Adding complexity to complexity: The role of concomitant cardiac surgery in lung transplantation.

Outcomes of lung transplantation have greatly improved over recent years. While patients with concomitant cardiac pathology used to be excluded from lung transplant, today, most of these cardiac conditions can be addressed safely and effectively. Interventional techniques should be preferred. Lung transplant performed by cardiac surgeons allows for concomitant interventions.

Long-Term Survival in Bilateral Lung Transplantation for Scleroderma-Related Lung Disease.

BACKGROUND: Lung disease is the leading cause of morbidity and death in scleroderma patients, but scleroderma is often considered a contraindication to lung transplantation because of concerns for worse outcomes. We evaluated whether 5-year survival in scleroderma patients after lung transplantation differed from other patients with restrictive lung disease. METHODS: This was a single-center, retrospective cohort study of all patients undergoing bilateral lung transplantation for scleroderma-related pulmonary disease between January 2006 and December 2014. This cohort was compared with patients undergoing bilateral lung transplantation for nonscleroderma group D restrictive disease. Primary outcomes reported were 1-year and 5-year survival. Diagnoses were identified by United Network of Organ Sharing listing and were confirmed by clinical examination and prelisting workup. RESULTS: We compared 26 patients who underwent BLT for scleroderma and 155 patients who underwent BLT for group D restrictive disease. Overall, the nonscleroderma cohort was younger, with lower lung allocation score but no difference in functional status. Donor characteristics were not different between the cohorts. Survival at 1 year was not different (73.1% vs 80.0%, p = 0.323). Long-term survival at 5 years was also not significantly different (65.4% vs 66.5%, p = 0.608). Multivariate Cox proportional hazards analysis found no differences in survival between scleroderma and nonscleroderma group D restrictive disease (hazard ratio, 2.19; p = 0.122). CONCLUSIONS: Despite being at high risk for extrapulmonary complications, patients undergoing bilateral lung transplantation for scleroderma have similar 1-year and 5-year survival as those with restrictive lung disease. Transplantation is a reasonable treatment option for a carefully selected population of candidates.

Retransplantation Outcomes at a Large Lung Transplantation Program.

BACKGROUND: With the increase of primary lung transplantation across major centers worldwide, over the last several years the need of lung retransplant (ReTX) is likely to increase. Therefore, characterization of ReTX patients is prudent and necessary. Our study aimed to investigate and characterize the covariates and outcomes associated with lung ReTX survival in a single large U.S. transplant center. METHODS: Demographic, clinical diagnoses, and comorbidities were analyzed. Kaplan-Meier statistics were used to calculate and predict survival for 30 days and up to 3 years. Cox proportional modeling was used to determine the variables associated with mortality. RESULTS: Of included 684 lung transplants performed at the Houston Methodist Hospital between January 2009 and December 2015, 49 were lung ReTX. Median age of primary lung transplant (non-ReTX) and ReTx recipients was 62 and 49 years, respectively. Chronic graft rejection in the form of restrictive chronic lung allograft dysfunction and bronchiolitis obliterans syndrome was the main indications for ReTX. Compared with non-ReTX patients, ReTX patients had higher median lung allocation score (46.2 vs 37.0, respectively) and higher mortality after 6 months posttransplant. ReTX, older age, female sex, hospitalization 15 days or longer, estimated glomerular filtration rate less than 60, 6-minute walk distance less than 400 ft, and donor/recipient height ratio less than 1 were significantly associated with decreased 1-year patient and graft survival. Chronic graft rejection was still the major cause of death in the long-term follow-up recipients. CONCLUSIONS: Our findings suggested that lung ReTX recipients have poor long-term survival outcomes. Lung ReTX should only be offered to carefully selected patients.

Case report: cardiac tamponade resembling an acute myocardial infarction as the initial manifestation of metastatic pericardial adenocarcinoma.

Pericardial malignancies are uncommon, usually metastatic, linked to terminal oncology patients, and rarely diagnosed premortem. A very small number of patients will develop signs and symptoms of malignant pericardial effusion as initial clinical manifestation of neoplastic disease. Among these patients, a minority will progress to a life-threatening cardiac tamponade. It is exceedingly rare for a cardiac tamponade to be the unveiling clinical manifestation of an unknown malignancy, either primary or metastatic to pericardium. We present the case of a 50-year-old male who was admitted to the emergency department with an acute myocardial infarction diagnosis that turned out to be a cardiac tamponade of unknown etiology. Further studies revealed a metastatic pericardial adenocarcinoma with secondary cardiac tamponade. We encourage considering malignancies metastatic to pericardium as probable etiology for large pericardial effusions and cardiac tamponade of unknown etiology.

Percutaneous stenting to treat pulmonary vein stenosis after single-lung transplantation.

Pulmonary vein stenosis after lung transplantation is rare. Untreated, it can cause transplant failure and death. We describe the case of a 56-year-old man in whom pulmonary vein stenosis developed after single-lung transplantation. He was successfully treated with angioplasty and stent implantation guided by intravascular ultrasonography. To our knowledge, this is the first report of using this method to evaluate the pulmonary vein after lung transplantation, to confirm the diagnosis of pulmonary vein stenosis, and to guide the sizing and positioning of a stent. In lung-transplant recipients, percutaneous stent implantation may preclude reoperation and salvage the transplanted lung when used as treatment for pulmonary vein stenosis.

Extracorporeal membrane oxygenation as a bridge to emergency heart-lung transplantation in a patient with idiopathic pulmonary arterial hypertension.

Lung transplantation with or without cardiac transplantation offers the only hope of long-term, symptom-free survival for patients with advanced idiopathic pulmonary arterial hypertension. We describe a patient who underwent an emergency pulmonary embolectomy. During surgery, it was discovered that the patient had idiopathic pulmonary arterial hypertension. After the patient was weaned from cardiopulmonary bypass, pulmonary hypertension caused right-sided heart failure, and a right ventricular assist device was inserted to compensate. Because of profound bleeding from the endotracheal tube, the patient was placed on extracorporeal membrane oxygenation in the hope of bridging the patient to heart-lung transplantation. Extracorporeal membrane oxygenation was required for 10 days until a donor heart and lung became available. The patient recovered from the transplant operation and was discharged home 76 days later.