The effect of lung preservation on alveolar surfactant.
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Animals↗
Biomedical subjects
R J Novick
Publications and source records attributed to R J Novick.
As originially published in 1991: Contralateral pneumonectomy after single-lung transplantation for emphysema. Updated in 1996.
An intractable contralateral air leak developed in a 46-year-old woman after right single-lung transplantation for emphysema. A left pneumonectomy was performed on postoperative day 17, leaving the patient with only one transplanted lung. Fifteen months postoperatively the patient is well and has satisfactory pulmonary function. Survival with a good quality of life is possible after single-lung transplantation and bilateral sequential pneumonectomies.
Female↗
Lung preservation: the importance of endothelial and alveolar type II cell integrity.
The practice of lung transplantation is constrained by a shortage of suitable donor organs. Furthermore, even "optimal" donor lung grafts are at risk of significant dysfunction perioperatively. Significant insights into the cellular and molecular mechanisms of pulmonary ischemia-reperfusion injury have occurred since the publication of previous reviews on lung preservation 3 to 4 years ago. Recent evidence indicates that the endothelium plays an essential role in regulating the dynamic interaction between pulmonary vasodilatation and vasoconstriction and is a major target during lung injury. In addition, the composition, function, and metabolism of pulmonary surfactant produced by alveolar type II cells are increasingly being recognized as important factors in pulmonary ischemia-reperfusion injury. We hypothesize that reperfusion after a period of pulmonary ischemia results in significant endothelial and alveolar type II cell dysfunction and that an important strategy in lung preservation is to preserve the integrity of these cells in the face of this injury. Given the persistent shortage of lungs available for transplantation, laboratory studies need to focus also on the "rescue" of compromised donor lungs that would have been previously regarded as unsuitable. Importantly, innovative work from the laboratory needs to be translated into clinical practice via prospective, randomized trials to ensure that the prevalence of postoperative lung graft dysfunction is reduced and the shortage of lung grafts for transplantation is alleviated.
Animals↗
Pulmonary retransplantation: does the indication for operation influence postoperative lung function?
OBJECTIVE: An international series of pulmonary retransplantation was updated to determine the factors associated with pulmonary function, bronchiolitis obliterans syndrome stage, and survival after operation. METHODS: One hundred sixty patients underwent retransplantation in 35 centers from 1985 to 1995. Logistic regression methods were used to determine variables associated with 3-month and 2-year survival after retransplantation. Values of forced expiratory volume in 1 second were contrasted between groups by unpaired, two-tailed t tests. RESULTS: The median follow-up in surviving recipients was 780 days. Actuarial survival was 45% +/- 4%, 41% +/- 4%, and 33% +/- 4% at 1, 2, and 3 years, respectively. On multivariable analysis, the only predictor of 3-month survival was preoperative ambulatory status (p = 0.005), whereas center experience with at least five pulmonary retransplantations was the sole predictor of 2-year survival (p = 0.04). The prevalence of stage 3 (severe) bronchiolitis obliterans syndrome was 12% at 1 year, 15% at 2 years, and 33% at 3 years after retransplantation. Retransplant recipients with stage 3 bronchiolitis obliterans syndrome at 1 year had a significantly worse actuarial survival than those with stages 0 to 2 (p < 0.01). By 3 years after retransplantation, the forced expiratory volume in 1 second was significantly lower in patients who underwent reoperation because of obliterative bronchiolitis than in patients who underwent retransplantation because of acute graft failure or an airway complication (p = 0.02). Only 31% of patients who underwent retransplantation because of obliterative bronchiolitis were free of bronchiolitis obliterans syndrome at 3 years versus 83% of patients who underwent retransplantation because of other indications (p = 0.02). CONCLUSIONS: Preoperative ambulatory status predicts early survival and center volume predicts intermediate-term outcome after retransplantation. Improved management strategies are necessary to prevent the development of progressive graft dysfunction after retransplantation for obliterative bronchiolitis.
Actuarial Analysis↗
Evaluation of surfactant treatment strategies after prolonged graft storage in lung transplantation.
We have previously documented alterations in endogenous surfactant after lung transplantation and improved graft function in some dogs after instillation of bovine lipid extract surfactant (bLES) into the recipient. To determine the effect of bLES delivery method and timing of treatment on physiologic response and surfactant recovery, 21 canine left lung grafts were divided into four groups: (1) Treatment of the donor for 3 h with aerosolized bLES prior to graft storage (Donor Aerosol); (2) Treatment of the recipient with instilled bLES immediately after transplantation (Recipient Instilled); (3) No bLES treatment (Control); and (4) Aerosolized bLES in donors and instilled bLES in recipients (Combined Therapy). Aerosolized bLES was labeled with [3H]-dipalmitoylphosphatidylcholine (DPPC) and instilled bLES with [14C]-DPPC. Grafts were stored for 36 h, transplanted and reperfused for 6 h. The native right and transplanted left lungs were then lavaged and protein yield, surfactant aggregates, and bLES recovery were measured. After 6 h of reperfusion, PO2/FlO2 ratio was significantly better after Combined Therapy (372 +/- 52 mm Hg) than in the Recipient Instilled (117 +/- 47 mm Hg) and Control groups (87 +/- 26 mm Hg), with intermediate values in Donor Aerosol dogs (232 +/- 64 mm Hg). The recovery of donor aerosolized bLES from transplanted lungs was increased in dogs given Combined Therapy versus Donor Aerosol treatment alone (p = 0.03). Furthermore, with Combined Therapy there was an increased percentage of instilled bLES recovered from transplanted lungs compared with the Recipient Instilled group. We conclude that surfactant treatment strategies influence physiologic response and bLES recovery after prolonged lung preservation. Treatment of lung donors with exogenous surfactant prior to graft storage was associated with less severe lung injury. Combined donor and recipient bLES therapy resulted in a superior physiologic response during reperfusion in this model.
Aerosols↗
The Registry of the International Society for Heart and Lung Transplantation: thirteenth official report--1996.
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Adolescent↗
Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for Thoracic Organ Transplantation.
1. The number of heart transplant operations performed in the United States grew modestly as indicated by a 12% increase from 1990 (n = 2,108) to 1995 (n = 2,360). From 1990 (n = 203) to 1995 (n = 871), lung transplant procedures increased by 329%. This trend has continued with 723 procedures performed in 1994 and 871 (21% increase from 1994) reported for 1995. As in the US, the number of non-US heart transplants has leveled during recent years. 2. The number of heart transplant programs in the United States has remained relatively constant over the last 3 years with a decrease of 5 heart programs from 1995 to 1996. The number of centers performing lung transplantation has also leveled during the last 3 years with an increase of only 4 programs from 1994 to 1996. Non-US lung programs increased 90% from 1994 to 1995. 3. The most frequently reported indication for heart transplantation in the US has changed from coronary artery disease (40.9%) in previous registry reports to all cardiomyopathies (44.7%). For other thoracic transplants, the most frequently reported indications included cystic fibrosis (36.7%) for double-lung, emphysema/COPD (46.8%) for single-lung and congenital lung disease (41.2%) for heart-lung transplants. The most frequently reported diagnoses for thoracic transplantation outside the US included cardiomyopathy (48.5%) for heart, cystic fibrosis (36.0%) for double-lung, idiopathic pulmonary fibrosis (26.5%) for single-lung and primary pulmonary hypertension (25.0%) for heart-lung transplants. 4. US heart transplant recipients were predominantly male (77.8%), 50-64 years old (51.1%) and white (82.7%). In contrast, US lung transplant recipients were predominantly female (52.9%), 35-64 years old (73.1%) and white (89.9%). No significant variance from the US recipient demographic profile was noted for non-US recipients in these analyses. 5. The one-year survival rate for US heart transplant recipients during recent years was fairly consistent, with only a 0.4% increase from 1990-1995. Improvement in the one-year US lung transplant survival rate was demonstrated by a rise from 35.3% in 1987 to 74.0% in 1995. The one-year survival rates at non-US centers were 76.0% for heart recipients and 64.5% for lung recipients in 1995. 6. The long-term thoracic patient survival rates in the United States were: 33.3% at 12 years for heart, 43.7% at 5 years for lung and 27.6% at 10 years for heart-lung recipients. Long-term survival rates for non-US cases were: 30.3% at 12 years for heart, 44.8% at 6 years for lung and 19.8% at 10 years for heart-lung. 7. The most important risk factor for US heart recipients at 1 month, 1 year, 3 years and 5 years after transplantation was receipt of a previous heart transplant. Other substantial long-term risk factors included recipient age less than 1 year, donor aged 45-54, and non-white recipient. 8. The most important mortality risk factor in US lung recipients was the order of the transplant (primary or repeat). Diagnosis and ventilator use remained highly influential risk factors for mortality.
Adolescent↗
Recurrence of obliterative bronchiolitis and determinants of outcome in 139 pulmonary retransplant recipients.
An international series of pulmonary retransplantation was updated to identify the predictors of outcome and the prevalence and recurrence rate of obliterative bronchiolitis after operation. The study cohort included 139 patients who underwent retransplantation in 34 institutions in North America and Europe between 1985 and 1994. Eighty patients underwent retransplantation because of obliterative bronchiolitis, 34 because of acute graft failure, 13 because of intractable airway complications, 8 because of acute rejection, and 4 because of other indications. Survivors were followed up for a median of 630 days, with 48 patients alive at 1 year, 30 at 2 years, and 16 at 3 years after retransplantation. Actuarial survival was 65% +/- 4% at 1 month, 54% +/- 4% at 3 months, 45% +/- 4% at 1 year, 38% +/- 5% at 2 years, and 36% +/- 5% at 3 years; nonetheless, of 90-day postoperative survivors, 65% +/- 6% were alive 3 years after retransplantation. Life-table and univariate Cox analysis revealed that more recent year of retransplantation (p = 0.009), identical match of ABO blood group (p = 0.01), absence of a donor-recipient cytomegalovirus mismatch (p = 0.04), and being ambulatory immediately before retransplantation (p = 0.04) were associated with survival. By multivariate Cox analysis, being ambulatory before retransplantation was the most significant predictor of survival (p = 0.008), followed by reoperation in Europe (p = 0.044). Complete pulmonary function tests were done yearly in every survivor of retransplantation and bronchiolitis obliterans syndrome stages were assigned. Eleven percent of patients were in stage 3 at 1 year, 20% at 2 years, and 25% at 3 years after retransplantation. Values of forced expiratory volume in 1 second decreased from 1.89 +/- 0.13 L early after retransplantation to 1.80 +/- 0.15 L at 1 year and 1.54 +/- 0.16 L at 2 years (p = 0.006, year 2 versus baseline postoperative value). Most of this decrease occurred in patients who underwent retransplantation because of obliterative bronchiolitis, whereas the pulmonary function of patients who underwent retransplantation because of other conditions did not significantly change. We conclude that survival after pulmonary retransplantation is improving. Optimal results can be obtained in patients who are ambulatory before retransplantation. Compared with recent data after primary lung transplantation, bronchiolitis obliterans syndrome does not appear to recur in an accelerated manner after retransplantation. As long as early mortality as a result of infection can be minimized, pulmonary retransplantation appears to offer a reasonable option in highly selected patients.
ABO Blood-Group System↗
Seventy-two pulmonary retransplantations for obliterative bronchiolitis: predictors of survival.
BACKGROUND: Obliterative bronchiolitis (OB) occurs in up to 40% of patients in the intermediate term after lung transplantation. In recent years an increasing number of recipients with end-stage OB have been treated with retransplantation. METHODS: Seventy-two patients with OB underwent retransplantation at 26 North American and European centers a median of 590 days after their first transplant operation. The predictors of survival were determined using life table and Cox proportional hazards methods, and the recurrence rate of OB was determined in survivors. RESULTS: The actuarial survival rate was 71% +/- 5% at 1 month, 43% +/- 6% at 1 year, and 35% +/- 6% at 2 years; nonetheless, of the 90-day postoperative survivors, 63% +/- 7% were alive 2 years after retransplantation. Institutional experience with more than three pulmonary retransplantations (p = 0.008), reoperation in Europe (p = 0.013), donor-recipient ABO blood group identity (p = 0.018), and more recent year of retransplantation (p = 0.03) were associated with survival. On multivariate analysis, reoperation after 1989 (p < 0.001), retransplantation performed in Europe (p = 0.017), and being ambulatory immediately before reoperation (p = 0.022) were found to be predictive of a positive outcome. Pulmonary function test analyses confirmed that the forced expiratory volume in 1 second decreased from postoperative baseline values by 11% +/- 9% at 1 year and 27% +/- 10% at 2 years (p = 0.02; year 2 versus baseline). Fourteen percent of patients were in stage 3 of the bronchiolitis obliterans syndrome at 1 year postoperatively, with 33% affected at 2 years. CONCLUSIONS: The results of pulmonary retransplantation for OB are improving. Current evidence indicates that OB does not recur in an accelerated manner after retransplantation, although pulmonary function does worsen again by 2 years. Pulmonary retransplantation is appropriate only in selected patients with OB who are ambulatory and are operated on at experienced centers.
Adolescent↗
Worldwide thoracic organ transplantation: a report from the UNOS/ISHLT International Registry for Thoracic Organ Transplantation.
The number of heart transplant operations performed in the United States has grown modestly as indicated by an 11% increase from 1990 (n=2,108) to 1994 (n=2,340). From 1987 (n=18) to 1993 (n=666), lung transplant procedures have increased by 3600%. This trend continued with 722 procedures performed in 1994 and 760 (22% increase from 1993) currently reported for 1995. Non-US heart transplants have also leveled during recent years. The number of new heart transplant programs in the United States has not increased during the last 2 years with no change from 1993-1994 and a decrease of 2 heart programs from 1994-1995. From 1990 (n=37) to 1995 (n=71), the number of centers performing lung transplantation increased by 92%. No significant changes were noted in the number non-US heart or lung programs from 1993-1994. The most frequently reported US indications for thoracic transplantation were coronary artery disease (43.5%) for heart, cystic fibrosis (37.9%) for double lung, emphysema/COPD (44.1 %) for single lung and congenital lung disease (40%) for heart-lung. The most frequently reported non-US diagnoses for thoracic transplantation included cardiomyopathy (48.8%) for heart, cystic fibrosis (39.4%) for double lung, idiopathic pulmonary fibrosis (31.4%) for single lung and primary pulmonary hypertension (24.3%) for heart-lung. US heart transplant recipients were predominantly male (77.9%), over 50 years of age (54.3%) and white (83.3%); while US lung transplant recipients were predominantly female (53.2%), between 35- 64 years of age (73.2%) and white (90.7%). No significant variance from the US recipient demographic profile was noted for non-US recipients in this analysis. Differences were noted in the percent distribution of non-US and US donor causes of death. The top US causes of donor death were motor vehicle accidents (31.7%), cerebrovascular/strokes (24.0%), gunshot/stab wounds (23.2%) and non-motor vehicle head traumas (11.8%). The leading causes of donor death for non-US cases included cerebrovascular/strokes (55.7%), non-motor vehicle head traumas (28.7%), motor vehicle accidents (7.7%) and central nervous system tumors (3.0%). Gunshot/stab wounds accounted for only 0.9% of donor deaths. A leveling of US heart transplant one-year survival during recent years was indicated by a 1.5% increase from 1988-1994. Improvement in one-year US lung transplant survival was indicated by a rise from 35.3% in 1987 to 74.1 % in 1994. Non-US one-year survival rates were 77.5% for heart and 67.5% for lung in 1994. The long-term thoracic patient survival rates in the United States were: 36.9% at 11 years for heart, 41 % at 5 years for lung and 24.7% at 10 years for heart-lung recipients. Long-term survival rates for non-US cases were 37.1 % at 11 years for heart, 39.7% at 5 years for lung and 16.8% at 10 years for heart-lung. The most important risk factor for US heart recipients at one month, one year, 2 years and 3 years posttransplant was receipt of a previous heart transplant. Other substantial risk factors included congenital diagnosis, donor age greater than 50 years and recipient on a ventilator at the time of transplant. The most important risk factor for mortality in US lung recipients was the transplant number (primary or repeat). Diagnosis and ventilator use were also highly influential risk factors for mortality.
Adolescent↗
Evaluation of pulsatile and nonpulsatile flow in capillaries of goat skeletal muscle using intravital microscopy.
It is commonly believed that pulsatile flow generated by the pumping action of the heart is dampened out by the time it reaches the microcirculation. In clinical practice, most of the cardiopulmonary bypass pumps and ventricular assist devices are nonpulsatile. To test the hypothesis that pulsatile flow generated by the heart does exist at the microvascular level, intravital microscopy of a large animal model (goat) was developed to visualize and to videorecord the surface microcirculation of the flexor carpi ulnaris muscle from the right forelimb. Density of perfused capillaries and red blood cell velocity in capillaries were measured in five goats during pulsatile perfusion provided by the heart and during a subsequent 3-hr period of nonpulsatile perfusion provided by a centrifugal ventricular assist device (Centrimed, Sarns 3M) that bypassed the heart. Throughout the experiment, the heart rate, innominate artery mean blood pressure, and flow remained unchanged. During the pulsatile regimen, velocities showed regular fluctuations that coincided with the period of the cardiac cycle (range of periods: 0.5-0.8 sec). The peak velocity amplitudes (range: 0.25-0.55 mm/sec) correlated directly with the amplitude of the pulse pressure. During the nonpulsatile regimen, no such correlations were seen. During pulsatile flow and during the 3-hr nonpulsatile period, capillary density remained stable at 24 capillaries/mm of test line but there were significant increases in red cell velocity, from 0.8 to 1.2 mm/sec (P < 0.05), and in coefficient of variation of velocity (used as an index of flow heterogeneity), from 19 to 34% (P < 0.05). We conclude that (1) pulsatility exists in the capillary bed and that it directly correlates with the pumping action of the heart and (2) nonpulsatile flow produced by the ventricular assist device does not cause an acute deterioration in microvascular perfusion. We interpret the increase in heterogeneity of flow as an early sign of microvascular dysfunction. Prolonged use of the nonpulsatile device may, therefore, lead to deterioration in perfusion that could compromize the function of the organ.
Animals↗
Effect of TENS on pain, medications, and pulmonary function following coronary artery bypass graft surgery.
The efficacy of transcutaneous electrical nerve stimulation (TENS) as an adjunct to narcotic medications for the management of postoperative pain was assessed in a prospective, randomized, controlled study of patients following coronary artery bypass graft (CABG) surgery with the right or left internal thoracic artery (ITA). Forty-five male patients (mean age, 57 +/- 6 years) were randomly assigned to (1) TENS, (2) placebo TENS, or (3) control treatments (n = 15 each), following extubation and during the 24- to 72-h postoperative period. Two-way analysis of variance tests indicated no significant differences among treatment groups for (1) pain with cough, (2) narcotic medication intake, (3) FVC, (4) FEV1, and (5) PEFR (p > 0.05). However, pain at rest reported by the TENS group was significantly lower than that reported by the control group (treatment main effect; p < 0.04), although no significant differences were observed between the TENS and placebo or between the placebo and control groups (p > 0.05). All six criterion measures were characterized by significant changes over time for the entire group (n = 45; time main effect; p < 0.01), as follows: pain and medication intake were similar on days 1 and 2, but were significantly less on day 3, and pulmonary functions were significantly lower than preoperatively on day 1, decreased further on day 2, and despite an improvement on day 3, remained significantly lower than preoperative values (p < 0.01). This study suggests that the addition of TENS, applied continuously during the immediate postoperative period following CABG with ITA, may not be advantageous in pain management or the prevention of pulmonary dysfunction.
Analgesics, Opioid↗
Aprotinin significantly decreases bleeding and transfusion requirements in patients receiving aspirin and undergoing cardiac operations.
BACKGROUND: Patients with heart disease are frequently maintained on a regimen of aspirin because of its ability to decrease thrombotic complications and reduce the prevalence of unstable angina and myocardial infarction. Aspirin-induced platelet acetylation also increases bleeding caused by impairment of platelet function during cardiac surgery. METHODS: Between October 1990 and November 1991 this double-blind, randomized, placebo-controlled, parallel group interventional study examined the efficacy of high-dose aprotinin administration (up to 7 million KIU) to decrease blood loss and transfusion requirements in patients receiving aspirin within 48 hours of undergoing coronary bypass or valvular heart operations. Primary outcome measures in this study were total volume of blood loss (intraoperative blood loss plus postoperative chest tube drainage) and volume of transfusion during hospitalization. RESULTS: Patients treated with aprotinin (n = 29) had significantly lower total blood loss (1409 +/- 232 ml versus 2765 +/- 248 ml; p = 0.0002), intraoperative blood loss (503 +/- 53 ml versus 1055 +/- 199 ml; p = 0.0001), postoperative blood loss (906 +/- 204 ml versus 1710 +/- 202 ml; p = 0.0074), and prevalence of transfusion (59% versus 88% of patients; p = 0.016) than the placebo group (n = 25). The prevalence of complications including myocardial infarction was similar in the two groups. CONCLUSIONS: High-dose aprotinin significantly reduces blood loss and red blood cell transfusions in patients receiving aspirin who undergo cardiac operations.
Aged↗
Exogenous surfactant therapy in thirty-eight hour lung graft preservation for transplantation.
Previous work in our laboratory has documented alterations in surfactant composition and function after prolonged lung graft storage and transplantation in dogs (Am Rev Respir Dis 1993;148:208-15). To determine whether exogenous surfactant therapy was beneficial, we pretreated 13 canine double lung blocks with prostacyclin, flushed them with 4 degrees C modified Euro-Collins solution, and stored them at 4 degrees C for 37 to 38 hours. After left lung transplantation and immediately before reperfusion, eight dogs were administered 50 mg of bovine lung lipid extract surfactant per kilogram (50 mg/ml) directly into the left main bronchus and five served as nontreated control animals. Blood gases, peak inspired pressures, and individual pulmonary artery blood flows were measured every 30 minutes during 6 hours of reperfusion. The native right and transplanted left lungs were then lavaged and surfactant large and small aggregates and protein yields were analyzed. All nontreated animals had physiologic evidence of severe ischemia-reperfusion lung injury during reperfusion. Three of eight dogs treated with bovine lung lipid extract surfactant had near normal lung function at 6 hours of reperfusion, as reflected by maintenance of an oxygen tension/inspired oxygen fraction ratio of more than 400 mm Hg and a normal carbon dioxide tension. Five of eight dogs did not respond to surfactant therapy and had decreases in gas exchange identical to those of the control animals. Blood flow through the left pulmonary artery was maintained in the three animals that responded to exogenous surfactant, whereas flow significantly decreased to the left lung in all other animals, reflecting the patterns of gas exchange. In addition, the ratio of poorly functioning small surfactant aggregates to the well-functioning large aggregates isolated from lung lavage after 6 hours of reperfusion was decreased in surfactant-treated animals, especially in those exhibiting a beneficial physiologic response to surfactant therapy. We conclude that therapy with bovine lung lipid extract surfactant can result in excellent preservation of lung grafts after prolonged storage and transplantation, but that the results are not consistent. Further investigations are required to determine the factors responsible for the differential response to surfactant therapy.
Animals↗
Pulmonary retransplantation for obliterative bronchiolitis. Intermediate-term results of a North American-European series.
An international series of pulmonary retransplantation was updated to identify the predictors of survival in the intermediate-term after reoperation for obliterative bronchiolitis. The study cohort included 32 patients with end-stage obliterative bronchiolitis who underwent retransplantation in 15 North American and European centers between 1988 and 1992. Five types of retransplantation procedures were done, including repeat ipsilateral single lung transplantation (7 patients), repeat contralateral single lung transplantation (8 patients), repeat double lung transplantation (3 patients), double lung transplantation after a previous single lung transplantation (3 patients), and single lung transplantation after a previous double lung or heart-lung transplantation (11 patients). The mean interval between transplants was 564 +/- 51 days (range 187 to 1589 days). Postoperative follow-up was 100% complete and the average follow-up in surviving patients was 678 +/- 63 days. Actuarial survival was 72%, 53%, 50%, 41%, and 33% at 1, 3, 6, 12, and 24 months, respectively. Survival did not differ according to the age, preoperative diagnosis, ambulatory or ventilator status, or cytomegalovirus serologic status of the recipient before reoperation. Life-table and Cox proportional hazards analysis identified the type of retransplantation procedure and the year of reoperation as significant (p < 0.05) predictors of postoperative survival. Actuarial survival was significantly better in patients without an old, retained contralateral graft after retransplantation and in patients who underwent reoperation between 1990 and 1992, as opposed to between 1988 and 1989. Infection was the most common cause of death at all time intervals after retransplantation, although all deaths beyond 2 years resulted from obliterative bronchiolitis of the second graft. Most surviving patients are in a satisfactory clinical condition, with a mean forced expired volume in 1 second of 59% +/- 13% of predicted (repeat double lung transplant recipients) or 41% +/- 6% of predicted (repeat single lung transplant recipients). We conclude that pulmonary retransplantation for obliterative bronchiolitis is associated with significantly worse survival than after primary lung transplantation. The absence of an old contralateral graft after retransplantation and reoperation after 1989 are important predictors of survival. Additional data and follow-up are required to determine the merit of pulmonary retransplantation for obliterative bronchiolitis.
Actuarial Analysis↗
Alterations in pulmonary surfactant composition and activity after experimental lung transplantation.
Pulmonary surfactant facilitates breathing by reducing the surface tension at the air/liquid interface. We examined the effect of experimental lung transplantation on the phospholipid pool sizes of alveolar surfactant large and small aggregates, the composition of the large aggregates, the surface tension-reducing ability of lipid extract surfactant, and the leakage of serum proteins into the lung. A double-lung block from the donor animal was stored for 2 or 12 h after perfusion with either Euro-Collins solution or University of Wisconsin solution. The right donor lung was lavaged immediately after the storage period to determine the effects of storage on pulmonary surfactant. The left donor lung was transplanted. The recipient animal, containing its own native right lung and the transplanted left lung, was reperfused for 6 h. After the reperfusion period, the transplanted left lung and the native right lung were lavaged. After an ischemic time of 12 h, impaired gas exchange was observed in the transplanted lung as well as the native lung during the 6 h of reperfusion. This impaired gas exchange was associated with several significant changes in pulmonary surfactant: (1) total serum protein in the lung lavage was increased, (2) the small to large surfactant aggregate ratio was increased, (3) sphingomyelin content was increased and phosphatidylglycerol content was decreased in large aggregates, and (4) the surfactant-associated protein A content was decreased in large aggregates. No significant differences were observed between the results obtained with Euro-Collins and University of Wisconsin solutions.(ABSTRACT TRUNCATED AT 250 WORDS)
Adenosine↗
Heart transplantation after cardioverter-defibrillator implantation. A case control study.
A case control study was performed to determine whether previous implantable cardioverter-defibrillator (ICD) insertion adversely affects outcome after heart transplantation. Six male heart transplant recipients who had undergone ICD insertion 12 +/- 5 months before heart transplantation were compared to a cohort of six heart transplant recipients who were matched according to age, preoperative status and hemodynamics, date of transplantation, graft ischemic time, history of a previous cardiac operation, and duration of follow-up. There were no significant differences in operating room time, chest tube drainage, time to extubation, and the duration of intensive care unit or hospital stay between the two groups. Furthermore, there were no significant differences in the number of units of packed cells, fresh frozen plasma, platelets and cryoprecipitate transfused. The number of treated rejection episodes and the number of patients requiring intravenous antibiotics for infection in the first 90 days was identical between groups. It was concluded that heart transplantation after ICD implantation did not appear to carry more risk than heart transplantation after a previous cardiac operation. Our limited experience supports the potential use of the ICD in patients with life-threatening ventricular dysrhythmias who are awaiting transplantation.
Blood Loss, Surgical↗
Recycling of cardiopulmonary bypass cannulae: a risk-benefit analysis.
OBJECTIVE: To determine whether recycling of arterial and venous cannulae for cardiopulmonary bypass is associated with an increased risk of infectious complications after open heart surgery. DESIGN: A prospective, risk-benefit analysis. SETTING: A university teaching hospital. PATIENTS: Five hundred and forty patients underwent a variety of non-transplant cardiac operations, which were performed by one surgeon between October 1988 and July 1993. INTERVENTIONS: Standard techniques of open heart surgery were used. Ascending aortic and vena caval cannulae and the multiple perfusion device for administering cardioplegia down saphenous vein bypass grafts were reused an average of 10 to 15 times after sterilization with ethylene oxide after each use. MAIN OUTCOME MEASURES: The postoperative morbidity and mortality and the estimated savings achieved by recycling the cannulae. RESULTS: The operative mortality (total in hospital plus within 30 days of operation) was 2.8% (15 patients). There were no cases of endocarditis; there was only one case of superficial presternal infection and one case of mediastinitis. Gram-negative organisms were cultured from the blood of two patients and gram-positive organisms from the blood of one patient. Only one patient died of an infectious complication. The estimated cost saving during the study period was more than $50,000. CONCLUSIONS: The risk of wound and hematogenous infection after open heart surgery in which recycled cannulae are used is less than 1%. This rate is lower than that quoted in most recent reports. Reuse of heart-lung bypass cannulae may realize substantial cost savings without detriment to the patient.
Cardiopulmonary Bypass↗