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Canadian Journal of Anaesthesia 04/2012; 55:4738671-4738671. · 2.35 Impact Factor
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Canadian Journal of Anaesthesia 04/2012; 53:26136-26136. · 2.35 Impact Factor
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ABSTRACT: To analyze the outcomes of patients with pulmonary arterial hypertension referred for lung transplantation and determine the changes over time.
All patients with pulmonary arterial hypertension referred for lung transplantation in our program from January 1997 to September 2010 were reviewed. Pulmonary arterial hypertension was classified as idiopathic (n = 123) or associated with congenital heart disease (n = 77), connective tissue disease (n = 102), or chronic thromboembolic disease (n = 14).
After completing their assessment, 61 patients (19%) were found to be unsuitable for lung transplantation, 38 (12%) refused lung transplantation, 65 (21%) were too early to be listed, and 48 (15%) died before their assessment (n = 34) or being listed (n = 14). Of the 100 patients listed for lung transplantation, 57 underwent bilateral lung transplantation, 22 underwent heart-lung transplantation, 18 died while waiting, and 3 were still waiting. The waiting list mortality was the greatest for patients with connective tissue disease-pulmonary arterial hypertension (34% vs 11% in the remaining patients, P = .005). The number of patients admitted to the hospital to be bridged to lung transplantation increased from 7% in the 1997-2004 cohort to 25% in the 2005-2010 cohort (P = .02). After lung transplantation, the 30-day mortality decreased from 24% in the 1997-2004 group to 6% in the 2005-2010 group (P = .007). The 10-year survival was worse for those with idiopathic pulmonary arterial hypertension (42% vs 70% for the remaining patients, P = .01). The long-term survival reached 69% at 10 years in the patients with connective tissue disease pulmonary arterial hypertension.
Lung transplantation is an option for about one third of the patients with pulmonary arterial hypertension referred for lung transplantation. The 30-day mortality after lung transplantation improved significantly over time, but the long-term survival remained similar between the two cohorts. Patients with connective tissue disease-pulmonary arterial hypertension have a high mortality on the waiting list but excellent long-term survival.
The Journal of thoracic and cardiovascular surgery 02/2012; 143(4):910-8. · 3.41 Impact Factor
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ABSTRACT: Pulmonary hypertension (PH) associated with pulmonary fibrosis (PF) is a severe condition with poor outcome. It is unknown whether patients with PF with associated PH (APH) represent a distinct phenotype of the disease. We hypothesized that the lung tissue gene expression pattern of patients with APH has a characteristic profile when compared with patients with PF without APH. We sought to determine if different gene expression signatures in PF could be determined based on pulmonary arterial pressures (PAPs) and to provide new insights into the pathobiology of APH.
Microarray analysis (Affymetrix) was performed after RNA was extracted from explanted lungs in 116 consecutive patients with PF (development set, n = 84; validation set, n = 32) and seven subjects with idiopathic pulmonary arterial hypertension undergoing lung transplant (LTx). PAP were recorded intraoperatively immediately before starting LTx. The development set was divided into three groups according to mean PAP (mPAP): severe PH group (mPAP ≥ 40 mm Hg, n = 17); intermediate PH group (mPAP 21-39 mm Hg, n = 45); NoPH group (mPAP ≤ 20 mm Hg, n = 22).
Distinct gene signatures were observed. Patients in the severe PH group showed increased expression of genes, gene sets, and networks related to myofibroblast proliferation and vascular remodeling, whereas patients in the NoPH group strongly expressed proinflammatory genes. Two-dimensional hierarchic clustering based on 222 differentially expressed genes (severe PH vs no PH) dichotomized subjects into two phenotypes in the intermediate PH group and in the validation set. Real-time polymerase chain reaction confirmed the differential expression of selected genes.
Gene expression profiles distinguish PF phenotypes with and without APH. This observation can have important implications for future trials.
Chest 08/2011; 141(3):661-73. · 5.25 Impact Factor
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Marc de Perrot,
John T Granton, Karen McRae,
Marcelo Cypel,
Andrew Pierre,
Thomas K Waddell,
Kazuhiro Yasufuku,
Michael Hutcheon,
Cecilia Chaparro,
Lianne Singer,
Shaf Keshavjee
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ABSTRACT: Our management of patients with idiopathic pulmonary arterial hypertension (iPAH) awaiting lung transplantation changed in 2006 with the introduction of extracorporeal life support (ECLS) as an option to bridge these patients to transplantation (BTT).
To study the effect of this change on waiting list mortality and post-transplant outcome, 21 consecutive iPAH patients listed for lung transplantation between January 2006 and September 2010 (second cohort) were compared with 23 consecutive iPAH patients listed between January 1997 and December 2005 (first cohort).
Between the first and second cohort, the number of patients admitted to the hospital as BTT increased from 4% (1 of 23) to 48% (10 of 21; p = 0.0009). Six patients were BTT with ECLS in the second cohort, including 4 with the Novalung device (Novalung GmbH, Hechingen, Germany) connected as a pumpless oxygenating right-to-left shunt between the pulmonary artery and left atrium. While on the waiting list, 5 patients (22%) died in the first cohort and none in the second cohort (p = 0.03). Time on the waiting list decreased from 118 ± 85 to 53 ± 40 days between the first and second cohort (p = 0.004). After lung transplantation, the 30-day mortality was 16.7% in the first cohort and 9.5% in the second cohort (p = 0.5). The postoperative intensive care unit stay increased from 17 ± 13 to 36 ± 30 days between the first and second cohort (p = 0.02). The long-term outcome after lung transplantation remained similar between both cohorts.
Aggressive management with ECLS of iPAH patients awaiting lung transplantation could have a major impact to reduce the waiting list mortality. This may, however, be associated with longer intensive care unit stay after transplant.
The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 04/2011; 30(9):997-1002. · 3.54 Impact Factor
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ABSTRACT: Blood transfusion requirements were reviewed for a consecutive series of 25 patients undergoing elective pulmonary endarterectomy (PEA) between August 2005 and March 2009 in our institution. Patients were divided into two groups based on the implementation of a conservative blood transfusion algorithm that combined antifibrinolytic therapy, intraoperative blood sequestration, blood salvage and lack of correction of coagulation parameters in the absence of ongoing bleeding. Despite similar perioperative coagulation profiles in the two groups, the introduction of a conservative blood transfusion algorithm was associated with a significant increase in the number of patients receiving no homologous blood products. Of 16 patients who underwent surgery after the introduction of the algorithm, nine (56%) required no homologous blood products and five (31%) required one or two units of homologous red blood cells only. The international normalized ratio normalized within six to 12 hours after discontinuation of cardiopulmonary bypass without transfusion of fresh frozen plasma or platelets in 13 of the 16 patients. In conclusion, a conservative blood transfusion strategy allows PEA to be safely performed with no or minimal blood product transfusions in a majority of patients despite deep hypothermic circulatory arrest.
Interactive cardiovascular and thoracic surgery 03/2011; 13(1):35-8.
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ABSTRACT: Dynamic hyperinflation describes the phenomenon of progressive gas trapping that occurs in patients with severe airflow obstruction. It is associated with significant hemodynamic instability and may precipitate cardiac arrest. This report describes a case of hemodynamic collapse secondary to dynamic hyperinflation in a patient during one-lung ventilation.
A 50-yr-old male with a pneumothorax secondary to a ruptured bulla was transferred to the operating room for a left bullectomy. Approximately 30 minutes after initiation of one-lung ventilation in the right lateral decubitus position, sudden ST segment elevation and hypotension occurred, which was refractory to large doses of vasopressor. This culminated in a pulseless electrical activity arrest. The patient was immediately placed supine, disconnected from the ventilator circuit, and resuscitated with chest compressions, fluids, and epinephrine. Auscultation of the right chest revealed no air entry, and needle decompression followed by chest tube insertion in the right chest did not demonstrate any evidence of a pneumothorax. Approximately three to five minutes after the onset of the arrest, the patient's hemodynamics stabilized and there was no evidence of ST elevation. The etiology of the arrest was likely due to dynamic hyperinflation.
This report highlights the importance of having a high index of suspicion for dynamic hyperinflation and the key to its treatment: disconnection from the ventilator circuit and cessation of mechanical ventilation to allow the lungs to return to functional residual capacity.
Canadian Anaesthetists? Society Journal 01/2011; 58(4):396-400. · 2.31 Impact Factor
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ABSTRACT: Despite a major reduction in pulmonary vascular resistance (PVR), patients with chronic thromboembolic pulmonary hypertension (CTEPH) do not always return to functional New York Heart Association (NYHA) class I after pulmonary endarterectomy (PEA). We hypothesized that residual abnormal compliance (Cp) after PEA is associated with incomplete functional recovery despite major improvement in PVR.
The Cp of 34 consecutive patients with CTEPH was assessed before and after PEA. Cp was defined as stroke volume over pulse pressure and was divided into three groups: < 2.0 mL/mm Hg, 2.0 to 3.9 mL/mm Hg, and ≥ 4 mL/mm Hg. To establish predicted Cp after PEA, we collected an age- and gender-matched control group.
Before PEA, Cp was < 2.0 mL/mm Hg in 82% (n = 28) of the patients. After PEA, Cp improved to 2.0 to 3.9 mL/mm Hg in 11 patients and to ≥ 4.0 mL/mm Hg in 14 patients. Residual Cp < 2.0 mL/mm Hg was associated with delayed extubation and prolonged hospital stay. At 3 months' follow-up, 13 patients (93%) with postoperative Cp ≥ 4.0 mL/mm Hg returned to NYHA class I, whereas 45% with Cp of 2.0 to 3.9 mL/mm Hg and 25% with Cp < 2.0 mL/mm Hg returned to NYHA class I. In multivariate analysis, postoperative Cp ≥ 4.0 mL/mm Hg was the only predictor of functional recovery to NYHA class I. The group of patients with postoperative Cp ≥ 4.0 mL/mm Hg was also the only group to achieve hemodynamic parameters similar to those of their matched control subjects.
Postoperative Cp is an important predictor of recovery after PEA. Residual vascular stiffness after PEA can be associated with persistent functional limitation and lack of complete remodeling of the right ventricle.
Chest 12/2010; 140(1):34-41. · 5.25 Impact Factor
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ABSTRACT: Collapse of the ipsilateral lung facilitates surgical exposure during thoracic procedures. The use of different gas mixtures during two-lung ventilation (2LV) may improve or impede surgical conditions during subsequent one-lung ventilation (OLV) by increasing or delaying lung collapse. We investigated the effects of three different gas mixtures during 2LV on lung collapse and oxygenation during subsequent OLV: Air/Oxygen (fraction of inspired oxygen [FIO(2)] = 0.4), Nitrous Oxide/Oxygen ("N(2)O," FIO(2) = 0.4) and Oxygen ("O(2)," FIO(2) = 1.0).
Subjects were randomized into three groups: Air/Oxygen (n = 33), N(2)O (n = 34) or O(2) (n = 33) and received the designated gas mixture during induction and until the start of OLV. Subjects' lungs in all groups were then ventilated with FIO(2) = 1.0 during OLV. The surgeons, who were blinded to the randomization, evaluated the lung deflation using a verbal rating scale at 10 and 20 min after the start of OLV. Serial arterial blood gases were performed before anesthesia induction, during 2LV, and every 5 min, for 30 min, after initiation of OLV.
The use of air in the inspired gas mixture during 2LV led to delayed lung deflation during OLV, whereas N(2)O improved lung collapse. Arterial oxygenation was significantly improved in the O(2) group only for the first 10 min of OLV, after which there were no differences in mean Pao(2) values among groups.
De-nitrogenation of the lung during 2LV is a useful strategy to improve surgical conditions during OLV. The use of FIO(2) 1.0 or N(2)O/O(2) (FIO(2) 0.4) during 2LV did not have an adverse effect on subsequent oxygenation during OLV.
Anesthesia and analgesia 05/2009; 108(4):1092-6. · 3.08 Impact Factor
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ABSTRACT: There is no consensus on the best technique for lung isolation for thoracic surgery. In this study, we compared the clinical performance of three bronchial blockers (BBs) available in North America with left-sided double-lumen tubes (DLTs) for lung isolation in patients undergoing left-sided thoracic surgery.
One hundred four patients undergoing left-sided thoracotomy or video-assisted thoracoscopic surgery were randomly assigned to one of the four lung isolation groups (n = 26/group). Lung isolation was with an Arndt wire-guided BB (Cook Critical Care, Bloomington, IN), a Cohen Flexi-tip BB (Cook Critical Care) or a Fuji Uni-blocker (Fuji Systems, Tokyo) or with a left-sided DLT (Mallinckrodt Medical, Cornamadde, Athlone, Westmeath, Ireland). Anesthetic management and lung isolation were performed according to a standardized protocol. Each group was randomly subdivided into two subgroups (n = 13/subgroup): immediate suction (at the time of insertion of the lung isolation device) (Subgroup I) or delayed suction (20 min after insertion of the lung separation device) (Subgroup D) according to when suction was applied to the BB suction channel or the bronchial lumen of the DLT. Using a verbal analog scale, lung collapse was assessed by the surgeons, who were blinded to the lung isolation technique.
There was no difference among the lung isolation devices in lung collapse scores at 0 (P = 0.66), 10 (P = 0.78), or 20 min (P = 0.51) after pleural opening. The time to initial lung isolation was less for DLTs (93 +/- 62 s) than BBs (203 +/- 132) (P = 0.0001). There were no differences among the BBs in the time to lung isolation (P = 0.78). There were significantly more repositions after initial placement of the lung isolation device with BBs (35 incidents) than with DLTs (two incidents) (P = 0.009). The Arndt BB required repositioning more frequently (16 incidents) than the Cohen BB (8) or the Fuji BB (11) (P = 0.032).
The three BBs provided equivalent surgical exposure to left-sided DLTs during left-sided open or video-assisted thoracoscopic surgery thoracic procedures. BBs required longer to position and required intraoperative repositioning more often. The Arndt BB needed to be repositioned more often than the other BBs.
Anesthesia and analgesia 05/2009; 108(4):1097-101. · 3.08 Impact Factor
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ABSTRACT: Little is known about the factors that predict the transition of acute, time limited pain to chronic pathological pain following postero-lateral thoracotomy. The aim of the present prospective, longitudinal study was to determine the extent to which (1) pre-operative pain intensity, pain disability, and post-traumatic stress symptoms (PTSS) predict post-thoracotomy pain disability 6 and 12 months later; and (2) if these variables, assessed at 6 months, predict 12 month pain disability. Fifty-four patients scheduled to undergo postero-lateral thoracotomy for intrathoracic malignancies were recruited before surgery and followed prospectively for one year. The incidence of chronic post-thoracotomy pain was 68.1% and 61.1% at the 6 and 12 month follow-ups, respectively. Multiple regression analyses showed that neither pre-operative factors nor acute movement-evoked post-operative pain predicted 6 or 12 month pain disability. However, concurrent pain intensity and emotional numbing, but not avoidance symptoms, made unique, significant contributions to the explanation of pain disability at each follow-up (total R(2)=76.3.0% and 63.9% at 6 and 12 months, respectively, both p<0.0009). The relative contribution of pain intensity decreased, while that of emotional numbing increased with time, indicating a progressive de-coupling of pain intensity and disability and a concomitant strengthening of the link between emotional numbing and disability. This suggests that pain may serve as a traumatic stressor which causes increased emotional numbing. The results also support recent suggestions that avoidance and emotional numbing constitute separate PTSS clusters. Further research is required to determine the source(s) of emotional numbing after postero-lateral thoracotomy and effective interventions.
European journal of pain (London, England) 12/2008; 13(8):870-8. · 3.37 Impact Factor
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ABSTRACT: Factors associated with increased risk of major complications after extrapleural pneumonectomy (EPP) for malignant pleural mesothelioma are not well characterized; in particular, the risks of induction chemotherapy and red blood cell (RBC) transfusion have not been well defined.
We reviewed our experience with 62 consecutive EPP (28 right sided) performed in our institution for malignant pleural mesothelioma between January 1993 and May 2007. A total of 44 patients underwent induction chemotherapy with cisplatin-based therapy.
The majority of patients (88%) received RBC transfusions (median, 4 units; range, 0 to 18 units). Patients undergoing induction chemotherapy had lower preoperative hemoglobin (122 +/- 16 g/L versus 134 +/- 15 g/L in the remaining patients, p = 0.02) and received more RBC transfusions (5.1 +/- 3.5 units versus 2.1 +/- 2.3 units in the remaining patients, p = 0.007). Twenty-two patients (35%) experienced major postoperative complications and 4 of them died (6.5%). Patients experiencing major complications were older (60 +/- 8 years versus 56 +/- 12 years, respectively; p = 0.2) and received more RBC transfusions (5.8 +/- 4.3 units versus 3.7 +/- 2.7 units, respectively; p = 0.02). Major complications occurred more frequently after right-sided EPP than after left-sided EPP (54% versus 21%, p = 0.007). Induction chemotherapy had no impact on the risk of major complications (p = 0.5). Transfusion of more than 4 units of RBC (p = 0.01) and right-sided EPP (p = 0.01) were associated with increased risk of major complications after EPP in multivariate analysis.
Right EPP and more than 4 units of RBC transfusion are associated with increased risk of major complications. Although patients undergoing induction chemotherapy received more RBC transfusions, induction chemotherapy did not directly impact the risk of major complications.
The Annals of thoracic surgery 05/2008; 85(4):1206-10. · 3.74 Impact Factor
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ABSTRACT: Better knowledge of the evolution of persistent pulmonary hypertension after acute pulmonary embolism (PE) is required to optimize the indication and timing of pulmonary endarterectomy (PEA).
We reviewed our experience with 17 consecutive patients demonstrated to have persistent pulmonary hypertension after acute massive (n = 1), submassive (n = 7), or recurrent PE (n = 9).
After a median of 18 weeks of anticoagulation (range, 12 to 30 weeks) since the last PE, 10 patients showed residual pulmonary artery systolic pressure (PAsP) > 50 mm Hg. These patients demonstrated a significant progression in PAsP over the ensuing 6 to 12 months, from 73 +/- 14 to 101 +/- 26 mm Hg (p = 0.005) [mean +/- SD], and eight patients were found to be suitable candidates for PEA. In contrast, among seven patients with residual PAsP from 35 to 40 mm Hg (n = 3) and 41 to 50 mm Hg (n = 4), six patients had evidence of residual perfusion defects on the ventilation/perfusion scan and CT. The PAsP did not change significantly over the ensuing 6 to 12 months, except in two patients who had new episodes of acute PE.
Two groups of patients can be identified based on the degree of residual pulmonary hypertension after acute PE. Patients with residual PAsP > 50 mm Hg should be evaluated for PEA since their pulmonary artery pressures will significantly progress over the ensuing 6 to 12 months despite the absence of recurrent PE. In contrast, patients with PAsP from 35 to 50 mm Hg are at risk for severe pulmonary hypertension if new PE occurs, and should therefore be closely monitored.
Chest 09/2007; 132(3):780-5. · 5.25 Impact Factor
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ABSTRACT: High endotracheal cuff pressures have been shown to cause high mucosal pressures and a reduction in mucosal blood flow, with the risk of mucosal ischemia. We aimed to directly measure the pressure exerted by the bronchial cuffs of double-lumen tubes (DLT) and by the cuffs of three new designs of endobronchial blocker (EBB).
Using a validated in vitro model and a previously described technique, we measured the static pressures exerted by the cuff of DLTs and EBBs with 1 mL increments in cuff volume until maximum inflation was achieved. The study was repeated under dynamic conditions of simulated positive pressure ventilation.
The pressures exerted by the cuffs of DLTs ranged from 16-155 mm Hg. Pressures exerted by the EBB cuffs ranged from 39-194 mm Hg. At intra-cuff volumes required to create a seal to 25 cm H2O positive pressure, the pressures exerted by the cuffs of all the devices were <30 mm Hg.
A transmitted pressure <30 mm Hg has been recommended to avoid mucosal injury. Our study shows that at clinically relevant cuff volumes, the pressures exerted by the cuffs do not exceed the recommended safe limit.
Anesthesia and analgesia 03/2007; 104(3):655-8. · 3.08 Impact Factor
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ABSTRACT: The objective of this study was to examine the long-term patient outcomes of lung transplantation in a single center.
Between 1983 and 2003, 521 lung transplants were performed in 501 patients. Major indications were cystic fibrosis (n = 124), chronic obstructive pulmonary disease (n = 88), alpha-1 antitrypsin deficiency (n = 63), pulmonary fibrosis (n = 97), primary pulmonary hypertension (n = 35), Eisenmenger syndrome (n = 21), and miscellaneous end-stage lung diseases (n = 93).
The 5-, 10-, and 15-year survivals for all recipients were 55.1% (95% confidence interval: +/-5%), 35.3% (+/-6%), and 26.5% (+/-11%), respectively. The most common causes of death were sepsis and bronchiolitis obliterans syndrome. Despite an increased postoperative mortality rate, patients with primary pulmonary hypertension achieved the best long-term survival (10-year survival: 59%). Recipients with cystic fibrosis without Burkholderia cepacia infection achieved significantly better long-term survival (10-year survival: 52%) than those with Burkholderia cepacia infection (10-year survival: 15%). The 10-year survival was also significantly better in recipients with chronic obstructive pulmonary disease (43%) than in recipients with alpha-1 antitrypsin deficiency (23%). Although the incidence of bronchiolitis obliterans syndrome was similar between recipients with chronic obstructive pulmonary disease (39%) and alpha-1 antitrypsin deficiency (46%), recipients with alpha-1 antitrypsin deficiency died of sepsis more frequently than recipients with chronic obstructive pulmonary disease (27% vs 6%, respectively; P =.0003).
Although bronchiolitis obliterans syndrome and sepsis still limit the durability of the benefit, lung transplantation returns many patients with end-stage lung disease to active and productive lives. Differences in the complications and long-term survival show the important contribution of the recipient diagnosis to the success of lung transplantation.
Journal of Thoracic and Cardiovascular Surgery 06/2004; 127(5):1493-501. · 3.41 Impact Factor
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ABSTRACT: To study the impact of minimally invasive trans-cervical thymectomy on the incidence of remission of patients with myasthenia gravis (MG) in a single institution over a 10-year period.
A total of 120 consecutive patients referred for video-assisted trans-cervical thymectomy between 1991 and 2000 were included in the analysis. Complete remission was defined as no symptoms and no treatment for 6 months, and remission as minimal ocular symptoms (slight ptosis) or treatment with pyridostigmine only for 6 months.
There were 86 females and 34 males with a median age of 33 (range 14-79) and 36 years (range 12-68), respectively. Symptoms of MG lasted between 2 months and 17 years before thymectomy (median 10 months). Surgery was converted to a partial upper sternotomy in 23 cases (19%). The median hospital stay decreased from 2 days (range 1-8) before 1994 to 1 day (range 1-8) thereafter (p<0.0001). Postoperative complications occurred in four patients (3.3%). After a median follow-up of 48 months (range 6-117 months), 50% of the patients were in complete remission (41%) or in remission (9%). Kaplan-Meier estimates rate of complete remission were 30% after 5 years of follow-up and 91% after 10 years.
Minimally invasive trans-cervical thymectomy can be performed with short hospital stay and low morbidity, and achieve excellent durable results at 10 years.
European Journal of Cardio-Thoracic Surgery 11/2003; 24(5):677-83. · 2.55 Impact Factor
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ABSTRACT: Inhalation of nitric oxide (NO) has been advocated as a method to prevent ischemia-reperfusion injury after lung transplantation. We enrolled 84 patients into a concealed, randomized, placebo-controlled trial to evaluate the effect of inhaled NO (20 ppm NO or nitrogen) initiated 10 minutes after reperfusion on outcomes after lung transplantation. The groups (n = 42) were balanced with respect to age, sex, lung disease, procedure, and total ischemic times. PaO2/FIO2 ratios were similar on admission to the intensive care unit (ICU) (NO 361 +/- 134; control patients 357 +/- 132), and over the duration of the study. There were no differences in hemodynamics between the two groups. Severe reperfusion injury (PaO2/FIO2 < 150) was present at the time of admission to the ICU in 14.6% NO patients versus 9.5% of control patients (p = 0.48). The groups had similar median times to first successful trial of unassisted breathing (25 vs. 27 hours; p = 0.76), successful extubation (32 vs. 34 hours; p = 0.65), ICU discharge (3.0 days for both groups), and hospital discharge (27 vs. 29 days; p = 0.563). Five NO versus six control patients died during their hospital stay. Adjusting for age, sex, lung disease etiology, presence of pulmonary hypertension, and total ischemic time did not alter these results. In conclusion, we did not detect a significant effect of inhaled NO administered 10 minutes after reperfusion on physiologic variables or outcomes in lung transplant patients.
American Journal of Respiratory and Critical Care Medicine 06/2003; 167(11):1483-9. · 11.08 Impact Factor
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Marc de Perrot,
Yumiko Imai,
George A Volgyesi,
Thomas K Waddell,
Mingyao Liu,
J Brendan Mullen, Karen McRae,
Haibo Zhang,
Arthur S Slutsky,
V Marco Ranieri,
Shaf Keshavjee
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ABSTRACT: Although mechanical ventilation can potentially worsen preexisting lung injury, its importance in the setting of lung transplantation has not been explored. This study was undertaken to examine the effect of 2 ventilatory strategies on the development of ischemia-reperfusion injury after lung transplantation.
In a rat lung transplant model animals were randomized into 2 groups defined by the ventilatory strategy during the early reperfusion period. In conventional mechanical ventilation the transplanted lung was ventilated with a tidal volume equal to 50% of the inspiratory capacity of the left lung and a low positive end-expiratory pressure. In minimal mechanical stress ventilation the transplanted lung was ventilated with a tidal volume equal to 20% of the inspiratory capacity of the left lung, and positive end-expiratory pressure was adjusted according to the shape of the pressure-time curve to minimize pulmonary stress.
After 3 hours of reperfusion, oxygenation from the transplanted lung was significantly higher with minimal mechanical stress ventilation than with conventional ventilation. In addition, elastance, cytokine levels, and morphologic signs of injury were significantly lower in the group with minimal mechanical stress ventilation.
This study demonstrates that the mode of mechanical ventilation used in the early phase of reperfusion of the transplanted lung can influence ischemia-reperfusion injury, and a protective ventilatory strategy on the basis of minimizing pulmonary mechanical stress can lead to improved lung function after lung transplantation.
Journal of Thoracic and Cardiovascular Surgery 01/2003; 124(6):1137-44. · 3.41 Impact Factor
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ABSTRACT: The presence of thymoma may be a negative prognostic factor with respect to the outcome of myasthenia gravis (MG).
Of 122 consecutive patients with MG undergoing thymectomy between August 1994 and September 2000, 37 had a thymoma. Postoperative radiation was administered to all patients with stage II thymoma and higher. To determine differences in presentation and outcome, thymoma patients were compared with patients with atrophic (n = 49) or hyperplastic (n = 36) thymus gland on final pathology.
Thymoma patients were significantly older (52 +/- 14 vs 36 +/- 15 years, p < 0.0001) and included a significantly higher proportion of males (54% vs 28%, p = 0.006) than patients without thymoma. However, the preoperative Osserman grade and the duration of symptoms before surgery were not significantly different between groups. Mean follow-up after thymectomy was not significantly different between patients with or without thymoma (32 +/- 23 vs 37 +/- 19 months, respectively, p = 0.3). At last follow-up, the proportion of asymptomatic patients (63% vs 70%, respectively, p = 0.5) and the mean Osserman grade (0.6 +/- 0.9 vs 0.5 +/- 0.9, respectively, p = 0.6) were similar in both groups. In addition, the rate of complete remission reached 36% at 5 years in patients with or without thymoma (p = 0.8).
Although myasthenic patients with thymoma are significantly older and include a greater proportion of males, the overall outcome, including the rate of complete remission, was similar between patients with or without thymoma. Therefore, the presence of a thymoma should not necessarily be viewed as a negative prognostic factor regarding recovery from myasthenia gravis.
The Annals of Thoracic Surgery 11/2002; 74(5):1658-62. · 3.74 Impact Factor
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ABSTRACT: Cytokines have been shown to play an important role in promoting inflammation in the setting of ischemia-reperfusion injury. However, their role in human lung transplantation has not been systematically explored. This study was undertaken to examine the kinetics of cytokine release in 18 consecutive human lung transplantation procedures and to examine the relationships between their levels and donor factors, length of ischemic time, and allograft function. TNF-alpha, IFN-gamma, IL-10, IL-12, and IL-18 were found at higher levels during the ischemic time, whereas IL-8 predominantly increased after reperfusion. IL-8 levels after 2 h of reperfusion correlated with lung function assessed by the Pa(O2 )/FI(O(2)) ratio, the mean airway pressure, and the APACHE score during the first 24 postoperative hours. The length of ICU stay also correlated with IL-8 levels after 2 h of reperfusion. Longer ischemic time was associated with significantly higher levels of IL-18 before reperfusion, and older donors had significantly lower levels of IL-10 after reperfusion. We have demonstrated the importance of IL-8 in predicting early graft function after human lung transplantation. In addition, we showed that donor age and ischemic time may influence release of specific cytokines during ischemia-reperfusion.
American Journal of Respiratory and Critical Care Medicine 02/2002; 165(2):211-5. · 11.08 Impact Factor
