Brazilian initial experience with lung transplantation due to irreversible lung fibrosis post-COVID-19 in a national reference center: a cohort study

ABSTRACT BACKGROUND: Lung transplantation (LTx) has been discussed as an option for treating irreversible lung fibrosis post-coronavirus disease 2019 (COVID-19), in selected cases. OBJECTIVES: To report on the initial experience and management of end-stage lung disease due to COVID-19 at a national center reference in Brazil. DESIGN AND SETTING: Cohort study conducted at a national reference center for lung transplantation. METHODS: Medical charts were reviewed regarding patients' demographics and pre-COVID-19 characteristics, post-LTx due to COVID-19. RESULTS: Between March 2020 and September 2021, there were 33 cases of LTx. During this period, we evaluated 11 cases of severe COVID-19-related acute respiratory distress syndrome (ARDS) that were potentially candidates for LTx. Among these, LTx was only indicated for three patients (9.1%). All of these patients were on venovenous extracorporeal membrane oxygenation (ECMO), and the procedure that they underwent was central venoarterial ECMO. All three patients were still alive after the first 30 postoperative days. However, patient #1 and patient #2 subsequently died due to fungal sepsis on the 47th and 52nd postoperative days, respectively. Patient #3 was discharged on the 30th postoperative day. CONCLUSIONS: LTx is feasible among these complex patients. Survival over the first 30 days was 100%, and this favors surgical feasibility. Nonetheless, these were critically ill patients.

Brazilian initial experience with lung transplantation due to irreversible lung fibrosis post-COVID-19 in a national reference center: a cohort study.

BACKGROUND: Lung transplantation (LTx) has been discussed as an option for treating irreversible lung fibrosis post-coronavirus disease 2019 (COVID-19), in selected cases. OBJECTIVES: To report on the initial experience and management of end-stage lung disease due to COVID-19 at a national center reference in Brazil. DESIGN AND SETTING: Cohort study conducted at a national reference center for lung transplantation. METHODS: Medical charts were reviewed regarding patients' demographics and pre-COVID-19 characteristics, post-LTx due to COVID-19. RESULTS: Between March 2020 and September 2021, there were 33 cases of LTx. During this period, we evaluated 11 cases of severe COVID-19-related acute respiratory distress syndrome (ARDS) that were potentially candidates for LTx. Among these, LTx was only indicated for three patients (9.1%). All of these patients were on venovenous extracorporeal membrane oxygenation (ECMO), and the procedure that they underwent was central venoarterial ECMO. All three patients were still alive after the first 30 postoperative days. However, patient #1 and patient #2 subsequently died due to fungal sepsis on the 47th and 52nd postoperative days, respectively. Patient #3 was discharged on the 30th postoperative day. CONCLUSIONS: LTx is feasible among these complex patients. Survival over the first 30 days was 100%, and this favors surgical feasibility. Nonetheless, these were critically ill patients.

Assessment of Pulmonary Function before and after Sinus Surgery in Lung Transplant Recipients

Abstract Introduction The association between sinus and lung diseases is well known. However, there are scarce studies regarding the effects of sinus surgery on pulmonary function in lung transplant recipients. The present study describes our experience with sinus surgery in lung transplant recipients with chronic rhinosinusitis. Objectives To assess the impact of sinus surgery for chronic rhinosinusitis on pulmonary function and on inpatient hospitalization days due to lower respiratory tract infection in lung transplant recipients. Methods A retrospective study conducted between 2006 and 2012 on a sample of lung transplant recipients undergoing sinus surgery for chronic rhinosinusitis. Pulmonary function, measured by forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), as well as inpatient hospitalization days due to lower respiratory tract infection, were compared 6 months before and 6 months after sinus surgery. Results The FEV1 values increased significantly, and the inpatient hospitalization days due to bronchopneumonia decreased significantly 6 months after sinus surgery. The preoperative and postoperative median FEV1 values were 2.35 and 2.68 respectively (p = 0.0056). The median number of inpatient hospitalization days due to bronchopneumonia 6 months before and 6 months after surgery were 32.82 and 5.41 respectively (p = 0.0013). Conclusion In this sample of lung transplant recipients with chronic rhinosinusitis, sinus surgery led to an improvement in pulmonary function and a decrease in inpatient hospitalization days due to bronchopneumonia.

Assessment of Pulmonary Function before and after Sinus Surgery in Lung Transplant Recipients.

Introduction The association between sinus and lung diseases is well known. However, there are scarce studies regarding the effects of sinus surgery on pulmonary function in lung transplant recipients. The present study describes our experience with sinus surgery in lung transplant recipients with chronic rhinosinusitis. Objectives To assess the impact of sinus surgery for chronic rhinosinusitis on pulmonary function and on inpatient hospitalization days due to lower respiratory tract infection in lung transplant recipients. Methods A retrospective study conducted between 2006 and 2012 on a sample of lung transplant recipients undergoing sinus surgery for chronic rhinosinusitis. Pulmonary function, measured by forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1), as well as inpatient hospitalization days due to lower respiratory tract infection, were compared 6 months before and 6 months after sinus surgery. Results The FEV1 values increased significantly, and the inpatient hospitalization days due to bronchopneumonia decreased significantly 6 months after sinus surgery. The preoperative and postoperative median FEV1 values were 2.35 and 2.68 respectively ( p = 0.0056 ). The median number of inpatient hospitalization days due to bronchopneumonia 6 months before and 6 months after surgery were 32.82 and 5.41 respectively ( p = 0.0013 ). Conclusion In this sample of lung transplant recipients with chronic rhinosinusitis, sinus surgery led to an improvement in pulmonary function and a decrease in inpatient hospitalization days due to bronchopneumonia.

Lung transplantation: overall approach regarding its major aspects / Transplante pulmonar: abordagem geral sobre seus principais aspectos

ABSTRACT Lung transplantation is a well-established treatment for patients with advanced lung disease. The evaluation of a candidate for transplantation is a complex task and involves a multidisciplinary team that follows the patient beyond the postoperative period. Currently, the mean time on the waiting list for lung transplantation in the state of São Paulo, Brazil, is approximately 18 months. For Brazil as a whole, data from the Brazilian Organ Transplant Association show that, in 2014, there were 67 lung transplants and 204 patients on the waiting list for lung transplantation. Lung transplantation is most often indicated in cases of COPD, cystic fibrosis, interstitial lung disease, non-cystic fibrosis bronchiectasis, and pulmonary hypertension. This comprehensive review aimed to address the major aspects of lung transplantation: indications, contraindications, evaluation of transplant candidates, evaluation of donor candidates, management of transplant recipients, and major complications. To that end, we based our research on the International Society for Heart and Lung Transplantation guidelines and on the protocols used by our Lung Transplant Group in the city of São Paulo, Brazil.

RESUMO O transplante pulmonar é uma terapia bem estabelecida para pacientes com doença pulmonar avançada.A avaliação do candidato para o transplante é uma tarefa complexa e envolve uma equipe multidisciplinar que acompanha o paciente para além do período pós-operatório.O tempo médio atual em lista de espera para transplante pulmonar é de aproximadamente 18 meses no estado de São Paulo. Em 2014, dados da Associação Brasileira de Transplante de Órgãos mostram que 67 transplantes pulmonares foram realizados no Brasil e que 204 pacientes estavam na lista de espera para transplante pulmonar.O transplante pulmonar é principalmente indicado no tratamento de DPOC, fibrose cística, doença intersticial pulmonar, bronquiectasia não fibrocística e hipertensão pulmonar.Esta revisão abrangente teve como objetivos abordar os aspectos principais relacionados ao transplante pulmonar: indicações, contraindicações, avaliação do candidato ao transplante, avaliação do candidato doador, gestão do paciente transplantado e complicações maiores. Para atingirmos tais objetivos, utilizamos como base as diretrizes da Sociedade Internacional de Transplante de Coração e Pulmão e nos protocolos de nosso Grupo de Transplante Pulmonar localizado na cidade de São Paulo.

Psychological criteria for contraindication in lung transplant candidates: a five-year study.

Lung transplantation presents a wide range of challenges for multidisciplinary teams that manage the care of the recipients. Transplant teams should perform a thorough evaluation of transplant candidates, in order to ensure the best possible post-transplant outcomes. That is especially true for the psychologist, because psychological issues can arise at any point during the perioperative period. The objective of our study was to evaluate the psychological causes of contraindication to waiting list inclusion in a referral program for lung transplantation. We retrospectively analyzed data on psychological issues presented by lung transplant candidates, in order to understand these matters in our population and to reflect upon ways to improve the selection process.

Lung transplantation.

Lung transplantation is a globally accepted treatment for some advanced lung diseases, giving the recipients longer survival and better quality of life. Since the first transplant successfully performed in 1983, more than 40 thousand transplants have been performed worldwide. Of these, about seven hundred were in Brazil. However, survival of the transplant is less than desired, with a high mortality rate related to primary graft dysfunction, infection, and chronic graft dysfunction, particularly in the form of bronchiolitis obliterans syndrome. New technologies have been developed to improve the various stages of lung transplant. To increase the supply of lungs, ex vivo lung reconditioning has been used in some countries, including Brazil. For advanced life support in the perioperative period, extracorporeal membrane oxygenation and hemodynamic support equipment have been used as a bridge to transplant in critically ill patients on the waiting list, and to keep patients alive until resolution of the primary dysfunction after graft transplant. There are patients requiring lung transplant in Brazil who do not even come to the point of being referred to a transplant center because there are only seven such centers active in the country. It is urgent to create new centers capable of performing lung transplantation to provide patients with some advanced forms of lung disease a chance to live longer and with better quality of life.

Lung transplantation / Transplante pulmonar

ABSTRACT Lung transplantation is a globally accepted treatment for some advanced lung diseases, giving the recipients longer survival and better quality of life. Since the first transplant successfully performed in 1983, more than 40 thousand transplants have been performed worldwide. Of these, about seven hundred were in Brazil. However, survival of the transplant is less than desired, with a high mortality rate related to primary graft dysfunction, infection, and chronic graft dysfunction, particularly in the form of bronchiolitis obliterans syndrome. New technologies have been developed to improve the various stages of lung transplant. To increase the supply of lungs, ex vivo lung reconditioning has been used in some countries, including Brazil. For advanced life support in the perioperative period, extracorporeal membrane oxygenation and hemodynamic support equipment have been used as a bridge to transplant in critically ill patients on the waiting list, and to keep patients alive until resolution of the primary dysfunction after graft transplant. There are patients requiring lung transplant in Brazil who do not even come to the point of being referred to a transplant center because there are only seven such centers active in the country. It is urgent to create new centers capable of performing lung transplantation to provide patients with some advanced forms of lung disease a chance to live longer and with better quality of life.

RESUMO O transplante pulmonar é um tratamento mundialmente aceito para alguma pneumopatias avançadas, conferindo aos receptores maior sobrevida e melhor qualidade de vida. Desde o primeiro transplante realizado com sucesso em 1983, mais de 40 mil transplantes foram feitos em todo mundo. Destes, cerca de 700 foram no Brasil. No entanto, a sobrevida do transplante é menor do que a desejada, com altos índices de mortalidade relacionados à disfunção primária do enxerto, infecções e disfunção crônica do enxerto, principalmente sob a forma da síndrome da bronquiolite obliterante. Novas tecnologias têm sido desenvolvidas para aprimoramento das diversas etapas do transplante pulmonar. Para aumentar a oferta de pulmões, o recondicionamento pulmonar ex vivo vem sendo utilizado em alguns países, inclusive no Brasil. Para suporte avançado de vida no período perioperatório, equipamentos de oxigenação extracorpórea e de suporte hemodinâmico vêm sendo utilizado como ponte para o transplante em pacientes gravemente doentes em lista de espera e para manter pacientes vivos até a resolução da disfunção primária do enxerto pós-transplante. Existe uma demanda reprimida de pacientes que necessitam de transplante pulmonar no Brasil e que nem sequer chegam a ser encaminhados a um centro transplantador, pois só existem sete deles ativos no país. É urgente a criação de novos centros capazes de realizar transplante pulmonar para oferecer a pacientes com algumas pneumopatias avançadas uma chance de viver mais e com melhor qualidade de vida.

Lung transplantation: overall approach regarding its major aspects.

Lung transplantation is a well-established treatment for patients with advanced lung disease. The evaluation of a candidate for transplantation is a complex task and involves a multidisciplinary team that follows the patient beyond the postoperative period. Currently, the mean time on the waiting list for lung transplantation in the state of São Paulo, Brazil, is approximately 18 months. For Brazil as a whole, data from the Brazilian Organ Transplant Association show that, in 2014, there were 67 lung transplants and 204 patients on the waiting list for lung transplantation. Lung transplantation is most often indicated in cases of COPD, cystic fibrosis, interstitial lung disease, non-cystic fibrosis bronchiectasis, and pulmonary hypertension. This comprehensive review aimed to address the major aspects of lung transplantation: indications, contraindications, evaluation of transplant candidates, evaluation of donor candidates, management of transplant recipients, and major complications. To that end, we based our research on the International Society for Heart and Lung Transplantation guidelines and on the protocols used by our Lung Transplant Group in the city of São Paulo, Brazil.

Tromboendarterectomia na hipertensão pulmonar tromboembólica / Thromboendarterectomy on thromboembolic pulmonary hypertension

Após a tromboembolia pulmonar, cerca de 1% a 3% dos pacientes desenvolvem embolismo crônico, seguido de elevação da pressão da artéria pulmonar e aumento da resistência vascular pulmonar. O aumento contínuo da pressão vascular leva ao remodelamento das pequenas artérias. Em pacientes selecionados, a tromboendarterectomia pulmonar é o procedimento de escolha para o tratamento da hipertensão pulmonar tromboembólica, com redução significativa da pressão pulmonar e melhora hemodinâmica. A morbimortalidade dessa cirurgia vem diminuindo progressivamente, especialmente nos centros com maior número de procedimentos. A melhora da qualidade de vida é evidente e grande parte dos pacientes retorna às suas atividades habituais...

After pulmonary embolism, 1% to 3% of these patients develop a chronic embolism, with elevated pulmonary artery pressure and increased pulmonary vascular resistance. The continuous elevated pressure leads to the remodeling of the small arteries. In selected patients, pulmonary thromboendarterectomy is the procedure of choice for the treatment of thromboembolic pulmonary hypertension, with significant reduction in pulmonary pressure and hemodynamic improvement.The morbidity and mortality of this surgery has been decreasing steadily, especially in centers with larger numbers of procedures. The improvement in quality of life is evident and most patients return to their usual activities...

Cytokine levels in pleural fluid as markers of acute rejection after lung transplantation.

Our objective was to determine the levels of lactate dehydrogenase, IL-6, IL-8, and VEGF, as well as the total and differential cell counts, in the pleural fluid of lung transplant recipients, correlating those levels with the occurrence and severity of rejection. We analyzed pleural fluid samples collected from 18 patients at various time points (up to postoperative day 4). The levels of IL-6, IL-8, and VEGF tended to elevate in parallel with increases in the severity of rejection. Our results suggest that these levels are markers of acute graft rejection in lung transplant recipients.

[Lung hyperinflation after single lung transplantation to treat emphysema]. / Hiperinsuflação pulmonar após transplante unilateral por enfisema.

Despite preventive measures, lung hyperinflation is a relatively common complication following single lung transplantation to treat pulmonary emphysema. The progressive compression of the graft can cause mediastinal shift and respiratory failure. In addition to therapeutic strategies such as independent ventilation, the treatment consists of the reduction of native lung volume by means of lobectomy or lung volume reduction surgery. We report two cases of native lung hyperinflation after single lung transplantation. Both cases were treated by means of lobectomy or lung volume reduction surgery.

Hiperinsuflação pulmonar após transplante unilateral por enfisema / Lung hyperinflation after single lung transplantation to treat emphysema

Apesar das medidas de prevenção, a hiperinsuflação pulmonar é uma complicação relativamente comum após transplantes unilaterais por enfisema. Quando progressiva, pode comprimir o pulmão transplantado, gerando desvio mediastinal e insuficiência respiratória. Além de estratégias terapêuticas como a ventilação independente, o tratamento consiste na redução volumétrica do pulmão nativo, seja por meio de cirurgia redutora, seja por lobectomia. São relatados dois casos de hiperinsuflação do pulmão nativo após transplante pulmonar, tratados com redução volumétrica do pulmão por meio de lobectomia ou cirurgia redutora.

Despite preventive measures, lung hyperinflation is a relatively common complication following single lung transplantation to treat pulmonary emphysema. The progressive compression of the graft can cause mediastinal shift and respiratory failure. In addition to therapeutic strategies such as independent ventilation, the treatment consists of the reduction of native lung volume by means of lobectomy or lung volume reduction surgery. We report two cases of native lung hyperinflation after single lung transplantation. Both cases were treated by means of lobectomy or lung volume reduction surgery.

Reatividade da artéria pulmonar, ao óxido nítrico inalado, antes e após a tromboendarterectomia / Pulmonary artery vascular reactivity, after nitric oxide inhalation, before and after pulmonary thromboendarterectomy

INTRODUÇÃO: Após a embolia pulmonar cerca de 1 a 3% dos pacientes desenvolvem embolismo crônico seguido de elevação da pressão da artéria pulmonar e aumento da resistência vascular pulmonar (RVP) e o aumento contínuo da pressão vascular leva ao remodelamento das pequenas artérias. Considerando estes dados, o objetivo deste estudo foi avaliar o aumento da reatividade da artéria pulmonar após a inalação de óxido nítrico, após à tromboendarterectomia (PTE) em comparação ao pré-operatório. MÉTODOS: Foram inclusos neste estudo vinte pacientes com idade entre 18 e 68 anos, submetidos à tromboendarterectomia no período de janeiro de 2005 a julho de 2008. Todos os pacientes no período pré-operatório foram submetidos a cateterização cardíaca direita, com medida da pressão pulmonar, entre as duas pressões, potência cardíaca e resistência vascular pulmonar. Estes mesmos pacientes foram submetidos à inalação de óxido nítrico (NO) por dez minutos e nova medida de todas as variáveis foi realizada. Três meses após a tromboendarterectomia, treze pacientes passaram por novos exames, antes e após a inalação de NO. Foi avaliada a reatividade pela comparação estatística dos parâmetros hemodinâmicos, antes e após a inalação do NO. Nós também consideramos o teste positivo de acordo com o critério clássico (redução 20% na PAPm e PVR após inalação de NO) e redefinimos o critério (PAPm diminuindo para 40 mmHg ou menos após inalação com NO, com um redução maior que 10 mmHg). RESULTADOS: A análise estatística usada para análise dos dados paramétricos foi o teste student t e para dados não paramétricos utilizou-se o Wilcoxcon Signed Ranks. Significância estatística 5%. Considerando somente os pacientes que completaram os testes hemodinâmicos (n=13), de acordo com o critério clássico seis indivíduos apresentaram resposta positiva ao NO inalado antes PTE, enquanto nove pacientes tiveram resposta positiva após PTE. A diferença entre pré-PTE e pós-PTE não foi estatísticamente...

INTRODUCTION: After pulmonary embolism, 1 to 3% of these patients develop a chronic embolism, with elevated pulmonary artery pressure and increased pulmonary vascular resistance (PVR). The continuous elevated pressure leads to the remodeling of the small arteries. The objective of this study is to determinate if there is an increase in the responsiveness to the inhaled nitric oxide, in the post-thromboendaterectomy test, in comparison to the preoperative test. METHODS: The study includes twenty patients, age 18 to 68, submitted to thromboendarterctomy, between January 2005 and December 2007. All patients, in the preoperative period, were submitted to right cardiac catheterization, with the measurement of the pulmonary pressures, wedge pressure, cardiac output and PVR. Afterwards, they inhaled 20 ppm of nitric oxide (NO) for ten minutes, with a new measurement of all variables. Three months after thromboendarterectomy, thirteen patients underwent a new measurement, before and after nitric oxide inhalation. We analyzed the reactivity of the pulmonary artery, considering the statistical changes in the hemodinamical parameters. We also considered a positive test according to classical criterion (reduction 20% in PAPm and PVR after NO inhalation) and redefined criterion (PAPm falling to 40 mmHg or less, after inhaled NO, with a drop higher than 10 mmHg). RESULTS: The statistical analyze used the Student-t test for parametrical data and the Wilcoxon Signed Ranks for non parametrical data. Statistical significance 5%. Regardling only the patients who complete both hemodynamic tests (n = 13), according to the classical criterion, six subjects had positive response to inhaled NO before PTE while nine patients had positive response after PTE. The difference between pre-PTE and post-PTE was not statistical significant: p = 0,375. Concernig the redefined criterion, two subjects had positive response in pre-PTE test and four subjects had positive response in post-PTE test...

Utilização de endoprótese metálica no tratamento de estenose brônquica após transplante pulmonar / Treatment of bronchial stenosis after lung transplantation using a self-expanding metal endobronchial stent

As complicações decorrentes da anastomose brônquica nos transplantes pulmonares, embora tenham diminuído ao longo do tempo, ainda figuram como um dos principais fatores de morbi-mortalidade nesses pacientes. As formas de tratamento dessas complicações incluem dilatação por balão, fotocoagulação por laser, endopróteses de silicone e metálicas, e reoperação. Relata-se o caso de um paciente que apresentou estenose brônquica após transplante pulmonar unilateral esquerdo, cujo tratamento foi realizado com endoprótese metálica auto-expansível de nitinol (Ultraflex®). Embora seja um caso pioneiro no Brasil, a boa resposta clínica, concordante com os dados da literatura, sugere que esse tratamento seja uma boa alternativa nesses casos.