Transplante de pulmão: Indicações atuais / Lung Transplantation: Current Indications

A doença pulmonar obstrutiva crônica representa cerca de 40% de todos os transplantes de pulmão. A fibrose pulmonar, idiopática ou secundária, caracteriza a indicação básica de transplante unilateral. A fibrose cística é a principal indicação de transplante em doenças supurativas. Há uma crescente tendência a aumentar as indicações de transplante bilateral. O transplante bilobar com doadores vivos representa a melhor opção para os receptores pediátricos e adolescentes. A terapia vasodilatadora modificou substancialmente a indicação de transplante em hipertensão pulmonar, primária e secundária. É intransferível a necessidade de divulgação dos critérios de inclusão em lista de espera, demovendo o equivocado conceito de que transplante é a terapia de desespero e, com isso, prevenindo mortes evitáveis.

Diagnosis of invasive aspergillosis in lung transplant recipients by detection of galactomannan in the bronchoalveolar lavage fluid.

BACKGROUND: Galactomannan (GM) detection in serum samples has been used to diagnose invasive aspergillosis (IA). Limited sensitivity has been observed in lung transplant recipients, for whom bronchoalveolar lavage (BAL) testing has been advocated. Because airway colonization with Aspergillus species occurs frequently in these patients, false-positive GM results have been reported if the cutoff validated for sera is used (i.e., 0.5). METHODS: Herein, we prospectively studied BAL fluid samples from 60 lung transplant patients to determine the optimal cutoff for BAL GM testing. Only one sample per patient was studied. BAL samples were vortexed and processed according to the manufacturer's instructions for serum samples. Sensitivity, specificity, and likelihood ratios were calculated in reference to proven or probable IA cases using receiver operating characteristic analysis. RESULTS: Eight patients had IA during the study (incidence 13.3%), including four patients with proven IA. Aspergillosis increased 5-fold the risk of death in lung transplant recipients. The positive predictive value of a positive BAL GM test at the 0.5 cutoff was low (24.2%). Raising the cutoff improved test specificity without compromising sensitivity. The best cutoff was defined at 1.5 (sensitivity 100% and specificity 90.4%). CONCLUSIONS: This study reinforces the importance of BAL GM testing in lung transplant recipients, particularly to exclude the diagnosis of IA. To minimize the frequency of false-positive results, a higher test cutoff should be applied to BAL samples, in comparison with serum samples.

Computed tomography measurement of lung volume in preoperative assessment for living donor lung transplantation: volume calculation using 3D surface rendering in the determination of size compatibility.

The objective of this study was to describe the use of CT volume quantification assessment of candidates for LLDLT. Six pediatric candidates for LDLLT and their donors were investigated with helical chest CT, as part of the preoperative assessment. The CT images were analyzed as per routine and additional post-processing with CT volume quantification (CT densitovolumetry) was performed to assess volume matching between the lower lobes of the donors and respective lungs of the receptors. CT images were segmented by density and region of interest, using post-processing software. Size matching was also assessed using the FVC formula. Compatible volumes were found in three cases. The other three cases were considered incompatible. All three recipients with compatible sizes survived the procedure and are alive and well. One patient with incompatible size was submitted to the procedure and died because of complications attributed to the incompatible volumes. One patient with incompatible size has subsequently grown and new measurements are to be taken to check the current volumes. Different donors are being sought for the remaining patient whose lung volumes were considered too big for the prospective transplant donor lobes. Under FVC formula criteria, all cases were considered compatible. CT volume quantification is an easy to perform, non-invasive technique that uses CT images for the preassessment of candidates for LDLLT, to compare the volume of the lower lobes from the donors with volume of each lung in the prospective recipients. Size matching based on CT densitovolumetry and FVC may differ.

Invasive pulmonary aspergillosis due to a mixed infection caused by Aspergillus flavus and Aspergillus fumigatus.

Invasive pulmonary aspergillosis is typically caused by a single Aspergillus species, most frequently Aspergillus fumigatus. Here we report that a lung transplant recipient developed invasive aspergillosis due to a mixed infection caused by Aspergillus flavus and A. fumigatus. The implications for this unusual finding are discussed.

Invasive pulmonary aspergillosis due to a mixed infection caused by Aspergillus flavus and Aspergillus fumigatus

La aspergilosis pulmonar invasora es producida típicamente por una únicaespecie de Aspergillus, siendo habitualmente Aspergillus fumigatus.Se presenta el caso clínico de un receptor de trasplante de pulmón quedesarrolló aspergilosis invasora por una infección mixta causada porAspergillus flavus y A. fumigatus. Se discuten las implicaciones de la rarezade este caso

Invasive pulmonary aspergillosis is typically caused by a single Aspergillusspecies, most frequently Aspergillus fumigatus. Here we report that a lungtransplant recipient developed invasive aspergillosis due to a mixed infectioncaused by Aspergillus flavus and A. fumigatus. The implications for thisunusual finding are discussed(AU)

The incidence of cytomegalovirus infection in lung transplant recipients under universal prophylaxis with intravenous ganciclovir.

The best strategy for control of cytomegalovirus (CMV) infection in lung transplant patients is still not determined. The aim of this study was to document the incidence of CMV infection in a cohort of lung transplant recipients under universal prophylaxis with intravenous ganciclovir. All patients received immunosuppressive regimens consisting of cyclosporine, azathioprine, and prednisone. Regardless of CMV serostatus, intravenous ganciclovir was prescribed for every patient in the first 3 months post-transplantation. CMV infection was defined as the detection of CMV pp65 in leukocytes. Eighty-two lung transplant patients were included over a 5-year period. The incidence of CMV infection in the first year post-transplantation was 68.3%, occurring after a median length of 114 days (range, 26-343 days). This study revealed a high incidence of CMV infection in the first year following lung transplantation despite prolonged universal ganciclovir prophylaxis.

The incidence of cytomegalovirus infection in lung transplant recipients under universal prophylaxis with intravenous ganciclovir

The best strategy for control of cytomegalovirus (CMV) infection in lung transplant patients is still not determined. The aim of this study was to document the incidence of CMV infection in a cohort of lung transplant recipients under universal prophylaxis with intravenous ganciclovir. All patients received immunosuppressive regimens consisting of cyclosporine, azathioprine, and prednisone. Regardless of CMV serostatus, intravenous ganciclovir was prescribed for every patient in the first 3 months post-transplantation. CMV infection was defined as the detection of CMV pp65 in leukocytes. Eighty-two lung transplant patients were included over a 5-year period. The incidence of CMV infection in the first year post-transplantation was 68.3 percent, occurring after a median length of 114 days (range, 26-343 days). This study revealed a high incidence of CMV infection in the first year following lung transplantation despite prolonged universal ganciclovir prophylaxis.

Transplante pulmonar na infância / Lung transplant in children

Objetivo: este artigo faz uma revisão dos principais aspectos relacionados com o transplante pulmonar na população pediátrica, e traz a experiência da equipe pioneira na realização do procedimento na América Latina.Fontes de dados: foram utilizadas informações através derevisão bibliográfica, realizada por busca direta de artigos científicos e por pesquisa nas bases de dados Medline e Lilacs. Síntese dos dados: o artigo é estruturado em tópicos, nos quais procura identificar as semelhanças e as diferenças com o transplante pulmonar do adulto. Discute os problemas específicos da criançatransplantada e enfatiza uma situação específica, a do transplante pulmonar com doadores vivos aparentados.Conclusões: os avanços observados no transplante pulmonarrealizado em adultos, para tratamento de doenças pulmonares, parenquimatosas ou vasculares, têm sido transferidos, nos últimos anos, para a população pediátrica, com sucesso crescente(AU);#S#as#FONTE#94#

[Lung transplant in children]. / Transplante pulmonar na infância.

OBJECTIVE: This article presents a review of the main aspects related to lung transplant in children and shows the experience of the first medical team to perform this procedure in Latin America. SOURCES: Literature review of scientific articles, using the MEDLINE and Lilacs databases. SUMMARY OF THE FINDINGS: The article was organized into topics. Similarities and differences regarding lung transplant in adults were identified. Specific problems presented by children subjected to transplant are discussed, and special emphasis is given to a specific situation: lung transplant with living related donors. CONCLUSIONS: Advances in adult lung transplant for the treatment of parenchymatous or vascular lung diseases have been successfully employed in the pediatric population during the last few years.

Comparative study of different forms of protection in a rat model of bronchial fistula

The authors present the results obtained with the development of an experimental model of bronchial fistula and compared different forms of post-pneumonectomy bronchial fistula protection. Forty rats were submitted to left pneumonectomy and bronchial stumps were protected with either pedicled muscle ( N=20 ) or pedicled fat ( N=20 ). The results showed that it was possible to develop a fistula model in 65 por cento of animals and that there was no statistical difference ( p>0.05 ) between the tissues used for bronchial protection

Desmoid tumor of the mediastinum

A desmoid tumor of the mediastinum was diagnosed and terated in a 35 year-old white male who presented with a right supraclavicular mass. He was treated with resection, which involved several vascular structures, requiring multiple vascular reconstructions followed by postoperative radiotherapy. The authors concluded that, when located in tha mediastinum, the invasive character of such tumors and its tendency to recur may pose a considerable surgical challenge, requiring careful preoperative planing and postoperative planning follow-up. The role of radiation therapy is limited to the control of local recurrences

Cardiac herniation after pneumonectomy: review and case reports

Cardiac Herniation after Pneumonectomy is reviewed in terms of etiology, clinical findings, diagnosis, prevention and available treatments. Sixty-six cases were reported between 1948 and 1994 were reported. Thirteen other cases were reviewed in a multicenter survey in Brazil. Among these, the two cases who died of total cardiac herniation following right intrapericardial pneumonectomy are reported with radiographic and surgical findings.

Erros mais freqüentes no atendimento do traumatizado de tórax / The mistakes that more frequently occur in the torax trauma patient

Os autores analisam sob a forma de tópicos individualizados os êrros mais frequentes no atendimento do traumatizado de tórax, incluindo aspectos da avaliaçao global do traumatizado grave, como a propedêutica da hipotensao arterial, reposiçao de volume, e indicaçoes de ventilaçao mecânica, até condiçoes específicas tais como: pneumotórax hipertensivo, hemotórax coagulado, ferimento cardíaco, e tórax instável. Cada situaçao é analisada quanto ao diagnóstico diferencial e conduçao terapêutica.