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Lung Transplant

Lung transplant management in COVID-19 patients

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Recognizing inadvertent central venous catheter complications and effective management options for patient with COVID-19 infection requiring bilateral lung transplant

 

Ahmad R. Parniani, MD and Yong G. Peng, MD, PhD, FASE, FASA

Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL

 

Summary: We describe the case of a 50-year-old man with COVID-19 who underwent a successful bilateral lung transplant. We also review the anesthetic management strategies for these patients including the role of ECMO and discuss complications associated with central venous catheter placement for lung transplant.

 

After reviewing the case, readers will be able to:

  • Identify the selection criteria of patients with severe COVID-19 for lung transplant.
  • Recognize the complications associated with central venous catheter placement for lung transplant.
  • Describe the pathophysiology of cardiac tamponade and management strategies.
  • Understand the role of ECMO in the management of patients with COVID-19.
  • Review the anesthetic challenges of patients infected with COVID-19 who are undergoing lung transplant.

 

Case   

            We describe the case of a 50-year-old man with a past medical history of prostate cancer and prostatectomy, chronic back pain, hypothyroidism, and hypertension. He tested positive for COVID-19 on April 26, 2021 after developing shortness of breath and cough and was sent home from the emergency department for quarantine. However, his condition deteriorated and he was admitted to the hospital 5 days later. He received a combination of remdesivir, dexamethasone, convalescent plasma, and tocilizumab as recommended medical therapy. Unfortunately, on hospital day 20 he was intubated and underwent a percutaneous tracheostomy on hospital day 34. Due to increasing ventilatory requirements, including positive end-expiratory pressure (PEEP) of 24 cm H2O with 100% fraction of inspired oxygen (FiO2), he was placed in the prone position with little improvement. The patient was subsequently placed on venovenous extracorporeal membrane oxygenation (VV-ECMO) on hospital day 60 and transferred to our facility to be evaluated for lung transplant. Given his worsening right ventricular function, he underwent conversion of VV-ECMO to veno-arterio-venous ECMO (VAV-ECMO) on hospital day 64. Epoprostenol and inhaled nitric oxide were continued to treat his pulmonary hypertension and support his worsening right ventricular systolic function. Continuous veno-venous hemofiltration was also initiated given his worsening acute kidney injury.

The patient underwent lung transplant evaluation during his hospital stay and was listed as a lung transplant candidate on August 27, 2021. On September 26, 2021, he underwent a bilateral lung transplant. He was transported to the operating room on VAV-ECMO. Anesthesia was induced with 250 mcg of fentanyl, 130 mg of propofol, and 100 mg of rocuronium. He was intubated orally with a 41-Fr left double-lumen endotracheal tube and the tracheostomy was removed. A transesophageal echocardiography (TEE) probe was inserted for intraoperative monitoring.

Before central venous catheter placement, the left side of his neck was scanned with the ultrasound probe because the ECMO cannulation was in place in his right internal jugular (IJ) vein. However, we could not identify the patent lumen of the left IJ vein (Figure 1).

Figure 1.

As a result, we decided to obtain central venous access through the left subclavian vein. A 9-Fr introducer catheter was successfully placed after one attempt and no resistance was encountered during the insertion. Shortly after the central venous catheter placement, the patient became hemodynamically unstable and unresponsive to multiple vasopressor boluses, including epinephrine. We administered fluids and medication boluses through the newly placed left subclavian central venous catheter. TEE was immediately used to assess his cardiac function and showed an enlarging pericardial effusion with tamponade physiology. At this point, the surgical team was immediately called and resuscitation with intravenous (IV) fluids and epinephrine was continued. We noticed that our boluses of epinephrine were not effective in maintaining his blood pressure, so we switched our infusions and boluses from the central venous catheter into the indwelling peripherally inserted central catheter (PICC). We also started transfusing blood through the ECMO circuit. A peripheral IV was inserted in his left external jugular vein and resuscitation was continued.

A clamshell incision was performed and the surgical exposure entered the pleural cavity on the fourth intercostal space. The pericardium was then opened, and a large amount of blood was evacuated. Afterward, the patient’s condition stabilized, the arterial line tracing became pulsatile once again, and the heart was filling and ejecting appropriately. We noted that the central venous catheter coming from the left subclavian vein tracked outside of the vessel on the thoracic inlet, perforating the pericardium and creating a small tear on the adventitia of the aorta (Figure 2).

Figure 2.

Vasa-vasorum from the aorta adventitia was copiously bleeding, which was controlled with bovie coagulation. The patient became hemodynamically stable and TEE confirmed that his bilateral ventricular function was improving. The surgical team could not access his left femoral vein because ultrasonography revealed thrombosis of the vein.  The case proceeded and a bilateral lung transplant was performed successfully. The patient was transported to the intensive care unit (ICU) postoperatively in a hemodynamically stable condition. He was decannulated from ECMO 1 week after his lung transplant and his tracheostomy was eventually removed. He remained stable on room air and was transferred to rehabilitation facility for further recovery.

 

What are the current medical therapies available for COVID-19 infection?

Randomized placebo-controlled trials have shown that remdsesivir has enhanced the recovery of hospitalized patients.1,2 Another randomized clinical trial demonstrated that a single dose of bamlanivimab (monoclonal antibody) reduced the viral load in outpatients.2 A large randomized controlled trial showed a mortality benefit with dexamethasone in hospitalized patients requiring oxygen.2 A combination of medical treatments is considered the most effective therapy for patients with COVID-19.

What are the potential treatments for refractory hypoxemia in patients with COVID-19 acute respiratory distress syndrome (ARDS)?

Prone positioning should be considered in patients with PaO2:FiO2 <150 mm Hg during respiration and FiO2 of 0.6 despite an appropriate PEEP. However, prone positioning requires equipment and training that may not be available at some medical centers. Inhaled pulmonary vasodilators such as inhaled nitric oxide can also improve oxygenation in refractory respiratory failure. ECMO can also be considered as an alternative rescue therapy for refractory respiratory failure; however, ECMO is associated with an increased risk of bleeding and requires extensive resources and trained staff.1

What are the ventilatory management strategies in patients with COVID-19 who are intubated?

Autopsies performed on patients with severe COVID-19 have revealed the presence of diffuse alveolar damage, which is a hallmark of ARDS. Essential ventilatory management should focus on avoiding further ventilator-induced lung injury. The main goals are reducing alveolar overdistension, hyperoxia, and cyclical alveolar collapse. Lung-protective ventilation is used by setting the ventilator for tidal volume at 6 mL/kg of predicted body weight. To prevent alveolar overdistention, the plateau pressure should not exceed 30 cm H2O. PEEP prevents alveolar collapse and facilitates the recruitment of unstable lung regions.2

What are the proposed criteria for the selection of patients with severe COVID-19 for lung transplant?

The general criteria are age younger than 65 to 70 years, preference for single organ failure, no malignancy, no substance misuse, and postoperative social support. Other criteria include healthy neurocognitive status, general condition (if the patient is participating in physical therapy while hospitalized), and evidence of irreversible lung damage.1

How long after the onset of ARDS secondary to COVID-19 should lung transplant be considered?

The exact time needed to determine irreversibility is not clear, but the recommendation is to wait approximately 6 weeks after ARDS onset. Ideally, when lung recovery is deemed unlikely after ARDS onset, lung transplant should be considered. Exceptions to these criteria include severe pulmonary complications such as severe pulmonary hypertension with concomitant right ventricular failure, refractory nosocomial pneumonias, or recurrent pneumothoraces that cannot be medically managed with or without ECMO.1

What are some of the concerns regarding ongoing infection at the time of transplant and reinfection of the allograft?

The risk of reinfection should be carefully reviewed as part of the pretransplant evaluation workup. Studies suggest that it is rare to detect replicating virus more than 10 days after infection with SARS-CoV-2 even though the PCR result may remain positive for weeks after infectivity. In cases where the PCR remains positive for extended durations, high-cycle thresholds are seen (Ct >24), but infectivity is usually not evident.1

What are some considerations regarding deep sedation and neuromuscular blockade effects on post-transplant outcomes?

As soon as 2 to 3 days after the start of mechanical ventilation, the diaphragm can lose approximately 50% of its fibers. This can have a significant impact on post-transplant recovery. As a result, weaning of sedation and participation in physical therapy should be highly encouraged.1 In addition, if patients can be weaned from sedation, they can actively participate in discussions regarding the direction of their care and therapeutic goals.

Why are patients with COVID-19 more prone to bleeding during their hospital stay?

ARDS is associated with a significantly increased bleeding risk. In addition, prolonged ECMO can lead to platelet dysfunction in a significant portion of patients. Pleural adhesions and the fragile tissue of these patients increase the risk of intraoperative bleeding.2

What is the approach for placing a subclavian central venous catheter using anatomic landmarks?

Starting 2 cm lateral and 2 cm caudal to the bend of the clavicle, a needle is inserted through the skin at a 30° angle toward the sternal notch. We recommend placing a finger of the nondominant hand in the sternal notch to help find the landmark. Once the needle is under the skin, the needle and syringe are lowered to run parallel to but beneath the clavicle. Access to the vein typically happens just beneath the clavicle, but it may be several centimeters under the skin.3 Medical professionals should be alert to possible complications such as pneumothorax, vascular injury leading to hemothorax, and other inadvertent injury to the adjacent thoracic structures.  

How frequent are complications associated with central venous catheter placement? 

Central venous catheter placement is an invasive procedure that requires planning and an organized approach. There are a number of potential complications associated with central venous catheter placement, most commonly infection, bleeding, pneumothorax, hemothorax, and vascular injury. A prospective randomized trial of patients undergoing subclavian central venous catheter placement at the University of Texas examined the rate of complications. There was a 6% rate of misplacement, 3.7% rate of arterial puncture, 1.5% rate of pneumothorax, and 0.6% rate of mediastinal hematoma.4 Another retrospective chart review was performed for all central venous catheters placed between November 1, 2012, and June 30, 2013, at MedStar Washington Hospital Center (MWHC). In that study, the rate of arterial injury was 1.3% of subclavian central venous catheters, 0.4% of IJ central venous catheters, and 1.4% of femoral central venous catheters.4,5

What is the pathophysiology of pericardial tamponade?

The primary abnormality in cardiac tamponade is impaired diastolic filling of the heart. This is caused by increased intrapericardial pressure that leads to compression of the atria and ventricles. Diastolic filling pressures increase and start to equilibrate with all cardiac chambers. Cardiac filling is reduced, resulting in decreased stroke volume, cardiac output, and systemic blood pressure. Compensatory mechanisms attempt to counteract the decrease in stroke volume by increasing systemic vasoconstriction and tachycardia.6

What are the treatment options and hemodynamic goals during management of patients with pericardial tamponade?

Definitive treatment is emergent drainage and/or relief of the pericardial compression. This can be achieved through pericardiocentesis or surgical decompression. The highlights of hemodynamic management include maintaining contractility and systemic vascular resistance with inotropes and vasopressors. Preload should be maintained with IV fluids and avoiding large tidal volumes of positive pressure ventilation. Additionally, reductions in heart rate should be strongly prohibited to preserve cardiac output because these patients have a fixed and reduced stroke volume.6

What is the role of ECMO in the management of patients with COVID-19?

VV-ECMO is a complicated and labor-intensive tool that is used in severe hypoxemic respiratory failure refractory to conventional mainstays of medical therapy including mechanical ventilation with optimal PEEP, neuromuscular blockade, and prone positioning. VA-ECMO is different from VV-ECMO in that it is typically initiated for patients in cardiac or circulatory failure with or without concomitant respiratory failure. VV-ECMO is commonly considered as a bridge to specific endpoints, such as recovery or lung transplant. Unfortunately, VV-ECMO may also become a bridge to nowhere; a careful assessment of the end goals of therapy is warranted.1,6

What are some of the complications associated with ECMO in patients with COVID-19?

ECMO is associated with thrombotic and hemorrhagic complications. A high proportion of patients with COVID-19 develop life-threatening thrombotic complications. In an autopsy series, most of the patients were diagnosed with deep vein thrombosis (DVT) or pulmonary embolisms. The mechanism of this hypercoagulable state is related to the major systemic inflammatory response along with endothelial dysfunction.7 The combination of a prothrombotic state and long-term use of ECMO cannulas can increase the risk of blood clots. In 80% of patients on ECMO, heparin can be used as a systemic anticoagulant. In patients with COVID-19 or heparin-induced thrombocytopenia (HIT), bivalirudin may be considered as an alternative anticoagulation strategy. Activated clotting times (ACTs) of 160 to 180 s for VV-ECMO and 180 to 220 s for VA-ECMO are necessary to avoid thrombotic complications. Other complications include vascular injury, infections, kidney failure, stroke, and mechanical equipment failure. Closely monitoring ECMO function is essential to the success of this unique bridge therapy.8

 

 

References

  1. Bharat A, Machuca TN, Querrey M, Kurihara C, Garza-Castillon R Jr, Kim S, Manerikar A, Pelaez A, Pipkin M, Shahmohammadi A, Rackauskas M, Kg SR, Balakrishnan KR, Jindal A, Schaheen L, Hashimi S, Buddhdev B, Arjuna A, Rosso L, Palleschi A, Lang C, Jaksch P, Budinger GRS, Nosotti M, Hoetzenecker K. Early outcomes after lung transplantation for severe COVID-19: a series of the first consecutive cases from four countries. Lancet Respir Med. 2021 May;9(5):487–497. doi: 10.1016/S2213-2600(21)00077-1. Epub 2021 Mar 31. PMID: 33811829; PMCID: PMC8012035.
  2. Berlin DA, Gulick RM, Martinez FJ. Severe Covid-19. N Engl J Med. 2020 Dec 17;383(25):2451–2460. doi: 10.1056/NEJMcp2009575. Epub 2020 May 15. PMID: 32412710.
  3. Braner DA, Lai S, Eman S, Tegtmeyer K. Videos in clinical medicine. Central venous catheterization–subclavian vein. N Engl J Med. 2007 Dec 13;357(24):e26. doi: 10.1056/NEJMvcm074357. PMID: 18077803.
  4. Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1994 Dec 29;331(26):1735–1738. doi: 10.1056/NEJM199412293312602. PMID: 7984193.
  5. Bell J, Goyal M, Long S, Kumar A, Friedrich J, Garfinkel J, Chung S, Fitzgibbons S. Anatomic site-specific complication rates for central venous catheter insertions. J Intensive Care Med. 2020 Sep;35(9):869–874. doi: 10.1177/0885066618795126. Epub 2018 Sep 19. PMID: 30231668.
  6. Gravlee GP. Hensley’s Practical Approach to Cardiothoracic Anesthesia. 6th ed. Wolters Klumer; 2018.
  7. Falcoz PE, Monnier A, Puyraveau M, Perrier S, Ludes PO, Olland A, Mertes PM, Schneider F, Helms J, Meziani F. Extracorporeal membrane oxygenation for critically ill patients with COVID-19-related acute respiratory distress syndrome: worth the effort? Am J Respir Crit Care Med. 2020 Aug 1;202(3):460–463. doi: 10.1164/rccm.202004-1370LE. PMID: 32543208; PMCID: PMC7397791.
  8. Huang J, Firestone S, Moffatt-Bruce S, Tibi P, Shore-Lesserson L. 2021 Clinical Practice Guidelines for Anesthesiologists on Patient Blood Management in Cardiac Surgery. J Cardiothorac Vasc Anesth. 2021 Dec;35(12):3493–3495. doi: 10.1053/j.jvca.2021.09.032. Epub 2021 Sep 24. PMID: 34654633.

 

 

 

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.

Evaluation for lung transplantation – Pulmonologist’s Perspective

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SATA Vanguard Committee Expert Lecture Series

Evaluation for lung transplantation – Pulmonologist’s Perspective

June 22, 2021 | 6:00pm EST

Barbara Wilkey, MD Associate Professor Director of Thoracic Transplant Anesthesia University of Colorado Anschutz Medical Campus Aurora, CO, USA

Dr. Wilkey earned her Bachelor of Science in Nursing in 1995. She then went on to earn her Master of Science in Physician Assistant Studies in 1999 and then her Medical degree in 2008. All three degrees from her beloved Alma Mater, the University of Florida. Dr. Wilkey came to Colorado in 2008, first to Presbyterian St. Luke’s Hospital for a Transitional Internship and then to the University of Colorado for Anesthesiology Residency and Cardiothoracic Anesthesiology Fellowship. Dr. Wilkey is currently working he University of Colorado as an Attending Anesthesiologist specializing in lung, heart and liver transplantation.

In 2020, Dr. Wilkey and other SATA colleagues published “Statement From the Society for the Advancement of Transplant Anesthesia: White Paper Advocating Desirable Milestones and Competencies for Anesthesiology Fellowship Training in the Field of Lung Transplantation”. This webinar is the first in our series of “virtual fellowship” webinars based upon the competencies outlined in this paper. We hope this series publicizes the intricacies of lung transplant anesthesia and eventually leads to the development of on-site fellowships or super fellowships in lung transplant anesthesiology.

Alice Gray, MD Associate Professor Medical Director, Lung Transplant Program University of Colorado Anschutz Medical Campus Aurora, CO, USA

After having received an undergraduate degree in English literature, Dr Gray recognized her affinity for biology and passion for helping people in her late twenties and pursued medical school at the University of Michigan. It was there that she developed an interest in pulmonary medicine. She then went to Duke University for internal medicine residency and pulmonary and critical care fellowship. While working in a basic science lab during her fellowship, Dr Gray became intrigued by the complex pathophysiology of chronic lung transplant rejection. This led to her career path as a transplant pulmonologist. After several years on faculty at Duke University, she was recruited to be the Medical Director of Lung Transplantation at University of Colorado in October 2018. She has developed robust systems and fostered multidisciplinary collaboration to advance the quality of care and improve outcomes for lung transplant recipients. Currently, she serves on the UNOS Membership and Professional Standards Committee out of a commitment to uphold the safety and integrity of the solid organ transplant system in the US, and is dedicated to improving lives and enacting progressive change throughout her career.

The Vanguard Committee Lecture on Evaluation for lung transplantation registration link is only available to current SATA members. – Join SATA

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Anesthetic Considerations for Lung Transplant of PAH Group1 Patients

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Case Presentation

A 16-year-old girl with familial pulmonary arterial hypertension (PAH) presented to our institution for consideration of bilateral lung transplant. She was small for her age because of her chronic medical condition and had been taking pulmonary vasodilators for the past several years…

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Conclusion

Concomitant severe PAH and RV systolic dysfunction present a significant clinical challenge for cardiothoracic anesthesiologists, who should be aware of the potential side effects of various PAH treatment options. A balanced anesthetic technique and appropriate vasoactive selection are essential to the success of lung transplant in this patient population.

Article by: T. Everett Jones, M.D., Yong G. Peng, M.D., Ph.D., FASE, FASA