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We report the case of an 18-year-old patient with a giant pulmonary artery aneurysm and primary pulmonary hypertension who was successfully treated with bilateral lung transplantation and complete reconstruction of the pulmonary artery.

Objective: Pulmonary transplant recipients are at high risk from various conditions requiring surgical intervention. As little is known about their exact incidence and course, we examined such procedures in detail., Methods and Patients: We have retrospectively analyzed major nonpulmonary surgical procedures performed in 124 consecutive patients who received an isolated lung transplant at the University of Vienna between 1989 and December 1995. Twenty-two patients underwent a total of 28 major interventions (22/124 = 17.7%), resulting in an incidence of one procedure every 5.8 patient years of follow-up. The mean interval between transplantation and intervention was 17.9 months (range 3 days to 62 months) with six interventions being carried out during the first month after transplantation. Fourteen emergency operations were performed, the remaining 14 procedures were carried out electively. Overall, 15 abdominal procedures, four thoracic, four orthopedic, two gynecological, one neurosurgical, one urological and one plastic surgery were performed., Results: There was no intraoperative death. Perioperatively, five surgery related deaths were observed (5/28, related mortality 17.9%) with multiple organ failure as the cause of death in all cases. All of these deaths followed emergency operations (5/14 = 35.7%) and all were observed in patients with septic abdominal complications. In contrast, even very extensive procedures were performed electively without related mortality (0/14, P = 0.02). During the first month after transplantation, major surgery was associated with a 50% (3/6) mortality, for late interventions mortality was 9.1% (2/22; P = 0.047)., Conclusions: Pulmonary transplant recipients showed a high incidence of conditions requiring surgical intervention. As expected, septic complications, especially during the immediate post transplant period, carried a very poor prognosis. However, it was reassuring to observe that even extensive surgical procedures could be performed safely without associated mortality in the elective setting.

Background and Methods: The importance of human leukocyte antigen matching for long-term outcome after lung transplantation is uncertain. We therefore analyzed retrospectively 78 consecutive primary, isolated lung transplantations (37 female, 41 male; 40 single, 38 bilateral) performed between October 1989 and October 1995 for which human leukocyte antigen typing of both donor and recipient was available. The follow-up ranged from 1 day to 60.3 months. Graft failure, defined as retransplantation or patient death, served as end point., Results: Graft survival was significantly better with one mismatch at the B locus than with two mismatches (p = 0.046): 67% versus 51% and 61% versus 25% graft survival at 12 and 36 months, respectively. For the B and DR loci combined, a marked matching effect was also observed (p = 0.21 for zero to two mismatches versus three to four mismatches: 81% versus 62% and 51% versus 29% graft survival at 12 and 36 months, respectively. The sum of mismatches at the A, B, C, and DR loci combined showed a similar effect (p = 0.17 for zero to four mismatches versus five to eight mismatches: 83% versus 62% and 58% versus 29% graft survival at 12 and 36 months, respectively. Although no clear effect could be shown for the isolated DR locus, the outcome for the three patients with zero mismatches was notably good: one patient is alive at 27 months, two died 37 and 48 months after transplantation. The number of acute rejection episodes showed a clear but insignificant correlation to the number of mismatches. A similar trend was observed for the incidence of bronchiolitis obliterans syndrome., Conclusions: In summary, a strong influence of human leukocyte antigen matching on the long-term outcome after lung transplantation is suggested by our results. A clear trend toward improved graft survival with better human leukocyte antigen matching was observed, with the most significant effect occurring at the B locus.

Background: Between October 1989 and December 1994 in 13 (four single and nine bilateral lung transplantations) of 124 lung transplantations, pulmonary allografts were considered to be too large to fit into the recipient thoracic cavity., Methods: In all these patients (emphysema n = 6, fibrosis n = 4, pulmonary hypertension n = 3), the transplanted lungs were trimmed by extra anatomic wedge resections with the use of mechanical stapling devices to reach an acceptable size., Results: No postoperative complication attributable to the tailoring procedure was observed., Conclusions: Tailoring of the lung is a safe and efficient method to overcome moderate size disparities between donor and recipient lungs.

Background and Methods: Between 1986 and 1995, 124 isolated lung and 29 combined heart-lung transplantations were performed at our institution. Twenty of these procedures were retransplantations. Four different types of reoperations were performed: ipsilateral single lung retransplantation (n = 3), single lung retransplantation after bilateral or heart-lung transplantation (n = 7), bilateral retransplantation after bilateral lung transplantation (n = 5), and bilateral retransplantation after single lung transplantation (n = 5). Nine patients underwent retransplantation while still in the intensive care unit after the primary transplantation. Indications for retransplantation in these patients were primary graft failure in seven and bronchial complications in two patients. In 11 patients a late retransplantation (3 to 30 months after the first transplantation) was performed. The indication was obliterative bronchiolitis in nine and late bronchial complications in two patients. Overall, 13 patients were ventilator-dependent before retransplantations., Results: Overall survival was 52.8% and 36.2% at 1 and 12 months, respectively. For early retransplantation the survival rate at 1 month was only 22.2% with 2 patients alive 5 and 22 months after the retransplantation. For late retransplantation survival at 1 and 12 months was 70.7% and 50.5%, respectively (p = 0.07), and the longest surviving patient was at 47 months after retransplantation at the time this article was written. Patients who were ventilator-dependent before retransplantation had a significantly worse outcome (survival at 1 and 12 months: 33.8% and 25.4% versus 85.7% and 57.1% for all others, p = 0.055). Of those surviving to date, all were in New York Heart Association class I or II., Conclusions: We conclude that late and elective lung retransplantation achieves acceptable results when offered to patients with chronic pulmonary dysfunction but with otherwise stable conditions. In view of the poor results, early acute retransplantation should be performed much more restrictively.

The short-chain fatty acid n-butyrate has recently been shown in vitro to specifically downregulate T cell reactivity to nominal antigen or to alloantigen, which possibly results from inhibition of cell cycle progression in early G1 phase during antigen contact. In the present study, we investigated the effect of cyclosporin A (CyA) on the modulation of alloreactivity in human mixed lymphocyte culture (MLC) by n-butyrate. Whereas in primary culture, CyA additively enhanced inhibition of DNA synthesis by n-butyrate, the effect of this agent on secondary T cell reactivity was clearly antagonized by CyA. Thus, specific downregulation of proliferative responsiveness to restimulation with antigen from the original donor, observed in cultures pretreated with n-butyrate alone, was at least partially prevented by the addition of CyA to the primary culture. Our in vitro finding indicates that specific downregulation of T cell alloreactivity by n-butyrate might depend on a calcium-dependent T cell receptor (TCR)-mediated signal sensitive to the immunosuppressive action of CyA.

Background: The aim of this study was to compare the effect of the most frequently used clinical preservation solution (Euro-Collins, group I) with a newly composed low potassium, glucose- and insulin-containing preservation solution (141 mmol/L sodium, 6.4 mmol/L potassium, 119 mmol/L chloride, 5 mmol/L magnesium, 10 gm/L glucose, 10 gm/L dextrane and 20 U/L insulin) (group II) on postischemic lung function., Methods: We studied 12 isolated New Zealand White rabbit lungs in a closed circuit model during the first 4 hours of reperfusion after 24 hours of ischemic hypothermic storage., Results: Oxygenation capacity, defined by the difference between the arterial and venous oxygen tension was significantly higher in group II compared with group I after 10 (58.7 +/- 5.8 versus 34.9 +/- 7.5 mm Hg), 30 (63.5 +/- 7.8 versus 27.3 +/- 10.4 mm Hg) and 180 minutes (77.7 +/- 7.2 versus 8.8 +/- 5.6 mm Hg). Ventilatory pressure was significantly lower in group II after 1 minute (11.3 +/- 1.3 mm Hg versus 13.7 +/- 0.5 mm Hg, p < 0.05), with no significant difference thereafter. No significant difference was found in pulmonary vascular resistance except after 20 minutes (30.8 +/- 1.2 dyns/cm5 [group I] versus 27.1 +/- 1.1 dyns/cm5 [group II], p < 0.05)., Conclusion: These data suggest that this new solution provides superior lung function after 24 hours ischemic time compared with Euro-Collins solution.

Incidence, aetiology, diagnosis and treatment of round lesions in the lungs were analysed in 64 patients after lung transplantation (33 men, 31 women; mean age 45 [21-68] years; postoperative survival > 2 weeks). These lesions were found in 8 patients 1-10 months (median of 5.8 months) after the transplantation, singly in two, multiple in six. In six patients it was an incidental finding, further elucidated by computed tomography or fine-needle biopsy. The aetiology varied from B-cell "lymphoma" (posttransplant lymphoproliferative disorder-PTLD) in three patients, aspergilloma in two, and bacterial abscess in one. Two patients died of septicaemia (Aspergillus; Pseudomonas aeruginosa/Staphylococcus aureus), while four had a full remission. The solitary lesions disappeared without specific treatment in 2-3 weeks. If round lesions are noted after lung transplantation, rapid histological and microbiological diagnosis and aggressive treatment are necessary to combat an otherwise high death-rate. PTLD and infection (bacterial or mycotic) are the most frequent causes.

The comparison of different preservation methods in lung transplantation demands a well standardized and reproducible animal model. The aim of this study was to establish as in vitro model in which the oxygenation capacity of the lung can be investigated over an extended period of time. Heart-lung blocks from 6 New Zealand white rabbits were harvested, the pulmonary artery and the left ventricle cannulated and the lungs perfused with whole rabbit blood by means of a roller pump and ventilated with room air. A dialyser was installed into the closed circuit perfusion for continuous deoxygenation of the oxygen-saturated blood gained from the left ventricle. Throughout the stable perfusion period the average arterial and venous partial oxygen pressure (pO2) levels were 105.8 +/- 15.5 mmHg and 55.2 +/- 6.2, respectively (P < 0.05). The average peak airway pressure steadily increased from 10.7 +/- 1.2 mmHg at the start of reperfusion to 21 +/- 14.4 mmHg after 180 minutes (P = NS). With this experimental setting it is possible to maintain stable conditions (i.e. constant venous and arterial blood gases) for at least 180 minutes. It is therefore feasible to compare the influences of different preservation methods on the quality of lung function.

A case of severe diffuse bronchial ischemia after bilateral sequential lung transplantation is presented. A combination of initial conservative treatment with silicone stenting and late bilateral retransplantation under stable conditions resulted in good clinical outcome. Factors in decision making and technical aspects of the stenting procedure are discussed.