Retransplantation after single lung transplantation

Objective

Our lung transplant program started in June 1989 with primary grafts including 21 heart-lung, 11 single lung, and 5 bilateral sequential single lung transplantation. Three patients required retransplantation for single lung and 2 patients for heart-lung grafts. The primary cause of death after lung transplantation is chronic graft dysfunction—bronchiolitis obliteran—though other causes, namely acute graft failure, have been mentioned. Retransplantation is considered to be the only treatment option. In experienced centers, the 1- and 5-year survivals are not as good as for other organ transplantations and for retransplantations the outcome is even worse. Our objective herein was to describe factors to be taken into account for retransplantation in our program, including the timing and indication for retransplantation and the presence of comorbidities.

Patients and Methods

In our experience of 11 single lung transplantations, 3 (27.3%) were retransplantations. The 3 patients were 3, 5, and 2 years after primary transplantation. The indications were overexpansion of the remaining lung compressing the new lung in one and bronchiolitis obliterans in the others.

Results

One patient with emphysema died in hospital after retransplantation because of acute myocardial infarction. One patient with lymphangioleiomyomatosis (LAM) disease died of lung complication after sudden cardiac arrest at 1.5 years after retransplantation. One patient with idiopathic pulmonary fibrosis is still alive at 5 years after retransplantation.

Conclusions

Bronchiolitis obliterans was a common reason for retransplantation among our patients as well as in other reports. Bronchiolitis exists with superimposed infection for years if it is the mild form. However, the clinical setting is progressively worse if it could not be controlled leading to retransplantation. At this stage, progressive deterioration of lung function must be considered because of inadequate therapy for infection. Finally, when there is infection usually both lungs are involved. The decision whether to replace the transplanted lung or the remaining lung is a concern, especially when the donor availability is scarce. In conclusion, lung retransplantation is the only treatment option for severe graft dysfunction, if there is no other therapy that can prolong life. Though bronchiolitis obliterans often is the indication for retransplantation, bronchiolitis itself is the signal of retransplantation.     

Complications in the native lung after single lung transplantation.

OBJECTIVES: Single lung transplantation is a viable option for patients with end-stage pulmonary disease; despite encouraging results, we observed serious complications arising in the native lung. We retrospectively reviewed 36 single lung transplants to evaluate the incidence of complications arising in the native lung, their treatment and outcome. METHODS: Between 1991 and 1997, 35 patients received 36 single lung transplants for emphysema (16), pulmonary fibrosis (14), lymphangioleiomyomatosis (4), primary pulmonary hypertension (1) and bronchiolitis obliterans (1). The clinical records were reviewed and the complications related to the native lung were divided into early (up to 6 weeks after the transplant) and late complications. RESULTS: Nineteen complications occurred in 18 patients (50%), leading to death in nine (25%). Early complications (within 6 weeks from the transplant) were bacterial pneumonia (1), overinflation (3), retention of secretions with bronchial obstruction and atelectasis (1), hemothorax (1), pneumothorax (1) and invasive aspergillosis (3); one patient showed active tuberculosis at the time of transplantation. Two patients developed bacterial pneumonia and invasive aspergillosis leading to sepsis and death. The other complications were treated with separate lung ventilation (1), bronchoscopic clearance (1), chest tube drainage (1) and wedge resection and pleurodesis (mechanical) by VATS (1). One patient with hyperinflation of the native lung eventually required pneumonectomy and died of sepsis. The patient with active tuberculosis is alive and well after 9 months of medical treatment. Late complications were recurrent pneumothorax (4), progressive overinflation with functional deterioration (2), aspergillosis (1) and pulmonary nocardiosis (1). Recurrent pneumothorax was treated with chest tube drainage alone (1), thoracoscopic wedge resection and/or pleurodesis (2) and pneumonectomy (1); hyperinflation was treated with thoracoscopic lung volume reduction in both cases; both patients with late infectious complications died. CONCLUSIONS: After single lung transplantation, the native lung can be the source of serious problems. Early and late infectious complications generally result in a fatal outcome; the other complications can be successfully treated in most cases, even if surgery is required.     

Differential lung ventilation after single-lung transplantation for emphysema

OBJECTIVE: To review outcome and cardiovascular and respiratory function after initiation of differential lung ventilation for acute severe native lung hyperinflation in patients who have had a single-lung transplant for end-stage emphysema. DESIGN: Retrospective review. SETTING: Cardiothoracic tertiary referral center. PARTICIPANTS: Thirteen patients who had differential lung ventilation for acute severe native lung hyperinflation, of a total of 132 patients who had a single-lung transplant for end-stage emphysema between 1988 and the end of 2000. INTERVENTIONS: None. measurements and main results: Thirteen patients had differential lung ventilation for acute severe native lung hyperinflation; 7 survived to 1 year after transplant. There was a highly significant (p = 0.0006) improvement in mean PaO(2) from 8.23 (95% confidence interval [CI], 6.15 to 10.3) to 16.6 (95% CI, 12.84 to 20.45) 1 hour after start of differential lung ventilation. The average ratio of estimated dynamic compliance in the native lung compared with the transplanted (donor) lung was 2.69 (95% CI, 1.75 to 3.62). CONCLUSION: In addition to previous case reports, this series shows that differential lung ventilation is an appropriate treatment for acute severe native lung hyperinflation. A difference in estimated effective dynamic compliance of > or = 2.69 between native and transplanted lung may require differential lung ventilation.     

单肺移植术后受者对侧自体肺并发症的分析

目的 探讨单肺移植术后自体肺并发症对移植疗效和受者预后的影响.方法 回顾性分析自2003年1月至2012年8月间单中心施行的48例单肺移植的临床资料.患者的原发疾病分别为慢性阻塞性肺病29例(61％),特发性肺间质纤维化14例(29％),闭塞性细支气管炎2例(4％),尘肺2例(4％),肺淋巴管肌瘤1例(2％).分析术后对侧自体肺并发症发生情况及其预防和处理,并探讨其对受者预后的影响.结果 48例单肺移植受者中,21例(43.7％)出现了对侧自体肺并发症,其中7例(14.6％)因自体肺并发症死亡.并发症分别为气胸2例(4.2％),对侧肺减容术术后持续漏气1例(2.1％),后期自体肺过度膨胀4例(8.3％),顽固性乳糜胸1例(2.1％),肺内恶性肿瘤2例(4.2％),细菌感染6例(12.5％),真菌感染5例(10.4％).有自体肺并发症及无自体肺并发症受者术后1、3和5年存活率分别为63％、42％、21％以及85％、55％、48％ (P＜0.05).自体肺感染性并发症为影响预后的独立因子(P＜0.05).结论 受体对侧自体肺并发症是影响单肺移植预后的重要因素之一;非感染性的自体肺并发症,采用外科手段常可成功治疗,而自体肺感染的预后较差.     

Native lung complications after single lung transplantation for emphysema

We reviewed the impact of the presence of the native diseased contralateral lung on the outcome after single lung transplantation for emphysema. Twenty consecutive recipients of single lung transplants for emphysema were reviewed for complications related to the native lung. Five patients (25 %) suffered major complications arising in the native lung and resulting in serious morbidity and mortality. The timing of onset varied from 1 day to 43 months after transplantation. We conclude that the susceptibility of the native lung to complications such as those described in this report is an additional fact to be considered in choosing the ideal transplant procedure for patients with obstructive lung disease. Received: 2 July 1996 Received after revision: 15 October 1996 Accepted: 28 October 1996     

Recurrence of hepatitis B after single lung transplantation

This study describes a patient who developed decompensated liver disease secondary to reactivation of hepatitis B infection 20 months after single lung transplantation following augmentation of immunosuppression to treat allograft rejection. Discussion focuses on the virologic and management issues of this case and reviews the approach taken when considering patients with chronic hepatitis B infection for lung transplantation.     

Partial resolution of acute interstitial pneumonia in native lung after single lung transplantation.

The case of a 49 year old man presenting with rapidly progressive interstitial lung disease is described. Radiological findings and the lung biopsy specimen were compatible with an acute interstitial pneumonia, as was the relentless clinical course culminating in hypoxic respiratory failure. After right single lung transplantation there was considerable improvement in lung function and radiographic clearing of disease in the native left lung.     

1例双肺移植术后分侧肺通气患者的护理

总结1例双肺移植术后患者分侧肺通气的临床观察和护理。密切观察患者呼吸潮气量、呼吸频率、呼吸机波形及呼吸机报警,及早发现双腔气管移位,护理操作过程中有效防止气管导管移位,实施有效的气道管理,确保呼吸道通畅等。住院63d患者转出ICU,继续治疗至好转出院。     

Urgent contralateral pneumonectomy after single lung transplantation for lymphangioleiomyomatosis

Left single lung transplantation in a 33-year-old woman affected by end-stage lymphangioleiomyomatosis was complicated by spontaneous and diffuse bleeding from the right lung at the end of the procedure. The right lung was completely deteriorated and the only option to stop the bleeding was a right pneumonectomy. At 14 months after transplantation, the single allograft showed good lung function with acceptable volumes. Single lung transplant and contralateral pneumonectomy can be considered a safe procedure in case of complications related to native lung either in case of lymphangioleiomyomatosis than for other lung diseases (emphysema, cystic fibrosis).     

The significance of a single episode of minimal acute rejection after lung transplantation

BACKGROUND: Bronchiolitis obliterans syndrome (BOS) remains the leading obstacle to better long-term outcomes after lung transplantation. Acute rejection has been identified as the primary risk factor for BOS, but the impact of minimal acute rejection, especially a solitary episode, has usually been discounted as clinically insignificant. METHODS: We performed a retrospective cohort study of 259 adult lung transplant recipients to determine the risk of BOS associated with a single episode of A1 rejection, without recurrence or subsequent progression to a higher grade. The cohort was divided into 3 groups based on the severity of acute rejection (none, single episode of A1, and single episode of A2). We determined the risks of BOS stages 1, 2, 3, and death for each group using univariate and multivariate Cox regression analyses. RESULTS: A solitary episode of A1 rejection was a significant risk factor for BOS stages 1 and 2, but not stage 3 or death, in the univariate analysis. Multivariate Cox regression models confirmed that the risk of BOS attributable to a single episode of A1 rejection was independent of other potential risk factors, such as community acquired respiratory viral infections, number of HLA mismatches, and cytomegalovirus pneumonitis. Likewise, univariate and multivariate analyses demonstrated that a single episode of A2 rejection was a significant risk factor for all stages of BOS but not death. CONCLUSIONS: A single episode of minimal acute rejection without recurrence or subsequent progression to a higher grade is a significant predictor of BOS independent of other risk factors.     

Noninvasive high-frequency percussive ventilation in the prone position after lung transplantation

Noninvasive positive-pressure ventilation (NIV), which represents a consolidated treatment of both acute and chronic respiratory failure, is increasingly being used to maintain spontaneous ventilation in lung transplant patients with impending pulmonary complications. Adding a noninvasive inspiratory support plus positive end-expiratory pressure (PEEP) has proven to be useful in preventing endotracheal mechanical ventilation, airway injury, and infections. Lung recipients with closure of the small airways in the dependent regions may also benefit from the prone position, which is helpful to promote recruitment of nonaerated alveoli and faster healing of consolidated atelectatic areas. In patients with localized or diffuse lung infiltrates, high-frequency percussive ventilation (HFPV), by either an invasive airway or a facial mask, has been adopted as an alternative ventilatory mode to enhance airway opening, limit potential respirator-associated lung injury, and improve mucus clearance. In nonintubated lung recipients at risk for volubarotrauma with conventional mechanical ventilation, it allows oxygen diffusion into the distal airways at lower mean airway pressures while avoiding repetitive cyclical opening and closing of the terminal airways. We summarize the clinical course of 3 patients with post-lung transplantation respiratory complications who were noninvasively ventilated with HFPV in the prone position. Major advantages of this treatment included gradual improvement of spontaneous clearance of bronchial secretions, significant attenuation of graft infiltrates and consolidations, a reduction in the number of bronchoscopies required, a decrease in spontaneous respiratory rate and work of breathing, and a significant improvement in gas exchange. The patients found HFPV with either standard facial mask or total mask interface to be comfortable or only mildly uncomfortable, and after the sessions they felt more restored. HFPV by facial mask in the prone position may be an interesting and attractive alternative to standard NIV, one that is more useful when implemented before full-blown respiratory failure is established.     

Mechanical ventilation as a bridge to lung transplantation.

Data describing the use of ventilation as a bridge to lung transplantation are scant. However, data from the International Registry suggest that patients who are ventilated at the time of transplantation are at increased risk. The decision to offer invasive ventilatory support to a lung transplant candidate with acute respiratory failure should be individualized and based on variables that include likelihood of expeditious transplantation, and the presence of a reversible superimposed process. A trial of NPPV is justified in patients who present in acute respiratory failure, but is more likely to be successful in patients with hypercapnia and chronic airway obstruction. Lung transplant candidates with chronic respiratory insufficiency secondary to obstructive airway disease are at increased risk of acute respiratory failure, and a trial of NPPV might be considered on an individual basis after maximization of conventional medical therapy. More research in this area is necessary to further define the roles of both invasive and noninvasive ventilation as bridge therapy to lung transplantation.     

Partial liquid ventilation for acute allograft dysfunction after canine lung transplantation

BACKGROUND: This study was designed to investigate the efficacy of partial liquid ventilation (PLV) on acute allograft dysfunction after lung transplantation. METHODS: The canine left lung allotransplantation model was used, with the graft preserved in 4 degrees C low-potassium dextran glucose solution for 18 hours. The control group (n = 6) had conventional mechanical ventilation, and the PLV group (n = 6) had perfluorooctylbromide instilled into the airway 30 minutes after reperfusion. For 360 minutes, allograft function and hemodynamics were evaluated. After the evaluation, myeloperoxidase activity of the graft tissue was assayed. RESULTS: All dogs survived for 360 minutes. In the PLV group, PaO2, shunt fraction, and alveolar to arterial gradient for O2 were significantly better than those in the control group after 120, 180, and 120 minutes, respectively (p < 0.05). After 240 minutes, peak airway pressure became significantly lower than that in the control group (p < 0.05). The PaO2 at 360 minutes was 102 +/- 55 mm Hg in the control group and 420 +/- 78 mm Hg in the PLV group (p < 0.0001), and the peak airway pressure was 21.4 +/- 4.1 mm Hg in the control group and 14.7 +/- 5.0 mm Hg in the PLV group (p < 0.05). Myeloperoxidase activity in the PLV group was lower than that in the control group. CONCLUSIONS: The study shows that PLV alleviated acute allograft dysfunction after lung transplantation.     

Influence of underlying lung disease on early postoperative course after single lung transplantation

BACKGROUND: Single lung transplantation can be a suitable therapeutic option for a wide range of end-stage lung diseases: pulmonary fibrosis, emphysema, primary pulmonary hypertension and Eisenmenger's syndrome. Yet, patients suffering from different diseases have significantly different cardiovascular and respiratory functional profiles that can exert a profound influence on their response to the perioperative procedures. Our purpose is to analyze whether the patient's underlying disease can influence the early postoperative outcome after single lung transplantation. METHODS: We carried out a retrospective analysis on perioperative charts of patients undergoing single lung transplantation during an 8-year period. We focused our attention on the following data: underlying lung disease, age, sex, baseline cardiorespiratory data (pulmonary artery pressure, cardiac index, forced expired volume, vital capacity, arterial blood gases, body mass index), intraoperative data (duration of graft ischemia, use of cardiopulmonary bypass) and indexes of adverse postoperative outcome (in-hospital death, mechanical ventilatory support >7 days). Patients were gathered in 3 groups (restrictive, obstructive and vascular) according to the kind of disease and functional data and the association between disease and outcome was assessed by means of logistic regression analysis. Moreover, we evaluated whether any of the patient's functional parameters could be considered predictive of adverse postoperative outcome. RESULTS: We observed a weak association between restrictive disease and adverse postoperative outcome while, on the other hand, obstructive and vascular forms showed a close association with an adverse outcome, with a borderline statistical significance. Among all the considered variables, only intraoperative use of CPB turned out to be predictive of adverse outcome, while other variables simply indicated a trend towards a better outcome. CONCLUSIONS: Patients with vascular and obstructive diseases have the worst postoperative course, with a higher in-hospital mortality rate and longer duration of ventilation; in particular, the perioperative course of vascular patients is heavily influenced by the intraoperative use of cardiopulmonary bypass.