BLTX with intra- and postoperatively prolonged ECMO in patients with pulmonary hypertension: beneficial effect on initial organ function.
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Journal Article↗
Biomedical subjects
O Senbaklavaci
Publications and source records attributed to O Senbaklavaci.
Rupture and dissection in pulmonary artery aneurysms: incidence, cause, and treatment--review and case report.
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Adult↗
Is long-term functional outcome after lung volume reduction surgery predictable?
OBJECTIVE: The aim of this retrospective study was to analyze which preoperative parameters might predict a persistent improvement in forced expiratory volume in 1 s (FeV1) 1 year after surgery. METHODS: Seventy consecutive lung volume reduction surgery (LVRS) patients (age, 56.5+/-1.2 years) with a follow-up period of at least 1 year were analyzed (from September 1994 to September 1997). The patients were described by lung function tests, blood gas analysis, ventilatory mechanics (intrinsic positive endexpiratory pressure (PEEP)) and morphometric data (degree of heterogeneity, DHG; degree of hyperinflation, DHI; severity of parenchymal destruction, SPD) preoperatively. Based on the postoperative course of FeV1 (percentual increase compared with preoperative values, % increase), patients were divided into four groups: group A, (n=21) no improvement (FeV1</=20% increase); group B, (n=10) FeV1>/=20% increase, which declined to preoperative values after 1 year; group C, (n=18) FeV1, 20-40% increase, sustaining at 1 year; group D, (n=21) FeV1>/=40% increase, sustaining at 1 year. The statistics comprised of analysis of variance (ANOVA) and chi-square testing, with values presented as means+/-SEM. RESULTS: No differences were found for lung function parameters (FeV1: 27.7+/-2.7, 26.0+/-2.5, 23. 9+/-2.2 and 23.9+/-1.9% predicted, in groups A, B, C and D, respectively). Arterial blood gas levels preoperatively revealed significant differences between the groups; the arterial pO(2) was 66.2+/-1.2 mmHg in groups A+B compared with 61.8+/-1.5 mmHg in groups C+D (P=0.030). The arterial pCO(2) was 39.2+/-1.1 mmHg in groups A+B compared with 43.3+/-1.5 mmHg in groups C+D (P=0.038). The morphometric data had a strong trend towards higher heterogeneity in groups C and D. Marked DHI was found in 59 and 81% of patients in groups A+B versus C+D, respectively (P=0.121). Marked DHG was present in 22 and 54% of patients in groups A+B versus C+D, respectively (P=0.010). CONCLUSION: Preoperative arterial pO(2) and pCO(2), and the DHG are predictors for long-term benefit after LVRS with regard to the FeV1, 1 year postoperatively.
Analysis of Variance↗
Lung transplantation following lung volume reduction surgery.
OBJECTIVE: Lung volume reduction surgery (LVRS) has been proposed as a possible alternative treatment to lung transplantation (LTX) for selected patients with end-stage emphysema. But whether LVRS is a temporary or permanent alternative to LTX is still under investigation. The aim of this study was to analyze the course of patients undergoing LVRS followed by subsequent LTX. METHODS: Fifteen patients (10 male, 5 female, mean age 53.3 +/- 1.7 years) out of 102 patients, who underwent LVRS between September 1994 and August 1998, underwent LTX 19.6 +/- 3.1 months after LVRS (range 1.7 to 37.6 months) between June 1996 and October 1998. In 9 patients bilateral LVRS was performed, in 6 patients unilateral LVRS. Subsequent LTX was performed bilaterally in 10 patients and unilaterally in 5 patients (1 of these on the contralateral side) to the previous LVRS. The course of lung function and clinical outcome were analyzed in these 15 patients. RESULTS: Mean forced expiratory volume in 1 second (FEV(1)) in the 15 patients prior to LVRS was 18.3 +/- 1.2% of predicted (%p) and increased to 27.0 +/- 2.9 %p (best value within the first 6 months postLVRS) (p = 0.043). In 8 of these patients (non-responders) (53%) LVRS failed to improve FEV(1), whereas in the other 7 patients (responders) (47%) a significant improvement was detected (FEV(1) 18.1 +/- 1.8 %p and 31.9 +/- 3.7 %p, pre- and post-LVRS, respectively, p = 0.003), but declined after 6 to 36 months. At the time of listing for LTX the mean FEV(1) was 18.0 +/- 1.9 %p (no difference between the 2 groups). LTX was performed 15.5 +/- 3.6 months (non-responders) and 25.7 +/- 4.6 months (responders) after LVRS. FEV(1) improved to 81.0 +/- 5.6 %p after LTX (p < 0.001 compared to pre-LTX). The mortality after LVRS was 0%. The 3-month mortality after LTX was 20% (1 patient with primary organ failure, 1 patient with ongoing rejection, 1 patient with sepsis). All 3 patients belonged to the group of nonresponders. Two patients died 5. 5 and 8.5 months after LTX (13.3%) due to fungal infection (Aspergillus spp.) and MRSA sepsis, respectively (1 non-responder, 1 responder). CONCLUSIONS: Successful LVRS delays the need for LTX and offers better conditions for LTX. However, patients without functional improvement after LVRS have a high perioperative risk at subsequent LTX.
Adult↗
[Results of lung-volume reduction surgery in end-stage lung emphysema].
BACKGROUND: Surgical treatment of diffuse, nonbullous emphysema was first described by Brantigan et al. in 1957 and was reintroduced by Cooper et al. in 1995 as lung-volume reduction surgery (LVRS). Meanwhile it has become an internationally established procedure in the treatment of lung emphysema. We report our results after LVRS in 91 patients. METHODS: Between September 1994 and August 1998 LVRS was performed through median sternotomy (n = 15), videoendoscopy (n = 49), thoracotomy (n = 18) or combined video endoscopy on one side and thoracotomy on the other (n = 9) in 91 patients (aged 33-80 years; mean 56,4 years). All patients showed progression of severe dyspnea despite maximum medical and physical therapy. RESULTS: Perioperative mortality was 5.5 % (5 patients). Seventy-five percent of the patients showed significant functional improvement [postoperatively above 120 % of the preoperative forced expiratory volume in 1 s (FeV1)]. Mean FeV1 significantly increased by 28.6 % from 25.5 +/- 1.2 % predicted (% p) preoperatively to 32.8 +/- 1.9 % p during the first 6 months postoperatively (p < 0.005). Furthermore, the mean RV was reduced from 320.3 +/- 7.9 % p preoperatively to 248.4 +/- 7.5 % p 6 months postoperatively and mean TLC from 140.2 +/- 2.4 % p to 126.1 +/- 2.1 % p (p < 0.005). Intrinsic PEEP decreased significantly from 5.1 +/- 0.4 cm H(2)O preoperatively to 2.3 +/- 0.3 cm H(2)O postoperatively (p < 0.05). CONCLUSION: LVRS is an excellent therapeutic option for selected patients with severe emphysema and additional signs of severe hyperinflation. It results in significant postoperative functional improvement and marked increase in quality of life. The long-term benefit of LVRS remains to be defined.
Adult↗
Morphologic grading of the emphysematous lung and its relation to improvement after lung volume reduction surgery.
BACKGROUND: The morphologic criteria for lung volume reduction surgery, such as severity and heterogeneity of disease, differ widely between patients, and this makes any comparison of functional results between centers difficult. Here we present a morphologic scoring system and describe its possible relation to functional results after lung volume reduction operations. METHODS: Between September 1994 and December 1996, 47 consecutive patients underwent bilateral lung volume reduction operations. The morphology of emphysema was quantified with standard chest roentgenograms and computed tomographic imaging, which were used to define the following four variables: degree of hyperinflation (grade 0 to 4), degree of impairment in diaphragmatic mechanics, degree of heterogeneity (grade 0 to 4), and severity of parenchymal destruction (range, 0 to 48). RESULTS: All four variables showed good reproducibility. Degree of heterogeneity had a significant influence on functional improvement in terms of forced expiratory volume in 1 second (p = 0.0413, r2 = 0.11). Severity of parenchymal destruction was significantly associated with 30-day mortality: patients who died after operation (n = 4) had a severity of parenchymal destruction of 28.4 +/- 2.1 compared with 21.3 +/- 1.0 for those who survived (n = 43) (p = 0.003). CONCLUSIONS: This morphologic scoring system is easy to use, is reproducible, and allows quantification of the morphology of emphysema, thereby allowing definition of different patient subgroups. Such an exact morphologic quantification may help in the comparison of functional results between centers. Furthermore, the risk factors for certain morphologic subgroups, such as patients with a homogeneous distribution pattern, may be clarified in the future.
Adult↗
Chronic hypercapnia should not exclude patients from lung volume reduction surgery.
OBJECTIVE: Chronic hypercapnia is still considered to increase the risk for perioperative mortality and therefore to be a contraindication for lung volume reduction surgery (LVRS). The aim of this study was to analyse the influences of hypercapnia upon postoperative outcome. METHODS: The functional improvement (preop vs. 3 months postop) and clinical outcome was studied in 22 patients with chronic hypercapnia (preoperative arterial pCO2 > or = 45 mmHg) who underwent LVRS between 9/94 and 2/97 and were compared to all other patients (n = 58) without hypercapnia. Data are expressed as the mean +/- SEM. RESULTS: The 30-day mortality was 9.1% (2/22) in patients with chronic hypercapnia (HC) and 5.2% (3/58) in patients with normal arterial pCO2 levels (control) (P = n.s). The stay on the ICU (3.5 +/- 0.8 vs. 2.1 +/- 0.3 days) and duration of chest drainage (7.3 +/- 1.2 vs. 7.2 +/- 0.8 days) was similar between both groups (HC vs. control) (P = n.s). The preoperative lung function (% of predicted) and blood gas (mmHg) parameters were significantly worse in HC patients compared to control patients. In both groups significant functional improvements were observed: FeV1 in the control group increased by 37% within the first 3 months (29.1 +/- 1.7% of predicted vs. 39.9 +/- 3.1% of predicted, P = 0.0198). In the HC group, FeV1 increased by 73% which was even higher than in the controls (19.5 +/- 1.5% of predicted vs. 33.7 +/- 4.7% of predicted, P = 0.0385). All patients of both groups who died perioperatively had a significantly higher severity of parenchymal destruction than those who survived (P = 0.0277 and 0.0380, respectively). CONCLUSIONS: Patients with chronic hypercapnia alone, had no significantly higher mortality and morbidity, and therefore should not be excluded from LVRS. However, the presence of additional risk factors, such as homogeneity of disease, high degree of parenchymal destruction or pulmonary hypertension should be considered as contraindications for the procedure.
Case-Control Studies↗
Functional improvement after volume reduction: sternotomy versus videoendoscopic approach.
BACKGROUND: Volume reduction has been proved to increase ventilatory mechanics in diffuse, nonbullous lung emphysema. However, the best approach is still controversial. METHODS: We retrospectively compared the perioperative data of and functional results in 15 patients having sternotomy (group I) with those of 15 patients having a videoendoscopic approach (group II). RESULTS: The 30-day mortality was 2 patients in group I and 1 patient in group II. Mean duration of chest tube drainage was 8.7 +/- 1.8 days and 8.0 +/- 1.9 days and mean hospital stay, 12.3 +/- 1.9 and 12.5 +/- 2.1 days in groups I and II, respectively. Work of breathing decreased from 1.89 +/- 0.33 J/L and 1.76 +/- 0.22 J/L preoperatively to 0.75 +/- 0.06 J/L and 0.8 +/- 0.06 J/L (p < 0.01 and p < 0.05, respectively) after 3 months; and intrinsic positive end-expiratory pressure decreased from 7.15 +/- 1.31 cm H2O and 6.24 +/- 1.33 cm H2O to preoperatively 0.79 +/- 0.46 cm H2O and 1.13 +/- 0.44 cm H2O (p < 0.005 and p < 0.01, respectively) after 3 months in groups I and II, respectively. Forced expiratory volume in 1 second increased from preoperative values of 21.6% +/- 2.9% and 25.3% +/- 2.4% of predicted to 34.5% +/- 5.0% and 40.9% +/- 7.5% of predicted after 3 months (p < 0.05 in both groups) in groups I and II, respectively. CONCLUSIONS: Both surgical approaches resulted in similar substantial improvement in lung function and physical fitness. The incidence of air leakage, the duration of chest tube drainage, and the hospital stay were the same for both procedures.
Case-Control Studies↗
Downsizing of the donor lung: peripheral segmental resections and lobar transplantation.
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Humans↗
Incidence and outcome of major non-pulmonary surgical procedures in lung transplant recipients.
OBJECTIVE: Pulmonary transplant recipients are at high risk from various conditions requiring surgical intervention. As little is known about their exact incidence and course, we examined such procedures in detail. METHODS AND PATIENTS: We have retrospectively analyzed major nonpulmonary surgical procedures performed in 124 consecutive patients who received an isolated lung transplant at the University of Vienna between 1989 and December 1995. Twenty-two patients underwent a total of 28 major interventions (22/124 = 17.7%), resulting in an incidence of one procedure every 5.8 patient years of follow-up. The mean interval between transplantation and intervention was 17.9 months (range 3 days to 62 months) with six interventions being carried out during the first month after transplantation. Fourteen emergency operations were performed, the remaining 14 procedures were carried out electively. Overall, 15 abdominal procedures, four thoracic, four orthopedic, two gynecological, one neurosurgical, one urological and one plastic surgery were performed. RESULTS: There was no intraoperative death. Perioperatively, five surgery related deaths were observed (5/28, related mortality 17.9%) with multiple organ failure as the cause of death in all cases. All of these deaths followed emergency operations (5/14 = 35.7%) and all were observed in patients with septic abdominal complications. In contrast, even very extensive procedures were performed electively without related mortality (0/14, P = 0.02). During the first month after transplantation, major surgery was associated with a 50% (3/6) mortality, for late interventions mortality was 9.1% (2/22; P = 0.047). CONCLUSIONS: Pulmonary transplant recipients showed a high incidence of conditions requiring surgical intervention. As expected, septic complications, especially during the immediate post transplant period, carried a very poor prognosis. However, it was reassuring to observe that even extensive surgical procedures could be performed safely without associated mortality in the elective setting.
Adolescent↗
Lung retransplantation: institutional report on a series of twenty patients.
BACKGROUND AND METHODS: Between 1986 and 1995, 124 isolated lung and 29 combined heart-lung transplantations were performed at our institution. Twenty of these procedures were retransplantations. Four different types of reoperations were performed: ipsilateral single lung retransplantation (n = 3), single lung retransplantation after bilateral or heart-lung transplantation (n = 7), bilateral retransplantation after bilateral lung transplantation (n = 5), and bilateral retransplantation after single lung transplantation (n = 5). Nine patients underwent retransplantation while still in the intensive care unit after the primary transplantation. Indications for retransplantation in these patients were primary graft failure in seven and bronchial complications in two patients. In 11 patients a late retransplantation (3 to 30 months after the first transplantation) was performed. The indication was obliterative bronchiolitis in nine and late bronchial complications in two patients. Overall, 13 patients were ventilator-dependent before retransplantations. RESULTS: Overall survival was 52.8% and 36.2% at 1 and 12 months, respectively. For early retransplantation the survival rate at 1 month was only 22.2% with 2 patients alive 5 and 22 months after the retransplantation. For late retransplantation survival at 1 and 12 months was 70.7% and 50.5%, respectively (p = 0.07), and the longest surviving patient was at 47 months after retransplantation at the time this article was written. Patients who were ventilator-dependent before retransplantation had a significantly worse outcome (survival at 1 and 12 months: 33.8% and 25.4% versus 85.7% and 57.1% for all others, p = 0.055). Of those surviving to date, all were in New York Heart Association class I or II. CONCLUSIONS: We conclude that late and elective lung retransplantation achieves acceptable results when offered to patients with chronic pulmonary dysfunction but with otherwise stable conditions. In view of the poor results, early acute retransplantation should be performed much more restrictively.
Adolescent↗
[Lung volume reduction in emphysema--experience and results of the first 2 years].
Between September 1994 and August 1996 Lung Volume Reduction Surgery (LVRS) was performed through median sternotomy, videoendoscopically or by thoracotomy in 60 patients (age 33 to 80 years, mean 56.7 years). All these patients had severe emphysema despite maximal conservative and physical therapy. The areas with the most destroyed lung parenchyma were resected by means of linear stapling devices, 3 patients (20%) out of 15 who were operated via sternotomy died postoperatively due to aspiration pneumonia, multiorgan failure and acute hepatic failure. In the videoendoscopic group with 45 patients, 2 patients (4.4%) died due to multiorgan failure and cardiorespiratory failure. 72.7% of the remaining patients showed a significant functional improvement (postoperative FEV1 > 130% of the preoperative value) with a marked decrease of dyspnea. There was no significant improvement in 23.7% of the patients (postoperative FEV1 = 90 to 110% of the preoperative value) and 3.6% of the patients had a functional deterioration. Residual volume decreased from 317.0 +/- 12.4% of predicted (%p) preoperatively to 226.2 +/- 8.8 %p within the first month (p = 0.0001). FEV1 significantly increased from 23.7 +/- 1.3 %p preoperatively to 36.6 +/- 4.1 %p during the first 6 months postoperatively (p = 0.0016). Radiological signs of hyperinflation and distention of the thorax preoperatively improved to narrowed intercostal spaces and a more shaped diaphragm. These morphological changes resulted in better ventilatory muscle function. The intrinsic PEEP significantly decreased from 5.92 +/- 0.64 cm H2O preoperatively to 1.70 +/- 0.25 cm H2O postoperatively (p = 0.0001). The work of breathing decreased from 1.58 +/- 0.09 J/l preoperatively to 0.99 +/- 0.07 J/l postoperatively (p = 0.0001). In conclusion, LVRS is an excellent therapeutic option for patients with severe emphysema and additional signs of severe hyperinflation with significant postoperative functional improvement and marked increase in quality of life.
Female↗
Acute pulmonary trunk dissection in a patient with primary pulmonary hypertension.
Spiral CT imaging findings including multiplanar reconstructions of an acute dissection of the pulmonary trunk in a 22-year-old female patient with primary pulmonary hypertension (PPH) are presented and discussed.
Acute Disease↗