Increased Donor Organ Size and Age is Associated with Reduced Survival in Female Lung Transplant Recipients.

BACKGROUND: Organ selection in lung transplantation (LTx) is still controversial. We here analyze the impact of mismatches in size, age, and gender on early and long-term outcome after LTx. METHODS: Retrospective analysis of donor and recipient characteristics of patients who underwent double LTx between March 2003 and December 2021. Statistical analysis was performed using SPSS and GraphPad software. RESULTS: Two hundred three patients were included (94 women and 109 men). In the whole cohort, oversizing donor organs 10% to 20% compared to the recipients' predicted total lung capacity led to a decreased incidence of severe Primary Graft Dysfunction grades 2 and 3 (2/3; 15% vs 41%, P = .03), and further oversizing > 20% was associated with reduced long-term survival (hazard ratio, 2.33, P = .011). Analyzing donor and recipient age, we found that increased donor age correlated with reduced long-term survival (P = .013). In this cohort, female recipients received older organs (median 57 vs 46 years, P = .0003) and had a higher incidence of > 20% oversizing (13% vs 4%, P = .019) of donor lungs, which resulted in a significantly reduced long-term survival (P = .02) compared with male recipients. Median Lung Allocation Scores were similar in both groups. CONCLUSION: Mismatch of donor age and size can be important for organ function and survival in LTx recipients. Particularly female recipients seem to have a higher risk for unfavorable long-term outcome when transplanting organs of increased size and age. Multicenter studies are warranted to further address this question. TRIAL REGISTRATION NUMBER: (DKRS): 00033312.

Endoscopic Lung Volume Reduction Prior to Lung Transplantation Does Not Increase Postoperative Pulmonary Complications.

INTRODUCTION: Lung transplantation (LTx) remains the only therapeutic option for selected patients with end-stage lung disease. In comparison to surgical lung volume reduction, few data exist on the risks and benefits of pretransplant endoscopic lung volume reduction (eLVR). Here, we investigate the risk of postoperative pulmonary complications (PPCs) after LTx in patients with emphysematous lung disease bridged with eLVR until transplantation. METHODS: Eighty-two patients with emphysematous lung disease who underwent double-LTx (DLTx) were included and retrospectively evaluated. Statistical analysis was performed using SPSS and GraphPad Prism software. RESULTS: 28/82 patients underwent eLVR prior to DLTx. eLVR patients spent comparable time on the waitlist; however, they were older at the time of DLTx (median 60 vs. 58 years, p = 0.02). Both groups showed comparable 90-day (92%) and long-term survival (eLVR 1-/5-/10-year survival: 92/88/77%, vs. control: 89/77/67%, p = 0.5). The odds for PPCs were similar in patients with and without eLVR (OR 0.7; 95% CI: 0.3-1.7), as well as major perioperative surgical and cardiovascular complications. In the entire cohort, we found ≥1 PPC to be a risk factor for death within 90 days (OR 9.7, 95% CI: 1.3-110). Among the PPCs, pneumonia (HR 4.6 95% CI: 1.1-14.9, p = 0.02) and ARDS (HR 11.2 95% CI: 1.6-229.2, p = 0.04) were identified as independent risk factors for reduced long-term survival. CONCLUSIONS: eLVR does not increase the risk for PPCs, surgical complications, or reduced survival after LTx in patients with emphysematous lung disease and can serve as a bridge to LTx.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased Morbidity and Mortality in Patients Undergoing Thoracic Surgery for Pleural Empyema.

OBJECTIVES: Surgery for pleural empyema carries a high burden of morbidity and mortality. The authors investigated the incidence of postoperative pulmonary complications (PPCs) and their effects on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs were analyzed. DESIGN: Retrospective observational study. SETTING: A single, large university hospital. PARTICIPANTS: A total of 250 adult patients were included who underwent thoracic surgery for pleural empyema between January 2017 and December 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 250 patients with pleural empyema underwent thoracic surgery by video-assisted thoracoscopic surgery (49%; n = 122) or open thoracotomy (51%; n = 128). A proportion (42% [105]) of patients had ≥1 PPCs; 28% (n = 70) had to undergo resurgery; and 10% (n = 25) were re-admitted unexpectedly to the ICU. Preoperative respiratory failure (odds ratio [OR]: 5.8, 95% CI: 2.4-13.1), general anesthesia without regional analgesia techniques (OR: 2.9, 95% CI: 1.4-5.8), open thoracotomy and subsequent resurgery (OR: 3.9, 95% CI 1.5-9.9), surgery outside the regular working hours (OR: 3.1, 95% CI 1.2-8.2), and postoperative sepsis (OR: 2.6, 95% CI 1.1-6.8) were identified as independent risk factors for PPCs. Postoperative pulmonary complications were independent factors for unplanned intensive care unit admission (OR: 10.5, 95% CI 2.1-51 for >1 PPC), death within 360 days (OR: 4.5, 95% CI 2.2-12.3 for ≥2 PPCs), and death within 30 days for ≥1 PPCs (OR: 1.2, 95% CI 1.1-1.3). CONCLUSIONS: The incidence of PPCs is a significant risk factor for morbidity and mortality after surgery for pleural empyema. Targeting the risk factors identified in this study could improve patient outcomes.

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry.

Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9-67), the presence of medical complications (OR 7.4, 95% CI 2.7-16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9-59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2-52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2-52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2-34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

Should cardiovascular comorbidities be a contraindication for pulmonary metastasectomy?

Background: Limited information is available about the impact of cardiovascular comorbidities (CVC) on the postoperative course of patients undergoing pulmonary metastasectomy (PM). In this study, we aim to compare the postoperative morbidity, mortality, and the long-term survival of patients with and without CVC undergoing PM. Methods: A retrospective monocentric study was conducted including 760 patients who underwent PM in curative intention. Patients were divided into two groups depending on the presence of CVC. Results: The data from 164 patients with CVC (21.6%) and 596 patients without CVC (78.4%) were investigated. In both groups, zero in-hospital-mortality and limited 30-day mortality was detected. Postoperative complications occurred more often in patients with CVC (N=47, 28.7% vs. N=122, 20.5%, P=0.02). However, most of them were minor (N=37, 22.6% vs. N=93, 15.6%, P=0.03). The presence of multiple CVC (N=18 patients, 40% vs. N=28, 23.9%, P=0.04) and reduced left ventricular function (N=5, 62.5% vs. N=42, 27.1%, P=0.03) were identified as risk factors for postoperative morbidity. Patients with CVC showed reduced overall survival (5-year survival rate: 75.8% vs. 68%, P=0.03). In the multivariate analysis lobectomy [hazard ratio (HR) 0.3, 95% confidence interval (CI): 0.1-0.8, P=0.02] and general vascular comorbidities (HR 2.1, 95% CI: 1.1-3.9, P=0.01) were identified as independent negative prognostic factors. Conclusions: Resection of pulmonary metastases can be performed safely in selected patients with stable CVC. The presence of CVC in patients undergoing PM is associated with reduced overall survival compared to patients without CVC in the long term follow up. However, a prolonged 5-year survival rate of 68% could be achieved.

Risk Factors for Postoperative Pulmonary Complications Leading to Increased In-Hospital Mortality in Patients Undergoing Thoracotomy for Primary Lung Cancer Resection: A Multicentre Retrospective Cohort Study of the German Thorax Registry.

Postoperative pulmonary complications (PPCs) represent the most frequent complications after lung surgery, and they increase postoperative mortality. This study investigated the incidence of PPCs, in-hospital mortality rate, and risk factors leading to PPCs in patients undergoing open thoracotomy lung resections (OTLRs) for primary lung cancer. The data from 1426 patients in this multicentre retrospective study were extracted from the German Thorax Registry and presented after univariate and multivariate statistical processing. A total of 472 patients showed at least one PPC. The presence of two PPCs was associated with a significantly increased mortality rate of 7% (p < 0.001) compared to that of patients without or with a single PPC. Three or more PPCs increased the mortality rate to 33% (p < 0.001). Multivariate stepwise logistic regression analysis revealed male gender (OR 1.4), age > 60 years (OR 1.8), and current or previous smoking (OR 1.6), while the pre-operative risk factors were still CRP levels > 3 mg/dl (OR 1.7) and FEV1 < 60% (OR 1.4). Procedural independent risk factors for PPCs were: duration of surgery exceeding 195 min (OR 1.6), the amount of intraoperative blood loss (OR 1.6), partial ligation of the pulmonary artery (OR 1.5), continuing invasive ventilation after surgery (OR 2.9), and infusion of intraoperative crystalloids exceeding 6 mL/kg/h (OR 1.9). The incidence of PPCs was significantly lower in patients with continuous epidural or paravertebral analgesia (OR 0.7). Optimising perioperative management by implementing continuous neuroaxial techniques and optimised fluid therapy may reduce the incidence of PPCs and associated mortality.

[Anesthetic Management in Pediatric Thoracic Surgery]. / Anästhesiologische Konzepte in der pädiatrischen Thoraxchirurgie.

Pediatric thoracic anesthesia is a challenging task. Specific implications arise from the patients' developmental stage, the disease and the intervention. An interdisciplinary management plan includes relevant factors. The main aspects are airway management, analgesic techniques and cardiorespiratory therapeutic strategies adapted to the underlying pathophysiology. Every step should be designed to provide optimal care. This article provides insight to specific airway, respiratory and regional anesthesia management in pediatric patients.

Anesthesia for interventional pulmonology.

PURPOSE OF REVIEW: Anesthesia for pulmonological interventions is a demanding challenge. This article discusses recent innovations and the implications for periinterventional anesthetic management. RECENT FINDINGS: Interventional pulmonology is a rapidly expanding specialty with very complex diagnostic and therapeutic approaches that include oncological staging, treatment of obstructive and restrictive lung diseases, recanalization of endobronchial obstructions, and retrieval of foreign bodies. With the development of advanced diagnostic and therapeutic interventions, the application is extended to critically ill patients. Current evidence focusing on the anesthetic techniques is presented here. SUMMARY: The development of new pulmonological methods requires a tailored anesthesiological approach. Their specific impact must be taken into account to ensure patient safety, goal-oriented outcome diagnostics and -quality, successful interventions, and patient comfort.

Anesthesia of thoracic surgery in children.

Providing anesthesia in children with thoracic disease is a challenging task. The effects of the underlying disease, the surgical interventions, and preexisting condition of the patient need to be considered when planning perioperative care. The perioperative care for children undergoing thoracic surgery requires specific techniques adapted to the pediatric physiology and anatomy. This review is focused on anesthetic strategies for thoracic surgery with an emphasis on perioperative analgesia including neuraxial techniques.