Pulmonary hemodynamics as predictors of mortality in patients awaiting lung transplantation.

Lung transplantation (LTx) is a therapeutic option for patients with end-stage lung disease. However, the mortality rate of patients on the waiting list is high. The purpose of this study was to examine the prognostic value of cardio-pulmonary hemodynamics for death in patients awaiting LTx. Retrospectively, 177 patients with advanced lung disease accepted for LTx at Sahlgrenska University Hospital from January 1990 through December 2003 were studied. Patient demographics, pulmonary function tests, gas exchange and hemodynamic variables were included in the analysis. Death while awaiting LTx was the primary endpoint for all analyses. Mean age was 49 +/- 9 years. Main diagnoses were alpha 1 antitrypsin deficiency (n = 56), chronic obstructive pulmonary disease (n = 61), cystic fibrosis (n = 14) and interstitial lung disease (n = 46). Thirty patients died (17%). LTx was performed in 143 cases. By univariate analyses, forced vital capacity (FVC) % of predicted, pulmonary vascular resistance (PVR) and diagnosis were associated with risk for death. In multivariate analysis PVR (HR, 1.22; 95% CI, 1.06-1.41; P = 0.006) and FVC% of predicted (HR, 0.97; 95% CI, 0.94-0.99; P = 0.01) were independently associated with death. Patients with increased PVR and a lower FVC % of predicted awaiting LTx should be considered for a higher organ allocation priority. Assessment of pulmonary hemodynamics needs to be considered during evaluation for LTx.     

Pulmonary artery thermodilution cardiac output vs. transpulmonary thermodilution cardiac output in two patients with intrathoracic pathology

In two adult patients, one with a severe hemorrhage and one with a partial anomalous pulmonary vein, cardiac output (CO) measurements were performed simultaneously by means of the bolus transpulmonary thermodilution technique (COao) and continuous pulmonary artery thermodilution method (CCOpa). In both cases, the methods revealed clinically significant different cardiac output values based upon the site of measurement and the underlying pathology. The assessment of cardiac output (CO) is considered an important part of cardiovascular monitoring of the critically ill patient. Cardiac output is most commonly determined intermittently by the bolus thermodilution technique with a pulmonary artery catheter (COpa). As continuous monitoring of CO is preferable to this intermittent technique, two major techniques have been proposed. Firstly, a nearly continuous thermodilution method (CCOpa) using a heating filament mounted on a pulmonary artery catheter (Baxter Edwards Laboratories, Irvine, CA), with a clinically acceptable accuracy compared with the intermittent bolus technique. Based on these results we assumed CCOpa equivalent to real CO during hemodynamically stable conditions, and secondly, a continuous cardiac output system based on pulse contour analysis (PCCO), such as the PiCCO system (Pulsion Medical System, Munchen, Germany). To calibrate this device, which uses a derivation of the algorithm of Wesseling and colleagues, an independently obtained value of CO by the transpulmonary thermodilution method (COao) is used. Clinical validation studies in patients without underlying intrathoracic pathology, comparing transpulmonary COao with the pulmonary technique (COpa), mostly yielded good agreement.     

Pulmonary artery catheterization and thermodilution cardiac output determination in the management of critically burned patients

Pulmonary artery catheterization was performed in thirty-nine critically burned patients. Hemodynamic changes, induced by thermal injury and its therapy, were measured. Pulmonary wedge pressure was found to be a more reliable indicator of circulating volume, whereas central venous pressure was often misleading. Measurements of both pulmonary hemodynamics and cardiac output were necessary to manage patients requiring high levels of pulmonary end-expiratory pressure (PEEP). These measurements enable one to define optimum PEEP levels which provide maximum oxygen delivery to the tissues. Depressed myocardial function was seen in the early phase of the injury. In this period dopamine administration increased left ventricular stroke work index with minimal changes in filling pressures. The usefulness of dopamine in treating this early myocardial depression deserves further study. Catheter-related complications were minimal when the catheters were used for periods of three days or less.     

Amrinone versus conventional therapy in pulmonary hypertensive patients awaiting cardiac transplantation

Pulmonary hypertension is associated with an increased perioperative mortality for orthotopic heart transplantation. A transpulmonary gradient greater than 15 mm Hg or a pulmonary vascular resistance greater than 5 Woods units increases mortality secondary to right heart failure. This study compares amrinone with conventional therapy in 38 transplant candidates with pulmonary hypertension. All patients had elevated transpulmonary gradient, pulmonary vascular resistance, or both. Group 1 (n = 21) received prolonged continuous intravenous amrinone therapy, whereas group 2 (n = 16) received high-dose oral diuretics, digitalis, and captopril. Both groups 1 and 2 had decreased pulmonary hypertension, transpulmonary gradient, and pulmonary vascular resistance. However, amrinone was more effective, with a 86% response rate versus 63% response for conventional therapy. Survival awaiting transplantation was significantly higher in group 1 (20 of 22, 91%) than in group 2 (10 of 16, 63%). Although both groups 1 and 2 had significantly decreased pulmonary vascular resistance, only group 2 had significantly decreased systemic vascular resistance. Comparison of pulmonary vascular resistance after therapy showed that the response in group 1 (amrinone) was significantly lower than the response in group 2 (conventional therapy), suggesting that amrinone may function as a direct vasodilator of the pulmonary vasculature. There were no operative deaths or episodes of perioperative right heart failure in either group. Amrinone appears to be more effective and safe than conventional therapy in the treatment of prospective heart transplant candidates with pulmonary hypertension.     

Pulmonary artery catheterization and mortality in critically ill patients

Pulmonary artery catheters are widely used in intensive care,but evidence to support their widespread use is sparse. Somepublished data suggest that greater mortality is associatedwith use of these catheters. The largest study to date lookedat >5500 patients in several centres in America and founda greater 30 day mortality in those patients receiving a pulmonaryartery catheter. We tested the hypothesis that, on our intensivecare unit, mortality was greater for those patients receivinga pulmonary artery catheter. Using a propensity score to accountfor severity of illness, the odds ratio for mortality in thosepatients receiving a pulmonary artery catheter was 1.08 (95%confidence interval 0.87–1.33). We believe that continueduse of the pulmonary artery catheter is safe; a large randomizedcontrolled trial examining outcome is unlikely to provide anadequate answer. Br J Anaesth 2000; 85: 611–5 ^* Corresponding author     

The management of splenic artery aneurysm in patients awaiting liver transplantation

Asthana S, Toso C, McCarthy M, Shapiro AMJ. The management of splenic artery aneurysm in patients awaiting liver transplantation.
Clin Transplant 2010 DOI: 10.1111/j.1399‐0012.2009.01192.x
© 2010 John Wiley & Sons A/S. Abstract: Splenic artery aneurysms (SAAs) are the third most common forms of intra‐abdominal aneurysm, and the most commonly encountered visceral aneurysms in the general population. SAAs occur more commonly in patients with portal hypertension and liver failure and, as such, are often encountered in patients undergoing high‐resolution abdominal imaging as part of a work‐up for liver transplantation. While rupture rates of between 2% and 10% have been reported in the literature, little is known about the natural history and behavior of these lesions in patients with liver disease. Interventional management options pose a challenge given the high anesthetic and surgical risk of such patients. This study was conducted to study the management of all SAAs diagnosed among patients presenting for a liver transplant assessment at a single center over a three‐yr period. We discuss the presentation and management options, with elective and emergent presentation of SAA in patients with end‐stage liver disease.     

Association of lung perfusion disparity and mortality in patients with cystic fibrosis awaiting lung transplantation.

BACKGROUND: The risk of death for patients with end-stage cystic fibrosis awaiting lung transplantation remains high and most patients succumb to respiratory failure. This study was conducted to evaluate the usefulness of ventilation-perfusion scintillation scans, obtained during the pre-transplant period, to identify patterns that predict prognosis while on the waiting list. These patterns were compared with other pulmonary physiologic markers of ventilation and perfusion obtained from pulmonary function and cardiopulmonary exercise tests. METHODS: From November 1990 to January 1999, 46 patients with cystic fibrosis were listed for bilateral lung transplantation. Fourteen (30.4%) died while waiting for a transplant (Group 1), whereas 32 were transplanted successfully or remain alive and waiting (Group 2). Mean arterial blood gas values, Brasfield radiograph scores, cardiopulmonary exercise data and the degree of scintillation scan abnormalities between lungs were compared for each group. RESULTS: Mean survival for Group 1 was 10.2 +/- 1.7 months, and for Group 2 was 23.5 +/- 3.0 months (p < 0.001). The right upper lung zone was the most severely affected segment. The Cox proportional hazards model revealed an increased perfusion disparity and resting hypercapnia as the main predictors of death while on the transplant list. The Kaplan-Meier analysis indicated greater survival for the groups with <30% disparity between lungs on the pre-transplant scintillation scans. CONCLUSIONS: The results suggest that severe, unilateral perfusion abnormalities seen on scintillation scans in patients with cystic fibrosis are associated with an increased risk of dying while on the lung transplant waiting list and may be helpful in identifying patients who should be considered for early or living-donor transplantation.     

终末期肺病患者等待肺移植期间的临床分析

目的 总结单中心终末期肺病患者等待肺移植期间的临床结局及其影响因素,探讨等待期患者排序的参考因素.方法 回顾性分析自2003年1月至2013年1月83例等待肺移植的终末期肺病患者的临床资料.结果 22例(26.5％)患者死于等待期,41例(49.4％)接受同种异体肺移植,20例(24.1％)仍在等待供肺.相对于慢性阻塞性肺疾病(COPD)患者,特发性肺纤维化(IPF)患者等待期间死亡率较高,死亡率分别为39.1％和15.6％(P=0.09).存活患者的等待期存活时间为(377.5±527.6)d,死亡患者的等待期存活时间为(181.7±196.9)d(P=0.016).存活的患者的平均肺动脉压力为(38.8±14.1)mm Hg(1 mm Hg=0.133 kPa),死亡患者的平均肺动脉压力为(54.3±25.9)mm Hg(P=0.08).死亡病例中,IPF患者的存活时间为(137.8±199.6)d,其他疾病患者为(212.1±196.9)d(P=0.397).等待期需要常规氧疗和无创正压通气的患者的死亡率为23.9％,接受机械通气患者的死亡率为41.7％(P=0.287).结论 原发疾病的类型、肺动脉高压和机械通气可能是影响终末期肺病患者等待期预后的主要因素,拟定肺移植等待排序时应综合考虑上述因素.     

A novel technique for intraaortic balloon pump placement via the left axillary artery in patients awaiting cardiac transplantation

In order to circumvent the problems associated with long-term femoral intraaortic balloon pump (IABP) placement we have developed and used a new technique of IABP placement. Over the past three years 13 patients awaiting cardiac transplantation have had placement of IABP via a vein cuff sewn to the left axillary artery. Thirteen patients have undergone IABP placement using this technique. The average duration of IABP support was 37 days (range 10-86 days). Ten patients were successfully transplanted. All patients were allowed to sit, stand and ambulate with assistance. No neurologic complications occurred. There were no episodes of sepsis related to balloon or insertion site. No patient had limb ischemia during IABP counterpulsation. Left axillary artery IABP insertion via a vein cuff portal is a straightforward technique with minimal complications. This method serves as a bridge to cardiac transplantation in a gravely ill group of patients while preserving patient mobility during the waiting period for a donor heart.     

Delayed chest closure assessed by transesophageal echocardiogram in single-lobe lung transplantation

A 6-year-old girl with idiopathic interstitial pneumonia successfully underwent living-donor right single-lobe lung transplantation from her mother. Her mother's right lower lobe was 207% bigger than her right chest cavity, and attempting chest closure caused significant compression and narrowing of the right pulmonary vein anastomosis, as assessed by transesophageal echocardiogram. Her chest was temporarily closed without rib approximation. The following day, her chest could be completely closed. The pulmonary vein anastomosis, confirmed by transesophageal echocardiogram, was now patent. Currently, 7 months after the transplantation, she is well without limitations.     

等待肺移植患者生存质量及其影响因素研究

目的了解等待肺移植患者的生存质量及其影响因素。方法采用简明健康问卷(SF-36)、焦虑自评量表(SAS)、抑郁自评量表(SDS)和领悟社会支持量表(PSSS)对55例等待肺移植患者进行调查。结果等待肺移植患者SF-36各维度得分23.18~74.57,显著低于常模(均P<0.01);SAS、SDS得分分别为48.09±9.06、52.18±9.98,显著高于常模(均P<0.01);PSSS社会总支持因子得分为5.56±1.04,其中家庭内支持因子得分显著高于家庭外支持因子(P<0.05)。多因素分析结果显示生存质量的影响因素为呼吸困难和抑郁(P<0.05,P<0.01)。结论等待肺移植患者的生存质量较低,其生存质量受呼吸困难和抑郁的影响。医务人员应从患者生理及心理方面进行有效干预,以提高其生存质量。     

The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation

OBJECTIVE: To determine the prevalence and proximal extent of gastroesophageal reflux (GERD) in patients awaiting lung transplantation. BACKGROUND: GERD has been postulated to contribute to accelerated graft failure in patients who have had lung transplantations. However, the prevalence of reflux symptoms, esophageal motility abnormalities, and proximal esophageal reflux among patients with end-stage lung disease awaiting lung transplantation are unknown. METHODS: A total of 109 patients with end-stage lung disease awaiting lung transplantation underwent symptomatic assessment, esophageal manometry, and esophageal pH monitoring (using a probe with 2 sensors located 5 and 20 cm above the lower esophageal sphincter). RESULTS: Reflux symptoms were not predictive of the presence of reflux (sensitivity, 67%; specificity, 26%). Esophageal manometry showed a high prevalence of a hypotensive lower esophageal sphincter (55%) and impaired esophageal peristalsis (47%) among patients with reflux. Distal reflux was present in 68% of patients and proximal reflux was present in 37% of patients. CONCLUSIONS: These data show that in patients with end-stage lung disease: 1) symptoms were insensitive and nonspecific for diagnosing reflux; 2) esophageal motility was frequently abnormal; 3) 68% of patients had GERD; 4) in 50% of the patients with GERD, acid refluxed into the proximal esophagus. We conclude that patients with end-stage lung disease should be screened with pH monitoring for GERD.