Impact of Native Lung Pneumonectomy in Single-Lung Transplant Recipients

Impact of Native Lung Pneumonectomy in Single-Lung Transplant Recipients

S310 The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015 12.5). Pre transplant diagnoses were: COPD: 5 p (62.5%), pulmonary hy...

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S310

The Journal of Heart and Lung Transplantation, Vol 34, No 4S, April 2015

12.5). Pre transplant diagnoses were: COPD: 5 p (62.5%), pulmonary hypertension: 2 p (25%) and 1 p with cystic fibrosis. Four p were SLTx and 4 p BLTx. Mean time to diagnosis was 29.6 months (4-156 months).after LTx, two of them (25%) within the first 6 months. All p developed respiratory symptoms with fever and productive cough of more than 15 days of evolution. Microbiological rescue was done in five p by broncoalveolar lavage, 1 p had positive sputum, 1 p had culture in the transbronchial biopsy and another in the surgical biopsy. The initial treatment was performed with 4 drugs (isoniazid, pyrazinamide, ethambutol and levofloxacin) for 2 months, completing a year with 2 drugs (Isoniazid + levofloxacin) achieving good clinical outcome. Three p received full treatment with 4 drugs. Conclusion: The incidence of TBC in our LTx population was 3.2%. Respiratory infections are the leading cause of morbimortality in LTx p and TBC should be considered in the differential diagnosis. 8( 54) Therapeutical Implications of Clinical Characteristics of Patients With Chagas Cardiomyopathy and Decompensated Heart Failure V.S. Issa , G.C. Lima, S.M. Ayub-Ferreira, S.G. Lage, M.T. Oliveira Jr, J. Nicolau, E.A. Bocchi.  Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil. Purpose: Data from patients with Chagas cardiomyopathy during episodes of decompensated heart failure are scarce, and the recognition of specific profiles may influence therapeutical decisions. We sought to compare the occurrence of system organ dysfunction, hemodymamic profiles and prognosis of patients with Chagas cardiomyopathy admitted for decompensated heart failure with other etiologies. Methods: We analyzed a cohort of 140 consecutive patients admitted for decompensated heart failure and evaluated for heart transplant from August 2013 through September 2014. Mean Age was 50.8±13.2 years, 84 (60%) patients were male and 56 (40%) female, with left ventricle ejection fraction of 28±11.6; 43 (30.7%) had Chagas cardiomyopathy, 30 (21.4%) ischemic heart disease, 22 (15.7%) idiopathic dilated cardiomyopathy and 13 (9.3%) hypertension. Results: As compared to other etiologies, patients with Chagas cardiomyopathy had lower blood pressure (86/60 vs 94/65mmHg, p= 0.019), lower left ejection fraction (25 vs 29%, p= 0.029), lower cardiac output (3.63 vs 4.34L/min, p= 0.021), higher B type natriuretic peptide (BNP) (1820 vs 1257pg/ml, p= 0.024), higher bilirubin levels (1.9 vs 1.3mg/dl, p= 0.018) and longer hospitalization (57 vs 40 days, p= 0.01). No differences were found in serum creatinine, urea, sodium levels, MELD and MELD XI score and right side pressures. Patients with Chagas cardiomyopathy had lower mortality during hospitalization (27.9 vs 36.1%, p=  0.018) and higher rate of heart transplantation (27.9% vs 10.3%, p = 0.018). Mortality adjusted for Intermacs was similar between groups (Figure). Conclusion: Clinical presentation and prognosis of patients with Chagas cardiomyopathy with decompensated heart failure are different from other etiologies, with possible impact in decision making regarding heart transplant and ventricular assist devices. 

8( 55) Tacrolimus Monotherapy After Pediatric Heart Transplantation A. Szabó , L. Ablonczy, C. Vilmányi, A. Szatmári.  Pediatric Cardiac Center, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary. Purpose: Routine long-term immunosuppression (IS) after pediatric heart transplantation is based on the combination of tacrolimus (TAC) and mycophenolate mofetil (MMF) or everolimus (EVE). Gastrointestinal sideeffects of the MMF and/or recurrent infections related to EVE can indicate the use of TAC monotherapy. The safety of TAC monotherapy was analized. Methods: Between 2007-2014 September, 26 pediatric heart transplantations were performed in our institute (age: 3 months-16 years; male/female: 12/14; weight: 4.4-61.5 kg). Tacrolimus monotherapy was indicated in 4 cases due to recurrent side effects (age: 11-23 months; male/female: 3/1; weight: 7.6-11.4 kg). Target level of tacrolimus was determined 2 ng/ml higher than used by combined therapy. Surveillance biopsies and echocardiography were performed to detect rejections. Rejections and incidence of infections were studied retrospectively. Results: In every case the first line therapy was the combination of TAC+MMF. In 3 of them MMF/EVE conversion was indicated due to severe enteral side-effects in spite of MMF dose reduction. TAC target level was reduced on TAC+EVE combination depending on posttransplant time. After the conversion the gastrointesinal symptoms were eliminated, but in all of 3 patients recurrent infections were occured (in 2 patients upper-airway infections, in 1 patient permanent high replication of Ebstein Barr virus developed). In 1 patient on TAC+MMF therapy CMV disease and recurrent CMV activations were detected, indicating the reduction of IS. The main follow-up were 14 months. No side-effects was documented related to higher tacrolimus-level. No rejections were detected on biopsies. Infection rate was significantly reduced in every patients. Conclusion: Reduced immunosuppression could be necessary in small children (< 2 yrs of age) due to recurrent side effects of TAC+MMF/EVE therapy. Tacrolimus monotherapy can be a good and safe alternative with higher target level. Long-term follow-up is needed to evaluate chronic rejection. 8( 56) Is Heart Transplantation a Therapeutic Intervention in Multi Drug Resistant Ventricular Assist Related Infections? A. Gkouziouta , S. Chatzianastasiou, N. Kogerakis, D. Degiannis, S. Adamopoulos, G. Saroglou, P. Sfirakis.  Heart Failure, MCS and Transplant Unit, Onassis Cardiac Surgery Centre, Athens, Greece. Purpose: Heart transplantation (HTx) remains the gold standard for refractory heart failure treatment. Due to severe donor shortage in Greece, VADs are increasingly used as a “bridge” to transplant. Driveline exit site, pump pocket infections, as well as endocarditis, remain the major complications despite progress in VAD application. Traditionally, HTx is contraindicated in the presence of active infection, although HTx may be appropriate treatment for life-threatening VAD infections due to multi-drug resistant (MDR) pathogens. Methods: VAD patients were monitored for local and sys- temic signs of infection, while blood and exit site cultures were performed weekly. Results: From February 2003 to October 2014, 15 out of 100 patients developed uncontrollable VAD related infections (15%),12 of which were successfully transplanted. One patient with Acinetobacter baumanii VAD endocarditis underwent VAD replacement with a Berlin Heart Excor BiVAD, yet he died of uncontrollable sepsis before a donor became available. MDR pathogens such as MRSA, Pseudomonas aeruginosa, Klebsiella pneumoniae,Candidas parapsilosis were isolated in blood and trauma cultures.Infection was primarily found in INTERMACS patients and in patients that exceeded 3.5 years of support. Conclusion: Aggressive antibiotic treatment is not adequate in VAD infection due to MDR nosococomial pathogens. Heart transplantation, evenat a pre-terminal stage, may offer reasonable chances of success. 8( 57) Impact of Native Lung Pneumonectomy in Single-Lung Transplant Recipients V. Rusanov ,1 D. Rosengarten,1 B. Fox,1 B. Medalion,2 M. Saute,2 M.R. Kramer.1  1Pulmonary Institute, Rabin Medical Center, Petach-Tikva,

Abstracts S311 Israel; 2Cardiothoracic Surgery, Rabin Medical Center, Petach-Tikva, Israel. Purpose: Single lung transplant recipients may develop complications in their native lung that have a significant impact on outcomes. Among the most serious complications requiring native lung pneumonectomy are infection and malignancy. There is a little data on safety of pneumonectomy after lung transplantation even the native lung usually has a minimal contribution to the overall lung function. The purpose of this study was to assess our institutional experience of native lung pneumonectomy in single-lung transplant recipients and determine its safety, short and long term complications and a impact on survival and lung function. Methods: A retrospective review of all single-lung transplant recipients at our institution from May 1, 1997 to September 1, 2014 who underwent native lung pneumonectomy. Results: During the study period 350 patients underwent single lung transplantation. Nine of these patients developed significant native lung complication requiring pneumonectomy (table 1). Seven patients underwent Right and two patients Left Pneumonectomy for Lung Cancer (7/9) and Infection (2/9). Four patients died in the perioperative period (7 days) from severe cardiovascular complications (3) and sepsis (1). Five patients survived post-operative period to hospital discharge without postoperative complications. Four of these five developed significant deterioration in lung function without evidence of infection, airway complication or acute rejection on trans-bronchial lung biopsy. Conclusion: In our experience native lung pneumonectomy is associated with high morbidity and mortality and may reveal to significant negative impact on lung function. Additional studies are needed to better understand the underlying mechanism of lung function deterioration.

The demographics, clinical data, surgical procedures type and outcome of the patients

N

Time Native Perioperative from Site of surgery/ lung death/sur- FEV1 Sex/age transpl cause perfusion vival (m) before

FEV1 3 month after

1 2 3 4 5 6 7 8 9

M/68 F/59 M/69 F/67 M/70 F/52 M/69 F/58 F/34

46 77 36 33 19

108 80 56 55 38 26 33 60 33

Rt/Cancer Rt/Cancer Rt/Cancer Lt/Cancer Rt/Cancer Rt/Cancer Rt/Infection Rt/Cancer Lt/Infection

11 22 35 20 22 41 7.2 30 25.1

No/8 Yes/0 Yes/0 No/alive Yes/0 Yes/0 No/alive No/alive No/3

71 46 70 71 55 25 61 74 35

8( 58) The Outcomes of VAD Implantation in Ege University: The Largest Experience of Turkey M. Ozbaran,1 T. Yagdi,1 C. Engin,1 S. Nalbantgil,2 S. Ertugay ,1 M. Zoghi.2  1Cardiovascular Surgery, Ege University Medical School Hospital, Izmir, Turkey; 2Cardiology, Ege University Medical School Hospital, Izmir, Turkey. Purpose: Since 2007, ventricular assist device (VAD) implantation has been the complementary treatment to heart transplant program which began 1998, in our center. Between April 2007 and December 2010 paracorporeal pulsatile pumps and since then continuous-flow pumps have been implanted mainly. Herein, we present the outcomes of the largest VAD program of Turkey. Methods: Between 2007 and 2014, 208 adult patients underwent VAD implantation. Median age was 51 (18-74) years and 87 % of them were male. The etiology was dilated cardiomyopathy in 69 % of patients. Berlin Heart Excor, Berlin Heart INCOR, HeartWare HVAD, Heartmate II, Syncardia Total Artificial Heart and Reliant Heart were implanted in 46, 8, 117, 28, 7 and 2 patients, respectively. The timing of implantation was decided according to the criteria of INTERMACS. Main target of implantation was bridgeto-transplantation.

Results: INTERMACS profile were 1,2,3,4 in 22%, 25%, 41% and 10% patients, respectively. Biventricular support with long-term devices was needed in 20 (10%) patients. The rate of bridge-to-transplantation was found 24%. The hospital mortality rate was found 15% in all groups. Main causes of death were right heart failure and infection at early period. The longest duration of support was days 1975 days with Berlin Heart INCOR. At longterm follow-up, device related infections and hemorrhagic stroke were the main causes of death. Conclusion: Ventricular assist device implantations have been performed in our center, in accordance with the current practice. Despite low rate of transplantation, survival rate is similar to the results in worldwide. VAD implantation serves to compensate shortage of donor in our country. 8( 59) Extracorporeal Membrane Oxygenation for Bridge to Heart Transplantation S.S. Wang , N.H. Chi, C.H. Wang, S.C. Huang, N.K. Chou, H.Y. Yu, I.H. Wu, Y.S. Chen, W.J. Ko.  Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan. Purpose: The purpose of this study was to evaluate the effect of extracorporeal membrane oxygenation (ECMO) support on the recipients waiting for heart transplantation (HT) and the influence of survival after HT. Methods: From 2005 to 2014, 1510 patients underwent ECMO support including 90 patients bridging to HT, while HT were performed in 237 patients during that 10-year period at the National Taiwan University Hospital (NTUH). The ECMO was instituted when the patient suffered from persistent low output despite large dose catecholamine infusion with inotropic equivalent over 50 microgram/kg/min or cardiopulmonary resuscitation (CPR). For ECMO assisted CPR (ECPR), the patient must have clear consciousness before CPR with presumed cardiac origin or easily reversible event in witnessed cardiac arrest and immediate effective CPR. The main indication for HT was congestive heart failure with maximal VO2 <  10 mL/kg/min, or intractable heart failure with maximal VO2 < 14 mL/kg/min. The commonest etiology for HT was dilated cardiomyopathy, and the second was ischemic cardiomyopathy. The age ranged from 4 months old to 74 years old with male predominant. Results: We found that ECMO was effective for CPR (ECPR) or short-term support. Those patients with pulmonary or renal dysfunction, systemic infection, or high creatinine kinase or lactate level had worse progress. The 1-year and 5-year survival of HT recipients with good renal and pulmonary function were 97.7% and 80.2% respectively. The 1-year and 5-year survival for patients bridged with ECMO were 80.9% and 69.7% respectively at NTUH. Conclusion: Although ECMO is effective for CPR or short-term support, the patients bridged with ECMO had worse 1-year and 5-year survival after heart transplantation. 8( 60) High Performance Liquid Chromatography Measured Metabolites of Endogenous Catecholamines and Their Relations to Chronic Kidney Disease and High Blood Pressure in Heart Transplant Recipients P. Przybylowski ,1 G. Wasilewski,1 M. Wilusz,2 K. Sztefko,2 L. Janik,1 E. Nowak,1 J. Małyszko.3  1Jagiellonian University Medical College, Krakow, Poland; 2Dep. of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland; 3Department of Nephrology and Transplantology, Medical University, Białystok, Poland. Purpose: Patients after solid organ transplant especially heart and kidneys are very prone to be hypertensive. Recently chronic kidney disease and renalase metabolism of endogenous catecholamines are thought to make major contribution to the pathogenesis of hypertension. The purpose of the study is to analyze for the very first time urine metabolites of endogenous catecholamines in relation to kidney function and blood pressure. Methods: We analyzed 75 heart recipients (80% man, 20% woman), medium age 54,9 (25 to 75 years); 0,5 to 22 years after HTX (medium 10,74). Diagnosis of hypertension was made on the basis of ABPM examination. Complete blood count, urea, creatinine, eGFR, renalase in serum and level of metanefrine, normetanefrine and 3-metoxytyramine in 24-hour urine collection calculated with HPLC (high performance liquid chromatography) were studied as well.