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International consensus recommendations for anesthetic and intensive care management of lung transplantation

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“International consensus recommendations for anesthetic and intensive care management of lung transplantation. An EACTAIC, SCA, ISHLT, ESOT, ESTS, and AST approved document.”

Nandor Marczin, MD, PhD, Eric E.C. de Waal, MD, PhD, Peter M.A. Hopkins, MD, Michael S. Mulligan, MD, Andre Simon, MD, PhD, Andrew D. Shaw, MB, FRCA, FRCPC, FFICM, Dirk Van Raemdonck, MD, PhD, Arne Neyrinck, MD, PhD, Cynthia J. Gries, MD, MS, Lars Algotsson, MD, PhD, Laszlo Szegedi, MD, PhD, and Vera von Dossow, MD, Task force Chairs and Writing Group (exclusive of the consensus developing and coordinating group members): Aidan Burrell, MBBS, PhD; Paula Carmona, MD, PhD; Donna Greenhalgh, MB, ChB, FRCA; Dominik Hochter, MD; Bessie Kachulis, MD; Christopher S. King, MD; Marc J. Licker, MD; David R. McIlroy, MBBS, MClinEpi, MD, FANZCA; Priya Nair, MBBS, MD, FCICM, PhD; Daniela Pasero, MD, MSc; David Pilcher, MBBS, MRCP, FCICM, FRACP; Steffen Rex, MD, PhD; David Royston, FRCA; Peter Slinger, MD, FRCPC; Franco Valenza, MD; Chris Walker, MBBS, FRCA, FFPMRCA, FFICM. Consensus members (exclusive of the consensus developing and coordinating group or co-chairs and writing group members): Antonio Arcadipane, MD; Oliver Bastien, MD, PhD; Joseph A. Bekkers, MD, PhD; Dominique Bettex, MD; Francesca Caliandro, MD; Erika Dal Checco, MD; Robert Duane Davis, MD; Goran Dellg- ren, MD, PhD; Andreas Espinoza, MD, PhD; Marie Louise Felten, MD; Paolo Feltracco, MD; Marc Fischler, MD; Linda J Fitzgerald, PharmD, BCPS; Ana Flo Forner, MD; Isabel Fragata, MD; Ana Gonzalez Roman, MD, PhD, MBA; Paul Harris, MBChB, FRCA, FFICM, RCPathME; Matthias Hommel, MD, MBA; Nicholas J. Lees, FRCA, EDIC, FFICM; Morgan Le Guen, MD, PhD; Marc Leone, MD, PhD; Thierry Lepoivre, MD; Carlo Marcucci, MD; Sabina Martelli, MD; Mir- eille Michel-Cherqui, MD; Ulrich Molitoris, MD; Philippe Montravers, MD, PhD; Roberto Mosca, MD; Barbora Parizkova, MD, FRCA; Mahesh Prabhu, MD, FRCA, FFICM; Francesco Pugliese, MD; Sanjeev M. Raman, MBBS, MD; Cristina Ramos, MD; Vito Marco Ranieri, MD; Maria I. Real, MD, PhD; Sven-Erik Ricks- ten; Ana Gonzalez Roman, MD, PhD, MBA; Bertrand Rozec, MD, PhD; Shiva M. Sale, MBBS, MD, FASE; Juan F. Sanchez, MD, FCCP; Johanna Schwarzenberger, MD; Sema Turan, MD; Kamen Valchanov, BSc, MD, FRCA, FFICM; Vincent G. Valentine MD, FCCP; Peter von Homeyer, MD, FASE; Alain Vuylsteke, BSc, MA, MD, (FRCA, FFICM); Thomas Weig, MD; Iratxe Zarragoikoetxea, MD, PhD; Sebastian Zenz, MD. Independent Reviewers: Pierre-Emmanuel Falcoz MD; Ilhan Inci, FEBTS; Andrew Roscoe, FRCA; Mert Senturk, MD.
J Heart Lung Transplant 2021 Nov;40(11):1327-1348.

This quarter’s editorial is taking a step off the beaten path. Last month the Journal of Heart and Lung Transplantation published, what I believe to be, a groundbreaking international multidisciplinary document for perioperative care of lung transplant recipients. This document acknowledges that anesthetic and intensive care management impacts long term outcomes in lung transplant recipients. It offers a combination of published data and expert opinion for guidance and is the first major consensus document to specifically address anesthetic care for lung transplantation.

Key themes include the inclusion of anesthesiologists and intensivists in the selection of lung transplant recipients, use of echocardiography intraoperatively, indications for intraoperative rescue mechanical support, timing of ECMO wean, and strategies for the prevention of primary graft dysfunction. This is a strong document. I hope you give it a read.

Barbara Wilkey, MD

Evaluation with Transesophageal Echocardiography of Pulmonary Artery Anastomoses during Orthotopic Lung Transplantation

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Michael Curtis, MD

University of California, San Francisco

Introduction

Lung transplantation remains only a class IIb indication for intraoperative monitoring via transesophageal echocardiography (TEE) in existing guidelines.1 However, some have suggested that TEE should become routine during these procedures2, given the multiple and varied impacts to the cardiovascular system throughout such a case (e.g., pulmonary artery clamping, reperfusion injury, air embolization, etc.) TEE may also be able to quickly detect obstruction at the pulmonary artery (PA) anastomosis at the pulmonary arteries and making immediate intraoperative revision possible if needed. While no society guidelines exist for diagnosing such a life-threatening complication on intraoperative TEE, there are many recommendations one may use to guide their evaluation.

Incidence and Related Complications

Obstruction of a pulmonary artery anastomosis is rare – it was reported in approximately 3% of lung transplantations reviewed in a recent meta-analysis by Kumar et al.3 A multitude of etiologies have been implicated, including donor-recipient size mismatch, external compression from surrounding tissue, twisting and/or kinking, thrombosis, and suture obstruction.3,4 Those with restrictive lung disease and females also appear to be at higher risk of PA obstruction. Finally, obstruction at the pulmonary arterial sites is generally accepted to be more common than at their venous counterparts, which is thought to result from differences in the surgical technique required at the different anastomotic sites.4,5

            Although relatively rare, such obstruction at a pulmonary artery anastomosis cannot be taken lightly: once diagnosed, the rate of mortality approaches nearly 25%.3 There are also associated complications that may result, such as graft failure, persistent hypoxemia, prolonged need for mechanical ventilation, and right-heart failure.3,5 These potentially devastating consequences highlight the importance of having high index of suspicion for such a lesion. For example, early clinical signs may be hemodynamic instability, pulmonary hypertension, a diminished capnography tracing, or unexplained hypoxemia or acidosis should all be concerning to providers.6,7

Role of Transesophageal Echocardiography

            With regards to objective testing, pulmonary angiography is regarded as being the gold standard for diagnosis of stenosis at the pulmonary artery anastomosis, given its imaging quality and ability to immediately intervene on the findings with catheter-based techniques.4 However, intraoperative TEE is able to provide much earlier insight into possible complications with an anastomotic site, allowing for immediate surgical revision and avoidance of any related post-operative complications.

            Unfortunately, consensus guidelines on the diagnosis of obstruction at a PA anastomosis by echocardiography do not exist. However, multiple measures have been proposed (Table 1), including the intraluminal narrowing of the pulmonary artery graft to 75% or less of the diameter of the native, ipsilateral PA, as put forth by Hausmann et al. in their 1992 publication.8 Other suggested measures that should be concerning are a mean velocity through the pulmonary artery of 2.6 m/s or greater, a gross PA diameter of less than  0.8 cm, the presence of turbulent flow on color doppler, and elevated pressure gradients across the anastomosis.3 What precisely constitutes an elevated gradient at the PA anastomosis itself lacks wide-agreement, though some having put forth using the American Society of Echocardiography (ASE) guidelines for pulmonary valve stenosis as a guide7, while others recommend that gradients should be of concern once 57 mm Hg or higher.3

            Interrogation of related structures by echo, such as the pulmonary veins, may also provide hints as to the functioning of the pulmonary arteries. For example, impaired flow as demonstrated by doppler (e.g., blunted S or D waves) or thrombosis due to stasis in the ipsilateral pulmonary veins may also be concerning for PA anastomotic obstruction.7 Similarly, evidence of increased perfusion through the contralateral pulmonary veins (e.g., increased velocities) may be a sign that a significantly greater proportion of right-heart output is going through one pulmonary artery due to the other being obstructed.

            Unfortunately, evaluation by the pulmonary arteries with TEE is inherently limited by anatomy. For example, the relative inability to evaluate the left pulmonary artery due to interference from the adjacent left mainstem bronchus. The relative orientation of the pulmonary arteries to the echo probe may also make it challenging to line up a doppler beam and obtain accurate velocities or pressure gradients. If concerned, other options that may be used intraoperatively include epipulmonary artery ultrasonography (i.e., direct, external contact with an ultrasound probe manipulated by surgical team), which one study has shown to be superior for imaging the left pulmonary artery than TEE itself.9 The surgeon may also directly cannulate the pulmonary artery of concern and measure a true pressure gradient by pullback technique.

Post-Operative Endovascular Interventions

Given that intraoperative diagnosis by TEE can be challenging, and that nearly 75% of patients diagnosed with PA obstruction post-operatively require some sort of procedural intervention3, it is fortunate that options exist now outside of open surgical techniques. For example, multiple reports of successful endovascular stenting have been published.10-12 Although balloon angioplasty alone is regarded as less useful in high-grade stenosis due to arterial elastic recoil10, it has still been shown to be successful in some cases.13

Conclusion

Although use of intraoperative TEE is not yet the standard of care during lung transplantation, it may provide information both critical to the hemodynamic management of the patient, as well as possible complications in the surgical procedure. Specifically, obstruction at a pulmonary artery anastomosis – a rare complication with high morbidity and mortality – may be caught early enough with thorough echocardiographic investigation to revise intraoperatively. However, it is important to remember inherent limitations of TEE prevent it from being a panacea for lesions at this location, and that sometimes it must be supplemented with alternative intraoperative or post-operative techniques when there is sufficient concern.

 

Table 1 – Signs Suggestive of Pulmonary Artery Anastomosis Obstruction on Transesophageal Echocardiography (TEE)
Gross Inspection of the Pulmonary Artery ·      Presence of an obstructive mass (e.g., thrombus)
Intraluminal Diameter ·      ≤ 75% of the native, ipsilateral pulmonary artery

·      < 0.8 cm intraluminal diameter
Pulmonary Artery Mean Velocity ·      ≥ 2.6 m/s
Color Doppler ·      Evidence of turbulent flow
Peak Pressure Gradient ·      No widespread agreement – however, suggestions to use gradients ≥ 57 mm Hg or ASE guidelines for grading pulmonary valve stenosis (i.e., mild < 36 mm Hg, moderate 36-64 mm Hg, and severe > 64 mm Hg)14 as a framework

 
Ipsilateral Pulmonary Veins ·      Evidence of diminished flows (e.g., blunted S or D waves) or stasis (e.g., presence of thrombus)

 
Contralateral Pulmonary Veins ·      Evidence of significantly increased flows (e.g., elevated velocities)

 

* American Society of Echocardiography (ASE)

 

 

 

 

References

  1. Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation. 2003;108(9):1146-62. Epub 2003/09/04. doi: 10.1161/01.CIR.0000073597.57414.A9. PubMed PMID: 12952829.
  2. Iyer MH, Bhatt A, Kumar N, Hussain N, Essandoh MK. Transesophageal Echocardiography for Lung Transplantation: A New Standard of Care? J Cardiothorac Vasc Anesth. 2020;34(3):741-3. Epub 2019/11/11. doi: 10.1053/j.jvca.2019.10.025. PubMed PMID: 31706852.
  3. Kumar N, Hussain N, Kumar J, Essandoh MK, Bhatt AM, Awad H, et al. Evaluating the Impact of Pulmonary Artery Obstruction After Lung Transplant Surgery: A Systematic Review and Meta-analysis. Transplantation. 2021;105(4):711-22. Epub 2021/03/25. doi: 10.1097/TP.0000000000003407. PubMed PMID: 33760790.
  4. Siddique A, Bose AK, Ozalp F, Butt TA, Muse H, Morley KE, et al. Vascular anastomotic complications in lung transplantation: a single institution’s experience. Interact Cardiovasc Thorac Surg. 2013;17(4):625-31. Epub 2013/06/22. doi: 10.1093/icvts/ivt266. PubMed PMID: 23788195; PubMed Central PMCID: PMCPMC3781793.
  5. Clark SC, Levine AJ, Hasan A, Hilton CJ, Forty J, Dark JH. Vascular complications of lung transplantation. Ann Thorac Surg. 1996;61(4):1079-82. Epub 1996/04/01. doi: 10.1016/0003-4975(96)00003-3. PubMed PMID: 8607660.
  6. Tan Z, Roscoe A, Rubino A. Transesophageal Echocardiography in Heart and Lung Transplantation. J Cardiothorac Vasc Anesth. 2019;33(6):1548-58. Epub 2019/02/03. doi: 10.1053/j.jvca.2019.01.005. PubMed PMID: 30709594.
  7. Abrams BA, Melnyk V, Allen WL, Subramaniam K, Scott CD, Mitchell JD, et al. TEE for Lung Transplantation: A Case Series and Discussion of Vascular Complications. J Cardiothorac Vasc Anesth. 2020;34(3):733-40. Epub 2019/10/02. doi: 10.1053/j.jvca.2019.09.005. PubMed PMID: 31570240.
  8. Hausmann D, Daniel WG, Mugge A, Heublein B, Hamm M, Schafers HJ, et al. Imaging of pulmonary artery and vein anastomoses by transesophageal echocardiography after lung transplantation. Circulation. 1992;86(5 Suppl):II251-8. Epub 1992/11/01. PubMed PMID: 1424008.
  9. Felten ML, Michel-Cherqui M, Sage E, Fischler M. Transesophageal and contact ultrasound echographic assessments of pulmonary vessels in bilateral lung transplantation. Ann Thorac Surg. 2012;93(4):1094-100. Epub 2012/03/06. doi: 10.1016/j.athoracsur.2012.01.070. PubMed PMID: 22387146.
  10. Waurick PE, Kleber FX, Ewert R, Pfitzmann R, Bruch L, Hummel M, et al. Pulmonary artery stenosis 5 years after single lung transplantation in primary pulmonary hypertension. J Heart Lung Transplant. 1999;18(12):1243-5. Epub 1999/12/28. doi: 10.1016/s1053-2498(99)00091-1. PubMed PMID: 10612386.
  11. Grubstein A, Atar E, Litvin S, Belenky A, Knizhnik M, Medalion B, et al. Angioplasty using covered stents in five patients with symptomatic pulmonary artery stenosis after single-lung transplantation. Cardiovasc Intervent Radiol. 2014;37(3):686-90. Epub 2014/02/11. doi: 10.1007/s00270-013-0758-0. PubMed PMID: 24510277.
  12. Berger H, Steiner W, Schmidt D, Forst H, Dienemann H. Stent-angioplasty of an anastomotic stenosis of the pulmonary artery after lung transplantation. Eur J Cardiothorac Surg. 1994;8(2):103-5. Epub 1994/01/01. doi: 10.1016/1010-7940(94)90102-3. PubMed PMID: 8172715.
  13. Shoji T, Hanaoka N, Wada H, Bando T. Balloon angioplasty for pulmonary artery stenosis after lung transplantation. Eur J Cardiothorac Surg. 2008;34(3):693-4. Epub 2008/07/22. doi: 10.1016/j.ejcts.2008.06.005. PubMed PMID: 18639464.
  14. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009;22(1):1-23; quiz 101-2. Epub 2009/01/10. doi: 10.1016/j.echo.2008.11.029. PubMed PMID: 19130998.

MitraClip in secondary mitral regurgitation as a bridge to heart transplantation: 1 year outcomes from the International MitraBridge

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Cardiothoracic Transplant Anesthesia Article of the Month

Godino C, Munafo A, Scotti A, Estevez-Loureiro R, Hernandez AP, et al. MitraClip in secondary mitral regurgitation as a bridge to heart transplantation: 1 year outcomes from the International MitraBridge Registry. J Heart Lung Transplant. 2020 Dec;39(12): 1353-1362.

Abstract:

BACKGROUND: Patients awaiting heart transplantation (HTx) often need bridging therapies to reduce worsening and progression of underlying disease. Limited data are available regarding the use of the MitraClip procedure in secondary mitral regurgitation for this clinical condition.

METHODS: We evaluated an international, multicenter (17 centers) registry including 119 patients (median age: 58 years) with moderate-to-severe or severe secondary mitral regurgitation and advanced heart failure (HF) (median left ventricular ejection fraction: 26%) treated with MitraClip as a bridge strategy according to 1 of the following criteria: (1) patients active on HTx list (in list group) (n = 31); (2) patients suitable for HTx but awaiting clinical decision (bridge to decision group) (n = 54); or (3) patients not yet suitable for HTx because of potentially reversible relative contraindications (bridge to candidacy group) (n = 34).

RESULTS: Procedural success was achieved in 87.5% of cases, and 30-day survival was 100%. At 1 year, Kaplan−Meier estimates of freedom from the composite primary end-point (death, urgent HTx or left ventricular assist device implantation, first rehospitalization for HF) was 64%. At the time of last available follow-up (median: 532 days), 15% of patients underwent elective transplant, 15.5% remained or could be included in the HTx waiting list, and 23.5% had no more indication to HTx because of clinical improvement.

CONCLUSIONS: MitraClip procedure as a bridge strategy to HTx in patients with advanced HF with significant mitral regurgitation was safe, and two thirds of patients remained free from adverse events at 1 year. These findings should be considered exploratory and hypothesis-generating to guide further study for percutaneous intervention in high-risk patients with advanced HF. “

Expert Summary by Barbara Wilkey, MD

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References:

  1. Feldman T, Foster E, Glower DD, Kar S, Rinaldi MJ, Fail PS, Smalling RW, Siegel R, Rose GA, Engeron E, Loghin C, Trento A, et al. for the EVEREST II Investigators. Percutaneous Repair or Surgery for Mitral Regurgitation. N Engl J Med 2011;364:1395-1406.
  2. Stone GW, Lindenfeld J, Abraham WT, Kar S, Lim S, Mishell JM, Whisenant B, Grayburn PA, Rinaldi M, Kapadia SR, Rajagopal V, Sarembock IJ et al. for the COAPT Investigators. Transcatheter Mitral-Valve Repair in Patients with Heart Failure. N Engl J Med 2018; 379: 2307-2318.

Prevalence and Patterns of Opioid Use Before and After Liver Transplantation

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Abdominal Organ Transplant Article of the Month

Abstract:

Background. Opioid use in liver transplantation is poorly understood and has potential associated morbidity.

Methods. Using a national data set of employer-based insurance claims, we identified 1257 adults who underwent liver transplantation between December 2009 and February 2015. We categorized patients based on their duration of opioid fills over the year before and after transplant admission as opioid naive/no fills, chronic opioid use (≥120 d supply), and intermittent use (all other use). We calculated risk-adjusted prevalence of peri-transplant opioid fills, assessed changes in opioid use after transplant, and identified correlates of persistent or increased opioid use post-transplant.

Results. Overall, 45% of patients filled ≥1 opioid prescription in the year before transplant (35% intermittent use, 10% chronic). Post-transplant, 61% of patients filled an opioid prescription 0–2 months after discharge, and 21% filled an opioid between 10–12 months after discharge. Among previously opioid-naive patients, 4% developed chronic use post-transplant. Among patients with pre-transplant opioid use, 84% remained intermittent or increased to chronic use, and 73% of chronic users remained chronic users after transplant. Pre-transplant opioid use (risk factor) and hepatobiliary malignancy (protective) were the only factors independently associated with risk of persistent or increased post-transplant opioid use.

Conclusions. Prescription opioid use is common before and after liver transplant, with intermittent and chronic use largely persisting, and a small development of new chronic use post-transplant. To minimize the morbidity of long-term opioid use, it is critical to improve pain management and optimize opioid use before and after liver transplant.

Expert summary by Cara Crouch, MD

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References:

  1. Cron D, Tincopa M, Lee J, Waljee A, Hammoud A, Brummet C, Waljee J, Englesbe M, Sonnenday C. Prevalence and Patterns of Opioid Use Before and After Liver Transplantation. Transplantation. 2021; 105(1):100-107
  2. Braun H, Ascher N. Opioid Use and Liver Transplantation. Transplantation. 2021; 105(1):25-26