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Bronchial Artery Revascularization and En Bloc Lung Transplant in Children
S290
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
Conclusion: Pleural symphysis is often required in the management of recurrent pneumothorax and chylous pleural effusions in LAM patients. Preoperative pleurodesis with doxycycline or talc does not appreciably increase rates of complications such as bleeding or chylothorax after LTx for LAM and post LTx lung function and survival rates were excellent. 7( 98) Bronchial Artery Revascularization and En Bloc Lung Transplant in Children F. Guzman-Pruneda ,1 Y. Orr,1 C.M. Mery,1 I. Adachi,1 M. Nugent,2 J. Maddox,2 M.G. Schecter,3 G.B. Mallory,1 D.L. Morales,3 J.S. Heinle,1 E.D. McKenzie.1 1Baylor College of Medicine, Houston, TX; 2Texas Children’s Hospital, Houston, TX; 3Cincinnati Children’s Hospital, Cincinnati, OH. Purpose: Major limitations to long term success in pediatric lung transplantation include infection and bronchiolitis obliterans syndrome (BOS). The more common bilateral sequential technique (BSLT) may result in bronchial ischemia leading to bronchial stenosis or dehiscence and may contribute to small airway loss that culminates in BOS. Bronchial artery revascularization (BAR) may reduce airway and mucosal ischemia, promote better airway healing, and potentially delay the onset of BOS. Additionally, BAR allows for safe tracheal anastomosis avoiding the need for bilateral bronchial anastomoses in infants. At Texas Children’s Hospital both BSLT and en bloc lung transplant with BAR (EBLT) have been employed in a parallel fashion. We sought to identify any differences in outcomes between patient groups. Methods: A retrospective chart review of all patients undergoing isolated primary bilateral lung transplantation from April 2005 to October 2013 was performed. Children who had a re-transplant or a multi-organ transplant were excluded. Results: 102 recipients were included; 83 underwent BSLT whereas 19 received EBLT. Median follow-up time was 2.5 years (range 14 days to 8 yrs). Cystic fibrosis was the most common indication for transplantation. Donor ischemic time was 374 min for BSLT and 393 min for EBLT (p= 0.38). Mean cardiopulmonary bypass time was 317 min for BSLT and 294 min for EBLT (p= 0.09). 51% of patients in the BSLT group experienced 1.6 ± 0.9 episodes of allograft rejection, while 26% of the EBLT group had 1.2 ± 0.5 episodes (p= 0.25). Three hospital mortalities occurred following BSLT and one after EBLT. Long-term survival was 65% and 79% for the BSLT and EBLT groups, respectively (p= 0.67). The incidence of BOS was 26% and 16% in the BSLT and EBLT groups, respectively (p= 0.57). 43% of patients with BSLT and 3% of patients with EBLT had ≥ 1 airway ischemic findings in the first 6 weeks postoperatively (p= 0.003). There were 10 airway re-interventions in 8 patients, all in the BSLT group (p= 0.11). Conclusion: En bloc lung transplant with BAR in children is a safe technique that does not increase operative or graft ischemic times. Airway complications requiring re-intervention are virtually eliminated with the combination of BAR and tracheal anastomosis. These results are consistent with published reports of BAR in adults that describe a lower incidence acute rejection and a delay in the onset of BOS. 7( 99) Ex-Vivo Lung Perfusion for Infected Non-Acceptable Donor Lungs: A Pilot Study M.N. Samano , L.G. Abdalla, L.M. Fernandes, N.A. Nepomuceno, K.A. Oliveira Braga, A.E. Azevedo-Pereira, P.M. Pêgo-Fernandes. Thoracic Surgery Departament, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. Purpose: Ex-vivo lung perfusion (EVLP) improves lung function of non-acceptable donor lungs. However, the evidence for using EVLP for infected non-acceptable donor lungs is scarce. Our aim was to evaluate the efficacy of EVLP with of antibiotic strategy in the improvement of lung function and microbiological profile of infected non-acceptable donor lungs. Methods: From August to October/2013, consecutive donors with non acceptable lungs with signs of pneumonia were included. Donor lung pneumonia was defined clinically (fever, leukocytosis), radiologically
(consolidation on chest x-ray), or by bronchoscopy (purulent sputum). After harvesting, the lungs were submitted to normothermic EVLP for 6 hours. Vancomycin (500mg) was added to conventional Steen perfusate. Partial pressure of arterial oxygen (PaO2), and lung compliance (LC) was measured each hour during EVLP. Lungs were classified as potentially acceptable for transplantation if the oxygen index (partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2)) of the perfusate reached 300 after 6h of EVLP. Results: Four donor lungs were included. Mean age was 35-years-old. Three patients were using antibiotics before harvesting (01 due to fever and consolidation on chest x-ray; 01 because of fever only; and 01 due to consolidation on chest x-ray only). There was a trend toward better oxygen index (p= 0.06) after 6h of EVLP. However, only one patient had enough improvement after EVLP to be considered potentially acceptable for transplantation (oxygen index= 333). There was no improvement on LC (p= 0.41) after 6h of EVLP. Table 1 summarizes microbiological panel before and after perfusion. Conclusion: The efficacy of EVLP in the improvement of lung function could be diminished in patients with infected non-acceptable donor lungs. Little changes in microbiological panel were observed in these cases. However, further data is necessary to confirm these findings.
Microbiological panel before and after perfusion Case 1 2
3 4
Initial culture
Klebsiella pneumoniae Enterococcus faecalis Yeast Enterococcus faecalis Candida glabatra Lactobacillus sp Klebsiella pneumoniae Stafilococcus Yeast
End culture Penicillinium sp Enterococcus faecalis Candida glabatra Lactobacillus sp Stenotrophomonas Klebsiella pneumonia
8( 00) Cryoanalgesia Complements Thoracic Epidural Use Following Lung Transplantation M.G. Hartwig ,1 A.A. Osho,2 S. Hirji,2 A.W. Castleberry,1 A. Ganapathi,1 S.S. Lin,1 D.R. Davis.1 1Department of Surgery, Duke University Medical Center, Durham, NC; 2School of Medicine, Duke University Medical Center, Durham, NC. Purpose: Despite improvements in anesthesia and analgesic techniques, acute and chronic postthoracotomy pain syndrome (PTPS) remains a significantly morbid condition. PTPS can also affect respiratory function following lung transplantation. We hypothesized that cryoanalgesia may provide a safe and efficient method of complementing current analgesia regimens. Methods: We performed intercostal cryoanalgesia, in addition to our standard protocol of thoracic epidural analgesia (TEA) use, on 27 lung transplant recipients (CRYO group). We matched them to 27 recipients who received our standard TEA protocol (CONTROL) and compared the primary endpoint of early postoperative pain graded by the verbal pain scale. Secondary endpoints included length of stay (LOS), epidural dosing, and spirometry at 30 days post-transplant. Cryoanalgesia was blinded to the patients. Results: Seventeen bilateral transplants via clamshell incisions and 10 single lung transplants via anterior thoracotomies were performed in each group. In the CRYO group there was a trend toward improvement in early pain score as described by the patient compared to the controls (pain score 2.2 vs. 3.0, p = 0.1531). 23 patients in the CONTROL group required both hydromorphone and bupivacaine in the TEA, compared to only 17 in the CRYO group (p = 0.0201). Hospital LOS and 30-day readmission rates were similar between the 2 groups (p = 0.6370; p = 0.8527). 30-day spirometry showed average percent predicted FVC of 58.8% in CRYO and 59.5% in CONTROL (p = 0.8804), while FEV1 was 62.4% and 61.8%, respectively (p = 0.8911). Conclusion: Intercostal cryoanalgesia appears to be a safe and efficacious method of complementing current protocols of TEA following lung transplantation.
The Journal of Heart and Lung Transplantation, Vol 32, No 4S, April 2014
Conclusion: Pleural symphysis is often required in the management of recurrent pneumothorax and chylous pleural effusions in LAM patients. Preoperative pleurodesis with doxycycline or talc does not appreciably increase rates of complications such as bleeding or chylothorax after LTx for LAM and post LTx lung function and survival rates were excellent. 7( 98) Bronchial Artery Revascularization and En Bloc Lung Transplant in Children F. Guzman-Pruneda ,1 Y. Orr,1 C.M. Mery,1 I. Adachi,1 M. Nugent,2 J. Maddox,2 M.G. Schecter,3 G.B. Mallory,1 D.L. Morales,3 J.S. Heinle,1 E.D. McKenzie.1 1Baylor College of Medicine, Houston, TX; 2Texas Children’s Hospital, Houston, TX; 3Cincinnati Children’s Hospital, Cincinnati, OH. Purpose: Major limitations to long term success in pediatric lung transplantation include infection and bronchiolitis obliterans syndrome (BOS). The more common bilateral sequential technique (BSLT) may result in bronchial ischemia leading to bronchial stenosis or dehiscence and may contribute to small airway loss that culminates in BOS. Bronchial artery revascularization (BAR) may reduce airway and mucosal ischemia, promote better airway healing, and potentially delay the onset of BOS. Additionally, BAR allows for safe tracheal anastomosis avoiding the need for bilateral bronchial anastomoses in infants. At Texas Children’s Hospital both BSLT and en bloc lung transplant with BAR (EBLT) have been employed in a parallel fashion. We sought to identify any differences in outcomes between patient groups. Methods: A retrospective chart review of all patients undergoing isolated primary bilateral lung transplantation from April 2005 to October 2013 was performed. Children who had a re-transplant or a multi-organ transplant were excluded. Results: 102 recipients were included; 83 underwent BSLT whereas 19 received EBLT. Median follow-up time was 2.5 years (range 14 days to 8 yrs). Cystic fibrosis was the most common indication for transplantation. Donor ischemic time was 374 min for BSLT and 393 min for EBLT (p= 0.38). Mean cardiopulmonary bypass time was 317 min for BSLT and 294 min for EBLT (p= 0.09). 51% of patients in the BSLT group experienced 1.6 ± 0.9 episodes of allograft rejection, while 26% of the EBLT group had 1.2 ± 0.5 episodes (p= 0.25). Three hospital mortalities occurred following BSLT and one after EBLT. Long-term survival was 65% and 79% for the BSLT and EBLT groups, respectively (p= 0.67). The incidence of BOS was 26% and 16% in the BSLT and EBLT groups, respectively (p= 0.57). 43% of patients with BSLT and 3% of patients with EBLT had ≥ 1 airway ischemic findings in the first 6 weeks postoperatively (p= 0.003). There were 10 airway re-interventions in 8 patients, all in the BSLT group (p= 0.11). Conclusion: En bloc lung transplant with BAR in children is a safe technique that does not increase operative or graft ischemic times. Airway complications requiring re-intervention are virtually eliminated with the combination of BAR and tracheal anastomosis. These results are consistent with published reports of BAR in adults that describe a lower incidence acute rejection and a delay in the onset of BOS. 7( 99) Ex-Vivo Lung Perfusion for Infected Non-Acceptable Donor Lungs: A Pilot Study M.N. Samano , L.G. Abdalla, L.M. Fernandes, N.A. Nepomuceno, K.A. Oliveira Braga, A.E. Azevedo-Pereira, P.M. Pêgo-Fernandes. Thoracic Surgery Departament, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil. Purpose: Ex-vivo lung perfusion (EVLP) improves lung function of non-acceptable donor lungs. However, the evidence for using EVLP for infected non-acceptable donor lungs is scarce. Our aim was to evaluate the efficacy of EVLP with of antibiotic strategy in the improvement of lung function and microbiological profile of infected non-acceptable donor lungs. Methods: From August to October/2013, consecutive donors with non acceptable lungs with signs of pneumonia were included. Donor lung pneumonia was defined clinically (fever, leukocytosis), radiologically
(consolidation on chest x-ray), or by bronchoscopy (purulent sputum). After harvesting, the lungs were submitted to normothermic EVLP for 6 hours. Vancomycin (500mg) was added to conventional Steen perfusate. Partial pressure of arterial oxygen (PaO2), and lung compliance (LC) was measured each hour during EVLP. Lungs were classified as potentially acceptable for transplantation if the oxygen index (partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2)) of the perfusate reached 300 after 6h of EVLP. Results: Four donor lungs were included. Mean age was 35-years-old. Three patients were using antibiotics before harvesting (01 due to fever and consolidation on chest x-ray; 01 because of fever only; and 01 due to consolidation on chest x-ray only). There was a trend toward better oxygen index (p= 0.06) after 6h of EVLP. However, only one patient had enough improvement after EVLP to be considered potentially acceptable for transplantation (oxygen index= 333). There was no improvement on LC (p= 0.41) after 6h of EVLP. Table 1 summarizes microbiological panel before and after perfusion. Conclusion: The efficacy of EVLP in the improvement of lung function could be diminished in patients with infected non-acceptable donor lungs. Little changes in microbiological panel were observed in these cases. However, further data is necessary to confirm these findings.
Microbiological panel before and after perfusion Case 1 2
3 4
Initial culture
Klebsiella pneumoniae Enterococcus faecalis Yeast Enterococcus faecalis Candida glabatra Lactobacillus sp Klebsiella pneumoniae Stafilococcus Yeast
End culture Penicillinium sp Enterococcus faecalis Candida glabatra Lactobacillus sp Stenotrophomonas Klebsiella pneumonia
8( 00) Cryoanalgesia Complements Thoracic Epidural Use Following Lung Transplantation M.G. Hartwig ,1 A.A. Osho,2 S. Hirji,2 A.W. Castleberry,1 A. Ganapathi,1 S.S. Lin,1 D.R. Davis.1 1Department of Surgery, Duke University Medical Center, Durham, NC; 2School of Medicine, Duke University Medical Center, Durham, NC. Purpose: Despite improvements in anesthesia and analgesic techniques, acute and chronic postthoracotomy pain syndrome (PTPS) remains a significantly morbid condition. PTPS can also affect respiratory function following lung transplantation. We hypothesized that cryoanalgesia may provide a safe and efficient method of complementing current analgesia regimens. Methods: We performed intercostal cryoanalgesia, in addition to our standard protocol of thoracic epidural analgesia (TEA) use, on 27 lung transplant recipients (CRYO group). We matched them to 27 recipients who received our standard TEA protocol (CONTROL) and compared the primary endpoint of early postoperative pain graded by the verbal pain scale. Secondary endpoints included length of stay (LOS), epidural dosing, and spirometry at 30 days post-transplant. Cryoanalgesia was blinded to the patients. Results: Seventeen bilateral transplants via clamshell incisions and 10 single lung transplants via anterior thoracotomies were performed in each group. In the CRYO group there was a trend toward improvement in early pain score as described by the patient compared to the controls (pain score 2.2 vs. 3.0, p = 0.1531). 23 patients in the CONTROL group required both hydromorphone and bupivacaine in the TEA, compared to only 17 in the CRYO group (p = 0.0201). Hospital LOS and 30-day readmission rates were similar between the 2 groups (p = 0.6370; p = 0.8527). 30-day spirometry showed average percent predicted FVC of 58.8% in CRYO and 59.5% in CONTROL (p = 0.8804), while FEV1 was 62.4% and 61.8%, respectively (p = 0.8911). Conclusion: Intercostal cryoanalgesia appears to be a safe and efficacious method of complementing current protocols of TEA following lung transplantation.