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Bilateral Living-Donor Lobar Lung Transplantation Using Right to Left Inverted Lobar Transplantation and Sparing Native Right Upper Lobe in a Patient with Undersized Donor Lungs
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The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
surgical was noted, a computed tomography of the chest revealed osteomyelitis of the sternum and a consolidation in the right upper lobe. Cultures from the surgical site and BAL were positive for M. abscessus subsp. abscessus. The wound was debrided and based on susceptibility testing the infection was treated with bedaquiline 400mg daily for 2 weeks followed by 200mg three times per week PO, tigecyline 50mg twice a day IV (MIC 0.5), and imipenem-cilastatin 1gr three times a day IV (MIC 16). The isolate was otherwise pan-resistant (erm type 1) with the exception of cefoxitin (MIC 64) to which the patient was allergic. With the instituted measures, wound care and twenty sessions of hyperbaric oxygen, during the next 11 weeks the surgical site drainage progressively decreased, the volume of the wound decreased from 131.04 to 2.97 cm3, and BAL AFB smear converted from positive to negative. Treatment was well tolerated; the patient did not experience nausea, vomiting, arthralgia, cardiac events or QTc prolongation by 12-lead ECG. Summary: The preliminary data of bedaquiline as salvage therapy for NTM infections, including our case report, is promising. Further studies are required to assess the role of bedaquiline in the treatment of NTM in transplant recipients. 3( 08) Successful Capture of LVAD-Emboli Using Carotid Filters Following Intra-Cavitary Thrombolysis for Pump Thrombosis S.S. Thomas ,1 R. Gallagher,1 J. Steiner,1 T.H. Song,2 I. Palacios,1 S. Elmariah,1 S. Wiafe,2 N. Roy,2 G. Cudemus,3 M.J. Semigran,1 G.D. Lewis,1 J.P. Garcia,2 K. Rosenfield.1 1Cardiology, Massachusetts General Hospital, Boston, MA; 2Cardiac Surgery, Massachusetts General Hospital, Boston, MA; 3Anesthesia, Critical Care and Pain Management, Massachusetts General Hospital, Boston, MA. Introduction: The clinical effectiveness of anti-thrombotic therapy in the management of pump thrombosis is challenged by major bleeding. Intracranial hemorrhage following heparin, GPIIb/IIIa inhibitors, direct thrombin inhibitors or thrombolytic use contributes to LVAD morbidity and mortality. Excessive anti-coagulation, acquired von-Willebrand syndrome and cardioembolic hemorrhagic conversion are presumed contributors to bleeding adversity. A strategy to improve pump thrombosis outcomes with intensive anticoagulation is needed. Case Report: A 67 year old man with a Heartware HVAD presented with worsening dyspnea, dark urine and acute renal failure. Hemolytic indices including hyperbilirubinemia, an elevated plasma free hemoglobin and a 10-fold increase in LDH, in addition to a power spike on HVAD interrogation, Figure A(*), prompted continuous heparinization for presumed pump thrombosis. However, symptom persistence and worsening hemolysis motivated intra-cavitary thrombolysis within the catheterization laboratory. Two NAV6 distal protection filters, Figure B(circles), were deployed into the internal carotid arteries bilaterally as an embolic protection strategy prior to alteplase infusion (total dose 30 mg) through a pigtail catheter positioned at the HVAD inflow cannula within the LV. Thrombolysis resulted in HVAD power normalization, Figure A(#). Removal of the distal protection devices revealed loose, Figure C(circle) and captured red thrombus within the device filters, Figure C(arrows). The patient eventually proceeded to cardiac transplant without a need for device exchange or embolic consequence of his lytic therapy. Summary: We demonstrate 1) direct evidence of LVAD-derived emboli following intra-cavitary thrombolysis; 2) feasibility of carotid filter deployment in an LVAD patient; and 3) successful prevention of a cerebrovascular accident using prophylactic endovascular neuroprotection devices in the treatment of pump thrombosis.
3( 09) Bilateral Living-Donor Lobar Lung Transplantation Using Right to Left Inverted Lobar Transplantation and Sparing Native Right Upper Lobe in a Patient with Undersized Donor Lungs Y. Goda . Department of Thoracic Surgery Kyoto University, Kyoto, Japan. Introduction: In Japan, living-donor lobar lung transplantation (LDLLT) plays an important role due to the critical deficit in deceased-donor organs. However, in LDLLT, size matching is pivotal and adult recipients frequently withdraw from LDLLT because of the small size of donor grafts. To solve this critical issue, we recently have developed two novel surgical techniques: sparing native upper lobe and right to left inverted lobar lung transplantation. To date, these new techniques have been performed in 13 cases out of 62 LDLLTs (21%). Either technique was used in 6 cases and both techniques were used only in 1 case. Herein, we report the first case of a successful bilateral LDLLT using these two novel surgical techniques simultaneously. Case Report: A 63-year-old man with end-stage idiopathic interstitial pneumonia was referred to our hospital for the possible candidate for lung transplantation. He was bed bound and his respiratory condition deteriorated day by day. His daughter and sister were the eligible donors for LDLLT. According to Date’s formula previously reported (J Thorac Cardiovasc Surg 2003), the estimated forced vital capacity (FVC) of the graft should be > 45-50% of the recipient’s predicted FVC. The right lower lobe (RLL) from his daughter and left lower lobe (LLL) from his sister were estimated to provide only 41.7% of the recipient’s predicted FVC and the RLLs from the two donors were estimated to provide 46.1%. This meant that the grafts could only provide the borderline size even if we performed bilateral LDLLT using right to left inverted lobar lung transplantation. Therefore, we decided to spare his right upper lobe because the lung perfusion scintigraphy of the recipient showed a right-to-left ratio of 88:12. Chest CT also showed that the right upper lobe looked less damaged. Consequently, we successfully performed bilateral LDLLT by transplanting a RLL graft into the right thorax with sparing the native right upper lobe, and by transplanting an inverted RLL graft into the left thorax. The post-operative course was uneventful. He was discharged on post-operative day 58 without oxygen supplementation. Summary: We report the first case of a successful bilateral LDLLT using two novel surgical techniques: right to left inverted lobar lung transplantation with sparing a native upper lobe. 3( 10) Evaluation of Anticoagulation and Non-Surgical Major Bleeding in Recipients of Continuous-Flow Left Ventricular Assist Devices T. Veasey , S. Strout, K. Rieger, C. Floroff, M. Brisco, J. Cook, J. Toole, M. Craig, A. VanBakel, D. Heyward, W. Uber, H. Meadows. Medical University of South Carolina, Charleston, SC. Purpose: Bleeding is the most frequently reported adverse event after continuous-flow left ventricular assist device (LVAD) implant and the risk may be increased by use of antithrombotic agents for prevention of pump thrombosis. Methods: This was a retrospective cohort study of 85 adult patients implanted with a Heartmate II® LVAD from January 2009 through June 2014. Major bleeding was defined as occurring more than 7 days after implant and included intracranial hemorrhage, events requiring at least 2 units of packed red blood cells within a 24 hour period, and bleeds resulting in death. Chart review was performed to evaluate incidence of major bleeding and correlation to baseline characteristics, level of anticoagulation during management, and patient outcomes. Results: Major bleeding occurred in 35 (41 %) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3,368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4,2.5). Median INR during follow up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline (Table). Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis or infection. Patients with major bleeding were less likely to receive a transplant. Conclusion: Major bleeding is a common and important complication during continuous-flow LVAD support. Incidence of non-sur-
The Journal of Heart and Lung Transplantation, Vol 35, No 4S, April 2016
surgical was noted, a computed tomography of the chest revealed osteomyelitis of the sternum and a consolidation in the right upper lobe. Cultures from the surgical site and BAL were positive for M. abscessus subsp. abscessus. The wound was debrided and based on susceptibility testing the infection was treated with bedaquiline 400mg daily for 2 weeks followed by 200mg three times per week PO, tigecyline 50mg twice a day IV (MIC 0.5), and imipenem-cilastatin 1gr three times a day IV (MIC 16). The isolate was otherwise pan-resistant (erm type 1) with the exception of cefoxitin (MIC 64) to which the patient was allergic. With the instituted measures, wound care and twenty sessions of hyperbaric oxygen, during the next 11 weeks the surgical site drainage progressively decreased, the volume of the wound decreased from 131.04 to 2.97 cm3, and BAL AFB smear converted from positive to negative. Treatment was well tolerated; the patient did not experience nausea, vomiting, arthralgia, cardiac events or QTc prolongation by 12-lead ECG. Summary: The preliminary data of bedaquiline as salvage therapy for NTM infections, including our case report, is promising. Further studies are required to assess the role of bedaquiline in the treatment of NTM in transplant recipients. 3( 08) Successful Capture of LVAD-Emboli Using Carotid Filters Following Intra-Cavitary Thrombolysis for Pump Thrombosis S.S. Thomas ,1 R. Gallagher,1 J. Steiner,1 T.H. Song,2 I. Palacios,1 S. Elmariah,1 S. Wiafe,2 N. Roy,2 G. Cudemus,3 M.J. Semigran,1 G.D. Lewis,1 J.P. Garcia,2 K. Rosenfield.1 1Cardiology, Massachusetts General Hospital, Boston, MA; 2Cardiac Surgery, Massachusetts General Hospital, Boston, MA; 3Anesthesia, Critical Care and Pain Management, Massachusetts General Hospital, Boston, MA. Introduction: The clinical effectiveness of anti-thrombotic therapy in the management of pump thrombosis is challenged by major bleeding. Intracranial hemorrhage following heparin, GPIIb/IIIa inhibitors, direct thrombin inhibitors or thrombolytic use contributes to LVAD morbidity and mortality. Excessive anti-coagulation, acquired von-Willebrand syndrome and cardioembolic hemorrhagic conversion are presumed contributors to bleeding adversity. A strategy to improve pump thrombosis outcomes with intensive anticoagulation is needed. Case Report: A 67 year old man with a Heartware HVAD presented with worsening dyspnea, dark urine and acute renal failure. Hemolytic indices including hyperbilirubinemia, an elevated plasma free hemoglobin and a 10-fold increase in LDH, in addition to a power spike on HVAD interrogation, Figure A(*), prompted continuous heparinization for presumed pump thrombosis. However, symptom persistence and worsening hemolysis motivated intra-cavitary thrombolysis within the catheterization laboratory. Two NAV6 distal protection filters, Figure B(circles), were deployed into the internal carotid arteries bilaterally as an embolic protection strategy prior to alteplase infusion (total dose 30 mg) through a pigtail catheter positioned at the HVAD inflow cannula within the LV. Thrombolysis resulted in HVAD power normalization, Figure A(#). Removal of the distal protection devices revealed loose, Figure C(circle) and captured red thrombus within the device filters, Figure C(arrows). The patient eventually proceeded to cardiac transplant without a need for device exchange or embolic consequence of his lytic therapy. Summary: We demonstrate 1) direct evidence of LVAD-derived emboli following intra-cavitary thrombolysis; 2) feasibility of carotid filter deployment in an LVAD patient; and 3) successful prevention of a cerebrovascular accident using prophylactic endovascular neuroprotection devices in the treatment of pump thrombosis.
3( 09) Bilateral Living-Donor Lobar Lung Transplantation Using Right to Left Inverted Lobar Transplantation and Sparing Native Right Upper Lobe in a Patient with Undersized Donor Lungs Y. Goda . Department of Thoracic Surgery Kyoto University, Kyoto, Japan. Introduction: In Japan, living-donor lobar lung transplantation (LDLLT) plays an important role due to the critical deficit in deceased-donor organs. However, in LDLLT, size matching is pivotal and adult recipients frequently withdraw from LDLLT because of the small size of donor grafts. To solve this critical issue, we recently have developed two novel surgical techniques: sparing native upper lobe and right to left inverted lobar lung transplantation. To date, these new techniques have been performed in 13 cases out of 62 LDLLTs (21%). Either technique was used in 6 cases and both techniques were used only in 1 case. Herein, we report the first case of a successful bilateral LDLLT using these two novel surgical techniques simultaneously. Case Report: A 63-year-old man with end-stage idiopathic interstitial pneumonia was referred to our hospital for the possible candidate for lung transplantation. He was bed bound and his respiratory condition deteriorated day by day. His daughter and sister were the eligible donors for LDLLT. According to Date’s formula previously reported (J Thorac Cardiovasc Surg 2003), the estimated forced vital capacity (FVC) of the graft should be > 45-50% of the recipient’s predicted FVC. The right lower lobe (RLL) from his daughter and left lower lobe (LLL) from his sister were estimated to provide only 41.7% of the recipient’s predicted FVC and the RLLs from the two donors were estimated to provide 46.1%. This meant that the grafts could only provide the borderline size even if we performed bilateral LDLLT using right to left inverted lobar lung transplantation. Therefore, we decided to spare his right upper lobe because the lung perfusion scintigraphy of the recipient showed a right-to-left ratio of 88:12. Chest CT also showed that the right upper lobe looked less damaged. Consequently, we successfully performed bilateral LDLLT by transplanting a RLL graft into the right thorax with sparing the native right upper lobe, and by transplanting an inverted RLL graft into the left thorax. The post-operative course was uneventful. He was discharged on post-operative day 58 without oxygen supplementation. Summary: We report the first case of a successful bilateral LDLLT using two novel surgical techniques: right to left inverted lobar lung transplantation with sparing a native upper lobe. 3( 10) Evaluation of Anticoagulation and Non-Surgical Major Bleeding in Recipients of Continuous-Flow Left Ventricular Assist Devices T. Veasey , S. Strout, K. Rieger, C. Floroff, M. Brisco, J. Cook, J. Toole, M. Craig, A. VanBakel, D. Heyward, W. Uber, H. Meadows. Medical University of South Carolina, Charleston, SC. Purpose: Bleeding is the most frequently reported adverse event after continuous-flow left ventricular assist device (LVAD) implant and the risk may be increased by use of antithrombotic agents for prevention of pump thrombosis. Methods: This was a retrospective cohort study of 85 adult patients implanted with a Heartmate II® LVAD from January 2009 through June 2014. Major bleeding was defined as occurring more than 7 days after implant and included intracranial hemorrhage, events requiring at least 2 units of packed red blood cells within a 24 hour period, and bleeds resulting in death. Chart review was performed to evaluate incidence of major bleeding and correlation to baseline characteristics, level of anticoagulation during management, and patient outcomes. Results: Major bleeding occurred in 35 (41 %) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3,368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4,2.5). Median INR during follow up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline (Table). Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis or infection. Patients with major bleeding were less likely to receive a transplant. Conclusion: Major bleeding is a common and important complication during continuous-flow LVAD support. Incidence of non-sur-