"Twinning procedure" in lung transplantation: influence of graft ischemia on survival and incidence of complications.

The limited number of suitable lung donors is the major obstacle to clinical application of lung transplantation. The "twinning procedure" may represent one strategy to optimize the use of the small pool of available grafts. From November 1991 to May 2003, 99 single lung transplants (SLTx) were performed including 46 (46%) cases of the "twinning procedure." We divided the study population into two groups: group A (recipients of the "first" lung) and group B (recipients of the "second" lung). The ischemia time was significantly different (A: 216 +/- 48 minutes, B: 310 +/- 89 minutes, P <.001). Differences were not observed in the incidence of graft failure (A: 2, B: 0, P = NS), in the length of mechanical ventilation (A: 12.8 +/- 29.4 days, B: 7.8 +/- 15.2 days, P = NS), or ICU stay (A: 18.8 +/- 50.6 days, B: 15.2 +/- 17.1 days, P = NS), or of hospitalization (A: 37.8 +/- 56.8 days, B: 31.4 +/- 31.7 days, P = NS). Three bronchial anastomotic complications occurred in each group. The incidence of infections (A: 0.015 events/patient/month, B: 0.011 events/patient/month, P = NS) and of treated acute rejections (A: 0.011 events/patient/month, B: 0.011 events/patient/month, P = NS) was similar in the two groups. One-year survival rates were 86% +/- 7% and 72% +/- 10% in group A and B patients, respectively (P = NS). In our experience the different ischemia times related to the twinning procedure did not increase the mortality or morbidity in the early and midterm period.

Orthotopic heart transplantation: standard versus bicaval technique.

We compared orthotopic heart transplantation (HT) by bicaval technique with the standard technique. Between January 1995 and December 1997, 117 patients underwent 118 HTs; 71 patients (15 women and 56 men) had 72 HTs by standard technique and 46 patients (9 women, 37 men) underwent HT using bicaval procedures. Preoperative parameters were similar in both groups; 5 patients who underwent the standard technique and no patients who underwent bicaval procedures required permanent pacemakers (p = NS). Isoproterenol infusion was significantly longer in the standard technique. Major perioperative arrhythmias (ventricular tachycardia and fibrillation, asystole) appeared in 8.2% and 7.0% of standard and bicaval HTs, respectively; atrial fibrillation appeared in 13.1% and 4.6%, respectively (p = NS). At 1 month, mitral and tricuspid regurgitation rates were higher in the standard group (p = NS); at 1 year only tricuspid regurgitation was still higher (p = NS). Right atrial pressure, Wood units, cardiac output, and cardiac index were examined (p = NS). At multivariate analysis, interaction between preoperative Wood units and transplant type was elicited for Wood units at 1 month and for right atrial pressure at 1, 3, and 6 months. In the high resistance subgroup, the patients who underwent bicaval procedures had higher resistances at 1 month. In the low resistance subgroup, right atrial pressure was higher in patients who underwent standard techniques at 1, 3, and 6 months follow-up. Thus, bicaval HT was found to be safe, without surgically related complications, it provoked significantly less blood loss, and required less isoproterenol use. No significant advantages were observed in conduction disturbances and major arrhythmias or regarding the need for temporary or permanent pacemakers.