Surgical technique of lung transplantation exerts significant impact on clinical prognosis of the recipients.Choosing an appropriate surgical incision determines the exposure of intraoperative visual field,which is the first step of surgical success and directly affects subsequent surgical procedures.Lung transplantation incision is usually considered as primary closure.Nevertheless,for patients with high-risk factors such as oversized lung allografts and primary graft failure after lung transplantation,primary closure cannot be achieved.Hence,delayed chest closure is an effective strategy.The selection of incisions and the adoption of delayed chest closure of lung transplantation exert profound impact upon perioperative prognosis,long-term quality of life and surgical complications of the recipients.Therefore,the development and research status of Clamshell incision,anterolateral incision,posterolateral incision and median sternal incision in lung transplantation were reviewed,highlighting the effect of incision patterns on clinical prognosis of lung transplantation and providing reference for the selection of incisions in clinical lung transplantation.

Objective To investigate the effects of different extracorporeal membrane oxygenation(ECMO)bypass modes on the prognosis of patients with combined pulmonary fibrosis and emphysema(CPFE)during lung transplantation.Methods A retrospective analysis was conducted on 44 CPFE patients who underwent lung transplantation,and they were divided into the venous-venous ECMO(VV-ECMO)group(30 cases)and the venous-arterial ECMO(VA-ECMO)group(14 cases).The preoperative,intraoperative,postoperative and follow-up related indicators of two groups were compared.Results Compared with the VV-ECMO group,the patients in the VA-ECMO group were younger,had higher pulmonary artery pressure before surgery,fewer posterolateral incision types,longer operation times,and higher incidence of postoperative bronchopleural fistula(all P<0.05).The pulmonary artery pressure decreased after surgery in both groups,with a greater decrease in the VA-ECMO group(P<0.05).There was no statistically significant difference in postoperative survival rates between the two groups(P>0.05).Conclusions Both VA-ECMO and VV-ECMO are safe and effective in lung transplant patients with CPFE.The bypass mode has no significant impact on the short and medium-term prognosis of the patients.VA-ECMO is more suitable for patients with higher preoperative pulmonary artery pressure.

The current organ allocation rules prioritize elderly and urgent patients on the lung transplantation (LT) waiting list. A steady increase in the threshold at which age is taken into consideration for LT has been observed. This retrospective cohort study recruited 166 lung transplant recipients aged ≽ 65 years between January 2016 and October 2020 in the largest LT center in China. In the cohort, subgroups of patients aged 65-70 years (111 recipients, group 65-70) and ≽ 70 years (55 recipients, group ≽ 70) were included. Group D restrictive lung disease was the main indication of a lung transplant in recipients over 65 years. A significantly higher percentage of coronary artery stenosis was observed in the group ≽ 70 (30.9% vs. 14.4% in group 65-70, P = 0.014). ECMO bridging to LT was performed in 5.4% (group 65-70) and 7.3% (group ≽ 70) of patients. Kaplan-Meier estimates showed that recipients with cardiac abnormalities had a significantly increased risk of mortality. After adjusting for potential confounders, cardiac abnormality was shown to be independently associated with the increased risk of post-LT mortality (HR 6.37, P = 0.0060). Our result showed that LT can be performed in candidates with an advanced age and can provide life-extending benefits.
Aged ; Humans ; East Asian People ; Heart Diseases/etiology* ; Lung Transplantation/adverse effects* ; Retrospective Studies

Objective To compare the clinical efficacy between Clamshell incision and bilateral posterolateral incision in the sequential double lung transplantation for end-stage lung disease. Methods Clinical data of 120 recipients undergoing double lung transplantation were retrospectively analyzed. All recipients were divided into bilateral posterolateral incision group (n=108) and Clamshell incision group (n=12) according to different surgical methods. Intraoperative parameters were collected and statistically compared between two groups, including operation time, amount of blood loss, amount of blood transfusion, use of extracorporeal membrane oxygenation (ECMO) or not, cold ischemia time on the first side, and cold ischemia time on the second side. Postoperative parameters were also compared between two groups, including the length of hospital stay, length of intensive care unit (ICU) stay, tracheal intubation duration, ECMO duration, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), incidence of anastomotic stenosis, incidence of bronchopleural fistula, perioperative fatality, and 6-minute walk test for the first time after operation. Results In the Clamshell incision group, the amount of blood loss and blood transfusion was significantly higher than those in the bilateral posterolateral incision group (both P < 0.05). The proportion of ECMO and cold ischemia time on the second side in the Clamshell incision group were significantly lower or shorter than those in the bilateral posterolateral incision group (both P < 0.05). In the Clamshell incision group, the tracheal intubation duration and ECMO duration were significantly shorter compared with those in bilateral posterolateral incision group (both P < 0.05). Conclusions Both Clamshell incision and bilateral posterolateral incision are safe and effective in sequential double lung transplantation. Bilateral posterolateral incision approach can significantly reduce the amount of blood loss and blood transfusion of the recipients without significantly prolonging the operation time. Compared with bilateral posterolateral incision approach, the cold ischemia time of lung graft, tracheal intubation duration and ECMO duration are significantly shortened via the Clamshell incision.

Objective To investigate the selection of recipients,operative technique, and perioperative management of lung transplantation.Methods From June 2013 to September 2016, 9 patients with pulmonary lymphangioleiomyomatosis un-derwent lung transplantation at Affiliated Wuxi People's Hospital.There were 9 females aged from 23 to 52 years.Chest en-hancement of CT in 9 patients prior to transplantation suggests multiple different sized thin-walled cystic shadows in whole lung. Nine patients received bilateral sequence lung transplantation ( BSLT) .The pathological findings after the operation indicated that cells of the abnormal proliferation of smooth muscle diffused around the bronchi , vessels and lymphatics , and widened the alveolar septum, which was consistent with the pathological changes in the patients with PLAM .We analyzed the differences of oxygenation index, forcedexpiratory volume at 1 sec(FEV1), and DLCO％ pred.Using paired t test to compare these indica-tors, P<0.05 was considered statistically significant.Results The oxygenation index was increased from(210 ±55) mmHg (1 mmHg=0.133 kPa) to(400 ±80)mmHg after treatment, the difference was statistically significant(P<0.05).The FEV1 was increased from(1.0 ±0.2)L to(2.8 ±0.4)L, and the difference was statistically significant(P<0.05).The DLCO％pred was increased from(27.5 ±2.5)％ to(75.0 ±10.0)％, and the difference was statistically significant(P<0.05).Fi-nally, 8 patients were discharged from the hospital, and the pulmonary function was good.1 patients died of infection and acute rejection on the 13 day after operation.Conclusion Lung transplantation is effective in the treatment of chronic thromboem-bolic pulmonary hypertension , and long-term survival requires further investigations .Lung transplantation is the only effective means for the treatment of end-stage pulmonary lymphangioleiomyomatosis .Bilateral sequence lung transplantation is the first choice.

Objective To explore the efficacy and prognosis of lung transplantation from donors combined with pulmonary contusion on the treatment of patients with end-stage lung disease. Methods Clinical data of 73 cases of donors and recipients were collected. The donors and recipients were divided into contusion group (23 cases of donors and recipients, with a maximum diameter of contusion in 5-8 cm) and standard group (50 cases of donors and recipients) depending on combined pulmonary contusion. Major clinical indicators [postoperative oxygenation index, duration of mechanical ventilation and chest tube drainage and incidence of primary graft dysfunction (PGD)] and prognosis of the recipients in both groups were compared. Results The recipients in both groups presented no significant difference in postoperative oxygenation index, duration of mechanical ventilation and chest tube drainage and incidence of PGD (all P>0.05). The postoperative 1-year survival of the recipients in standard group and contusion group was 74％ and 83％, which presented no statistically significant difference (P>0.05). Conclusions The efficacy and prognosis of lung transplantation from donors combined with pulmonary contusion (with a maximum diameter of 5-8 cm) are comparable to those of lung transplantation from standard donors.

Objective To study the influence of pulmonary artery hypertension (PAH) on survival of patients with advanced chronic obstructive pulmonary disease (COPD) on the waiting list of lung transplantation.Methods The characteristics of 143 patients with COPD receiving lung transplantation evaluation from January 2014 to August 2016 were queried.Mild PAH was defined as mean pulmonary artery pressure (mPAP) ≥25 mmHg and severe ≥35 mrnHg by right heart catheterization measurements.The incidence of PAH was studied,and the patients were divided to different groups to determine the effect of PAH on survival prior to transplantation on the basis of different definitions of PAH.Kaplan Meier method was used to draw survival curves,and a log-rank test was used to analyze the effect of PAH on survival of COPD patients on the waiting list of pulmonary transplantation.Univariate and multivariate Cox proportional hazard models were performed to test the relationship between each main covariate and the hazard of mortality.The waiting time was tracked from wait list entry date until death or censoring,and the censoring issues were as follows:receiving lung transplantation,removing from the waiting list without transplant,and still wating for donor until the last follow-up day (2016-08-30).Results Of 143 COPD patients,there were 119 males and 24 males,with mean age of 61.73 years old;46 patients received lung transplantation,and the remaining 97 not;50 had mPAP ≥25 mmHg and 21 had mPAP ≥35 mmHg.A total of 23 cases (22.88％) died on the waiting list.Thirty-eight patients were removed from the list prior to transplantation,and 36 were still on the waiting list.Kaplan-Meier survival function showed suvival of patients with mild PAH or severe PAH was significantly shorter than that of patients without PAH (P＜0.001).Using Cox proportional hazards models,univariate analysis revealed significant differences in survival for mild PAH (HR =2.147,95％CI 1.429-3.157,P＜ 0.001) and severe PAH (HR =3.458,95 ％ CI 2.518-4.859,P＜0.001).Multivariate Cox models identified significant risk for death for mild PAH (HR=2.518,95％CI 1.728-3.364,P＜0.001) and severePAH HR=4.027,95％ CI 3.257-4.703,P＜0.001).Conclusion The incidence of PAH among COPD patients waiting for lung transplantation was high.PAH is associated with significantly increased risk of death among COPD patients waiting for lung transplantation.

Objective To investigate the institution of extracorporeal membrane oxygenation(ECMO) for primary graft dysfunction( PGD) after lung transplantation and analysis its clinical outcome. Methods From September 2002 to December 2013, 286 patients with end-stage lung disease underwent lung transplantation(LTx) in Wuxi People's Hospital. Among them, there were 22 patients occured grade 3 PGD in early stage after LTx. In which there were 2 cases with chronic obstructive pulmonary disease, 12 with idiopathic pulmonary fibrosis, 4 case with primary pulmonary hypertension, 1 case with lung tuber-culosis, 1 case with silicosis, 2 cases with bronchiectasis. There were 7 patients with single LTx(3 cases with ECMO support) and 15 patients with bilateral LTx(2 cases with CPB support and 6 cases with ECMO support). According to the severity levels of PGD, different treatment measures were used, such as reinforce ventilatory support, negative fluid balance, extending the treatment time of the ventilator, the use of pulmonary vasodilators, such as prostaglandin E1 and ECMO. Results Six patients were treated by adjusting low volume, high frequency and high positive end expiratory pressure ventilation( PEEP) mode, and 2 cases reversed, 4 cases died of respiratory failure. 16 cases accepted ECMO support, among them 10 cases apply venous-ve-nous mode, 6 cases venous-artery mode, the average flow time was 5. 5 days. 10 cases dismantled from ECMO successly and 6 cases died of multiple organ failure, infection and cardiac arrest. 30-day, 1-year and 5-year survival of PGD recipients post-op-eratively were 55％, 40％, 25％, respectively. Conclusion The high incidence of PGD causes high mortality peri-operative-ly after LTx. Preventing PGD can improve the survival rate of the lung transplant patients. Once PGD happens, appropriate treatment should be given as soon as possible. ECMO can effectively promote the transplanted lung function recovery, reduce the perioperative mortality. If the indications of ECMO use was reached, the institution of ECMO should as soon as possible.

Objective To summarize the lung transplant program using donation after death of citizens (DCD).Methods Retrospective characteristics of 242 patients with end-stage lung diseases receiving lung transplantation in our hospital were reviewed between January 2015 and December 2016.The data about evaluation and collection of all donors were analyzed.The survival rate,causes of deaths,and postoperative complications were reviewed.Kaplan Meier survival curves and a logrank test of differences in survival functions were used to assess the effect of lung transplant type and extracorporeal membrane oxygenation (ECMO) on survival post transplant.Results A total of 231 patients donated their lungs,including China type three (135 cases),China type two (19 cases),and China type one (77 cases).242 lung transplantations were successfully performed.The 3-month,6-month and 1-year survival rate after lung transplantation was 80.6％,80.6％,and 77.8％,respectively.There were 47 deaths during perioperative period,including 22 cases of primary graft dysfunction,14 cases of sepsis,6 cases of multiple organ failure,3 cases of heart failure,and 2 cases of stomal leak.One hundred and thirty-two patients received bilateral lung transplantation,with 3-month,6-month,and 1-year survival rate being 78.6％,78.6％,and 75.6％ respectively.110 underwent single lung transplantation with 3-month,6-month,and 1-year survival rate being 82.7 ％,82.7 ％,and 80.1％,respectively.No significant difference in survival rate was observed between single and bilateral lung transplantation (P＞0.05).One hundred and twenty-nine cases of lung transplants were conducted under ECMO support,with the 3-month,6-month and 1-year survival rate being 72.5％,72.5％,and 70.5％ respectively,which was significantly higher in those without ECMO with the 3-month,6-month and 1-year survival rate being 90.2％,90.2％ and 86.6％ respectively (n =113) (P ＜ 0.05).Conclusion DCD may facilitate the development of lung transplantation in China with long-term survival.

Objective To investigate the selection of recipients,operative technique,and perioperative management of lung transplantation for chronic thromboembolic pulmonary hypertension.Methods This article reviews the clinical data of 6 patients with chronic thromboembolic pulmonary hypertension receiving lung transplantation from January 2012 to June 2016.From January 2012 to June 2016,6 patients with chronic thromboembolic pulmonary hypertension underwent lung transplantation at Department of Thoracic Surgery,Affiliated Wuxi People's Hospital,Nanjing Medical University.There were 4 male and 2 female patients aged from 34 to 59 years.Chest enhancement of CT or CTPA in 6 patients prior to transplantation suggests a different degree of pulmonary embolism.The mean pulmonary artery pressure (mPAP) was＞30 mmHg,NYHA 11Ⅰ or Ⅳ.Four patients received bilateral sequence lung transplantation (BSLT) under extracorporeal membrane oxygenation (ECMO) support.Two patients received single lung transplantation (SLT).We analyzed the differences of oxygenation index,pulmonary systolic pressure,pulmonary artery diastolic pressure,mean pulmonary arterial pressure,and central venous pressure before and after treatment.Using paired t test to compare these indicators,P＜0.05 was considered statistically significant.Results The oxygenation index increased from (195 ± 85) to (440 ± 140) mmHg after treatment,the difference was statistically significant (P＜0.05).the The systolic pressure of pulmonary artery was decreased from (108 ± 28) mmHg to (56 ± 16) mmHg,and the difference was statistically significant (P＜0.05).the The diastolic pressure of pulmonary artery was decreased from (72 ± 18) mmHg to (25 ± 10) mmHg,and the difference was statistically significant (P＜0.05).the The mean pulmonary artery pressure was decreased from (84 ± 27) mmHg to (36 ± 10) mmHg,and the difference was statistically significant (P＜0.05).the The central venous pressure was decreased from (17.5 ± 4.5) mmHg to (8.5 ± 1.5) mmHg,and the difference was statistically significant (P＜0.05).Finally,5 patients were discharged from the hospital,and the pulmonary valve? functioned? well.1 patients died of shock and systemic failure 3 days after operation.Conclusion Lung transplantation is effective in the treatment of chronic thromboembolic pulmonary hypertension,and long-term survival requires further investigations.