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50: Lung Function after Single Lung Transplantation (SLTx): Emphysema Versus Pulmonary Fibrosis
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Abstracts
50 Lung Function after Single Lung Transplantation (SLTx): Emphysema Versus Pulmonary Fibrosis C.H. Wigfield,1 M.A. Chaudhry,1 T. Small,2 G. Parry,1 J.H. Dark,1,2 P.A. Corris,1,2 A.J. Fisher,1,2 1Cardiopulmonary Transplantation, Freeman Hospital, Newcastle upon Tyne, England, United Kingdom; 2Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, England, United Kingdom Purpose: SLTx is advocated to optimize organ availability for endstage obstructive or fibrotic respiratory disease.Contra-lateral native lung hyperinflation in recipients with obstructive lung disease may limit functional improvements after SLTx. We hypothesized that recipients with fibrotic lung disease will achieve higher best FEV1 after SLTx than obstructive recipients. Methods and Materials: Single centre, retrospective review of recipients surviving more than 12 months after SLTx for fibrotic or obstructive disease was performed. Pre-transplant spirometry, total lung capacity (TLC) and residual volume (RV) were correlated with the best achieved FEV1 after SLTx. The best post-transplant FEV1 was compared between the fibrotic and obstructive recipients. Results: 57 SLTx recipients were included, 35 obstructive, median age 55yrs (range 37-64), 22 fibrotic, 57yrs (30-64). Post-SLTx survival was not different between the two groups 7.4 v 6.5 yrs respectively. Pre-transplant lung function showed significantly higher TLC (7.99 v 3.50 l, p⬍0.001Mann-WhitneyU test), RV (5.91 v 1.36 l, p⬍0.001) and lower FEV1 (0.66 v 1.59 l/s, p⬍0.001) in obstructive recipients compared with fibrotics. Post-SLTx, the maximal achieved FEV1 was significantly higher in fibrotics (2.38 v 1.83 l/s, p⬍0.0004). The best post-SLTx FEV1 was corrected for sex, height & age as % predicted FEV1 and showed higher values in the fibrotic group (72.8% v 57.3%, p⫽0.002). There was no correlation between pre-transplant % predicted TLC or RV and post-SLTx % predicted FEV1in obstructive recipients (r⫽0.11 p⫽0.6 Spearman). Conclusions: SLTx recipients for fibrotic lung disease achieve better maximal FEV1 than those with obstructive disease. Our data suggest that native lung hyperinflation in patients with obstructive disease may not be the only factor to account for this difference. Single lung transplantation should be the operation of choice in patients with fibrotic lung disease. The lower achieved lung function in obstructive disease is more complex than hyperinflation and requires further investigation. 51 Effects of Native Lung Physiology (Obstructive vs. Restrictive) on Graft Volume after Single-Lung Transplantation (SLT) M. Estenne,1 D. Kienzl,2 C. Knoop,1 B. Rondelet,1 M. Dumonceaux,1 P. Jaksch,3 W. Klepetko,3 A. Bankier,4 1Lung Transplantation Unit and Dpt of Thoracic Surgery, Erasme Hospital, Brussels, Belgium; 2Radiology, Medical University of Vienna, Vienna, Austria; 3Lung Transplantation Unit and Dpt of Surgery, Medical University of Vienna, Vienna, Austria; 4 Radiology, Beth Israel Deaconess Medical Center, Boston, MA Purpose: In patients with SLT for emphysema (E), hyperinflation of the native lung produces a shift of the mediastinum towards the graft which is thaught to decrease its volume. The opposite is expected to occur in patients with SLT for interstitial lung disease (ILD). To assess the functional impact of this phenomenon, we assessed the displacement of the mediastinum and the volumes of both lungs in patients with SLT for E or ILD. Methods and Materials: We studied 32 patients (19 M, age 55) who had undergone SLT (19 right, 13 left) for E (21) or ILD (11) on average 1010 (range 192-3125) days before the study. The volume of each lung and the degree of mediastinal shift were measured at total lung
The Journal of Heart and Lung Transplantation February 2008
capacity (TLC) and residual volume (RV) by computerized tomography. Predicted values in seated posture divided by 2 were taken as reference values for the volume of each lung. Results: At TLC, the mediastinum was shifted towards the graft in 19/21 patients with E and towards the native lung in 7/11 patients with ILD; on average the mediastinum was shifted by 6.3° towards the graft in the former and by 2.6° towards the native lung in the latter. In patients with E, TLC was greater for the native lung than for the graft, and conversely, VC was greater for the graft than for the native lung; differences between the 2 lungs were not significant in patients with ILD. Importantly, there was no difference in the TLC of the graft the in patients with E (83% pred) vs. ILD (71% pred); corresponding values for VC were 60% and 55%, respectively (NS). Conclusions: We conclude that the mediastinum is shifted towards the graft in patients with SLT for E, and to a lesser extent towards the native lung in patients with SLT for ILD. This different displacement, however, does not translate into differences in the volume of the graft which is unaffected by the physiology of the native lung. Therefore, the presence of hyperinflation before transplantation should not be considered as an argument in favor of double, as opposed to single, grafting. 52 Techniques for Bronchial Anastomosis in Lung Transplantation M. Kamler,1 K. Tsagakis,1 K. Pilarczyk,1 N. Pizanis,1 U. Herold,1 H. Jakob,1 1Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany Purpose: Airway anastomotic complications are still recognized as an important source of morbidity after lung transplantation (LTX) and there is a controversy about the optimal construction of the bronchial anastomosis. In this study, we address the results achieved by using the standard technique with a running suture of the membraneous and single stitches or figure-of-eight-stitches on the cartilaginous portion of the bronchus compared to the single running suture technique. Methods and Materials: 148 bronchial anastomosis in 74 patients undergoing bilateral sequential lung transplantation were retrospectively analysed in two groups: group 1 (n ⫽ 118): standard technique, group 2 (n ⫽ 30): single running suture. Bronchial anastomoses were performed end-to-end using monofilament synthetic absorbable sutures without bronchial artery reimplantation or bronchial wrapping. Airway complications were assessed by bronchoscopy with a medium follow-up of 25,4 months. Results: Incidence of severe stenosis of the anastomosis and the right bronchus intermedius was significantly higher in group 2 (2/119 vs. 4/30, p⬍0.001 and 1/119 vs. 4/119, p⬍ 0.001) In addition, bronchial healing defects as well as airway instability were observed more frequently in the single suture group (p ⬍ 0.05). In summary, major airway complications occurred more frequently in group 2 (9/119 vs. 8/30, p ⬍ 0.05). Accordingly, number of performed airway interventions was higher in group 2 (p ⬍ 0.001). Morbidity was increased in group 2, but did not reach statistical significance (6.7 % vs. 1.7%, p ⫽ 0.29). One-year survival rate was comparable between the two groups with 74.5 % for group 1 vs. 80.0 % for group 2. Operative time and cardiopulmonary bypass time did not differ between the groups. Conclusions: The single suture technique is associated with impaired bronchial healing and increased airway complications requiring interventions more frequently. Based on our experiences, we would recommend using the safe and reliable standard suture technique for bronchial anastomosis in LTX.
Abstracts
50 Lung Function after Single Lung Transplantation (SLTx): Emphysema Versus Pulmonary Fibrosis C.H. Wigfield,1 M.A. Chaudhry,1 T. Small,2 G. Parry,1 J.H. Dark,1,2 P.A. Corris,1,2 A.J. Fisher,1,2 1Cardiopulmonary Transplantation, Freeman Hospital, Newcastle upon Tyne, England, United Kingdom; 2Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, England, United Kingdom Purpose: SLTx is advocated to optimize organ availability for endstage obstructive or fibrotic respiratory disease.Contra-lateral native lung hyperinflation in recipients with obstructive lung disease may limit functional improvements after SLTx. We hypothesized that recipients with fibrotic lung disease will achieve higher best FEV1 after SLTx than obstructive recipients. Methods and Materials: Single centre, retrospective review of recipients surviving more than 12 months after SLTx for fibrotic or obstructive disease was performed. Pre-transplant spirometry, total lung capacity (TLC) and residual volume (RV) were correlated with the best achieved FEV1 after SLTx. The best post-transplant FEV1 was compared between the fibrotic and obstructive recipients. Results: 57 SLTx recipients were included, 35 obstructive, median age 55yrs (range 37-64), 22 fibrotic, 57yrs (30-64). Post-SLTx survival was not different between the two groups 7.4 v 6.5 yrs respectively. Pre-transplant lung function showed significantly higher TLC (7.99 v 3.50 l, p⬍0.001Mann-WhitneyU test), RV (5.91 v 1.36 l, p⬍0.001) and lower FEV1 (0.66 v 1.59 l/s, p⬍0.001) in obstructive recipients compared with fibrotics. Post-SLTx, the maximal achieved FEV1 was significantly higher in fibrotics (2.38 v 1.83 l/s, p⬍0.0004). The best post-SLTx FEV1 was corrected for sex, height & age as % predicted FEV1 and showed higher values in the fibrotic group (72.8% v 57.3%, p⫽0.002). There was no correlation between pre-transplant % predicted TLC or RV and post-SLTx % predicted FEV1in obstructive recipients (r⫽0.11 p⫽0.6 Spearman). Conclusions: SLTx recipients for fibrotic lung disease achieve better maximal FEV1 than those with obstructive disease. Our data suggest that native lung hyperinflation in patients with obstructive disease may not be the only factor to account for this difference. Single lung transplantation should be the operation of choice in patients with fibrotic lung disease. The lower achieved lung function in obstructive disease is more complex than hyperinflation and requires further investigation. 51 Effects of Native Lung Physiology (Obstructive vs. Restrictive) on Graft Volume after Single-Lung Transplantation (SLT) M. Estenne,1 D. Kienzl,2 C. Knoop,1 B. Rondelet,1 M. Dumonceaux,1 P. Jaksch,3 W. Klepetko,3 A. Bankier,4 1Lung Transplantation Unit and Dpt of Thoracic Surgery, Erasme Hospital, Brussels, Belgium; 2Radiology, Medical University of Vienna, Vienna, Austria; 3Lung Transplantation Unit and Dpt of Surgery, Medical University of Vienna, Vienna, Austria; 4 Radiology, Beth Israel Deaconess Medical Center, Boston, MA Purpose: In patients with SLT for emphysema (E), hyperinflation of the native lung produces a shift of the mediastinum towards the graft which is thaught to decrease its volume. The opposite is expected to occur in patients with SLT for interstitial lung disease (ILD). To assess the functional impact of this phenomenon, we assessed the displacement of the mediastinum and the volumes of both lungs in patients with SLT for E or ILD. Methods and Materials: We studied 32 patients (19 M, age 55) who had undergone SLT (19 right, 13 left) for E (21) or ILD (11) on average 1010 (range 192-3125) days before the study. The volume of each lung and the degree of mediastinal shift were measured at total lung
The Journal of Heart and Lung Transplantation February 2008
capacity (TLC) and residual volume (RV) by computerized tomography. Predicted values in seated posture divided by 2 were taken as reference values for the volume of each lung. Results: At TLC, the mediastinum was shifted towards the graft in 19/21 patients with E and towards the native lung in 7/11 patients with ILD; on average the mediastinum was shifted by 6.3° towards the graft in the former and by 2.6° towards the native lung in the latter. In patients with E, TLC was greater for the native lung than for the graft, and conversely, VC was greater for the graft than for the native lung; differences between the 2 lungs were not significant in patients with ILD. Importantly, there was no difference in the TLC of the graft the in patients with E (83% pred) vs. ILD (71% pred); corresponding values for VC were 60% and 55%, respectively (NS). Conclusions: We conclude that the mediastinum is shifted towards the graft in patients with SLT for E, and to a lesser extent towards the native lung in patients with SLT for ILD. This different displacement, however, does not translate into differences in the volume of the graft which is unaffected by the physiology of the native lung. Therefore, the presence of hyperinflation before transplantation should not be considered as an argument in favor of double, as opposed to single, grafting. 52 Techniques for Bronchial Anastomosis in Lung Transplantation M. Kamler,1 K. Tsagakis,1 K. Pilarczyk,1 N. Pizanis,1 U. Herold,1 H. Jakob,1 1Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany Purpose: Airway anastomotic complications are still recognized as an important source of morbidity after lung transplantation (LTX) and there is a controversy about the optimal construction of the bronchial anastomosis. In this study, we address the results achieved by using the standard technique with a running suture of the membraneous and single stitches or figure-of-eight-stitches on the cartilaginous portion of the bronchus compared to the single running suture technique. Methods and Materials: 148 bronchial anastomosis in 74 patients undergoing bilateral sequential lung transplantation were retrospectively analysed in two groups: group 1 (n ⫽ 118): standard technique, group 2 (n ⫽ 30): single running suture. Bronchial anastomoses were performed end-to-end using monofilament synthetic absorbable sutures without bronchial artery reimplantation or bronchial wrapping. Airway complications were assessed by bronchoscopy with a medium follow-up of 25,4 months. Results: Incidence of severe stenosis of the anastomosis and the right bronchus intermedius was significantly higher in group 2 (2/119 vs. 4/30, p⬍0.001 and 1/119 vs. 4/119, p⬍ 0.001) In addition, bronchial healing defects as well as airway instability were observed more frequently in the single suture group (p ⬍ 0.05). In summary, major airway complications occurred more frequently in group 2 (9/119 vs. 8/30, p ⬍ 0.05). Accordingly, number of performed airway interventions was higher in group 2 (p ⬍ 0.001). Morbidity was increased in group 2, but did not reach statistical significance (6.7 % vs. 1.7%, p ⫽ 0.29). One-year survival rate was comparable between the two groups with 74.5 % for group 1 vs. 80.0 % for group 2. Operative time and cardiopulmonary bypass time did not differ between the groups. Conclusions: The single suture technique is associated with impaired bronchial healing and increased airway complications requiring interventions more frequently. Based on our experiences, we would recommend using the safe and reliable standard suture technique for bronchial anastomosis in LTX.