Ann Thorac Surg 2014;98:1837–8
References 1. Ishikawa T, Pollak S, Perdekamp MG, et al. Hemorrhage from a cavernous hemangioma with fatal blood aspiration: a rare cause of sudden unexpected death. Leg Med (Tokyo) 2010;12: 308–12. 2. Galliani CA, Beatty JF, Grosfeld JL. Cavernous hemangioma of the lung in an infant. Pediatr Pathol 1992;12:105–11. 3. Fine SW, Whitney KD. Multiple cavernous hemangiomas of the lung: a case report and review of the literature. Arch Pathol Lab Med 2004;128:1439–41. 4. Mori A, Obata K, Tada T, et al. A case of multiple cavernous hemangiomas of the lung. Gan No Rinsho 1985;31:1433–8. 5. Glade R, Vinson K, Richter G, et al. Endoscopic management of airway venous malformations with Nd:YAG laser. Ann Otol Rhinol Laryngol 2010;119:289–93. 6. Kase M, Sakamoto K, Yamagata T, et al. A case of pulmonary cavernous hemangioma: immunohistological examination revealed its endothelial cell origin. Kyobu Geka 2000;53:1055–7. 7. Xavier C, Emil S. Spontaneous resolution of lymphatic and venous malformations. Eur J Pediatr Surg 2010;20:342–5.
Successful Lung Transplantation After Donor Lung Reconditioning With Urokinase in Ex Vivo Lung Perfusion System Ilhan Inci, MD, Yoshito Yamada, MD, PhD, Sven Hillinger, MD, Wolfgang Jungraithmayr, MD, PhD, Michael Trinkwitz, and Walter Weder, MD Departments of Thoracic Surgery and Cardiovascular Surgery, University Hospital, Zurich, Switzerland
Acute pulmonary embolism is considered a contraindication to lung donation for transplantation as it might result in graft dysfunction. Ex vivo lung perfusion (EVLP) is a novel method to assess and recondition a questionable donor graft before transplantation. In this report we present a case of successful bilateral lung transplant after donor lung assessment and treatment with a fibrinolytic agent, urokinase, during EVLP. (Ann Thorac Surg 2014;98:1837–8) Ó 2014 by The Society of Thoracic Surgeons
Accepted for publication Jan 14, 2014. Address correspondence to Dr Inci, Department of Thoracic Surgery, University Hospital, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
1837
D
espite improvements in both donor management and organ preservation, only a limited number of potential donor lungs are considered acceptable for transplantation. This leads to high waiting list mortality for lung transplant recipients. Ex vivo lung perfusion (EVLP) is a novel technique proposed for the assessment, resuscitation, and repair of extended donor lungs [1, 2]. Similar early outcomes have been reported in recipients who underwent transplantation after EVLP to those with conventionally selected and transplanted lungs [1–3]. We report successful bilateral lung transplantation after donor lung treatment and assessment in the EVLP system with a fibrinolytic agent, urokinase.
Recipient was a 27-year-old male suffering with endstage cystic fibrosis (176 cm, 75 kg, body mass index 24 kg/m2), diagnosed in childhood due to recurrent respiratory symptoms and found to have a delta F508 homozygous cystic fibrosis genotype. Forced expiratory volume in 1 second (FEV1) and forced vital capacity were 1.7 l, 40% predicted and 3.38 l, 64% predicted, respectively. Informed consent was obtained from the patient. The donor was a 45-year-old female (180 cm, 98 kg) who was hospitalized for spine surgery. At postoperative day 4 she had suffered diffuse arterial and venous emboli. She underwent femoral arterial embolectomy and received intravenous lytic treatment for pulmonary emboli. Thereafter she developed intracranial bleeding resulting in brain death. She was declared brain dead after developing intracranial bleeding. Her arterial oxygen partial pressure at the time of retrieval was 360 mm Hg. Chest X-ray revealed bilateral infiltrations. Thorax computed tomography (CT) scan could not rule out persistent segmental arterial lung emboli. The lung was accepted for EVLP and reconditioning during EVLP with urokinase. Acellular normothermic EVLP [1] was performed. At 37 C 100,000 IU urokinase was added into the reservoir. During EVLP for the functional assessment, tidal volume was set at 10 mL per kilogram of donor body weight and 10 breaths per minute, with fraction of inspired oxygen at 1.0. Lung function was evaluated hourly during EVLP according to the following calculations: Delta PO2 (partial pressure of oxygen) ¼ [left atrial PO2 – pulmonary-artery PO2 (in mm Hg)], and pulmonary vascular resistance ¼ [(pulmonary-artery pressure – left atrial pressure)] O pulmonary-artery flow (in Wood Units), dynamic compliance (in mL/cm H20), and peak inspiratory pressure (in cm H2O). The lung was functionally evaluated for 3 hours and then cooled down to Table 1. Parameters During Ex Vivo Lung Perfusion Time (hour)
PVR
C-Dyn
Delta PO2
PiP
Lactate
1 2 3
4.9 4.9 3.7
72 73 74
278 322 280
14 15 15
1.4 2.5 3.1
C-Dyn ¼ dynamic lung compliance (mL/cm H2O); PiP ¼ peak inspiratory pressure (cm H2O); PO2 ¼ partial pressure of oxygen; PVR ¼ pulmonary vascular resistance (Wood Units).
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.076
FEATURE ARTICLES
spontaneously resolved. These experiences highlight that radiographic follow-up may play a significant role in asymptomatic and stable PCH. In summary, PCHs are extremely rare. They can be asymptomatic or can present with life-threatening symptoms. The clinical features are not well revealed. For a solitary PCH, surgical excision yields excellent outcomes, but for multiple PCHs, surgical intervention or close radiographic follow-up remains the treatment of choice.
CASE REPORT INCI ET AL UROKINASE IN EVLP
1838
CASE REPORT WANG ET AL PNEUMOTHORAX AS INITIAL MANIFESTATION OF IHS
20 C (Table 1). Then the lung block was placed in a bag filled with 1 L of cold Perfadex (Vitrolife, G€ oteburg, Sweden) and stored in cold saline until transplantation. The cold ischemic time after EVLP was 3 hours for the right and 5 hours for the left lung. Total operation time was 5 hours and 30 minutes. The recipient did not receive any blood transfusion. The patient was extubated 6 hours after the transplantation. Intensive care unit stay was 3 days. Primary graft dysfunction score at postoperative time 48 hours and 72 hours was 0. The last chest tube was removed at postoperative day 6. The patient was discharged from the hospital at postoperative day 21. The FEV1 at discharge was 2.8 l (64%). The patient is alive and follow-up time is 6 weeks posttransplant.
Comment
FEATURE ARTICLES
We report a successful lung transplantation after reconditioning and treatment with urokinase during EVLP. Perfusion of grafts from non-heart-beating donors (NHBD) shows typically high resistance and inadequate microperfusion suggesting the presence of thrombi and fibrin deposition in the microcirculation [4]. Plasminogen activators are such agents utilized for this purpose. Adding a plasminogen activator, urokinase, into the perfusion solution during ex vivo perfusion and evaluation after 3 hours of warm ischemia resulted in improved graft function and significant reduction of pulmonary vascular resistance (PVR) [4]. This effect of urokinase has been attributed to reconditioning of the graft by dissolving microthrombi [4]. Improvements in pH, PO2, and partial pressure of carbon dioxide with EVLP all may have led to reductions in PVR in addition to the effect of urokinase, which has contributed to the dissolving of microthrombi. In our case, the donor had initially central pulmonary emboli, which were treated by an intravenous thrombolytic agent. Thorax CT scan, which was performed for donor evaluation, showed lyses of central emboli but persistent peripheral arterial lung emboli could not be ruled out. For this reason, we added urokinase into the perfusion solution during EVLP. As seen in Table 1, PVR dropped from 4.9 to 3.7 Wood Units, as well as excellent lung compliance. Lung compliance during retrieval was 42 mL/cm H2O, improved to 74 mL/H2O, and was stable during EVLP. Oxygenation remained stable. Reduction of PVR is a very important indicator for dissolving microemboli [4]. In the early postoperative period, we did not observe any problems such as allergic or toxic effects, or bleeding-related complications to urokinase. Primary graft dysfunction score at 48 and 72 hours was 0, showing an excellent graft function. In a research project the use of EVLP to evaluate a donor lung graft with acute pulmonary embolism has been recently reported [5]. The authors observed decreased PVR, increased lung compliance, and oxygenation during EVLP. In conclusion, our case report may encourage other groups which utilize NHBD category 1 or 2 donors (other than Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2014;98:1838–41
brain death donors with pulmonary embolism) to add urokinase in the perfusion solution during EVLP. The authors thank Mrs Laurie Theurer for reading and correcting language and syntax errors.
References 1. Cypel M, Yeung JC, Liu M, et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 14(364):1431–40. 2. Wierup P, Haraldsson A, Nilsson F, et al. Ex vivo evaluation of nonacceptable donor lungs. Ann Thorac Surg 2006;81:460–6. 3. Aigner C, Slama A, H€ otzenecker K, et al. Clinical ex vivo lung perfusion–pushing the limits. Am J Transplant 2012;12: 1839–47. 4. Inci I, Zhai W, Arni S, et al. Fibrinolytic treatment improves the quality of lungs retrieved from non-heart-beating donors. J Heart Lung Transplant 2007;26:1054–60. 5. Brown CR, Brozzi NA, Vakil N, et al. Donor lungs with pulmonary embolism evaluated with ex vivo lung perfusion. ASAIO J 2012;58:432–4.
Pneumothorax as the Initial Manifestation of Idiopathic Hypereosinophilic Syndrome Yu-Bing Wang, MD,* Ya-Juan Han, MD,* Kenzo Uchida, MD, PhD, Bing-Cheng Zhao, Ke-Bing Chen, MD, PhD, Wei-Ying Ma, MD, Feng-Jiao Xie, Tie-Lian Liu, MD, and Li-Xi Zhang, MD Departments of Cardiothoracic Surgery, Endocrinology, Spine Surgery, and Clinical Laboratory, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China; Department of Orthopaedics and Rehabilitation Medicine, Fukui University of Medical Sciences, Fukui, Japan; Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China; and Department of Anesthesiology, The Second Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
We report a case of hypereosinophilic syndrome in a 47-year-old man who had acute pneumothorax as the initial presentation. Peripheral blood eosinophil count increased continuously over a period of 1 month and was associated with pulmonary changes and appearance of skin lesions on the right chest wall. Idiopathic hypereosinophilic syndrome was confirmed by bone marrow aspiration biopsy and skin lesion biopsy after exclusion of all possible secondary etiologies. The clinical status and chest radiographs showed marked improvement after treatment with corticosteroids. (Ann Thorac Surg 2014;98:1838–41) Ó 2014 by The Society of Thoracic Surgeons
Accepted for publication Dec 30, 2013. *Drs Wang and Han contributed equally to this article. Address correspondence to Dr Chen, Spine Surgery, The Third Affiliated Hospital, Southern Medical University, Guangzhou 510630, China; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.078
References 1. Ishikawa T, Pollak S, Perdekamp MG, et al. Hemorrhage from a cavernous hemangioma with fatal blood aspiration: a rare cause of sudden unexpected death. Leg Med (Tokyo) 2010;12: 308–12. 2. Galliani CA, Beatty JF, Grosfeld JL. Cavernous hemangioma of the lung in an infant. Pediatr Pathol 1992;12:105–11. 3. Fine SW, Whitney KD. Multiple cavernous hemangiomas of the lung: a case report and review of the literature. Arch Pathol Lab Med 2004;128:1439–41. 4. Mori A, Obata K, Tada T, et al. A case of multiple cavernous hemangiomas of the lung. Gan No Rinsho 1985;31:1433–8. 5. Glade R, Vinson K, Richter G, et al. Endoscopic management of airway venous malformations with Nd:YAG laser. Ann Otol Rhinol Laryngol 2010;119:289–93. 6. Kase M, Sakamoto K, Yamagata T, et al. A case of pulmonary cavernous hemangioma: immunohistological examination revealed its endothelial cell origin. Kyobu Geka 2000;53:1055–7. 7. Xavier C, Emil S. Spontaneous resolution of lymphatic and venous malformations. Eur J Pediatr Surg 2010;20:342–5.
Successful Lung Transplantation After Donor Lung Reconditioning With Urokinase in Ex Vivo Lung Perfusion System Ilhan Inci, MD, Yoshito Yamada, MD, PhD, Sven Hillinger, MD, Wolfgang Jungraithmayr, MD, PhD, Michael Trinkwitz, and Walter Weder, MD Departments of Thoracic Surgery and Cardiovascular Surgery, University Hospital, Zurich, Switzerland
Acute pulmonary embolism is considered a contraindication to lung donation for transplantation as it might result in graft dysfunction. Ex vivo lung perfusion (EVLP) is a novel method to assess and recondition a questionable donor graft before transplantation. In this report we present a case of successful bilateral lung transplant after donor lung assessment and treatment with a fibrinolytic agent, urokinase, during EVLP. (Ann Thorac Surg 2014;98:1837–8) Ó 2014 by The Society of Thoracic Surgeons
Accepted for publication Jan 14, 2014. Address correspondence to Dr Inci, Department of Thoracic Surgery, University Hospital, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
1837
D
espite improvements in both donor management and organ preservation, only a limited number of potential donor lungs are considered acceptable for transplantation. This leads to high waiting list mortality for lung transplant recipients. Ex vivo lung perfusion (EVLP) is a novel technique proposed for the assessment, resuscitation, and repair of extended donor lungs [1, 2]. Similar early outcomes have been reported in recipients who underwent transplantation after EVLP to those with conventionally selected and transplanted lungs [1–3]. We report successful bilateral lung transplantation after donor lung treatment and assessment in the EVLP system with a fibrinolytic agent, urokinase.
Recipient was a 27-year-old male suffering with endstage cystic fibrosis (176 cm, 75 kg, body mass index 24 kg/m2), diagnosed in childhood due to recurrent respiratory symptoms and found to have a delta F508 homozygous cystic fibrosis genotype. Forced expiratory volume in 1 second (FEV1) and forced vital capacity were 1.7 l, 40% predicted and 3.38 l, 64% predicted, respectively. Informed consent was obtained from the patient. The donor was a 45-year-old female (180 cm, 98 kg) who was hospitalized for spine surgery. At postoperative day 4 she had suffered diffuse arterial and venous emboli. She underwent femoral arterial embolectomy and received intravenous lytic treatment for pulmonary emboli. Thereafter she developed intracranial bleeding resulting in brain death. She was declared brain dead after developing intracranial bleeding. Her arterial oxygen partial pressure at the time of retrieval was 360 mm Hg. Chest X-ray revealed bilateral infiltrations. Thorax computed tomography (CT) scan could not rule out persistent segmental arterial lung emboli. The lung was accepted for EVLP and reconditioning during EVLP with urokinase. Acellular normothermic EVLP [1] was performed. At 37 C 100,000 IU urokinase was added into the reservoir. During EVLP for the functional assessment, tidal volume was set at 10 mL per kilogram of donor body weight and 10 breaths per minute, with fraction of inspired oxygen at 1.0. Lung function was evaluated hourly during EVLP according to the following calculations: Delta PO2 (partial pressure of oxygen) ¼ [left atrial PO2 – pulmonary-artery PO2 (in mm Hg)], and pulmonary vascular resistance ¼ [(pulmonary-artery pressure – left atrial pressure)] O pulmonary-artery flow (in Wood Units), dynamic compliance (in mL/cm H20), and peak inspiratory pressure (in cm H2O). The lung was functionally evaluated for 3 hours and then cooled down to Table 1. Parameters During Ex Vivo Lung Perfusion Time (hour)
PVR
C-Dyn
Delta PO2
PiP
Lactate
1 2 3
4.9 4.9 3.7
72 73 74
278 322 280
14 15 15
1.4 2.5 3.1
C-Dyn ¼ dynamic lung compliance (mL/cm H2O); PiP ¼ peak inspiratory pressure (cm H2O); PO2 ¼ partial pressure of oxygen; PVR ¼ pulmonary vascular resistance (Wood Units).
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.076
FEATURE ARTICLES
spontaneously resolved. These experiences highlight that radiographic follow-up may play a significant role in asymptomatic and stable PCH. In summary, PCHs are extremely rare. They can be asymptomatic or can present with life-threatening symptoms. The clinical features are not well revealed. For a solitary PCH, surgical excision yields excellent outcomes, but for multiple PCHs, surgical intervention or close radiographic follow-up remains the treatment of choice.
CASE REPORT INCI ET AL UROKINASE IN EVLP
1838
CASE REPORT WANG ET AL PNEUMOTHORAX AS INITIAL MANIFESTATION OF IHS
20 C (Table 1). Then the lung block was placed in a bag filled with 1 L of cold Perfadex (Vitrolife, G€ oteburg, Sweden) and stored in cold saline until transplantation. The cold ischemic time after EVLP was 3 hours for the right and 5 hours for the left lung. Total operation time was 5 hours and 30 minutes. The recipient did not receive any blood transfusion. The patient was extubated 6 hours after the transplantation. Intensive care unit stay was 3 days. Primary graft dysfunction score at postoperative time 48 hours and 72 hours was 0. The last chest tube was removed at postoperative day 6. The patient was discharged from the hospital at postoperative day 21. The FEV1 at discharge was 2.8 l (64%). The patient is alive and follow-up time is 6 weeks posttransplant.
Comment
FEATURE ARTICLES
We report a successful lung transplantation after reconditioning and treatment with urokinase during EVLP. Perfusion of grafts from non-heart-beating donors (NHBD) shows typically high resistance and inadequate microperfusion suggesting the presence of thrombi and fibrin deposition in the microcirculation [4]. Plasminogen activators are such agents utilized for this purpose. Adding a plasminogen activator, urokinase, into the perfusion solution during ex vivo perfusion and evaluation after 3 hours of warm ischemia resulted in improved graft function and significant reduction of pulmonary vascular resistance (PVR) [4]. This effect of urokinase has been attributed to reconditioning of the graft by dissolving microthrombi [4]. Improvements in pH, PO2, and partial pressure of carbon dioxide with EVLP all may have led to reductions in PVR in addition to the effect of urokinase, which has contributed to the dissolving of microthrombi. In our case, the donor had initially central pulmonary emboli, which were treated by an intravenous thrombolytic agent. Thorax CT scan, which was performed for donor evaluation, showed lyses of central emboli but persistent peripheral arterial lung emboli could not be ruled out. For this reason, we added urokinase into the perfusion solution during EVLP. As seen in Table 1, PVR dropped from 4.9 to 3.7 Wood Units, as well as excellent lung compliance. Lung compliance during retrieval was 42 mL/cm H2O, improved to 74 mL/H2O, and was stable during EVLP. Oxygenation remained stable. Reduction of PVR is a very important indicator for dissolving microemboli [4]. In the early postoperative period, we did not observe any problems such as allergic or toxic effects, or bleeding-related complications to urokinase. Primary graft dysfunction score at 48 and 72 hours was 0, showing an excellent graft function. In a research project the use of EVLP to evaluate a donor lung graft with acute pulmonary embolism has been recently reported [5]. The authors observed decreased PVR, increased lung compliance, and oxygenation during EVLP. In conclusion, our case report may encourage other groups which utilize NHBD category 1 or 2 donors (other than Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier
Ann Thorac Surg 2014;98:1838–41
brain death donors with pulmonary embolism) to add urokinase in the perfusion solution during EVLP. The authors thank Mrs Laurie Theurer for reading and correcting language and syntax errors.
References 1. Cypel M, Yeung JC, Liu M, et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 14(364):1431–40. 2. Wierup P, Haraldsson A, Nilsson F, et al. Ex vivo evaluation of nonacceptable donor lungs. Ann Thorac Surg 2006;81:460–6. 3. Aigner C, Slama A, H€ otzenecker K, et al. Clinical ex vivo lung perfusion–pushing the limits. Am J Transplant 2012;12: 1839–47. 4. Inci I, Zhai W, Arni S, et al. Fibrinolytic treatment improves the quality of lungs retrieved from non-heart-beating donors. J Heart Lung Transplant 2007;26:1054–60. 5. Brown CR, Brozzi NA, Vakil N, et al. Donor lungs with pulmonary embolism evaluated with ex vivo lung perfusion. ASAIO J 2012;58:432–4.
Pneumothorax as the Initial Manifestation of Idiopathic Hypereosinophilic Syndrome Yu-Bing Wang, MD,* Ya-Juan Han, MD,* Kenzo Uchida, MD, PhD, Bing-Cheng Zhao, Ke-Bing Chen, MD, PhD, Wei-Ying Ma, MD, Feng-Jiao Xie, Tie-Lian Liu, MD, and Li-Xi Zhang, MD Departments of Cardiothoracic Surgery, Endocrinology, Spine Surgery, and Clinical Laboratory, The Third Affiliated Hospital, Southern Medical University, Guangzhou, China; Department of Orthopaedics and Rehabilitation Medicine, Fukui University of Medical Sciences, Fukui, Japan; Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China; and Department of Anesthesiology, The Second Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
We report a case of hypereosinophilic syndrome in a 47-year-old man who had acute pneumothorax as the initial presentation. Peripheral blood eosinophil count increased continuously over a period of 1 month and was associated with pulmonary changes and appearance of skin lesions on the right chest wall. Idiopathic hypereosinophilic syndrome was confirmed by bone marrow aspiration biopsy and skin lesion biopsy after exclusion of all possible secondary etiologies. The clinical status and chest radiographs showed marked improvement after treatment with corticosteroids. (Ann Thorac Surg 2014;98:1838–41) Ó 2014 by The Society of Thoracic Surgeons
Accepted for publication Dec 30, 2013. *Drs Wang and Han contributed equally to this article. Address correspondence to Dr Chen, Spine Surgery, The Third Affiliated Hospital, Southern Medical University, Guangzhou 510630, China; e-mail: [email protected].
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.12.078
