JTCS Medtronic Endurant
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pilcher, D. V.
Right arrow Articles by Snell, G. I.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pilcher, D. V.
Right arrow Articles by Snell, G. I.
Related Collections
Right arrow Lung - transplantation

J Thorac Cardiovasc Surg 2007;133:1071-1077
© 2007 The American Association for Thoracic Surgery

Cardiothoracic Transplantation

Predictors of independent lung ventilation: An analysis of 170 single-lung transplantations

David V. Pilcher, MRCP, FJFICMa,*, Georg M. Auzinger, MRACPa, Biswadev Mitra, MBBSa, David V. Tuxen, FRACP, FJFICMa, Robert F. Salamonsen, FANZCAa, Andrew R. Davies, FRACP, FJFICMa, Trevor J. Williams, FRACPb, Gregory I. Snell, FRACPb

a Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia.
b Department of Allergy, Immunology, and Respiratory Medicine, The Alfred Hospital, Melbourne, Victoria, Australia.

Received for publication June 29, 2006; revisions received September 28, 2006; accepted for publication October 9, 2006.

* Address for reprints: David Pilcher, MD, Intensive Care Unit, The Alfred Hospital, Commercial Rd, Prahran 3181, Victoria, Australia. (Email: d.pilcher{at}alfred.org.au).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Objective: Single-lung transplantation for chronic obstructive pulmonary disease can cause unique postoperative problems that might require independent lung ventilation. We evaluated preoperative and immediate postoperative factors to predict the need for independent lung ventilation.

Methods: We retrospectively studied 170 patients who received a single-lung transplant over a 15-year period, 20 (12%) of whom required independent lung ventilation.

Results: Patients requiring independent lung ventilation were similar in age, sex, ischemic time, and donor characteristics to those who required conventional ventilation. Patients receiving independent lung ventilation had a greater degree of preoperative airflow limitation, more hyperinflation, lower postoperative PaO 2/fraction of inspired oxygen ratios, more radiologic mediastinal shift, and more transplant lung infiltrate on the postoperative chest radiograph. Multivariate logistic regression analysis showed that independent lung ventilation was associated with increasing levels of recipient hyperinflation (percentage total lung capacity compared with predicted value; odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .032) and reduced early postoperative PaO 2/fraction of inspired oxygen ratio (odds ratio, 0.97; 95% confidence interval, 0.95-0.99; P = .005). Length of ventilation and intensive care unit stay and mortality were higher in the independent lung ventilation group. Among patients who survived to hospital discharge, there were no differences in long-term mortality between the 2 groups.

Conclusions: The need for independent lung ventilation in patients undergoing single-lung transplantation for obstructive lung disease is predicted by the combination of increased hyperinflation measured on recipients’ preoperative lung function tests and a low PaO 2/fraction of inspired oxygen ratio, indicating graft dysfunction in the immediate postoperative period.

Abbreviations and Acronyms COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 second; ICU = intensive care unit; ILV = independent lung ventilation; PEEP = positive end-expiratory pressure; SLT = single-lung transplantation; TLC = total lung capacity


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
Until 2 successful cases of single-lung transplantation (SLT) for end-stage emphysema were reported by Mal and colleagues1Go in 1989, SLT was considered to be contraindicated in patients with chronic obstructive pulmonary disease (COPD). Initial concerns were that hyperexpansion of the native lung would compress the graft and that the higher vascular resistance of the native lung would divert excessive blood flow to the transplant lung, with the combination leading to unacceptable ventilation-perfusion mismatch. Experimental studies and two successful SLTs for emphysema did much to alleviate these concerns and supported the feasibility of the procedure.2Go These authors showed that significant ventilation-perfusion mismatch and arterial hypoxemia did not occur unless rejection, infection, or reperfusion injury developed in the transplant lung. Since then, end-stage emphysema has become the most common indication for SLT. In recent years, however, there has been an increasing tendency to perform double-lung transplantations for these patients because of a long-term survival advantage.3Go

After transplantation, the new allograft is predisposed to early injury from a variety of sources. These include primary graft dysfunction, injury caused by lung handling, fluid loading in a lung with increased permeability and absent lymphatic drainage, early infection, and, in occasional patients, impaired venous drainage. When early lung allograft injury does occur, it can lead to atelectasis, hypoxia, hypercapnia, and reduced compliance in the transplant lung. The latter increases the proportion of ventilation to the native lung, thereby increasing its dynamic hyperinflation, and can lead to increased intrathoracic pressure, circulatory compromise, and increasing mediastinal shift, with further atelectasis and shunt in the transplant lung. Attempts to alleviate hypoxia, hypercapnia, and transplant lung atelectasis by increasing ventilation or positive end-expiratory pressure (PEEP) often increase dynamic hyperinflation in the native lung and worsen atelectasis and gas exchange in the transplant lung.4Go This remains a serious problem, especially in the early postoperative period. Because the ventilation and PEEP requirements of the transplant lung aggravate dynamic hyperinflation in the native (COPD) lung, independent-lung ventilation (ILV) has been proposed as a successful treatment of early postoperative dynamic hyperinflation and graft failure.5,6Go

The principal aim of our study was to identify preoperative and early postoperative predictors for the need for ILV in patients who received ILV in clinical management. We hypothesized that a number of factors might combine to determine the requirement for ILV: pre-existing dynamic recipient hyperinflation, postoperative hyperinflation of the native lung, size mismatch between the native and transplanted lungs, mediastinal shift caused by hyperinflation of the native lung, and injury to the transplanted lung. Additional aims were to study the early and long-term outcomes (duration of ventilation, length of stay in the intensive care unit [ICU], hospital mortality, and survival after leaving the hospital) of patients requiring ILV compared with those of patients not receiving ILV.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusions
 References
 
A retrospective chart, medical record, and database review of all SLTs performed from October 1990 (when the service began) until October 2005 was conducted. Patients who received an SLT for obstructive lung diseases were identified for analysis. Variables were grouped into those that were available preoperatively and those that could be assessed in the immediate postoperative period.

Preoperative Variables
Recipients’ age, sex, height, weight, lung function test results, and chest radiographic measurements were recorded. Donor factors included were age, sex, height, PaO 2 (taken on a fraction of inspired oxygen [FIO 2] of 100% and a 5 cm H2O PEEP), and estimated total lung capacity (TLC).7Go Total graft ischemic time for the organ was also recorded.

Postoperative Variables
Estimates of lung size and mediastinal shift were taken by using the first postoperative chest radiograph and compared with the most recent preoperative radiograph. The severity of transplant lung infiltrate was graded from 0 (absence of infiltrate) to 4 (dense alveolar consolidation of the entire lung field).8Go Gas exchange was assessed by recording the lowest PaO 2/FIO 2 ratio in the first 24 hours or before instituting ILV (whichever came first).

We analyzed variables as predictors for the need for ILV by comparing preoperative and early postoperative findings in the ILV and non-ILV groups during the first 24 postoperative hours. Outcome parameters were compared between the ILV and non-ILV groups. Outcomes assessed were incidence of ILV, duration of mechanical ventilation, duration of stay in the ICU, ICU mortality, hospital mortality, and long-term survival.

General Method for SLT
Split-lung function studies were performed on all patients (nuclear quantitative perfusion scans). The worst functional side was always selected for transplantation. There were insufficient retrospective data to include this in our analysis. General methods for recipient selection, donor selection, pulmonary allograft procurement, surgical technique for SLT, and postoperative management have been described in detail previously.4,9-11Go However, principles included immunosuppressive and antiviral therapy (described previously),12Go maintenance of low central venous pressure, minimal PEEP, active airway clearance, maximal bronchodilator therapy, and nitric oxide, where appropriate.

Indications for ILV
There was no protocol for the initiation of ILV. Treating clinicians instigated ILV on the basis of one or a combination of the following: (1) serious hemodynamic compromise attributed to excessive dynamic hyperinflation and (2) serious gas exchange compromise attributed to excessive dynamic hyperinflation.

Transplant lung infiltrate on chest radiography was usually present but was not by itself an indication for ILV. Asymptomatic hyperinflation was not considered an indication for ILV.

Technical Aspects of ILV
Patients who required ILV were intubated with a double-lumen endotracheal tube (Bronchocath; Mallinckrodt, Athlone, Ireland; size range, 35F-41F). The side of the bronchial lumen was positioned bronchoscopically to lie in the main bronchus of the native lung to avoid injury to the bronchial anastomosis. In all patients, asynchronous ILV was used. The native lung was ventilated with low tidal volumes (3-6 mL/kg), a low ventilator rate (3-6 breaths/min), and 0 PEEP or not ventilated at all by using continuous positive airway pressure (5 cm H2O). The transplanted lung was ventilated with higher ventilator rates (10-26 breaths/min) and variable tidal volumes (3.5-10 mL/kg). PEEP (5-15 cm H2O) was adjusted to achieve a maximal improvement in gas exchange and compliance.

Statistical Analysis
All data are expressed as means ± standard deviation. Data were analyzed by using the Student t test and Wilcoxon and {chi}2 tests as appropriate. A stepwise multivariate logistic regression model was used to correct for the effect of multiple variables and their interactions on requiring ILV in the early postoperative period. Variables that were associated with the requirement for ILV at a P value of less than .1 in the univariate analysis were entered into the multivariate model. The initial model was constructed by using preoperative variables. Postoperative variables were selected afterward and then incorporated into the final model. Software used was SAS version 9.1.3 (Enterprise Guide) for Windows (SAS Institute, Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusions
 References
 
Of 211 SLTs performed between October 1990 (when the service began) and October 2005, 170 patients received an SLT for obstructive lung diseases (133 for emphysema caused by smoking, 23 for emphysema caused by {alpha}1-antitrypsin deficiency, 8 for obliterative bronchiolitis, 4 for lymphangioleiomyomatosis, 1 for agammaglobulinemia, and 1 for asthma). These 170 patients formed the basis of our analysis. ILV was used in 12% (20/170) of SLTs for obstructive lung disease. One of these 20 patients had obliterative bronchiolitis; the remainder had emphysema caused by smoking. Other than one case, in which the patient was returned to the ICU from the operating theater with a double-lumen endotracheal tube in situ, ILV was instigated by the treating intensivist. ILV was initiated within the first 24 hours in 19 patients. One patient had a pneumothorax in the native lung on the fourth postoperative day, and this patient’s condition subsequently deteriorated, requiring ILV. There was one instance of ILV use in a patient with restrictive lung disease caused by pulmonary fibrosis (before institution of extracorporeal membrane oxygenation), and this patient was not included in this study.

Demographic data for all patients receiving an SLT for COPD are shown in Table 1. The mean age for the whole cohort was typical for this patient group, and there was a female preponderance.


View this table:
[in this window]
[in a new window]

  		TABLE 1 Comparison of baseline preoperative demographic data for the ILV and conventional ventilation groups
 
Table 2 shows the lung function and chest radiographic assessments available in the preoperative period. All recipients had severe airflow limitation. Those who subsequently required ILV had lower forced expiratory volume in 1 second (FEV1) to forced vital capacity ratios expressed as a percentage of predicted value. Patients undergoing ILV had greater degrees of functional hyperinflation, higher TLC expressed as a percentage of predicted value and functional residual capacity expressed as a percentage of predicted value, than those who required only conventional ventilation postoperatively. Of those patients who had TLCs greater than 150% of predicted value, 26.5% (9/34) required ILV compared with only 6.6% (8/121) of those with TLCs less than this value (P = .003). Indeed, of the 9 patients who had TLCs greater than 175% of predicted value, 4 (ie, 44%) required ILV. There were no significant differences between the radiologic assessments of lung size (in donors and recipients) between both groups.


View this table:
[in this window]
[in a new window]

  		TABLE 2 Comparison of preoperative lung function and radiologic variables
 
Table 3 shows data from the immediate postoperative period. The patients who needed ILV had greater degrees of pulmonary infiltrate (P < .001), worse gas exchange (P < .001), and more mediastinal shift (P = .018). A PaO 2/FIO 2 ratio of less than 100 was observed in 61.1% (11/18) of patients in the ILV group as opposed to only 11% (15/136) patients requiring conventional ventilation. Although the mean amount of radiologic mediastinal shift was different between the 2 groups, the presence of significant mediastinal shift (>2.5 cm) was a relatively poor discriminator (45% of patients in the ILV group as opposed to 32% in the conventional ventilation group). Two patients in the ILV group had only 1 cm or less mediastinal shift on radiography. Both of these patients had significant cardiovascular compromise, with low cardiac output and hypotension. Their PaO 2/FIO 2 ratios were 97 and 170, respectively. Five patients in the conventional ventilation group had mediastinal shift greater than or equal to 4 cm.


View this table:
[in this window]
[in a new window]

  		TABLE 3 Comparison of postoperative variables
 
ILV was required more commonly after left lung transplantation (left: 17% [14/82] vs right: 7% [6/88], P = .037). There were nonsignificant trends toward more mediastinal shift (1.8 ± 1.4 cm vs 1.5 ± 1.2 cm, respectively; P = .158) and higher hospital mortality (left: 10/72 vs right: 5/83, P = .178) in left compared with right lung transplants. However, duration of ventilation (left: 8.0 hours [interquartile range, 2.5-23.5 hours] vs right: 7.0 hours [interquartile range, 2.3-18.8 hours], P = .671) was similar.

The multivariate analysis (Table 4) demonstrated that the only 2 factors that were significantly associated with the requirement for ILV were TLC percent predicted (P = .032) and the postoperative PaO 2/FIO 2 ratio (P = .005). There was a nonsignificant trend toward a relationship with the degree of the pulmonary infiltrate (P = .06).


View this table:
[in this window]
[in a new window]

  		TABLE 4 Multivariate logistic regression analysis for variables associated with a requirement for ILV
 
Outcomes of the patients are shown in Table 5. Not surprisingly, the patients who needed ILV required more prolonged duration of ventilation (P < .001) and had longer stays in the ICU (P = .005). During the first half of the study period (1990-1998), 6 of 11 patients died compared with 2 deaths from 9 patients during the later years. Although not statistically significant (P = .19), this was suggestive of a learning-curve effect. Indeed, of the first 4 patients in whom ILV was attempted, 3 died. The higher mortality at 1 year in the ILV group (P < .001) is accounted for by the early deaths. Among those who died after hospital discharge, the incidence of bronchiolitis obliterans syndrome did not differ between the 2 groups (4/7 vs 39/96, P = .447). The Kaplan–Meier curve for the patients who survived to hospital discharge is shown in Figure 1. There was no significant difference in long-term outcomes of survivors (P = .352).


View this table:
[in this window]
[in a new window]

  		TABLE 5 Outcomes: Comparison of ILV with conventional ventilation group
 

Figure 1
View larger version (7K):
[in this window]
[in a new window]

  		Figure 1. Kaplan–Meier survival curve for hospital survivors after independent lung ventilation and after conventional ventilation. Wilcoxon test for difference between survival curves, P = .352. +, Censored values.

 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusions
 References
 
Our study has shown that increasing hyperinflation (TLC percent predicted) in the recipient and subsequent graft dysfunction (PaO 2/FIO 2 ratio) in the early postoperative period combine and lead to the requirement for ILV.

The reported frequency of use of ILV in SLT series for obstructive airways disease also varies widely, from 0%13-17Go to 43%,18Go with an overall frequency of ILV use of 9%.6,13-21Go This compares with 12% in our study. In part, this variability between series relates to the threshold for using ILV and to the availability and frequency of use of techniques such as extracorporeal membrane oxygenation.

A number of other studies have investigated risk factors for ILV, such as severity of airflow obstruction in the native lung, the size of the transplanted lung, and the side of the transplantation. Severity of airflow obstruction will directly affect the degree of dynamic hyperinflation.22Go Yonan and colleagues6Go found that patients who had native lung hyperinflation had higher pulmonary artery pressures, higher pulmonary artery to wedge pressure gradients, higher residual volumes, and lower FEV1 values than patients who did not have symptomatic postoperative hyperinflation. Pulmonary hypertension and a high transpulmonary gradient were not studied in our patients. Although we found the degree of preoperative airflow limitation (FEV1/forced vital capacity percent predicted) was worse in the ILV group, this was not a significant factor after multivariate adjustment. Because our population size is relatively small, it was unlikely that we would detect many significant factors in multivariate analysis.

The size of the donor lung and its relationship to estimated recipient lung volume has been identified by several authors5,17,21Go as an important factor. We could not demonstrate any such relationship using radiologic, measured, or estimated measures of lung function.

Several reports have suggested a higher incidence of native lung hyperinflation with left SLTs. Weill and associates20Go found radiographic hyperinflation in 37% of left SLTs and 25% of right SLTs, with no difference in the incidence of symptomatic hyperinflation. Angles and colleagues18Go did not report radiographic hyperinflation but found symptomatic hyperinflation in 83% of left SLTs and 50% of right SLTs. In our study there was no significant difference in postoperative native lung hyperinflation (as evidenced by mediastinal shift) between left and right SLTs (1.8 ± 1.4 cm vs 1.5 ± 1.2 cm, respectively; P = .158), but ILV was required more than twice as often with left SLTs. However, we have previously reported23Go higher long-term mortality (primarily because of airway complications) with left lung transplants compared with that seen with right lung transplants.

A reduced PaO 2/FIO 2 ratio (odds ratio, 0.97; 95% confidence interval, 0.95-0.99, P = .005) in the immediate postoperative period was associated with the requirement for ILV. This is not surprising because impaired gas exchange is likely to have been an important factor in determining the intensivist’s decision to initiate ILV. A reduced PaO 2/FIO 2 ratio is the basis of the definition for primary graft dysfunction24Go and is associated with worse early outcomes after lung transplantation.25,26Go It is possible that attempts to improve graft function by providing greater minute ventilation, PEEP, or a longer inspiratory time might worsen dynamic hyperinflation in the native lung, resulting in hemodynamic deterioration. Fluid administration as a treatment for hypotension and low cardiac output might further jeopardize graft function by increasing edema in the transplanted lung.

Other reported treatment options for severe dynamic hyperinflation in association with early graft failure include the use of a bronchial blocker,21Go contralateral lobectomy or pneumonectomy,27,28Go lung volume reduction surgery of the native lung,29Go retransplantation,21Go and extracorporeal membrane oxygenation30Go (as was required by one of our patients). It is noteworthy that the reported cases of lung volume reduction surgery and contralateral lobectomy or pneumonectomy have not been performed in the setting of early graft injury as an immediate postoperative complication.

The patients who required ILV had an initial hospital mortality of 40%, although it is likely that the mortality within this group would have been much higher without this intervention. Two case series in which data on all patients undergoing SLT and ILV survival were recorded6,19Go have reported mortality rates of 25% and 46%, respectively, which is significantly worse than for patients with SLT who required only conventional ventilation. However, the study by Weill and associates,20Go which described a mortality of 0%, had only 2 patients who required ILV. However, it is important to note that among those who survive to leave the hospital, satisfactory long-term outcomes can be achieved, as shown in Figure 1. We know of no other reports on the long-term survival of patients who have required ILV.

Potential limitations of our study are that it is a single-center, retrospective, nonrandomized analysis of relatively small numbers of patients. Generalizing our findings to other centers should be done with caution. However, this is the largest case series of which we are aware. It is possible that patient selection for ILV could have been biased by a desire to optimize results. At our center, there has been a trend away from SLT for COPD in recent years (15 SLTs between 2003 and 2005 compared with 45 in the preceding 3 years). This has been driven by a perceived late survival advantage,3Go with bilateral transplantation rather than conscious selection of patients at risk of needing ILV because of significant preoperative hyperinflation. We could not include cardiovascular parameters in our study, mainly because there were insufficient data for most patients. The presence of hypotension caused by native lung hyperinflation (with or without a low PaO 2/FIO 2 ratio) has been considered an absolute indication for initiating ILV at our hospital. Our aim was to investigate other parameters that the clinician might use to assess the risk of requiring ILV. The presence of preoperative hyperinflation with TLC percent predicted of greater than 150% should alert those selecting patients for SLT of a significant risk of requiring ILV in the postoperative period. The additional finding of a reduced PaO 2/FIO 2 ratio (<100) in the immediate postoperative period should prompt early consideration of ILV.


   Conclusions
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
References
 
ILV after SLT is associated with increased duration of ventilation, increased duration of stay in the ICU, and increased mortality. The need for ILV in these patients is predicted by the combination of increased hyperinflation (increased TLC percent predicted) measured on recipients’ preoperative lung function tests and a low PaO 2/FIO 2 ratio, indicating graft dysfunction in the immediate postoperative period. Long-term outcomes among recipients who require ILV and survive to leave the hospital are comparable with those of the group as a whole.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 

  1. Mal H, Andreassian B, Pamela F, Duchatelle JP, Rondeau E, Dubois F, et al. Unilateral lung transplantation in end-stage pulmonary emphysema. Am Rev Respir Dis 1989;140:797-802.[Medline]
  2. Veith FJ, Koerner SK, Siegelman SS, Torres M, Bardfeld PA, Attai LA, et al. Single lung transplantation in experimental and human emphysema. Ann Surg 1973;178:463-476.[Medline]
  3. Meyer DM, Bennett LE, Novick RJ, Hosenpud JD. Single vs bilateral, sequential lung transplantation for end-stage emphysema: influence of recipient age on survival and secondary end-points. J Heart Lung Transplant 2001;20:935-941.[Medline]
  4. Snell G, Klepetko W. Peri-operative lung transplant management. Eur Respir Mon 2003;26:130-142.
  5. Gavazzeni V, Iapichino G, Mascheroni D, Langer M, Bordone G, Zannini P, et al. Prolonged independent lung respiratory treatment after single lung transplantation in pulmonary emphysema. Chest 1993;103:96-100.[Medline]
  6. Yonan NA, el-Gamel A, Egan J, Kakadellis J, Rahman A, Deiraniya AK. Single lung transplantation for emphysema: predictors for native lung hyperinflation. J Heart Lung Transplant 1998;17:192-201.[Medline]
  7. Quanjer PH, Tammeling GJ, Cotes JE, Pedersen OF, Peslin R, Yernault JC. Lung volumes and forced ventilatory flows. Report of the Working Party on Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J Suppl 1993;16:5-40.[Medline]
  8. Halperin BD, Feeley TW, Mihm FG, Chiles C, Guthaner DF, Blank NE. Evaluation of the portable chest roentgenogram for quantitating extravascular lung water in critically ill adults. Chest 1985;88:649-652.[Medline]
  9. Esmore DS, Brown R, Buckland M, Briganti EM, Fetherston GJ, Rabinov M, et al. Techniques and results in bilateral sequential single lung transplantation. The National Heart & Lung Replacement Service. J Card Surg 1994;9:1-14.[Medline]
  10. Cooper JD, Pearson FG, Patterson GA, Todd TR, Ginsberg RJ, Goldberg M, et al. Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 1987;93:173-181.[Abstract]
  11. Snell GI, Rabinov M, Griffiths A, Williams T, Ugoni A, Salamonsson R, et al. Pulmonary allograft ischemic time: an important predictor of survival after lung transplantation. J Heart Lung Transplant 1996;15:160-168.[Medline]
  12. Gabbay E, Williams TJ, Griffiths AP, Macfarlane LM, Kotsimbos TC, Esmore DS, et al. Maximizing the utilization of donor organs offered for lung transplantation. Am J Respir Crit Care Med 1999;160:265-271.[Abstract/Free Full Text]
  13. Hansen LN, Ravn JB, Yndgaard S. Early extubation after single-lung transplantation: analysis of the first 106 cases. J Cardiothorac Vasc Anesth 2003;17:36-39.[Medline]
  14. Montoya A, Mawulawde K, Houck J, Sullivan H, Lonchyna V, Blakeman B, et al. Loyola Lung Transplant Team Survival and functional outcome after single and bilateral lung transplantation. Surgery 1994;116:712-718.[Medline]
  15. Marinelli WA, Hertz MI, Shumway SJ, Fox JM, Henke CA, Harmon KR, et al. Single lung transplantation for severe emphysema. J Heart Lung Transplant 1992;11:577-583.[Medline]
  16. Low DE, Trulock EP, Kaiser LR, Pasque MK, Dresler C, Ettinger N, et al. Morbidity, mortality, and early results of single versus bilateral lung transplantation for emphysema. J Thorac Cardiovasc Surg 1992;103:1119-1126.[Abstract]
  17. Patterson GA, Maurer JR, Williams TJ, Cardoso PG, Scavuzzo M, Todd TR, The Toronto Lung Transplant Group Comparison of outcomes of double and single lung transplantation for obstructive lung disease. J Thorac Cardiovasc Surg 1991;101:623-632.[Abstract]
  18. Angles R, Tenorio L, Roman A, Soler J, Rochera M, de Latorre FJ. Lung transplantation for emphysema. Lung hyperinflation: incidence and outcome. Transpl Int 2005;17:810-814.[Medline]
  19. Mitchell JB, Shaw AD, Donald S, Farrimond JG. Differential lung ventilation after single-lung transplantation for emphysema. J Cardiothorac Vasc Anesth 2002;16:459-462.[Medline]
  20. Weill D, Torres F, Hodges TN, Olmos JJ, Zamora MR. Acute native lung hyperinflation is not associated with poor outcomes after single lung transplant for emphysema. J Heart Lung Transplant 1999;18:1080-1087.[Medline]
  21. Kaiser LR, Cooper JD, Trulock EP, Pasque MK, Triantafillou A, Haydock D, The Washington University Lung Transplant Group The evolution of single lung transplantation for emphysema. J Thorac Cardiovasc Surg 1991;102:333-341.[Abstract]
  22. Tuxen DV, Lane S. The effects of ventilatory pattern on hyperinflation, airway pressures, and circulation in mechanical ventilation of patients with severe air-flow obstruction. Am Rev Respir Dis 1987;136:872-879.[Medline]
  23. Snell GI, Shiraishi T, Griffiths A, Levvey B, Kotsimbos T, Esmore DS, et al. Outcomes from paired single-lung transplants from the same donor. J Heart Lung Transplant 2000;19:1056-1062.[Medline]
  24. Christie JD, Carby M, Bag R, Corris P, Hertz M, Weill D. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part II: definition. A consensus statement of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2005;24:1454-1459.[Medline]
  25. Pilcher DV, Snell GI, Scheinkestel CD, Bailey MJ, Williams TJ. High donor age, low donor oxygenation, and high recipient inotrope requirements predict early graft dysfunction in lung transplant recipients. J Heart Lung Transplant 2005;24:1814-1820.[Medline]
  26. Oto T, Levvey BJ, Pilcher DV, Bailey MJ, Snell GI. Evaluation of the oxygenation ratio in the definition of early graft dysfunction after lung transplantation. J Thorac Cardiovasc Surg 2005;130:180-186.[Abstract/Free Full Text]
  27. Novick RJ, Menkis AH, Sandler D, Garg A, Ahmad D, Williams S, et al. Contralateral pneumonectomy after single-lung transplantation for emphysema. Ann Thorac Surg 1991;52:1317-1319.[Abstract/Free Full Text]
  28. Le Pimpec-Barthes F, Debrosse D, Cuenod CA, Gandjbakhch I, Riquet M. Late contralateral lobectomy after single-lung transplantation for emphysema. Ann Thorac Surg 1996;61:231-234.[Abstract/Free Full Text]
  29. Kapelanski DP, Anderson MB, Kriett JM, Colt HG, Smith CM, Mateos M, et al. Volume reduction of the native lung after single-lung transplantation for emphysema. J Thorac Cardiovasc Surg 1996;111:898-899.[Free Full Text]
  30. de Hoyos AL, Patterson GA, Maurer JR, Ramirez JC, Miller JD, Winton TL, The Toronto Lung Transplant Group Pulmonary transplantation. Early and late results. J Thorac Cardiovasc Surg 1992;103:295-306.[Abstract]



This article has been cited by other articles:


Home page
 Lung TransplantationHome page
G. Massard, N. Santelmo, P.-E. Falcoz, and R. Kessler
Noninfectious complications
Lung Transplantation, June 7, 2010; 177 - 193.
[Abstract] [Fulltext] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J. G.T. Augoustides
Independent lung ventilation in adult single-lung transplantation: Is it time for fast-track anesthesia and early tracheal extubation?
J. Thorac. Cardiovasc. Surg., September 1, 2007; 134(3): 825 - 825.
[Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
D. V. Pilcher, G. M. Auzinger, B. Mitra, D. V. Tuxen, R. F. Salamonsen, A. R. Davies, T. J. Williams, and G. I. Snell
Reply to the Editor
J. Thorac. Cardiovasc. Surg., September 1, 2007; 134(3): 825 - 826.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Pilcher, D. V.
Right arrow Articles by Snell, G. I.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Pilcher, D. V.
Right arrow Articles by Snell, G. I.
Related Collections
Right arrow Lung - transplantation

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS