公民心死亡器官捐献肝移植

目的 总结公民心死亡器官捐献肝移植的临床经验.方法 回顾性分析2006年7月至2011年5月广州军区广州总医院施行的20例公民心死亡器官捐献肝移植供受者的临床资料.脑心双死亡器官捐献(DBCD)供者通过体外膜肺氧合技术(ECMO)避免热缺血,M-Ⅲ供者不采用ECMO,待心跳停止5 min后实施肝脏获取手术.受者均采用原位肝移植术,其中17例行胆管端端吻合,3例行胆肠吻合.所有受者获定期随访.采用Kaplan-Meier法绘制生存曲线.结果 20例供者中M-Ⅲ占10％( 2/20),DBCD占90％ (18/20).20例受者均顺利完成手术,平均手术时间、无肝期、术中出血量和术后ICU时间分别为(6.2±2.7)h、(54±13) min、(2305±1311)ml和(44±35)h.全组无手术死亡,术后肝功能恢复满意,无原发性肝脏无功能或移植肝功能恢复延迟;术后1个月内1例受者因脓毒血症死亡,1例因肺部感染死亡,其余18例受者长期生存,最长生存时间为58个月.结论 公民心死亡器官捐献是现阶段我国可以应用的供肝获取方法,其中以DBCD为主要类型;建立科学的心死亡器官捐献肝移植流程,合理使用ECMO等保护供肝质量措施,对我国公民死亡器官捐献工作有着积极的作用.     

亲属活体肾移植供者的选择和安全性评估(附79例报告)

目的探讨亲属活体肾移植供者的选择评估及围手术期安全性。方法 2007年6月至2010年8月,广西中医学院附属瑞康医院移植泌尿外科严格按照供体的评估程序,对79例拟行亲属活体肾移植的供体进行评估,依据供者入选和剔除标准选出合格供体。所有患者均签署知情同意书,符合医学伦理学规定。对供、受者的临床资料进行回顾性分析。收集供者的一般资料、肾功能、捐献关系,分析拟供者剔除的原因,了解供、受者的配型、手术情况,追踪供者、受者术后随访情况。结果 79名拟供者,经严格的筛选最终确定为亲属活体肾移植供体38名。剔除的41例中,糖尿病和高血压,占34%,其余依次为双侧肾功能损害、患乙型病毒性肝炎或丙型病毒性肝炎。供、受者的关系:父母捐献给子女15名,3代以内血亲捐献10名,兄弟之间捐献8名,夫妻之间捐献5名。供、受者血型相同33对、相容5对。供、受者补体依赖淋巴细胞毒性试验均为(-)、群体反应性抗体均为(-)。供者手术时间1～2h,供肾热缺血时间30～60s,冷缺血时间1～2h。供者术前及术后的血清肌酐水平都有不同程度的升高,但均于术后7d恢复正常。供者围手术期间均未发生外科及内科并发症,住院时间10～14d。本组受者中,除1例夫妻之间捐献的肾移植患者术后发生急性排斥反应外,其他病例无出现急性排斥反应、肾功能延迟恢复等状况,随访至2010年7月,移植肾均正常。结论对于亲属活体肾移植的供体安全应予重视。严格进行术前评估,选择合格的供者,术中操作规范,术后加强管理,活体肾移植的供者围手术期是安全的。     

双肺移植30例临床分析

目的探究双肺移植手术安全性并分析影响受者短期预后的危险因素。 方法回顾性分析中日友好医院胸外科2017年4月至2018年6月30例行双肺移植供、受者临床资料。根据术后90 d受者生存情况，将其分为存活组(22例)和死亡组(8例)。采用成组t检验比较两组供肺获取前供者氧合指数、受者年龄和体质指数、供/受者体表面积差、左/右供肺冷缺血时间、手术时间、术中失血量和输液量。采用Wilcoxon符号秩和检验比较两组受者术中输血量和尿量。采用χ²检验比较供者感染情况、受者性别、原发病、术前感染情况及是否使用呼吸机和体外膜肺氧合(EMCO)、双肺移植顺序、术中是否输血和使用EMCO以及术后是否出现吻合口瘘。P<0.05为差异有统计学意义。 结果30例供者供肺获取前病原学培养阳性19例，其中单一感染14例，混合感染5例。30例双肺移植受者术前病原学培养阳性16例，其中单一感染12例，混合感染4例。30例受者中11例先行左侧单肺移植，19例先行右侧单肺移植。30例受者术后90 d受者死亡比例为26.7%(8/30)，死亡原因包括感染中毒性休克4例及吻合口瘘、大咯血、循环功能衰竭和活动性出血各1例。短期预后危险因素分析提示，死亡组和存活组受者术中输血量分别为900 mL(0～6 450 mL)和25 mL(0～1 450 mL)，差异有统计学意义(z＝－2.524，P<0.05)。 结论双肺移植围手术期死亡率较低，受者术中输血量可能影响移植术后受者存活率。     

体外膜肺氧合在临床肺移植中的应用

目的 总结体外膜肺氧合(ECMO)技术在临床肺移植中应用的经验.方法 45例肺移植受者,年龄(50.5±8.6)岁(16～74)岁.原发病为肺纤维化合并肺动脉高压32例,慢性阻塞性肺病4例,矽肺2例,肺结核2例,弥漫性细支气管炎1例,支气管扩张2例,以及原发性肺动脉高压2例.其中3例受者在术前经股动、静脉切开置ECMO管道,分别维持13、19和6d后,在ECMO支持下接受了肺移植手术;40例受者在术中应用了ECMO辅助;2例未在体外循环下接受肺移植的受者,因原发性移植物功能丧失(PGD)于术后行ECMO辅助支持.结果 40例术中应用ECMO者,37例于术毕顺利撤除ECMO,术中辅助流量为(2.8±0.6)L/min,辅助持续时间为(7.7±0.9)h,存活31例;3例术后继续使用ECMO,直至血流动力学稳定,其中2例分别于术后36 h和7d时顺利撤除,另1例术后使用ECMO维持5d后出现急性肾功能衰竭,术后2周时死于多器官功能衰竭.2例术中无体外循环辅助受者和其余3例术中辅助受者因术后发生PGD或急性心力衰竭,而初次或再次使用ECMO,辅助流量分别为(2.5±0.3)L/min和(2.6±0.4)L/min,辅助持续时间分别为(53.5±21.9)h和(88.7±45.9)h,其中3例治愈出院,2例因多器官功能衰竭而死亡.所有受者均未发生明确与ECMO相关的并发症.结论 ECMO是肺移植围手术期支持的重要辅助工具,对于降低等待肺移植过程中的死亡率、稳定术中血流动力学、改善术后严重呼吸功能障碍以及原发性移植物功能不良,可以提供良好的辅助功能.     

体外膜肺氧合在原发性及继发性肺动脉高压肺移植中的应用

目的 探讨体外膜肺氧合(ECMO)在肺移植围手术期应用的方法及疗效.方法 2005年11月至2009年7月,对30例原发性及终末期肺病伴继发性肺动脉高压的患者在肺移植术中应用了ECMO辅助,完成单肺移植18例,不横断胸骨序贯式双肺移植12例.2例患者在术前经股动静脉切开置ECMO管道,分别维持19 d和6 d,术中仍在ECMO支持下进行肺移植;其余患者在麻醉完成后置ECMO管道,开始肺移植术.移植完成后,受者在氧合和血流动力学平稳后撤除ECMO.结果 所有受者均顺利完成移植.27例受者于移植手术结束后顺利撤除ECMO;3例受者术后继续使用ECMO,直至血流动力学稳定,其中2例分别于术后36 h和7 d时顺利撤除,另1例术后用ECMO维持5 d后出现急性肾功能衰竭,术后2周时死于多器官功能衰竭.术后股动静脉切开处伤口感染2例,股动脉血栓形成(中度)1例,经治疗后均好转出院.结论 体外膜肺氧合可安全有效地应用于伴有原发性或继发性肺动脉高压患者的肺移植手术.术中应用ECMO能控制肺动脉高压,同时进行呼吸和循环支持,减少了肺移植手术的并发症.     

体外膜肺氧合用于心死亡供肝的初步经验

目的 总结体外膜肺氧合(ECMO)保护心死亡供肝的初步经验.方法 回顾分析2009年7月至2011年5月期间广州军区总医院肝移植中心施行的17例心死亡肝移植供者临床资料,了解供者原发病和有关指标、供者捐献与获取流程、ECMO使用方法.结果 17例供者均先诊断脑死亡然后等待心脏停跳,属于脑心双死亡供者(DBCD).在心死亡过程全部应用了ECMO,ECMO时间51～380(平均187)min.所有供者均成功获取了供肝并用于受者.受者全组无手术死亡.术后肝功能恢复满意,未发生原发性移植肝无功能并发症.术后1个月内因肺部感染死亡1例,其余16例顺利康复出院并随访至今,随访最长时间为29个月.结论 DBCD是我国公民心死亡供体的特殊类型.ECMO可以控制DBCD热缺血损伤且没有伦理学争议,对我国公民心死亡器官捐献有着十分重要的作用.     

儿童心脏死亡器官捐献供者双肾整块移植早期临床疗效观察

目的：观察儿童心脏死亡器官捐献（ DCD ）供者双肾整块移植的早期临床疗效。方法回顾性分析中山大学附属第一医院器官移植中心2010年2月至2013年9月儿童DCD供者双肾整块移植供、受者临床资料。6例儿童DCD供者中位年龄3岁（10个月～6岁）,均捐献给相同血型受者。6例受者中位年龄39．5岁（17～48岁）,成年人5例,17岁男性1例,原发病均为慢性肾小球肾炎;均为首次肾移植,群体反应性抗体均阴性, HLA错配数1～4个。均采用右侧髂窝整块移植法。结果6例受者手术均获成功。移植肾热缺血时间中位数为17．5 min （0～23 min）,冷缺血时间中位数为6．6 h （4．8～7．4 h）。术后肾功能恢复均较顺利,未发生急性排斥反应、移植肾原发性无功能和移植肾功能延迟。其中4例为移植肾功能立即恢复（即术后第5天血清肌酐≤265μmol/L ）,2例为移植肾功能缓慢恢复（即术后第5天血清肌酐＞265μmol/L）。1例受者术后7 d右侧移植肾动脉血栓形成;1例受者术后15 d诊断为肺结核行正规抗结核治疗;1例受者术后1年出现移植肾动脉吻合口狭窄,介入治疗后恢复。术后随访1～36个月,受者和移植肾全部存活,所有受者肾功能均正常。结论儿童DCD供者双肾整块移植早期临床疗效良好,是一种扩大供者来源的良好途径。     

单中心心脏死亡和脑死亡供肺肺移植临床经验总结

目的 总结单中心脑死亡器官捐赠(DBD)和心脏死亡器官捐赠(DCD)的供肺获取以及肺移植的临床经验.方法 11例潜在器官捐献供者进行了术前评估,所有供者均进行痰培养、床旁支气管镜、胸部X线片及血液气体分析等检查.11例供者中,6例为DCD供者,5例为DBD供者.1例DCD和2例DBD供者因两肺广泛炎症浸润,氧合指数差未行供肺获取;1例DCD供者因心跳停止时间过长未行供肺获取;其余7例临床评估供肺良好,按照临床器官捐赠相关规定流程,在气管插管机械通气下完成供肺获取.7例供、受者术前淋巴细胞毒交叉配合试验均为阴性,供、受者ABO血型相同,供肺大小匹配.结果 7例肺移植均在体外膜肺氧合辅助下完成,包括5例双肺移植和2例右侧单肺移植,受者手术顺利.1例术后并发严重感染,术后39 d死亡;1例术后第9天死于多器官功能衰竭.2例分别于术后30 d、19 d并发急性排斥反应,治疗后好转.3例术后无严重并发症,恢复顺利,肺功能得到极大改善,出院后接受长期随访,术后平均存活23.3个月(3～51个月).结论 应该严格按照临床器官捐献相关规定的要求进行器官捐赠工作.在全面评估供肺质量的前提下,DCD和DBD供肺肺移植的效果可靠.     

体外膜肺氧合在器官移植领域中的应用进展

体外膜肺氧合(ECMO)是一种能代替心肺功能、维持器官持续灌注的体外循环技术。近年来,因其出色的心肺支持功能,ECMO被越来越多地运用于器官移植领域,从器官捐献供者器官的保护,到器官移植受者移植前的安全过渡、移植中生命支持及移植后呼吸循环系统并发症的处理。ECMO在扩大供者来源、提高移植手术安全性和移植受者存活率方面发挥了重要作用。本文就ECMO在器官移植领域中的应用研究进展进行综述。     

肺移植治疗特发性肺间质纤维化32例报告

目的 探讨肺移植治疗特发性肺间质纤维化(IPF)的手术适应证、手术方式及疗效.方法 76例肺移植中32例为肺移植治疗IPF.移植前,患者均经高分辨螺旋CT检查显示为典型的弥漫性蜂窝肺,经开胸或纤维支气管镜肺活组织病理检查确诊为IPF的有16例,动脉血气分析显示动脉血氧分压(PaO_2)≤50 mm Hg(1 mm Hg=0.133 kPa)的有28例,平均肺动脉压≥30 mm Hg的有15例.32例IPF患者中,28例接受单肺移植,其中常规体外循环下完成2例,体外膜肺氧合(ECMO)支持下完成14例;4例双肺移植均在ECMO支持下进行,取双侧前胸切口不横断胸骨,依次完成双侧单肺移植.术后对所有受者进行了随访,观察患者的预后情况.结果 所有受者均顺利完成手术.18例应用ECMO辅助的受者中,术后有17例成功撤除ECMO辅助,1例于术后2周因多器官功能衰竭而死亡.除上述死亡的1例外,术后早期还有4例死亡,1例术后发生支气管吻合口漏,经手术修补后发生吻合口裂开而死亡,1例死于移植肺活动性出血,2例死于移植肺功能丧失.术后1年内有12例发生急性排斥反应,发生率为37.5%,1例因重症排斥反应死亡,2例因严重感染死亡.受者术后3个月、1年及3年存活率分别为84.3%、75%和54.5%,中位存活时间为51个月,受者肺功能改善明显,生活质量显著提高.结论 肺移植是治疗IPF的有效方法,术后可明显延长受者存活时间,单肺移植可作为IPF的常用术式.对年龄较轻者应选择双肺移植.     

Successful bilateral lung transplant outcomes in recipients 61 years of age and older

BACKGROUND: Controversy exists regarding the optimal use of bilateral lung transplant (BLT) in older recipients in diseases where either single or bilateral transplant is appropriate. International Society for Heart and Lung Transplant (ISHLT) guidelines suggest an upper age limit of 60 for BLT, despite limited data regarding outcomes with BLT in patients over 60. We hypothesize that BLT offers comparable, if not superior, clinical outcomes to SLT in all patients independent of recipient age. METHODS: In order to test our hypothesis, we conducted a case-control study to compare the effect of transplant operation on survival and the onset of bronchiolitis obliterans syndrome (BOS) in consecutive lung transplant recipients 61 years of age or older using Kaplan- Meier analysis and Cox proportional hazard models. RESULTS: We identified 107 consecutive lung transplant recipients 61 or older at the time of transplant. Patients received SLT (n=46) or BLT (n=61) based on donor organ availability. Comparable survival was achieved with BLT in older patients vs. SLT P=0.19). One-, two-, and five-year survival estimates in BLT were 82%, 75% and 68%, respectively, vs. in SLT 78%, 70% and 44%, respectively. A comparable onset of BOS was also observed in the patients who received BLT vs. SLT (P=0.23). CONCLUSION: Successful short- and medium-term outcomes are achieved with BLT in older recipients and are comparable to those achieved with SLT. Our results suggest that age over 60 should not exclude patients from consideration of BLT.     

Bilateral versus single lung transplantation for chronic obstructive pulmonary disease: intermediate-term results

Background. There is controversy regarding the transplant procedure of choice in chronic obstructive pulmonary disease We reviewed our intermediate-term outcomes with single lung transplantation (SLT) versus bilateral lung transplantation (BLT).

Methods. We retrospectively reviewed 130 patients with chronic obstructive pulmonary disease: 84 underwent SLT, 46 BLT. The mean age was 51.1 ± 1.2 years for those who underwent BLT and 56.2 ± 0.7 years for those who underwent SLT (p < 0.0001). Male patients represented 65% of the BLT group and 46% of the SLT group (p = 0.04). Spirometry and 6-minute walk tests were obtained preoperatively and at 3- to 6-month intervals. Posttransplant survival and survival from time of onset of bronchiolitis obliterans syndrome were calculated by Kaplan-Meier method. The mean follow-up was 32.4 months.

Results. The 90-day mortality rate was 13.0% For BLT and 15.5% for SLT (p = 0.71). Actuarial survival rates at 1, 3, and 5 years were 82.6%, 74.6%, and 61.9% for BLT and 72.2%, 63.4%, and 57.4% for SLT; the favorable survival trend with BLT did not achieve statistical significance. There were no differences in preoperative spirometry or 6-minute walk tests. The improvements in forced expiratory volume in one second , forced vital capacity (FVC), and 6 MWT were significantly greater following BLT. The incidence of bronchiolitis obliterans syndrome was 22.4% in SLT and 22.2% in BLT; survival following onset of bronchiolitis obliterans syndrome was similar.

Conclusions. For patients with chronic obstructive pulmonary disease, BLT is associated with superior lung function, exercise tolerance, and a trend toward enhanced survival. Younger candidates may be best suited for BLT. Given the limited donor lungs, SLT remains the preferred alternative for all other patients.     

Impact of Lung Transplant Operation on Bronchiolitis Obliterans Syndrome in Patients with Chronic Obstructive Pulmonary Disease

Previous studies suggest that bilateral (BLT) compared with single lung transplantation (SLT) for patients with chronic obstructive pulmonary disease (COPD) results in improved long-term survival. The effect of transplant operation on bronchiolitis obliterans syndrome (BOS) is unknown. A retrospective study of all lung transplant recipients with pre-transplant diagnoses of COPD at the University of Toronto and at Duke University was performed. Data collected were age, gender, date and type of transplant, acute rejection, survival, presence and time of BOS. 221 (bilateral n = 101, single n = 120) patients met our criteria. Patients with BLT were younger (53.0 vs. 55.3 years; p = 0.034), more likely to be male (56.3% vs. 42.4%; p = 0.039) and more likely to be transplanted at the University of Toronto (79.6% vs. 16.1%; p < 0.001). Freedom from BOS was similar at 1 year post-transplant. However, BLT recipients were more commonly free from BOS 3 years (57.4% vs. 50.7%) and 5 years (44.5% vs. 17.9%) post-transplant (p = 0.024). Survival of BLT was better than SLT recipients at 3 and 5 years post-transplant (BLT vs. SLT: 67.5% vs. 61.1% and 60.7% vs. 34.1%, respectively; p = 0.018). Similar trends on survival were observed after development of BOS. BLT results in lower rates of BOS in patients with COPD that are eligible for both SLT and BLT.     

Single vs bilateral, sequential lung transplantation for end-stage emphysema: influence of recipient age on survival and secondary end-points.

BACKGROUND: The appropriate age to perform bilateral, sequential lung transplants (BSLT) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Although single lung transplant (SLT) offers an advantage in terms of organ availability, the long-term survival may not warrant this strategy in all age groups. METHODS: We analyzed 2,260 lung transplant recipients (1835 SLT, 425 BSLT) with COPD recorded in the International Society for Heart and Lung Transplantation/United Network for Organ Sharing thoracic registry between January 1991 and December 1997. To assess mortality, we performed univariate (Kaplan-Meier method and the chi-square statistic) and multivariate analyses (proportional hazards method). Because of incomplete morbidity data in the international registry, only data from U.S. centers (n = 1778, 1467 SLT, 311 BSLT) were used in the morbidity analysis. RESULTS: Survival rates (%) computed using the Kaplan-Meier method at 30 days, 1 year, and 5 years for the patients aged < 50 years were 93.6, 80.2, and 43.6, respectively, for the SLT patients, and 94.9, 84.7, and 68.2, respectively, for the BSLT patients. For patients aged 50 to 60 years, survival rates (%) were 93.5, 79.4, and 39.8 for the SLT patients compared with 93.0, 79.7, and 60.5 for the BSLT patients. For those aged > 60 years, SLT survival (%) was 93.0, 72.9, and 36.4, compared with 77.8 and 66.0 for the BSLT group (a 5-year rate could not be completed in this group). The multivariate model showed a higher risk ratio for mortality in patients aged 40 to 57 years who received SLT vs BSLT. Recipient age and procedure type did not appear to affect the development of rejection, bronchiolitis obliterans, bronchial stricture, or lung infection. CONCLUSIONS: Single lung transplant may offer acceptable early survival for patients with end-stage respiratory failure. However, long-term survival data favors BSLT in recipients until approximately age 60 years. These data suggest that a BSLT approach offers a significant survival advantage to recipients younger than 60 years of age.     

Physiologic aspects in human lung transplantation.

Heart-lung transplantation (HLT), followed by single lung transplantation (SLT) and subsequently bilateral lung transplantation (BLT) have been developed as treatments for patients with end-stage pulmonary diseases. Initially, SLT was limited to idiopathic pulmonary fibrosis (IPF) cases and thought to be contraindicated not only for infectious diseases, but also for non-infectious diseases, including pulmonary emphysema (PE) and primary pulmonary hypertension (PPH), based on physiologic points of view. However, SLT is now widely performed for those non-infectious diseases and most of the recipients return to a normal active life. It is quite possible that BLT is superior to SLT in terms of pulmonary function, and it has been reported that BLT is better for PE and PPH patients in regards to perioperative course, postoperative exercise capacity, and long-term survival. For those situations and because of the present scarcity of donor organs, SLT must be utilized for selected non-infectious diseases for which it is safe and effective. When a single lung is replaced for IPF, PE, and PPH recipients, different physiologic situations are produced postoperatively, the understanding of which is extremely important to achieve good results, not only in the perioperative but also in the long term.     

Lung transplant at the Favaloro Foundation: a 13-year experience

BACKGROUND: The outcomes of lung transplantation (LT) are well known in developed countries, but not in Latin America. Our objective was to report the LT experience at a single center in Argentina. METHODS: From June 1994 to February 2003, the 54 LT that were performed included 36 single-lung transplants SLT (45.5%) and 18 double-lung transplants (DSLT) (22.7%). Indications for SLT (n = 36) were emphysema (n = 23) and pulmonary fibrosis (n = 13); for DSLT (n = 18), bronchiectasis (n = 8), cystic fibrosis (n = 8), pulmonary emphysema (n = 1), and bronchiolitis obliterans syndrome caused by graft-versus-host disease after bone-marrow transplantation (n = 1). A univariate analysis, chi-square test with Yates' correction was used for qualitative variables; Wilcoxon-Mann-Whitney test, for quantitative and ordinal variables. Survivals were estimated by the Kaplan-Meier method. RESULTS: In-hospital mortality (HM) was 21.1%. Among SLT, early death was due to sepsis in six patients and by ischemia-reperfusion injury (IRI) and acute rejection in other two. In DSLT, two patients died due to IRI and one, sepsis. The overall estimated survival rates at 1, 2, and 4 years were 70.1% +/- 6.5%, 54.3% +/- 7.2%, and 44.3% +/- 7.9%, respectively. The median overall survival was 26.5 (10 to 34) months. When HM was excluded, survival at 4 years was 51.3% +/- 8.7%. The estimated survival at 3 years was 43.3% +/- 9.3% for SLT and 58.7% +/- 13% for DSLT (P = 6). Survival differences according to the baseline diagnosis were not significant (P =.6). Median follow-up time (percentiles 25 to 75) was 16 (2 to 27) months. CONCLUSIONS: Our LT program shows similar results to those reported by the International Society for Heart and Lung Transplantation for developed countries.     

Lung transplantation for primary and secondary pulmonary hypertension.

BACKGROUND: Single lung transplantation (SLT) and bilateral lung transplantation (BLT) are routinely performed in patients with primary pulmonary hypertension (PPH) and secondary pulmonary hypertension (SPH). It is unclear which procedure is preferable. We reviewed our experience with lung transplants for PPH and SPH to determine if any advantage exists with SLT or BLT for either PPH or SPH. METHODS: We reviewed the outcomes of all lung transplants performed for PPH or SPH for 4.5 years (July 1995 to January 2000). Survival was reported by the Kaplan-Meier method, and log rank analysis was used to determine significance. Statistical analyses of clinical data were performed using analysis of variance and chi2 analysis. RESULTS: A total of 57 recipients met criteria for pulmonary hypertension with a mean pulmonary artery pressure of greater than or equal to 30 mm Hg. There were 15 patients with PPH and 40 patients with SPH. There were 6 patients who had SLTs and 9 patients who had BLTs in the PPH group; and there were 9 patients who had SLTs and 21 patients who had BLTs in the SPH group. We found a survival advantage for PPH patients who underwent BLTs at all time points up to 4 years (100% vs 67%; p < or = 0.02). There was no clear advantage to SLTs or BLTs for SPH. At 4 years there was a trend toward improved survival with SLTs (91% vs 75%) in SPH patients with a mean pulmonary artery pressure less than or equal to 40 mm Hg (p < or = 0.11) with equivalent survival (80%) in patients with a mean pulmonary artery pressure greater than or equal to 40 mm Hg. There was also a trend toward improved survival in patients with a mean pulmonary artery pressure greater than or equal to 40 mm Hg (PPH and SPH) with BLTs (88% vs 62%; p = 0.19). The incidence of rejection, infection, and other complications was comparable between SLTs and BLTs in each group. CONCLUSIONS: We believe that BLT is the procedure of choice for PPH. The procedure of choice is less clear for SPH. Patients with SPH and a mean pulmonary artery pressure greater than 40 mm Hg may benefit from a BLT and those with a mean pulmonary artery pressure less than or equal to 40 mm Hg may do better with an SLT; however, no clear advantage is seen.     

Liver transplantation trends for older recipients: regional and ethnic variations

BACKGROUND: Liver transplantation (LT) provides long-term survival for adults with end-stage liver disease. As a result of improved survival and an aging United States population the demand for LT in older patients is expected to increase. The aim of this study was to describe the transplantation trends in the older recipient (older than 65 years). METHODS: Using the United Network for Organ Sharing database, we identified LT recipients between 1990 and 2006. We used Kaplan-Meier method to calculate overall survival (1, 3, 5 and 10 years) and Cox regression for predictors of survival. RESULTS: During the study period 5630 (7.6%) LT recipients were older than 65 years. There were 4256 (79.4%) whites, Hispanic (10.3%), African Americans (AA) (3.6%), and rest (6.7%). There was an increase in LT for older than 65 years from 4.1% in 1990 to 10.2% in 2006 (P=0.002) and a regional variation (P<0.001). The 10-year patient and graft survival was 60% and 57% for less than 65 years versus 42% and 40% for more than 65 years (P<0.0001). With age stratification (65-75 years vs. >75 years), there was no difference in survival but when adjusted for race there was a significant difference in graft survival with a 10 year (white 40%, Hispanic 44%, and AA 19%) (P=0.04). CONCLUSION: The demand for LT in recipients older than 65 years is increasing. Although their survival is lower in comparison with recipients less than 65 years, there seems to be no difference in unadjusted survival with age stratification above 65 years. Among ethnic minorities, there was a disproportionately lower percentage of African Americans LT and a decreased survival.     

Bilateral lung transplantation with intra- and postoperatively prolonged ECMO support in patients with pulmonary hypertension.

OBJECTIVE: Lung transplantation for pulmonary hypertension (PH) is usually performed on cardiopulmonary bypass, with the disadvantage of full systemic anticoagulation, uncontrolled allograft reperfusion and aggressive ventilation. These factors can be avoided with intra- and postoperatively prolonged extracorporeal membrane oxygenator (ECMO) support. PATIENTS AND METHODS: Between February 1999 and March 2001, 17 consecutive patients with PH (systolic pulmonary artery pressure >70 mmHg) of different etiologies underwent bilateral lung transplantation (BLTX). There were 11 females and six males in the age range from 7 to 50 years (mean age, 28.4+/-12.9 years). Six patients were preoperatively hospitalized, four in the intensive care unit (ICU), one was on ECMO for 3 weeks pretransplantation, and one was resuscitated and bridged with ECMO for 1 week until transplantation. Femoral venoarterial ECMO support with heparin-coated circuits was set up after induction of anesthesia and discontinued at the end of surgery (n=3) or extended for 12 h median into the postoperative period (n=14). Postoperative ventilation pressure was kept below 25 mmHg. Allograft function at 2 h after discontinuation of ECMO, outcome and adverse events were monitored in all patients. Mean follow up time was 18+/-11.4 months. RESULTS: The perioperative mortality was 5.9% (n=1). Arterial oxygen pressure measured 2 h after weaning from ECMO, and under standard mechanical ventilation with a peak pressure of 25 mmHg and inspired oxygen fraction of 0.4, was 157+/-28 mmHg. The mean pulmonary artery pressures were reduced to 29+/-3,4 from 66+/-15 mmHg before transplantation. Postoperative complications included rethoracotomy due to bleeding (n=4) and temporary left ventricular failure (n=4). Median ICU stay was 12 days. Incidence of rejection within the first 100 days was 0.4 per patient. CONCLUSION: BLTX with intraoperative and postoperatively prolonged ECMO support provides excellent initial organ function due to optimal controlled reperfusion and non-aggressive ventilation. This results in improved outcome even in advanced forms of PH.     

Frequency of whole‐organ in lieu of split‐liver transplantation over the last decade: Children experienced increased wait time and death

Organ shortage is a barrier to liver transplantation (LT). Split LT (SLT) increases organ utilization, saving 2 recipients. A simulation of Organ Procurement and Transplantation Network/United Network for Organ Sharing data (2007‐2017) was performed to identify whole‐organ LT grafts (WLT) that met the criteria for being splittable to 2 recipients. Waitlist consequences presented. Deceased donor (DD) livers transplanted as whole organs were evaluated for suitability to split. Of these DD organs, we identified the adolescent and adult recipients of WLT who were suitable for SLT. Pediatric candidates suitable to share the SLT were ascertained from DD match‐run lists, and 1342 splittable DD organs were identified; 438 WLT recipients met the criteria for accepting a SLT. Review of the 438 DD match‐run lists identified 420 children next on the list suitable for SLT. Three hundred thirty‐three children (79%) underwent LT, but had longer wait‐times compared to 591 actual pediatric SLT recipients (median 147 days vs 44 days, P  < 0.001). Thirty‐three of 420 children died on waitlist after a mean 206 days (standard deviation 317). Sharing organs suitable for splitting increases the number of LT, saving more lives. With careful patient selection, SLT will not be a disadvantage to the adult recipients. With a children‐first allocation scheme, SLT will naturally increase the number of allografts because adult organs are too large for small children.