red blood cells (range, 0 to 22 units), 2 units of fresh frozen plasma (range, 0 to 10 units), 1 unit of platelets (range, 0 to 4 units) and 2 units of cryoprecipitate (range, 0 to 16 units). Female patients (p 0.001), longer CPB time (p 0.024) and lower pre-operative haemoglobin (p 0.001) predicted greater RBC use. Greater transfusions of all blood products were significantly associated with prolonged hospital stays, ICU stays and ventilation time. Mortality risk was not significantly different for any transfusion product. Time-to-first A3 or higher rejection and the number of rejections in the first year post-transplant were not significantly related to increased blood product use. However, increased cryoprecipitate transfusion was associated with greater severity of rejections. Post-transplant predicted forced expiratory volume in 1 second at 3 months, 6 months and 12 months was significantly worse if patients received more intra-operative blood products. Conclusion Increased intra-operative blood transfusions in lung transplant recipients did not significantly increase risk of lung rejection or mortality. However, increased blood transfusions were associated with prolonged hospital stay, ICU stay and ventilation time. Higher volumes of all blood products were also show significantly worse lung function up to 1 year post-transplant.