Surgical Complications After Lung Transplantation: The Reina Sofía Hospital Experience.

OBJECTIVE: To assess the incidence of surgical complications after lung transplantation and its influence on early mortality and long-term survival. METHODS: Retrospective review of 792 lung transplants (LTs) performed from 1994 to 2022. Among them, 769 with complete data were selected. Patients with and without surgical complications were compared by univariable and multivariable analyses. RESULTS: There were 385 single LTs (50%), 371 double LTs (48%), 8 bilobar LTs (1%), and 5 combined liver LTs (1%). Two hundred forty-nine patients presented surgical complications (32%) as follows: bronchial (n = 61), vascular (n = 55), pneumothorax (n = 33), and phrenic nerve palsy (n = 22). Thirty-day mortality (noncomplicated vs complicated) was 57 (41%) vs 80 (59%), P < .001. Transplants for bronchiectasis (58%), pulmonary hypertension (50%), and re-transplants (78%) presented more surgical complications (P < .001). Double LT (40%), bilobar LT (88%), and combined liver LT (100%) presented more surgical complications (P < .001). Complicated recipients were younger (49 ± 15 vs 45 ± 17 years; P = .001), with longer ischemic times (429 ± 67 vs 450 ± 76 min [2nd graft]; P = .007), and required extracorporeal support (ECLS) more often (43% vs 57%; P < .001). Survival at 1, 5, 10, 15, and 20 years (noncomplicated vs complicated): 78%, 63%, 52%, 41%, 31% vs 52%, 42%, 35%, 26%, 22%; P < .001). Predictors of mortality were the need for ECLS (odds ratio [OR] 4.14; P < .001), postoperative ventilation (hours) (OR 1.01; P < .001), and vascular complications (OR 4.78; P < .001). CONCLUSION: Surgical complications remain an important source of morbidity and mortality after lung transplantation. Complex surgical procedures requiring ECLS develop frequent surgical complications needing long postoperative ventilation that are associated with early mortality and poorer long-term survival.

Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation.

BACKGROUND: We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. CASE REPORT: A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. CONCLUSION: Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.

Influence of Donor Type-Donation After Brain Death Versus Donation After Circulatory Death-on Lung Transplant Outcomes.

BACKGROUND: We sought to analyze the influence of lung donor type (brain death [BD] vs controlled donation after cardiac death [DCD]) on lung graft viability and to compare short-term outcomes of lung transplantation using grafts from BD and DCD donors. METHODS: This was a retrospective study of the lung donor population and lung transplants performed at our Institution between January 2020 and December 2022. Demographic characteristics of the donors and donation type (BD vs DCD) were assessed. Lung graft viability rate and post-transplant outcomes were analyzed and compared between donor types. RESULTS: There were 203 donors; among them, 149 (73%) were viable. There were 176 BD donors (87%) and 27 DCD donors (13%), with viability rates of 75% and 59%, respectively, performing 81 single (40%) and 122 double-lung transplants (60%). Recipient PaO2/fraction of inspired oxygen and primary graft dysfunction at 24 and 72 hours did not differ between donor types. Thirty-day mortality did not differ between recipients from BD donors and recipients from DCD donors: n = 28 (21%) vs n = 3 (18%), respectively (P = .81). CONCLUSIONS: Donation after cardiac death donors is a safe source to increase the donor pool for lung transplantation, allowing similar short-term outcomes as lung transplants from BD donors regarding graft function and early survival.

Influence of De Novo Malignancies on Long-Term Survival after Lung Transplantation.

(1) Background: Malignancies are an important cause of mortality after solid organ transplantation. The purpose of this study was to analyze the incidence of malignancies in patients receiving lung transplants (LT) and their influence on patients' survival. (2) Methods: Review of consecutive LT from 1994 to 2021. Patients with and without malignancies were compared by univariable and multivariable analyses. Survival was compared with Kaplan-Meier and Cox regression analysis. (3) Results: There were 731 LT malignancies developed in 91 patients (12.4%) with related mortality of 47% (n = 43). Native lung cancer, digestive and hematological malignancies were associated with higher lethality. Malignancies were more frequent in males (81%; p = 0.005), transplanted for emphysema (55%; p = 0.003), with cyclosporine-based immunosuppression (58%; p < 0.001), and receiving single LT (65%; p = 0.011). Survival was worse in patients with malignancies (overall) and with native lung cancer. Risk factors for mortality were cyclosporine-based immunosuppression (OR 1.8; 95%CI: 1.3-2.4; p < 0.001) and de novo lung cancer (OR 2.6; 95%CI: 1.5-4.4; p < 0.001). (4) Conclusions: Malignancies are an important source of morbidity and mortality following lung transplantation that should not be neglected. Patients undergoing single LT for emphysema are especially at higher risk of mortality due to lung cancer in the native lung.

Relationship Among Radiological Measurements of Anterior Mediastinal Fat and Outcomes of Lung Transplantation in Fibrotic Patients / Relación entre las medidas radiológicas de la grasa mediastínica anterior y los resultados del trasplante de pulmón en pacientes con fibrosis

OBJECTIVE: Lung transplantation (LT) for pulmonary fibrosis is related to higher mortality than other transplant indications. We aim to assess whether the amount of anterior mediastinal fat (AMF) was associated to early and long-term outcomes in fibrotic patients undergoing LT. METHODS: Retrospective analysis of 92 consecutive single lung transplants (SLT) for pulmonary fibrosis over a 10-year period. AMF dimensions were measured on preoperative CT-scan: anteroposterior axis (AP), transverse axis (T), and height (H). AMF volumes (V) were calculated by the formula: AP×T×H×3.14/6. According to the radiological AMF dimensions, patients were distributed into two groups: low-AMF (V < 20 cm3) and high-AMF (V > 20 cm3), and early and long-term outcomes were compared by univariable and multivariable analyses. RESULTS: There were 92 SLT: 73M/19F, 53 ± 11 [14-68] years old. 30-Day mortality (low-AMF vs. high-AMF): 5 (5.4%) vs. 15 (16.3%), p = 0.014. Patients developing primary graft dysfunction within 72 h post-transplant, and those dying within 30 days post-transplant presented higher AMF volumes: 21.1 ± 19.8 vs. 43.3 ± 24.7 cm3 (p = 0.03) and 24.4 ± 24.2 vs. 56.9 ± 63.6 cm3 (p < 0.01) respectively. Overall survival (low-AMF vs. high-AMF) (1, 3, and 5 years): 85%, 81%, 78% vs. 55%, 40%, 33% (p < 0.001). Factors predicting 30-day mortality were: BMI (HR = 0.77, p = 0.011), AMF volume (HR = 1.04, p = 0.018), CPB (HR = 1.42, p = 0.002), ischaemic time (HR = 1.01, p = 0.009). Factors predicting survival were: AMF volume (HR=1.02, p < 0.001), CPB (HR = 3.17, p = 0.003), ischaemic time (HR = 1.01, p = 0.001). CONCLUSION: Preoperative radiological assessment of mediastinal fat dimensions and volumes may be a useful tool to identify fibrotic patients at higher risk of mortality after single lung transplantation

OBJETIVO: El trasplante de pulmón (TP) para el tratamiento de la fibrosis pulmonar está relacionado con una mayor mortalidad que otras indicaciones de trasplante. Nuestro objetivo es evaluar si la cantidad de grasa mediastínica anterior (GMA) se asoció a los diferentes resultados tempranos y a largo plazo en pacientes con fibrosis a los que se les realizó un TP. MÉTODOS: Análisis retrospectivo de 92 trasplantes de pulmón unilaterales (TPU) consecutivos para el tratamiento de la fibrosis pulmonar durante un período de 10 años. Se midieron las dimensiones de la GMA en la TC preoperatoria: eje anteroposterior (AP), eje transversal (T) y altura (A). Los volúmenes de GMA (V) se calcularon mediante la fórmula: AP×T×A×3,14/6. Según las dimensiones radiológicas de la GMA, los pacientes se distribuyeron en 2 grupos: GMA baja (V < 20 cm3) y GMA alta (V > 20 cm3), y los resultados tempranos y a largo plazo se compararon mediante análisis univariables y multivariables. RESULTADOS: Se realizaron 92 TPU: 73V/19M, 53 ± 11 (14-68) años. Mortalidad a 30 días (GMA baja frente a GMA alta): 5 (5,4%) frente a 15 (16,3%); p = 0,014. Los pacientes que desarrollaron disfunción precoz del injerto dentro de las 72 h posteriores al trasplante, y los que murieron dentro de los 30 días posteriores al trasplante presentaron mayores volúmenes de GMA: 21,1±19,8 frente a 43,3 ± 24,7 cm3 (p = 0,03) y 24,4 ± 24,2 frente a 56,9 ± 63,6 cm3 (p < 0,01), respectivamente. Supervivencia global (GMA baja frente a GMA alta) (a los 1, 3 y 5 años): 85, 81 y 78% frente al 55, 40 y 33% (p < 0,001), respectivamente. Los factores que predijeron la mortalidad a los 30 días fueron: IMC (HR = 0,77; p = 0,011), volumen de la GMA (HR = 1,04; p = 0,018), CEC (HR = 1,42; p = 0,002), tiempo de isquemia (HR=1,01; p = 0,009). Los factores que predijeron la supervivencia fueron: volumen GMA (HR = 1,02; p < 0,001), CEC (HR = 3,17; p = 0,003) y tiempo de isquemia (HR = 1,01; p = 0,001)

Relationship Among Radiological Measurements of Anterior Mediastinal Fat and Outcomes of Lung Transplantation in Fibrotic Patients.

OBJECTIVE: Lung transplantation (LT) for pulmonary fibrosis is related to higher mortality than other transplant indications. We aim to assess whether the amount of anterior mediastinal fat (AMF) was associated to early and long-term outcomes in fibrotic patients undergoing LT. METHODS: Retrospective analysis of 92 consecutive single lung transplants (SLT) for pulmonary fibrosis over a 10-year period. AMF dimensions were measured on preoperative CT-scan: anteroposterior axis (AP), transverse axis (T), and height (H). AMF volumes (V) were calculated by the formula: AP×T×H×3.14/6. According to the radiological AMF dimensions, patients were distributed into two groups: low-AMF (V<20cm3) and high-AMF (V>20cm3), and early and long-term outcomes were compared by univariable and multivariable analyses. RESULTS: There were 92 SLT: 73M/19F, 53±11 [14-68] years old. 30-Day mortality (low-AMF vs. high-AMF): 5 (5.4%) vs. 15 (16.3%), p=0.014. Patients developing primary graft dysfunction within 72h post-transplant, and those dying within 30 days post-transplant presented higher AMF volumes: 21.1±19.8 vs. 43.3±24.7cm3 (p=0.03) and 24.4±24.2 vs. 56.9±63.6cm3 (p<0.01) respectively. Overall survival (low-AMF vs. high-AMF) (1, 3, and 5 years): 85%, 81%, 78% vs. 55%, 40%, 33% (p<0.001). Factors predicting 30-day mortality were: BMI (HR=0.77, p=0.011), AMF volume (HR=1.04, p=0.018), CPB (HR=1.42, p=0.002), ischaemic time (HR=1.01, p=0.009). Factors predicting survival were: AMF volume (HR=1.02, p<0.001), CPB (HR=3.17, p=0.003), ischaemic time (HR=1.01, p=0.001). CONCLUSION: Preoperative radiological assessment of mediastinal fat dimensions and volumes may be a useful tool to identify fibrotic patients at higher risk of mortality after single lung transplantation.