ABSTRACT
OBJECTIVES: To evaluate outcomes after heart retransplantation. METHODS: From January 6, 1968, to June 2019, 123 patients (112 adult and 11 pediatric patients) underwent heart retransplantation, and 2092 received primary transplantation at our institution. Propensity-score matching was used to account for baseline differences between the retransplantation and the primary transplantation-only groups. Kaplan-Meier survival analyses were performed. The primary end point was all-cause mortality, and secondary end points were postoperative complications. RESULTS: Retransplantation recipient age was 39.6 ± 16.4 years, and donor age was 26.4 ± 11.2 years. Ninety-two recipients (74.8%) were male. Compared with recipients who only underwent primary heart transplantation, retransplantation recipients were more likely to have hypertension (44/73.3% vs 774/53.3%, P = .0022), hyperlipidemia (40/66.7% vs 447/30.7%, P < .0001), and require dialysis (7/11.7% vs 42/2.9%, P = .0025). The indications for heart retransplantation were cardiac allograft vasculopathy (32/80%), primary graft dysfunction (6/15%), and refractory acute rejection (2/5%). After matching, postoperative outcomes such as hospital length of stay, severe primary graft dysfunction requiring intra-aortic balloon pump or extracorporeal membrane oxygenation, cerebral vascular accident, respiratory failure, renal failure requiring dialysis, and infection were similar between the 2 groups. Matched median survival after retransplantation was 4.6 years compared with 6.5 years after primary heart transplantation (log-rank P = .36, stratified log-rank P = .0063). CONCLUSIONS: In this single-center cohort, the unadjusted long-term survival after heart retransplantation was inferior to that after primary heart transplantation, and short-term survival difference persisted after propensity-score matching. Heart retransplantation should be considered for select patients for optimal donor organ usage.
Subject(s)
Coronary Artery Disease/surgery , Graft Rejection/surgery , Heart Failure/surgery , Heart Transplantation , Primary Graft Dysfunction/surgery , Adolescent , Adult , California , Coronary Artery Disease/etiology , Coronary Artery Disease/mortality , Coronary Artery Disease/physiopathology , Female , Graft Rejection/etiology , Graft Rejection/mortality , Graft Rejection/physiopathology , Heart Failure/mortality , Heart Failure/physiopathology , Heart Transplantation/adverse effects , Heart Transplantation/mortality , Humans , Male , Middle Aged , Primary Graft Dysfunction/etiology , Primary Graft Dysfunction/mortality , Primary Graft Dysfunction/physiopathology , Recovery of Function , Reoperation , Retrospective Studies , Risk Assessment , Risk Factors , Time Factors , Treatment Outcome , Young AdultABSTRACT
BACKGROUND: Late onset non-infectious pulmonary complications (LONIPCs) following allogenic hematopoietic stem cell transplantation (allo-HSCT) confer a significant mortality risk. Lung transplantation (LTx) has the potential to provide survival benefit but the impact of prior allo-HSCT on post-LTx outcomes is not well studied. METHODS: This retrospective, single-centre cohort study assessed the post-LTx outcomes of adults with LONIPCs of allo-HSCT. Outcomes of LTx for LONIPCs were compared to propensity-score matched LTx controls (n = 38, non-HSCT) and recipients of re-LTx (n = 70) for chronic lung allograft dysfunction (CLAD). RESULTS: Nineteen patients underwent DLTx for LONIPCs of allo-HSCT between 2003 and 2019. Post-LTx survival was 50% at 5-years. Survival to 1-year post-LTx was similar to matched controls (p = 0.473). Survival, conditional on 1-year survival, was lower in the allo-HSCT cohort (p = 0.034). An increased risk of death due to infection was identified in the allo-HSCT cohort compared to matched controls (p = 0.003). Compared to re-LTx recipients, the allo-HSCT cohort had superior survival to 1-year post-LTx (p = 0.034) but conditional 1-year survival was similar (p = 0.145). CONCLUSION: This study identifies an increased risk of post-LTx mortality in recipients with previous allo-HSCT, associated with infection. It supports the hypothesis that allo-HSCT LTx recipients are relatively more immunosuppressed than patients undergoing LTx for other indications. Optimisation of post-LTx immunosuppressive and antimicrobial strategies to account for this finding should be considered.
Subject(s)
Hematopoietic Stem Cell Transplantation/adverse effects , Lung Transplantation/methods , Postoperative Complications , Primary Graft Dysfunction/surgery , Propensity Score , Transplant Recipients , Adolescent , Adult , Biopsy , Bronchoscopy , Chronic Disease , Female , Follow-Up Studies , Humans , Lung/pathology , Male , Middle Aged , Primary Graft Dysfunction/diagnosis , Primary Graft Dysfunction/etiology , Retrospective Studies , Risk Factors , Time Factors , Transplantation, Homologous/adverse effects , Young AdultABSTRACT
BACKGROUND: We studied the determinants of hemodynamics and analyzed the incidence, risk factors, and clinical impact of pulmonary homograft dysfunction following Ross surgery, after a 20-year follow-up at our referral center. METHODS: From 1997 to 2017, a total of 142 patients underwent surgery using the Ross procedure. The development of moderate-severe stenosis (peak transhomograft pressure gradient 36 mm Hg or greater) and surgical or percutaneous Ross homograft reinterventions were evaluated by echocardiography in the immediate postoperative period and at annual intervals. RESULTS: After 20 years of follow-up, 31% of patients had moderate-severe homograft stenosis, and 9.1% had had to undergo one or two reinterventions, of which, six were valve replacements and seven were percutaneous interventions. At 1, 5, and 20 years, 89.4%, 74.6%, and 69% of these patients, respectively, were free from moderate-severe stenosis; and 99.3%, 95.7%, and 90.9%, respectively, had freedom from homograft reintervention. The pediatric group had a higher risk factor for homograft stenosis (hazard ratio 3.70; 95% confidence interval, 1.56 to 7.20, P = .002), whereas donor age behaved as a protective factor (hazard ratio 0.98; 95% confidence interval, 0.95 to 0.99; P = .044). Pulmonary homograft stenosis tended to appear in the first year (10.6%) or at 5 years (25.4%). CONCLUSIONS: Pulmonary homografts implanted in the Ross procedure offer satisfactory long-term results, but the level of homograft dysfunction is not negligible. Young recipient and donor age were associated with a higher rate of homograft stenosis during follow-up. Moreover, homograft dysfunction usually occurred during the first few years of follow-up, and may have been related to immune responses.
Subject(s)
Cardiac Surgical Procedures/adverse effects , Forecasting , Heart Valve Diseases/surgery , Primary Graft Dysfunction/diagnosis , Pulmonary Valve/surgery , Adolescent , Adult , Aged , Allografts , Child , Child, Preschool , Echocardiography , Female , Follow-Up Studies , Humans , Male , Middle Aged , Primary Graft Dysfunction/surgery , Reoperation , Retrospective Studies , Risk Factors , Young AdultSubject(s)
Fluorine Radioisotopes , Fluorodeoxyglucose F18 , Positron Emission Tomography Computed Tomography , Primary Graft Dysfunction/diagnostic imaging , Radiopharmaceuticals , Embolization, Therapeutic , Female , Fever of Unknown Origin/etiology , Humans , Kidney Transplantation , Lymphocytes/pathology , Nephrectomy , Plasma Cells/pathology , Postoperative Complications/diagnostic imaging , Primary Graft Dysfunction/pathology , Primary Graft Dysfunction/surgery , Primary Graft Dysfunction/therapy , Thrombotic Microangiopathies/diagnostic imagingABSTRACT
INTRODUCTION: Bronchiolitis obliterans (BO) is the most common expression of chronic allograft dysfunction in lung transplantation. Moreover, BO represents the major cause of death in the long-term after this procedure. On the other hand, mesenchymal stem cells have been tested in animal models of BO aiming to interfere in its development. The aim of this experimental study is to explore the role of bone-marrow derived stem cells (BMSCs) as a preventive intervention of BO occurrence. MATERIALS AND METHODS: This an experimental randomized study. A bronchiolitis obliterans animal model in rats was reproduced: heterotopical tracheal transplant model in lung parenchyma. Five of these animals were used as control group. After setting up the model, individuals were divided in 3 groups of treatment (n = 15), in which BMSCs were administered in 3 different time points after the tracheal transplant (tracheal transplantation and BMSCs administration occurred the same day, group G0; after 7 days, group G7; after 14 days, group G14. In addition, within each group, BMSCs were administered through 3 different routes: endotracheally, endovascular and topically in the lung parenchyma). Animals were sacrificed at 21 days. Histology, fluorescence in situ hybridization and immunohistochemistry techniques were performed for identifying stem cells. RESULTS: Compared to control group, animals receiving BMSCs showed large neovessels in a loose fibrous matrix. Group G7 showed less fibrosis (p < 0.033) and edema (p < 0.028). Moreover, G7 animals receiving stem cells endotracheally showed no fibrosis (p < 0.008). Alveolar-like patches of tissue were observed among all groups (53.4%, 46.7% and 40% in G0, G7 and G14 respectively), consisting of cells expressing both stem and alveolar cells biomarkers. CONCLUSION: BMSCs modify the course of bronchiolitis obliterans and differentiate into alveolar cells. Endotracheal administration of BMSCs 7 days after the heterotopical tracheal transplant might be considered an effective way to prevent BO in this animal model
INTRODUCCIÓN: La bronquiolitis obliterante (OB) es la forma más frecuente de disfunción crónica del injerto en el trasplante pulmonar. Asimismo, representa la principal causa de mortalidad a largo plazo tras este procedimiento. Por otro lado, las células madre mesenquimales se han utilizado en diferentes modelos animales de BO, con el propósito de interferir en el desarrollo de dicha disfunción. El objetivo de este estudio experimental es explorar el papel del trasplante de células madre mesenquimales derivadas de la médula ósea (BMSC, por sus siglas en inglés) como tratamiento preventivo de la BO. MATERIAL Y MÉTODOS: Se trata de un estudio experimental y aleatorizado en el que se empleó un modelo de BO en ratas basado en el trasplante traqueal heterotópico en parénquima pulmonar. Los animales se dividieron en los siguientes grupos: grupo control (n = 5) y 3 grupos de tratamiento (n = 15) en los que las células madre mesenquimales derivadas de médula ósea se administraron a distintos tiempos tras el trasplante traqueal heterotópico (el mismo día [grupo G0]; a 7 días [grupo G7], y a 14 días [grupo G14]). Además, dentro de cada grupo, las células se trasplantaron mediante 3 vías diferentes: endotraqueal, endovascular y tópicamente en el parénquima pulmonar. Todos los animales se sacrificaron a los 21 días tras el trasplante traqueal. Las células madre se identificaron mediante técnicas histológicas utilizando hibridación fluorescente in situ (FISH) e inmunohistoquímica. RESULTADOS: Comparado con el grupo control, los animales que recibieron las BMSC mostraron neovasos de gran tamaño en una matriz muy laxa de tejido fibroso. En el grupo G7 se observó menor grado de fibrosis (p < 0,033) y edema (p < 0,028). Además, ninguno de los animales del grupo G7 que recibieron las células madre por vía endotraqueal desarrolló algún grado de fibrosis (p < 0,008). En todos los grupos se observaron parches de tejido con características histológicas similares al tejido alveolar (53,4, 46,7% y 40% in G0, G7 y G14, respectivamente) con expresión de marcadores tanto alveolares como de células madre. CONCLUSIONES: Las células madre mesenquimales derivadas de la médula ósea modifican el curso histopatológico de la BO y son capaces de diferenciarse a células de tipo alveolar. La administración endotraqueal de estas células a los 7 días del trasplante traqueal heterotópico podría considerarse una vía efectiva para prevenir el desarrollo de BO en este modelo animal
Subject(s)
Humans , Female , Rats , Bronchiolitis Obliterans/prevention & control , Bronchiolitis Obliterans/surgery , Mesenchymal Stem Cell Transplantation , Lung Transplantation/adverse effects , Primary Graft Dysfunction/pathology , Primary Graft Dysfunction/surgery , Disease Models, Animal , Random Allocation , Chronic DiseaseABSTRACT
Chronic allograft dysfunction (CAD), defined as the replacement of functional renal tissue by extracellular matrix proteins, remains the first cause of graft loss. The aim of our study was to explore the potential role of the cannabinoid receptor 1 (CB1) during CAD. We retrospectively quantified CB1 expression and correlated it with renal fibrosis in 26 kidney-transplanted patients who underwent serial routine kidney biopsies. Whereas CB1 expression was low in normal kidney grafts, it was highly expressed during CAD, especially in tubular cells. CB1 expression significantly increased early on after transplantation, from day 0 (D0) to month 3 post-transplant (M3) (22.5% ± 15.4% vs 33.4% ± 13.8%, P < .01), and it remained stable thereafter. CB1 expression correlated with renal fibrosis at M3 (P = .04). In an in vitro model of tacrolimus-mediated fibrogenesis by tubular cells, we found that tacrolimus treatment significantly induced mRNA and protein expression of CB1 concomitantly to col3a1 and col4a3 up regulation. Administration of rimonabant, a CB1 antagonist, blunted collagen synthesis by tubular cells (P < .05). Overall, our study strongly suggests an involvement of the cannabinoid system in the progression of fibrosis during CAD and indicates the therapeutic potential of CB1 antagonists in this pathology.
Subject(s)
Fibrosis/etiology , Kidney Transplantation/adverse effects , Primary Graft Dysfunction/complications , Receptor, Cannabinoid, CB1/metabolism , Animals , Cells, Cultured , Chronic Disease , Female , Fibrosis/metabolism , Fibrosis/pathology , Humans , Immunosuppressive Agents/toxicity , Male , Mice , Mice, Inbred C57BL , Middle Aged , Primary Graft Dysfunction/surgery , Receptor, Cannabinoid, CB1/genetics , Retrospective Studies , Tacrolimus/toxicityABSTRACT
Introducción: La supervivencia del trasplante pulmonar (TP) viene condicionada fundamentalmente por el desarrollo de disfunción crónica del injerto (DCI). El retrasplante pulmonar (RP) es una alternativa para una población seleccionada con DCI. El objetivo del estudio fue revisar la experiencia de RP en nuestro centro. Pacientes y métodos: Se ha realizado un estudio retrospectivo de los pacientes sometidos a RP entre agosto de 1990 y julio de 2017. Resultados: Se realizaron 14 RP de un total de 998 (1,4%) TP. Doce RP se dieron por causa de DCI: 10 (71,4%) por síndrome de bronquiolitis obliterante y 2 (14,3%) por síndrome restrictivo del injerto. En 2 pacientes el RP se realizó en los 30 días siguientes al primer TP. En el RP por DCI el tiempo medio entre el TP y el RP fue de 48 meses. Tras el RP el tiempo medio de ventilación mecánica fue de 32 días. El incremento del FEV1 tras el RP fue del 24 ± 18%. Los mejores valores en la espirometría se observaron a los 7,3 meses. La supervivencia media de la serie fue de 43,8 meses, en los pacientes con síndrome de bronquiolitis obliterante fue de 63,4 meses mientras que en los pacientes con síndrome restrictivo del injerto fue de 19,5 meses. Solo un paciente de los 2 RP precoces sobrevivió a este. Conclusión: El RP es una opción terapéutica en pacientes seleccionados con DCI. Sin embargo, estos resultados no son reproducibles si el RP se realiza en los primeros días
Introduction: Long-term survival of lung transplantation (LT) patients is mainly limited by the development of chronic lung allograft dysfunction (CLAD). Lung retransplantation (LR) is an alternative for a selected population. The aim of this study was to review the LR experience in our center. Patients and methods: We conducted a retrospective study of patients undergoing LR between August 1990 and July 2017. Results: Fourteen LR out of a total of 998 (1.4%) LT were performed. Twelve patients (85.7%) underwent LR due to CLAD: 10 (71.4%) because of bronchiolitis obliterans syndrome and 2 (14.3%) due to restrictive allograft syndrome. LR was performed in 2 patients within 30 days of the first LT. In those who underwent LR due to CLAD, mean time between the first LT and LR was 48 months, and mean duration of invasive mechanical ventilation was 32 days. The increase in FEV1 after LR was 24 ± 18%. The best spirometry values were observed after 7.3 months. Mean survival of the cohort was 43.8 months. In patients with bronchiolitis obliterans syndrome, mean survival was 63.4 months, while in those with restrictive allograft syndrome, it was 19.5 months. Only 1 of the 2 early LR patients survived. Conclusion: LR is a therapeutic option in selected patients with CLAD, with acceptable survival. Indication for LR early after LT shows poor outcomes
Subject(s)
Humans , Male , Female , Adolescent , Young Adult , Adult , Middle Aged , Primary Graft Dysfunction/surgery , Lung Transplantation/adverse effects , Host vs Graft Reaction , Lung Transplantation/mortality , Retrospective Studies , Chronic Disease , ReoperationABSTRACT
INTRODUCTION: Long-term survival of lung transplantation (LT) patients is mainly limited by the development of chronic lung allograft dysfunction (CLAD). Lung retransplantation (LR) is an alternative for a selected population. The aim of this study was to review the LR experience in our center. PATIENTS AND METHODS: We conducted a retrospective study of patients undergoing LR between August 1990 and July 2017. RESULTS: Fourteen LR out of a total of 998 (1.4%) LT were performed. Twelve patients (85.7%) underwent LR due to CLAD: 10 (71.4%) because of bronchiolitis obliterans syndrome and 2 (14.3%) due to restrictive allograft syndrome. LR was performed in 2 patients within 30 days of the first LT. In those who underwent LR due to CLAD, mean time between the first LT and LR was 48 months, and mean duration of invasive mechanical ventilation was 32 days. The increase in FEV1 after LR was 24±18%. The best spirometry values were observed after 7.3 months. Mean survival of the cohort was 43.8 months. In patients with bronchiolitis obliterans syndrome, mean survival was 63.4 months, while in those with restrictive allograft syndrome, it was 19.5 months. Only 1 of the 2 early LR patients survived. CONCLUSION: LR is a therapeutic option in selected patients with CLAD, with acceptable survival. Indication for LR early after LT shows poor outcomes.
Subject(s)
Bronchiolitis Obliterans/surgery , Lung Transplantation , Primary Graft Dysfunction/surgery , Adolescent , Adult , Chronic Disease , Female , Hospital Units , Humans , Male , Middle Aged , Reoperation , Retrospective Studies , Spain , Treatment Outcome , Young AdultABSTRACT
OBJECTIVES: Primary graft dysfunction (PGD) is a devastating complication and the most common cause of early death following a heart transplant. The goal of this study was to report our experience of using mechanical circulatory support to manage severe PGD. METHODS: Following 208 heart transplants performed between January 2007 and May 2017, 14 (6.7%) patients presented with severe PGD. We provided haemodynamic support using the following approaches: a venoarterial extracorporeal membrane oxygenation device, left ventricular assist device, right ventricular assist device and biventricular assist device. Primary complications included severe PGD, which resulted in hospital deaths and late survival. The mean follow-up was 3.7 ± 2.7 years. RESULTS: Fourteen (6.7%) heart transplant recipients presented with severe PGD. Seven patients received a venoarterial extracorporeal membrane oxygenation device; 1 patient received a left ventricular assist device; 4 patients received a right ventricular assist device; and 2 patients received a biventricular assist device. Mean device support and explantation times were 4.7 ± 2 and 6.3 ± 2 days, respectively. Weaning with cardiac recovery was successful in 57.1% of the patients. The hospital mortality rate was 50%. Postoperative causes of morbidity included renal failure that necessitated dialysis in 28.5%, surgical re-exploration due to postoperative bleeding in 57.1%, pneumonia in 28.5%, sepsis in 14.2%, sternal wound infection in 14.2% and mediastinitis in 7.1% of the patients, respectively. There were no deaths following hospital discharge or later follow-up appointments. CONCLUSIONS: Mechanical support devices such as venoarterial extracorporeal membrane oxygenation specifically offer a reliable therapeutic approach. Recognizing the relatively high number of deaths in-hospital, patients who have cardiac recovery and a successful hospital discharge can expect a favourable late outcome.
Subject(s)
Extracorporeal Membrane Oxygenation/methods , Heart Transplantation/adverse effects , Heart-Assist Devices , Primary Graft Dysfunction/surgery , Adult , Female , Hospital Mortality , Humans , Male , Middle Aged , Postoperative Hemorrhage , Primary Graft Dysfunction/therapy , Sepsis , Treatment OutcomeABSTRACT
An infant unable to be weaned from cardiopulmonary bypass after orthotopic heart transplantation was cannulated for extracorporeal membrane oxygenation. During the next 3 days, allograft failure and intracardiac thrombosis necessitated cardiectomy. To provide acute mechanical circulatory support, artificial atrial chambers were constructed with Gore-Tex conduits and PediMag centrifugal pumps were connected to each by Berlin Heart EXCOR cannulae. The PediMag pumps were subsequently exchanged for 10-mL Berlin Heart EXCOR pumps. After 60 days of support by total artificial heart, the patient was bridged successfully to a second heart transplant.
Subject(s)
Heart Failure/surgery , Heart Transplantation/adverse effects , Heart, Artificial , Primary Graft Dysfunction/surgery , Female , Graft Survival , Heart Failure/etiology , Humans , InfantABSTRACT
BACKGROUND & AIMS: Primary nonfunction (PNF) is a rare complication after liver transplantation that requires urgent retransplantation. PNF is associated with livers from extended criteria donors. Clinical and biochemical factors have not been identified that reliably associate with graft function after liver transplantation. Serum patterns of N-glycans associate with changes in the liver. We analyzed perfusate from grafted liver to identify protein glycosylation patterns associated with PNF. METHODS: We performed a prospective study of consecutive patients who underwent liver transplantation (66 patients, from 1 center, in the derivation set, and 56 patients, from 2 centers, in the validation set) in Belgium, from October 1, 2011, through April 30, 2017. All donor grafts were transported using cold static storage, and perfusate samples were collected from the livers by flushing of hepatic veins before transplantation. Protein-linked N-glycans were isolated from perfusate samples and analyzed with a multicapillary electrophoresis-based ABI3130 sequencer. We compared glycan patterns between patients with vs without PNF of transplanted livers. PNF was defined as the need for urgent retransplantation when a graft had no evidence of function, after exclusion of other causes, such as hepatic artery thrombosis or acute cellular rejection. RESULTS: The relative abundance of a single glycan, agalacto core-alpha-1,6-fucosylated biantennary glycan (NGA2F) was significantly increased in perfusate of livers given to 4 patients who developed PNF after liver transplantation compared with livers given to patients who did not develop PNF. Level of NGA2F identified patients with PNF with 100% accuracy. This glycomarker was the only factor associated with PNF in multivariate analysis in the derivation and the validation sets (P < .0001). CONCLUSIONS: In an analysis of patients who underwent liver transplantation, we associated graft perfusate level of glycan NGA2F present on perfusate proteins with development of PNF with 100% accuracy, and validated this finding in a separate cohort of patients. This biomarker might be used to assess grafts before transplantation, especially when high-risk organs are under consideration.
Subject(s)
Blood Proteins/metabolism , Glycomics/methods , Liver Transplantation/adverse effects , Perfusion/adverse effects , Primary Graft Dysfunction/etiology , Protein Processing, Post-Translational , Tissue Donors , Adult , Aged , Belgium , Biomarkers/blood , Cold Ischemia/adverse effects , Electrophoresis, Capillary , Feasibility Studies , Female , Glycosylation , Humans , Liver Function Tests , Liver Transplantation/methods , Male , Middle Aged , Predictive Value of Tests , Primary Graft Dysfunction/blood , Primary Graft Dysfunction/diagnosis , Primary Graft Dysfunction/surgery , Proof of Concept Study , Prospective Studies , Reoperation , Risk Factors , Time Factors , Treatment Outcome , Up-RegulationABSTRACT
BACKGROUND: We reviewed the available literature on patients undergoing lung transplantation supported by cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO). METHODS: A systematic literature search was performed in three databases, in accordance with the PRISMA guidelines. Meta-analyses were used to compare the outcomes of ECMO and CPB procedures. RESULTS: Seven observational studies met the inclusion criteria incorporating 785 patients. ECMO support showed lower rate of primary graft dysfunction, bleeding, renal failure requiring dialysis, tracheostomy, intraoperative transfusions, intubation time, and hospital stay. Total support time was greater for the ECMO-supported group. No difference was reported between operative and ischemic time. CONCLUSIONS: The present study indicates that the intraoperative use of ECMO is associated with increased efficacy and safety, regarding short-term outcomes, compared to CPB. Well-designed, randomized studies, comparing ECMO to CPB, are necessary to assess their clinical outcomes further.
Subject(s)
Cardiopulmonary Bypass/methods , Extracorporeal Membrane Oxygenation/methods , Lung Transplantation/methods , Humans , Length of Stay , Primary Graft Dysfunction/surgery , Retrospective Studies , Treatment OutcomeABSTRACT
Primary nonfunction due to thrombosis after pancreas transplant is still the leading cause of nonimmunologic graft failure. Early identification of pancreatic graft arterial thrombus and prompt surgical intervention are effective for rescue of graft perfusion and its associated complications. Here, we report a case of successful surgical thrombectomy of the splenic artery, with particular emphasis on clinical presentation, diagnosis, and surgical technique.
Subject(s)
Arterial Occlusive Diseases/surgery , Pancreas Transplantation/adverse effects , Primary Graft Dysfunction/surgery , Splenic Artery/surgery , Thrombectomy , Thrombosis/surgery , Adult , Arterial Occlusive Diseases/diagnostic imaging , Arterial Occlusive Diseases/etiology , Arterial Occlusive Diseases/physiopathology , Computed Tomography Angiography , Female , Humans , Primary Graft Dysfunction/diagnostic imaging , Primary Graft Dysfunction/etiology , Primary Graft Dysfunction/physiopathology , Salvage Therapy , Splenic Artery/diagnostic imaging , Splenic Artery/physiopathology , Thrombosis/diagnostic imaging , Thrombosis/etiology , Thrombosis/physiopathology , Treatment Outcome , Ultrasonography, Doppler, Color , Vascular PatencyABSTRACT
Introducción: Después de transcurridos más de 50 años desde el primer trasplante de páncreas realizado en la Universidad de Minnesota, las técnicas quirúrgicas empleadas han experimentado muchas modificaciones. La colocación del injerto en posición retroperitoneal reproduce la fisiología del páncreas «nativo». El objetivo del estudio es presentar la experiencia de la aplicación de una técnica modificada, con el injerto pancreático en posición retroperitoneal, con drenaje venoso sistémico y duodenoduodenostomía para el drenaje entérico. Métodos: Análisis retrospectivo de los trasplantes de páncreas realizados entre mayo de 2016 y enero de 2017 en una sola institución. Resultados: Se incluyen un total de 10 trasplantes (6 hombres: mediana de edad de 41 años [IQR 36-54]). El tiempo de isquemia fría fue de 10,30 h [IQR 5,30-12,10]. La solución de preservación utilizada fue Celsior (n = 7), IGL-1 (n = 2) y UW (n = 1). No se han identificado complicaciones relacionadas directamente con la posición retroperitoneal y la derivación duodenoduodenal. Un paciente requirió trasplantectomía a las 12 h por trombosis del injerto proveniente de un donante con paro cardiorrespiratorio prolongado. Otro procedimiento fue abortado debido a una trombosis arterial intraoperatoria en un paciente con ateromatosis ilíaca grave. Los restantes pacientes presentaron una correcta función del injerto, sin requerimientos de insulina. La estancia hospitalaria fue de 13,50 días (IQR 10-27). Conclusiones: La colocación del injerto retroperitoneal es una técnica factible, que permite un fácil acceso para la disección de los vasos y posterior reconstrucción vascular y que minimiza, a su vez, el riesgo de oclusión intestinal (AU)
Introduction: In the 50 years since the first pancreas transplant performed at the University of Minnesota, the surgical techniques employed have undergone many modifications. Techniques such as retroperitoneal graft placement have further improved the ability to reproduce the physiology of the «native» pancreas. We herein present our experience of a modified technique for pancreatic transplant, with the organ placed into a fully retroperitoneal position with systemic venous and enteric drainage of the graft by duodeno-duodenostomy. Methods: All pancreas transplantations performed between May 2016 and January 2017 were prospectively entered into our transplant database and retrospectively analyzed. Results: A total of 10 transplants were performed using the retroperitoneal technique (6 men: median age of 41 years [IQR 36-54]). Median cold ischemia times was 10,30 h [IQR 5,30-12,10]. The preservation solution used was Celsior (n = 7), IGL-1 (n = 2), and UW ( n= 1). No complications related to the new surgical technique were identified. In one patient, transplantectomy at 12 h was performed due to graft thrombosis, probably related to ischemic conditions from a donor with prolonged cardio-respiratory arrest. Another procedure was aborted without completing the graft implant due to an intraoperative immediate arterial thrombosis in a patient with severe iliac atheromatosis. No primary pancreas non-function occurred in the remaining 8 patients. The median hospital stay was 13,50 days [IQR 10-27]. Conclusions: Retroperitoneal graft placement appears feasible with easy access for dissection the vascular site; comfortable technical vascular reconstruction; and a decreased risk of intestinal obstruction by separation of the small bowel from the pancreas graft (AU)
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Pancreas Transplantation/methods , Surgical Flaps , Retroperitoneal Space , Retrospective Studies , Primary Graft Dysfunction/surgery , Graft Rejection/epidemiology , Graft SurvivalABSTRACT
OBJECTIVE: Early allograft dysfunction may be caused by several technical factors including vascular complications such as thrombosis, kinking, or extrinsic compression. Renal allograft compartment syndrome (RACS) is an unrecognized cause of early allograft dysfunction. This complication is characterized by increased pressure of the iliac fossa that reduces the blood supply to the graft with a potentially devastating consequence. The main objective when recognizing this condition is to create a tension-free muscle closure. Many approaches have been proposed involving mesh such as the mesh hood fascial closure technique.1-4 PATIENT AND METHODS: We describe in the video an RACS during an operation. The recipient is a 23-year-old young man with a body mass index of 22, with renal failure secondary to chronic reflux. Past history of failure to peritoneal dialysis currently on hemodialysis. He received a living donor's kidney. After performing a standard anastomosis, his urine output was brisk. The fascia was then closed with no force, at which point he stopped making urine. A RACS was suspected; intraoperative examination and ultrasound showed no flow in the graft, with no signs of kinking. Immediately, reexploration was performed, showing the graft with abnormal color and turgor. After relieving the pressure, the graft returned to normal. The closure was redone with a large ellipsoid piece of polypropylene mesh draped loosely and without tension over the graft. RESULTS: A Doppler ultrasound, after the skin closure was performed, showed good flow, and the postoperative course was unremarkable. There was minimal bulking in the right iliac area, making it cosmetically acceptable. CONCLUSION: RACS could be associated with a lack of compliance in the retroperitoneal cavity.5 The RACS required a prompt intervention. The timely suspicion is a watershed in the prognosis of this rare pathology. We propose that mesh hood fascial closure is easy, effective, and a safe method to treat these complications.
Subject(s)
Compartment Syndromes/surgery , Kidney Transplantation/adverse effects , Primary Graft Dysfunction/complications , Salvage Therapy/methods , Surgical Mesh , Compartment Syndromes/diagnosis , Compartment Syndromes/etiology , Humans , Male , Primary Graft Dysfunction/diagnosis , Primary Graft Dysfunction/surgery , Retroperitoneal Space , Transplantation, Homologous , Ultrasonography, Doppler , Young AdultABSTRACT
PURPOSE: Liver retransplantation is the only therapeutic option for patients with graft failure after liver transplantation. The aim of this study is to evaluate the outcomes of pediatric retransplantation from living donor at a single center. METHODS: Between December 1998 to August 2015, retransplantation from a living donor was performed for 14 children (<18 years of age) at Kumamoto University Hospital. The characteristics of the retransplantation recipient and the clinicopathological factors between primary transplantation and retransplantation were analyzed to detect the prognostic factors. RESULTS: In retransplantation, the operative time was longer and the amount of blood loss was greater in comparison to primary transplantation. The 1-, 3-, and 5-year survival rates from the date of retransplantation were 85.7, 85.7, and 78.6%, respectively. The rates of re-laparotomy after primary transplantation, bile leakage and postoperative bleeding after retransplantation were higher than after primary transplantation. Among the three patients who died after retransplantation, the operative time, the rate of re-laparotomy after primary transplantation and the incidence of gastrointestinal complications were higher in comparison to the surviving patients. CONCLUSION: Pediatric retransplantation from a living donor is an acceptable procedure that could save the lives of recipients with failing allografts when organs from deceased donors are scarce. To ensure good results, it is essential to make an appropriate assessment of the cardiopulmonary function and the infectious state of the patients before Re-LDLT.
Subject(s)
Liver Transplantation , Living Donors , Primary Graft Dysfunction/surgery , Adolescent , Allografts , Child , Child, Preschool , Female , Humans , Infant , Male , Primary Graft Dysfunction/diagnosis , Primary Graft Dysfunction/etiology , Reoperation , Treatment OutcomeABSTRACT
Single living-donor lobar lung transplantation provides acceptable results for critically ill children; however, an additional lung transplantation may be required in the future as the recipient grows. We describe a case of successful lung retransplantation in a grown-up patient after single lobar lung transplantation in childhood. A 23-year-old man underwent bilateral cadaveric lung retransplantation for chronic lung allograft dysfunction 13 years after right single living-donor lobar transplantation for idiopathic pulmonary arterial hypertension performed at the age of 10 years. The postoperative course was uneventful. The patient had received growth hormone therapy at a local hospital for 3 years until the development of chronic lung allograft dysfunction after the initial transplantation. Pediatric recipients undergoing single living-donor lobar lung transplantation should be cautiously followed for potential retransplantation.
Subject(s)
Hypertension, Pulmonary/surgery , Lung Transplantation/methods , Primary Graft Dysfunction/surgery , Allografts , Humans , Living Donors , Male , Reoperation , Young AdultABSTRACT
BACKGROUND: A large proportion of donor lungs are discarded due to known or presumed organ dysfunction. Ex vivo lung perfusion (EVLP) has proven its value as a tool for discrimination between reversible and irreversible donor lung pathology. However, the long-term outcome after transplantation of lungs after EVLP is essentially unknown. We report short-term and midterm outcomes of recipients who received transplants of EVLP-evaluated lungs. METHODS: Single-center results of recipients of lungs with prior EVLP were compared with consecutive recipients of non-EVLP lungs (controls) during the same period. Short-term follow-up included time to extubation, time in the intensive care unit, and the presence of primary graft dysfunction at 72 hours postoperatively. Mortality and incidence of chronic lung allograft dysfunction were monitored for up to 4 years after discharge. RESULTS: During a 4-year period, 32 pairs of initially rejected donor lungs underwent EVLP. After EVLP, 22 double lungs and 5 single lungs were subsequently transplanted. During this period, 145 patients received transplants of conventional donor lungs that did not have EVLP and constituted the control group. Median time to extubation was 7 hours in the EVLP group and 6 hours in the non-EVLP control group (p = 0.45). Median intensive care unit stay was 4 days vs. 3 days, respectively (p = 0.15). Primary graft dysfunction grade > 1 was present in 14% in the EVLP group and in 12% in the non-EVLP group at 72 hours after transplant. Survival at 1 year was 92% in the EVLP group and 79% in the non-EVLP group. Cumulative survival and freedom from retransplantation or chronic rejection were also comparable between the 2 groups (p = 0.43) when monitored up to 4 years. CONCLUSIONS: Selected donor lungs rejected for transplantation can be used after EVLP. This technique is effective for selection of transplantable donor lungs. Patients who received lungs evaluated under EVLP have short-term and midterm outcomes comparable to recipients of non-EVLP donor lungs.
Subject(s)
Coronary Artery Disease/surgery , Graft Survival , Lung Transplantation/methods , Lung/diagnostic imaging , Perfusion/adverse effects , Primary Graft Dysfunction/surgery , Female , Follow-Up Studies , Humans , Incidence , Male , Middle Aged , Primary Graft Dysfunction/epidemiology , Primary Graft Dysfunction/etiology , Retrospective Studies , Survival Rate/trends , Time Factors , Treatment Outcome , United States/epidemiologyABSTRACT
BACKGROUND: Lung transplantation (LT) is the final treatment option for patients with pulmonary arterial hypertension (PAH). Perioperative challenges after LT are unique and commonly include excessive bleeding, arrhythmias, and primary graft dysfunction. Transient left ventricular dysfunction (LVD) is a known postoperative complication, but not fully explored. We describe our experiences at a single institution. METHODS: We reviewed our database for patients with PAH who underwent LT from July 2008 to July 2012. The data were analyzed for preoperative inotrope use, intravenous prostacyclin, cardiac catheterization, and imaging. Also measured were perioperative ischemic time, bypass time, primary graft dysfunction, ventilator days, length of stay, and mortality. LVD is defined as acute cardiopulmonary compromise (acute worsening of hypoxia with new bilateral infiltrates on imaging) with a drop in LV systolic function of 15% from baseline. We compared data between patients with LVD and without LVD. RESULTS: Sixteen patients met the criteria, the majority of patients (10) with World Health Organization (WHO) group 1 PAH. Thirteen received intravenous prostacyclin therapy, and 6 required inotropes before surgery. Five patients (31%) developed LVD after transplantation. Average time to onset of LVD was 4.2 days. Preoperative vasopressors were required in 60% of those developing LVD. Patients with LVD had lower right and left ventricular ejection fraction with higher left ventricular end diastolic volume before surgery. All patients recovered from LVD within 4 months after LT. CONCLUSIONS: LVD is a phenomenon observed mostly in patients with WHO group 1 PAH receiving LT. Prompt recognition and treatment of this condition reduced morbidity.
Subject(s)
Hypertension, Pulmonary/surgery , Lung Transplantation/adverse effects , Postoperative Complications/etiology , Ventricular Dysfunction, Left/etiology , Adult , Antihypertensive Agents/therapeutic use , Cardiac Catheterization , Cardiotonic Agents/therapeutic use , Epoprostenol/therapeutic use , Female , Follow-Up Studies , Humans , Length of Stay , Male , Middle Aged , Postoperative Complications/physiopathology , Preoperative Care/methods , Primary Graft Dysfunction/etiology , Primary Graft Dysfunction/surgery , Retrospective Studies , Ventricular Dysfunction, Left/physiopathology , Ventricular Function, LeftABSTRACT
We sought to determine whether ventricular assist device (VAD) support is an effective therapy in children with cardiac graft dysfunction. We conducted a retrospective review of VAD usage in this scenario at our institution. Although short-term VAD support was highly successful (89% [eight out of nine] were bridged to recovery), only 29% (2 out of 7) with long-term VAD survived to retransplant. Of note, three out of five mortalities with long-term VAD were related to sepsis (two fungal and one Gram-negative bacterial). Infectious risk imposed by ongoing immunosuppressive therapy limits the role of long-term VAD in this population.