Lung Transplantation
P re f a c e L u n g Tra n s p l a n t a t i o n
Sudish C. Murthy, MD, PhD, FACS, FCCP Editor
issues have plagued lung transplant from the very outset and persist today. In addition to endobronchial approaches to palliate airway complications, bronchial artery revascularization is being investigated as a way to eliminate these dreaded complications altogether. Pleural space complications can affect allograft function, and a surprising variety of insults are contributory. The gamut of complications includes nuisance pleural effusion to densely trapped lung and can dramatically impact the quality of posttransplant life. In addition, even an indolent process such as reflux may have long-reaching and intractable effects on allograft function. Finally, as with all evolving processes, the future very quickly becomes the past, and accordingly, a brief look ahead is almost always a worthwhile undertaking. Is there a better mousetrap on the horizon? That thought is briefly explored as lung replacement theory and technology are reviewed. It is my hope that this tour through the numerous facets of lung transplantation will help focus readers’ attention on current dilemmas and possible solutions and create avenues for additional thought and innovation. Sudish C. Murthy, MD, PhD, FACS, FCCP Section Head, Thoracic Surgery, Surgical Director Center of Major Airway Disease Thoracic and Cardiovascular Surgery Cleveland Clinic 9500 Euclid Avenue, J4-1 Cleveland, OH 44195, USA
Thorac Surg Clin 25 (2015) ix http://dx.doi.org/10.1016/j.thorsurg.2014.10.001 1547-4127/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
E-mail address: [email protected]
thoracic.theclinics.com
Lung transplantation continues to be an imperfect science. Now, some 25 years into its run, morbidity, donor organ availability, worsening condition of candidates, and rejection all conspire to make long-term survival less than ideal. These moving parts make the orchestration of care formidable and mandate expert multidisciplinary care. Nonetheless, slow but consistent advances have been made in the field, in part attributable to many of the authors whose articles are contained herein. Uncertainty in regard to lung transplantation begins from the very start. Selection of appropriate candidates until just less than a decade ago continued to vex clinicians. Waitlist time, once a variable in the decision-making process, has now been supplanted by the Lung Allocation Score, which represents an assessment of risk of death on a waiting list versus risk of death posttransplant. Sicker candidates are given precedence on the list, which has created some problems in deciding “how sick is too sick for transplant?” To this end, bridging strategies with extracorporeal membrane oxygenation are becoming more commonplace. Donor organs remain in short supply, and novel approaches are being trialed to extend and expand the donor pool. Changes in the condition of the donor (postcardiac death) are being critically examined for their impact on organ quality. Ex vivo rehabilitation of organs offers the promise of salvaging unusable organs and, if validated, might double the number of donor organs. Finally, are two organs always better than one and, if not, might this serve to conserve organs and more broadly distribute them? Postoperative care issues continue to pose challenging problems. Airway anastomotic healing
P re f a c e L u n g Tra n s p l a n t a t i o n
Sudish C. Murthy, MD, PhD, FACS, FCCP Editor
issues have plagued lung transplant from the very outset and persist today. In addition to endobronchial approaches to palliate airway complications, bronchial artery revascularization is being investigated as a way to eliminate these dreaded complications altogether. Pleural space complications can affect allograft function, and a surprising variety of insults are contributory. The gamut of complications includes nuisance pleural effusion to densely trapped lung and can dramatically impact the quality of posttransplant life. In addition, even an indolent process such as reflux may have long-reaching and intractable effects on allograft function. Finally, as with all evolving processes, the future very quickly becomes the past, and accordingly, a brief look ahead is almost always a worthwhile undertaking. Is there a better mousetrap on the horizon? That thought is briefly explored as lung replacement theory and technology are reviewed. It is my hope that this tour through the numerous facets of lung transplantation will help focus readers’ attention on current dilemmas and possible solutions and create avenues for additional thought and innovation. Sudish C. Murthy, MD, PhD, FACS, FCCP Section Head, Thoracic Surgery, Surgical Director Center of Major Airway Disease Thoracic and Cardiovascular Surgery Cleveland Clinic 9500 Euclid Avenue, J4-1 Cleveland, OH 44195, USA
Thorac Surg Clin 25 (2015) ix http://dx.doi.org/10.1016/j.thorsurg.2014.10.001 1547-4127/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
E-mail address: [email protected]
thoracic.theclinics.com
Lung transplantation continues to be an imperfect science. Now, some 25 years into its run, morbidity, donor organ availability, worsening condition of candidates, and rejection all conspire to make long-term survival less than ideal. These moving parts make the orchestration of care formidable and mandate expert multidisciplinary care. Nonetheless, slow but consistent advances have been made in the field, in part attributable to many of the authors whose articles are contained herein. Uncertainty in regard to lung transplantation begins from the very start. Selection of appropriate candidates until just less than a decade ago continued to vex clinicians. Waitlist time, once a variable in the decision-making process, has now been supplanted by the Lung Allocation Score, which represents an assessment of risk of death on a waiting list versus risk of death posttransplant. Sicker candidates are given precedence on the list, which has created some problems in deciding “how sick is too sick for transplant?” To this end, bridging strategies with extracorporeal membrane oxygenation are becoming more commonplace. Donor organs remain in short supply, and novel approaches are being trialed to extend and expand the donor pool. Changes in the condition of the donor (postcardiac death) are being critically examined for their impact on organ quality. Ex vivo rehabilitation of organs offers the promise of salvaging unusable organs and, if validated, might double the number of donor organs. Finally, are two organs always better than one and, if not, might this serve to conserve organs and more broadly distribute them? Postoperative care issues continue to pose challenging problems. Airway anastomotic healing
