Lung Transplant for Interstitial Lung Diseases

Lung transplant is an important treatment modality for select cases of advanced interstitial lung disease. However, the pre- and postoperative management requires several unique considerations. The decision to transplant is based largely on clinical severity of illness and the lung allocation score. Transplant improves overall mortality across the interstitial lung diseases, though not all ILD subtypes experience equal benefit from lung transplant. Broadly speaking, there is no difference in benefit between single- and bilateral-lung transplants, though we will discuss some important clinical nuances to this decision as well. Lastly, there are a number of immunosuppression, coagulation, and malignancy risk considerations that must be carefully understood in caring for the lung transplant patient. This chapter will provide a general overview of the indications for lung transplant, risk stratification for lung transplant across the interstitial lung diseases, as well as general postoperative management details

Pre-arterialization of coronary veins prior to retroperfusion of ischemic myocardium: percutaneous closure device

BackgroundChronic coronary retroperfusion to treat myocardial ischemia has previously failed due to edema and hemorrhage of coronary veins suddenly exposed to arterial pressures. The objective of this study was to selectively adapt the coronary veins to become arterialized prior to coronary venous retroperfusion to avoid vascular edema and hemorrhage.Methods and resultsIn 32 animals (Group I = 19 and Group II = 13), the left anterior descending (LAD) artery was occluded using an ameroid occlusion model. In Group I, the great cardiac vein was blocked with suture ligation (Group IA = 11) or with occlusion device (Group IB = 8) to arterialize the venous system within 2 weeks at intermediate pressure (between arterial and venous levels) before a coronary venous bypass graft (CVBG) was implemented through a left internal mammary artery (LIMA) anastomosis. Group II only received the LAD artery occlusion and served as control. Serial echocardiograms showed recovery of left ventricular (LV) function with this adaptation-arterialization approach, with an increase in ejection fraction (EF) in Group I from 38% ± 5% after coronary occlusion to 53% ± 7% eight weeks after CVBG, whereas in Group II the EF never recovered (41% ± 2%–33% ± 7%). The remodeling of the venous system not only allowed restoration of myocardial function when CVBG was implemented but possibly promoted a novel form of “collateralization” between the native arterioles and the newly arterialized venules, which revascularized the ischemic myocardium.ConclusionsThese findings form a potential rationale for a venous arterialization-revascularization treatment for the refractory angina and the “no-option” patients using a hybrid percutaneous (closure device for arterialization)/surgical approach (CVBG) to revascularize the myocardium

Context-dependent roles of mitochondrial LONP1 in orchestrating the balance between airway progenitor versus progeny cells

While all eukaryotic cells are dependent on mitochondria for function, in a complex tissue, which cell type and which cell behavior are more sensitive to mitochondrial deficiency remain unpredictable. Here, we show that in the mouse airway, compromising mitochondrial function by inactivating mitochondrial protease gene Lonp1 led to reduced progenitor proliferation and differentiation during development, apoptosis of terminally differentiated ciliated cells and their replacement by basal progenitors and goblet cells during homeostasis, and failed airway progenitor migration into damaged alveoli following influenza infection. ATF4 and the integrated stress response (ISR) pathway are elevated and responsible for the airway phenotypes. Such context-dependent sensitivities are predicted by the selective expression of Bok, which is required for ISR activation. Reduced LONP1 expression is found in chronic obstructive pulmonary disease (COPD) airways with squamous metaplasia. These findings illustrate a cellular energy landscape whereby compromised mitochondrial function could favor the emergence of pathological cell types

Spontaneous Left Atrial Thrombus Formation on the Catheter Delivery System During WATCHMAN Implantation.

We present a rare complication of spontaneous thrombus formation on the WATCHMAN delivery system, on both the right- and left-sided systemic circulation. We also describe the multidisciplinary team approach and the use of percutaneous vacuum-assisted aspiration system (AngioVac, AngioDynamics, Latham, New York) for successful thrombus removal. (Level of Difficulty: Intermediate.)

Treatment of Bronchopleural and Alveolopleural Fistulas in Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation, a Case Series and Literature Review

ObjectivesTo describe a ventilator and extracorporeal membrane oxygenation management strategy for patients with acute respiratory distress syndrome complicated by bronchopleural and alveolopleural fistula with air leaks.Design setting and participantsCase series from 2019 to 2020. Single tertiary referral center-University of California, San Diego. Four patients with various etiologies of acute respiratory distress syndrome, including influenza, methicillin-resistant Staphylococcus aureus pneumonia, e-cigarette or vaping product use-associated lung injury, and coronavirus disease 2019, complicated by bronchopleural and alveolopleural fistula and chest tubes with air leaks.Measurements and main resultsBronchopleural and alveolopleural fistula closure and survival to discharge. All four patients were placed on extracorporeal membrane oxygenation with ventilator settings even lower than Extracorporeal Life Support Organization guideline recommended ultraprotective lung ventilation. The patients bronchopleural and alveolopleural fistulas closed during extracorporeal membrane oxygenation and minimal ventilatory support. All four patients survived to discharge.ConclusionsIn patients with acute respiratory distress syndrome and bronchopleural and alveolopleural fistula with persistent air leaks, the use of extracorporeal membrane oxygenation to allow for even lower ventilator settings than ultraprotective lung ventilation is safe and feasible to mediate bronchopleural and alveolopleural fistula healing

Improved kidney function and one-year survival with transitioning from intravenous to enteral tacrolimus in lung transplant recipients

Background: Acute kidney injury (AKI) is common after lung transplant and may increase risk of chronic kidney disease (CKD). Calcineurin inhibitors (CNIs) such as tacrolimus contribute to AKI risk. This study evaluated outcomes among lung transplant recipients administered enteral or oral versus intravenous (IV) tacrolimus immediately post-lung transplant. Methods: We performed a single-center retrospective study of lung transplant recipients from 2011 to 2019. Tacrolimus concentrations, rates of perioperative AKI, CKD, and one-year survival were compared between those that received IV versus oral tacrolimus post-LT. Results: A total of 153 patients were included; 110 and 43 received IV tacrolimus and enteral or oral tacrolimus, respectively. AKI within 14 days post-LT occurred more frequently in patients that received IV tacrolimus versus enteral administration (84.5 vs 44.1 %, p = <0.001). Additionally, those patients that received IV tacrolimus had supratherapeutic tacrolimus concentrations for more days than those that received enteral (3 days, IQR 1–5 vs 1 day, IQR 0–1; p < 0.001). CKD rates at 1 year were not significantly different between groups. One year survival was 97.7 % in group that received enteral tacrolimus compared to 82.7 % in IV tacrolimus group (p = 0.01) Conclusion: IV tacrolimus in the initial period post-LT was associated with higher AKI rates and lower 1-year survival compared to enteral tacrolimus. There was no difference in CKD rates at 1 year

Implementation and Outcomes of a Mobile Extracorporeal Membrane Oxygenation Program in the United States During the Coronavirus Disease 2019 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic began in the United States around March 2020. Because of limited access to extracorporeal membrane oxygenation (ECMO) in the authors' region, a mobile ECMO team was implemented by April 2020 to serve patients with COVID-19. Several logistical and operational needs were assessed and addressed to ensure a successful program, including credentialing, equipment management, and transportation. A multidisciplinary team was included in the planning, decision-making, and implementation of the mobile ECMO. From April 2020 to January 2021, mobile ECMO was provided to 22 patients in 13 facilities across four southern California counties. The survival to hospital discharge of patients with COVID-19 who received mobile ECMO was 52.4% (11 of 21) compared with 45.2% (14 of 31) for similar patients cannulated in-house. No significant patient or transportation complications occurred during mobile ECMO. Neither the ECMO nor transport teams experianced unprotected exposures to or infections with severe acute respiratory syndrome coronavirus 2. Herein, the implementation of the mobile ECMO team is reviewed, and patient characteristics and outcomes are described

A Pilot Trial for Prevention of Hepatitis C Virus Transmission From Donor to Organ Transplant Recipient With Short-Course Glecaprevir/Pibrentasvir

A 7-day course of glecaprevir/pibrentasvir started in the preoperative period prevented transmission of hepatitis C virus (HCV) from viremic donors to 10 HCV-negative recipients (2 heart, 1 lung, 6 kidney, 1 heart/kidney) with 100% sustained virological response at 12 weeks

Treatment of Bronchopleural and Alveolopleural Fistulas in Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation, a Case Series and Literature Review

OBJECTIVES:. To describe a ventilator and extracorporeal membrane oxygenation management strategy for patients with acute respiratory distress syndrome complicated by bronchopleural and alveolopleural fistula with air leaks. DESIGN, SETTING, AND PARTICIPANTS:. Case series from 2019 to 2020. Single tertiary referral center—University of California, San Diego. Four patients with various etiologies of acute respiratory distress syndrome, including influenza, methicillin-resistant Staphylococcus aureus pneumonia, e-cigarette or vaping product use-associated lung injury, and coronavirus disease 2019, complicated by bronchopleural and alveolopleural fistula and chest tubes with air leaks. MEASUREMENTS AND MAIN RESULTS:. Bronchopleural and alveolopleural fistula closure and survival to discharge. All four patients were placed on extracorporeal membrane oxygenation with ventilator settings even lower than Extracorporeal Life Support Organization guideline recommended ultraprotective lung ventilation. The patients bronchopleural and alveolopleural fistulas closed during extracorporeal membrane oxygenation and minimal ventilatory support. All four patients survived to discharge. CONCLUSIONS:. In patients with acute respiratory distress syndrome and bronchopleural and alveolopleural fistula with persistent air leaks, the use of extracorporeal membrane oxygenation to allow for even lower ventilator settings than ultraprotective lung ventilation is safe and feasible to mediate bronchopleural and alveolopleural fistula healing