Oxigenación con membrana extracorpórea en la disfunción primaria del injerto en trasplante bipulmonar pediátrico: a propósito de un caso

Primary graft dysfunction is a leading cause of morbimortality in the immediate postoperative period of patients undergoing lung transplantation. Among the treatment options are: lung protective ventilatory strategies, nitric oxide, lung surfactant therapy, and supportive treatment with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery of lung function or re-transplant.We report the case of a 9-year-old girl affected by cystic fibrosis who underwent double-lung transplantation complicated with a severe primary graft dysfunction in the immediate postoperative period and refractory to standard therapies. Due to development of multiple organ failure, it was decided to insert arteriovenous ECMO catheters (pulmonary artery-right atrium). The postoperative course was satisfactory, allowing withdrawal of ECMO on the 5 th post-surgical day. Currently the patient survives free of rejection and with an excellent quality of life after 600 days of follow up.     

Refractory Heart Failure Dependent on Short‐Term Mechanical Circulatory Support: What Next? Heart Transplant or Long‐Term Ventricular Assist Device

Chronic heart failure is a progressive and eventually fatal illness. Although the disease cannot be cured and treatment is symptom oriented, most of the patients benefit from optimum medical treatment. Patients with rapid deterioration in chronic advanced heart failure refractory to medical treatment need inotropic support and may need intra‐aortic balloon pump to maintain circulatory support, which of course cannot be prolonged beyond a certain limit. The outcome of heart transplant and long‐term ventricular assist device (VAD) in such patients is poor. The short‐term mechanical circulatory support (MCS) offered to such patients not only provides effective circulatory support and stabilizes them hemodynamically, but also halts the ensuing or reverts the established end‐organ failure. As the name suggests, the short‐term MCS offers support for the short term, usually less than a month. Although some patients with acute heart failure experience recovery of myocardial function with short‐term MCS support, others become dependent. These patients, stabilized and “stuck” with short‐term MCS, can be “rescued” with long‐term VAD or heart transplantation. Both the procedures, when done in this special situation, have their inherent advantages, disadvantages, and complications and hence need the careful consideration about the choice of the procedure. We have tried to elucidate this situation by considering the advantages and disadvantages of both options.     

Liver transplantation

Huge developments in the field of liver transplantation have occurred over the last 30 years. Improved immunosuppression regimens brought about by the introduction of ciclosporin and tacrolimus, the development of organ preservation solutions and enhanced perioperative care have meant that survival at 1 year following liver transplantation now reaches approximately 90%. The spectrum of disease now treated with liver transplantation has also grown to encompass a wide range of chronic disease and primary liver malignancy. Early referral to specialist centres affords better outcomes for potential recipients and has prompted the development of specific scoring systems to objectively assess liver failure and guide organ allocation. The consistent gap between the number of recipients and availability of organs, however, has driven many new developments such as split grafts and live donor transplantation. The use of the marginal graft is now commonplace in many centres in an attempt to reduce waiting list mortality. Here, we examine the origins and evolution of the specialty and describe some of the latest developments in the field of liver transplantation, with specific reference to the surgical techniques currently used as well as recent advances in immunosuppression therapy.     

Impact of a goal-directed therapy protocol on postoperative fluid balance in patients undergoing liver transplantation: A retrospective study

Objective

Liver transplantation carries major risks during the perioperative period. Few studies focused on the hemodynamics of patients undergoing liver transplantation. The present study was aimed to evaluate the impact of the implementation of a protocol including goal-directed therapy in patients undergoing liver transplantation. Our first goal was to determine its impact on the fluid balance. Secondarily, we evaluated possible improvements in the patient outcomes.

Study design

A before and after study.

Patients and methods

Fifty patients undergoing liver transplantation were included during two successive six-month periods. During the first period, the management of the patients was left at the discretion of the senior physicians (control group, n = 25). During the second period, the patients were treated according to a predetermined protocol including a specific hemodynamic monitoring (protocol group, n = 25).

Results

The fluid balance was negative in the protocol group and positive in the control group at 24 h (−606 mL vs. +3445 mL, P < 0.01) and 48 h (−2315 mL vs. +1170 mL, P < 0.01) after liver transplantation. The volume of the crystalloid administration was lower in the protocol group than in the control group (5000 mL vs. 8000 mL, P < 0.01, and 1500 mL vs. 6000 mL, P < 0.01, during surgery and 48 h after liver transplantation, respectively). The duration of mechanical ventilation and postoperative ileus were significantly reduced in the protocol group, as compared with the control group, 20 h vs. 94 h (P < 0.01) and 4 days vs. 6 days (P < 0.01), respectively.

Conclusion

For patients undergoing liver transplantation, the implementation of a protocol aiming to optimize hemodynamics was associated with reduced fluid balance and decreased requirement for mechanical ventilation and postoperative ileus duration.     

Outcomes of Primary Total Joint Arthroplasty After Lung Transplantation

Lung transplantation is increasingly common with improving survival rates. Post-transplant patients can be expected to seek total hip (THA) and knee arthroplasty (TKA) to improve their quality of life. Outcomes of 20 primary total joint arthroplasties (15 THA, 5 TKA) in 14 patients with lung transplantation were reviewed. Clinical follow-up time averaged 27.5 and 42.8 months for THA and TKA respectively. Arthroplasty indications included osteonecrosis, osteoarthritis, and fracture. All patients subjectively reported good or excellent outcomes with a final average Harris Hip Score of 88.7, Knee Society objective and functional score of 92.0. There were 4 minor and 1 major acute perioperative complications. 1 late TKA infection was successfully treated with two-stage revision. The mortality rate was 28.5% (4/14 patients) at an average 20.6 months following but unrelated to arthroplasty. Overall, total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients.