Effect of development of antibodies to hla and cytomegalovirus mismatch on lung transplantation survival and development of bronchiolitis obliterans syndrome

AbstractObjective: A retrospective analysis was performed to examine the role of HLA antibodies and cytomegalovirus mismatch on the development of bronchiolitis obliterans syndrome and survival after lung transplantation. Methods: Of 339 consecutive lung transplantations performed over a 102-month interval, 301 patients survived at least 3 months. There was a minimum follow-up period of 13 months. Bronchiolitis obliterans syndrome was defined as a decline in forced expiratory volume in 1 second less than 80% of posttransplantation baseline and/or histologic presence of obliterative bronchiolitis and was defined as occurring “early” if documented within 3 years of transplantation. Variables analyzed included preoperative donor and recipient cytomegalovirus status and the development of antibodies to human leukocyte antigens after transplantation. Microcytotoxicity was used to determine the presence of antibodies to human leukocyte antigens. Variables were subjected to Kaplan-Meier analysis to determine their impact on freedom from bronchiolitis obliterans syndrome and survival. Results: The development of antibodies to human leukocyte antigens after transplantation correlated significantly with bronchiolitis obliterans syndrome (P = .02). The development of antibodies to human leukocyte antigens did not affect survival (P = .33) unless they were detected within 2 years of transplantation (P = .04). There was greater frequency of early bronchiolitis obliterans syndrome in cytomegalovirus seronegative patients who received allografts from seropositive donors compared with all other combinations (P = .02). There was also a trend toward worse survival of cytomegalovirus seronegative patients who received allografts from seropositive donors (P = .13). Conclusion: These data suggest that bronchiolitis obliterans syndrome is the result of an immune-mediated process in which HLA antibodies and cytomegalovirus may play a significant role. (J Thorac Cardiovasc Surg 1998;116:812-20

Fatal thrombosis after administration of activated prothrombin complex concentrates in a patient supported by extracorporeal membrane oxygenation who had received activated recombinant factor VII

AbstractJ Thorac Cardiovasc Surg 2002;124:852-

Pediatric And Adult Lung Transplantation For Cystic Fibrosis

AbstractObjective: This paper was undertaken to review the experience at our institution with bilateral sequential lung transplantation for cystic fibrosis.Methods: Since 1989, 103 bilateral sequential lung transplants for cystic fibrosis have been performed (46 pediatric, 48 adult, 9 redo); the mean age was 21 ± 10 years. Cardiopulmonary bypass was used in all but one pediatric (age <18) transplant, and in 15% of adults.Results: Hospital mortality was 4.9%, with 80% of early deaths related to infection. Bronchial anastomotic complications occurred with equal frequency in the pediatric and the adult populations (7.3%). One- and 3-year actuarial survival are 84% and 61%, respectively (no significant difference between pediatric and adult age groups; average follow-up 2.1 ± 1.6 years). Mean forced expiratory volume in 1 second increased from 25% ± 9% before transplantation to 79% ± 35% 1 year after transplantation. Acute rejection occurred 1.7 times per patient-year, with most episodes taking place within the first 6 months after transplantation. The need for treatment of lower respiratory tract infections occurred 1.2 times per patient in the first year after transplantation. Actuarial freedom from bronchiolitis obliterans was 63% at 2 years and 43% at 3 years. Redo transplantation was performed only in the pediatric population and was associated with an early mortality of 33%. Eight living donor transplants (four primary transplants, four redo transplants) were performed with an early survival of 87.5%.Conclusion: Patients with end-stage cystic fibrosis can undergo bilateral lung transplantation with morbidity and mortality comparable to that seen in pulmonary transplantation for other disease entities. (J Thorac Cardiovasc Surg 1998;115:404-14

Economic evaluation of the specialized donor care facility for thoracic organ donor management

Background: Over the last decade two alternative models of donor care have emerged in the United States: the conventional model, whereby donors are managed at the hospital where brain death occurs, and the specialized donor care facility (SDCF), in which brain dead donors are transferred to a SDCF for medical optimization and organ procurement. Despite increasing use of the SDCF model, its cost-effectiveness in comparison to the conventional model remains unknown. Methods: We performed an economic evaluation of the SDCF and conventional model of donor care from the perspective of U.S. transplant centers over a 2-year study period. In this analysis, we utilized nationwide data from the Scientific Registry of Transplant Recipients and controlled for donor characteristics and patterns of organ sharing across the nation\u27s organ procurement organizations (OPOs). Subgroup analysis was performed to determine the impact of the SDCF model on thoracic organ transplants. Results: A total of 38,944 organ transplants were performed in the U.S. during the study period from 13,539 donors with an observed total organ cost of $1.36 billion. If every OPO assumed the cost and effectiveness of the SDCF model, a predicted 39,155 organ transplants (+211) would have been performed with a predicted total organ cost of$1.26 billion (-$100 million). Subgroup analysis of thoracic organs revealed that the SDCF model would lead to a predicted 156 additional transplants with a cost saving of$24.6 million. Conclusions: The U.S. SDCF model may be a less costly and more effective means of multi-organ donor management, particularly for thoracic organ donors, compared to the conventional hospital-based model

Neurobehavioral Functioning and Survival Following Lung Transplantation

Neurobehavioral functioning is widely recognized as being an important consideration in lung transplant candidates, but little is known about whether these factors are related to clinical outcomes. The present study examined the relationship of neurobehavioral functioning, including measures of executive function and memory, depression, and anxiety, to long-term survival among lung transplant recipients

Improved airway healing after lung transplantation An analysis of 348 bronchial anastomoses

AbstractWe evaluated various clinical factors to identify predictors of airway complication after lung transplantation. Two hundred twenty-nine consecutive single (n = 110) and bilateral (n = 119) lung transplants were done between September 1988 and August 1994. These 348 bronchial anastomoses were retrospectively analyzed. Airway complication that necessitated clinical intervention affected 33 anastomoses (9.5%) in 29 patients (12.8%). Satisfactory healing was achieved in 22 of these patients by conservative therapy such as one or a combination of dilation, stent, and laser. There were five deaths (2.2%) attributable to airway complications. One patient had an early postoperative death unrelated to airway complication and one patient has a recalcitrant bronchus intermedius stricture. Complication occurred more often in single-lung than in bilateral lung transplants (16/110, 14.4%, versus 17/238, 7.1%; p < 0.05). The use of a mattress suture (21/153, 13.7%) was associated with more frequent complications than was simple interrupted suture (8/122, 6.6%) or figure-of-eight suture (4/73, 5.5%) (p < 0.05). For patients in whom airway complications subsequently developed, the duration of postoperative mechanical ventilation was greater than that for those in whom an airway complication did not develop. The prevalence of airway complications as our program evolved was evaluated by separating the 229 transplants into three groups: phase I, the first 77 transplants; phase II, the next 76 transplants; and phase III, the most recent 76 transplants. The airway complication rate per anastomosis was significantly lower in phase III (5/126, 4.0%) than in phase I (12/110, 10.9%; p < 0.05) and phase II (16/112, 14.3%; p < 0.01). The majority of airway complications are successfully treated and rarely fatal. The recent reduction in prevalence of airway complications is likely a result of better maintenance immunosuppression and rejection surveillance. (J THORAC CARDIOVASC SURG 1995;110:1424-33

Echocardiographic characterization of the improvement in right ventricular function in patients with severe pulmonary hypertension after single-lung transplantation

AbstractObjectives. This study was designed to characterize immediate, early and long-term changes in right ventricular structure and function, as defined by two-dimensional and Doppler echocardiography, after single-lung transplantation in patients with severe pulmonary hypertension.Bacground. Single-lung transplantation has recently been shown to dramatically improve hemodynamics in patients with primary pulmonary hypertension who had unsuccessful medical therapy.Method. Fourteen patients with severe pulmonary hypertension who underwent single-lung transplantation were studied with transthoracic and transesophageal two-dimensional and Doppler echocardiography. Right ventricular dimensions were measured in the apical four-chamber view. Right ventricular ejection and acceleration times and peak velocity of tricuspid regurgitation were measured by Doppler study. Results of right heart catheterization were available early (<3 months) after transplantation in 10 of 13 patients and late after transplantation (6 month to 2 years) in 11 patients.Results. In the early posttransplantation studies, right ventricular dimensions decreased and fractional area change and ejection fraction increased in all patients, but right ventricular wall thickness did not change significantly. Tricuspid regurgitation lessened markedly in all patients. Long-term decreases in right ventricular dimension and improvement in systolic function were sustained. Right ventricular wall thickness significantly decreased compared with the early postoperative value (0.76 ± 0.1 cm compared with 0.63 ± 0.14 cm, p < 0.02).Conclusions. Two-dimensional echocardiography demonstrates sustained improvement in right ventricular function after single-lung transplantation for severe pulmonary hypertension despite severe preoperative dysfunction