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Radiation therapy and platinum-based chemotherapy are common treatments for lung cancer patients. Several factors are considered for the low overall survival rate of lung cancer, such as the patient’s physical state and the complex heterogeneity of the tumor, which leads to resistance to the treatment. Consequently, precision medicines are needed for the patients to improve their survival and their quality of life. Until now, no patient-derived tumoroid model has been reported to predict the efficiency of radiation therapy in non-small-cell lung cancer. Using our patient-derived tumoroid model, we report that this model could be used to evaluate the efficiency of radiation therapy and cisplatin-based chemotherapy in non-small-cell lung cancer. In addition, these results can be correlated to clinical outcomes of patients, indicating that this patient-derived tumoroid model can predict the response to radiotherapy and chemotherapy in non-small-cell lung cancer.

Controlled organ donation after circulatory determination of death is increasingly being used for the donation of organs also in thoracic transplantation. This document outlines the position of the International Society for Heart and Lung Transplantation on thoracic organ transplantation in circulatory determination of death. The document also includes a position regarding some of the methods applied to ensure the viability of Donation after Circulatory Death organs retrieved after certification of death.

We here describe a prototype of a patient-derived tumoroid that prefigures the precision medicine approach by helping experimental assessment of response to current treatments. The introduction of microvessels to help forming a tumor-connected vasculature, and of peripheral blood immune cells was shown to be essential for the representativeness of the model. The study is based on a cohort of 11 patients at various stages of the disease. Noteworthy, this predictive vascularized, and immunocompetent micromodel can be obtained within 2 weeks, matching the constraints of the patient journey. Histological analyses confirmed that major features of the original tumor were conserved. Transcriptomic analysis confirmed the functionality of the tumoroid. The responses to either anti-angiogenic treatment or platinum-based chemotherapy regimen highlighted the role of immune mechanisms. We also discussed the possibility to apply this original experimental model to the analysis of response to immune checkpoint blockers, or oncolytic vector-based therapies.

International audience; Lung transplantation (LTx) is a steadily expanding field. The considerable developments have been driven over the years by indefatigable work conducted at LTx centers to improve donor and recipient selection, combined with multifaceted efforts to overcome challenges raised by the surgical procedure, perioperative care, and long-term medical complications. One consequence has been a pruning away of contraindications over time, which has, in some ways, complicated the patient selection process. The Francophone Pulmonology Society (Société de Pneumology de Langue Française, SPLF) set up a task force to produce up-to-date working guidelines designed to assist pulmonologists in managing end-stage respiratory insufficiency, determining which patients may be eligible for LTx, and appropriately timing LTx-center referral. The task force examined the most recent literature and evaluated the risk factors that limit patient survival after LTx. Ideally, the objectives of LTx are to prolong life while also improving quality of life. The guidelines developed by the task force apply to a limited resource and are consistent with the ethical principles described below.

OBJECTIVES Since video-assisted thoracic surgery (VATS) was first performed in the early 1990s, there have been many developments, and the conversion rate has decreased over the years. This article highlights the specific outcomes of patients undergoing conversion to thoracotomy despite initially scheduled VATS lung resection. METHODS We retrospectively reviewed 501 patients who underwent thoracoscopic anatomic lung resection (i.e. lobectomy, segmentectomy or bilobectomy) between 1 January 2012 and 1 August 2017 at our institution. We explored the risk factors for surgical conversion and adverse events occurring in patients who underwent conversion to thoracotomy. RESULTS A total of 44/501 patients underwent conversion during the procedure (global rate: 8.8%). The main reasons for conversion were (i) anatomical variation, adhesions or unexpected tumour extension (37%), followed by (ii) vascular causes (30%) and (iii) unexpected lymph node invasion (20%). The least common reason for conversion was technical failure (13%). We could not identify any specific risk factors for conversion. The global complication rate was significantly higher in converted patients (40.9%) than in complete VATS patients (16.8%) (P = 0.001). Postoperative atrial fibrillation was a major complication in converted patients (18.2%) [odds ratio (OR) 5.09, 95% confidence interval (CI) 1.80–13.27; P = 0.001]. Perioperative mortality was higher in the conversion group (6.8%) than in the VATS group (0.2%) (OR 33.3, 95% CI 3.4–328; P = 0.003). CONCLUSIONS Through the years, the global conversion rate has dramatically decreased to

Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis (CF), and restoring metabolic control in these patients may improve their management after lung transplantation. In this multicenter, prospective, phase 1-2 trial, we evaluate the feasibility and metabolic efficacy of combined pancreatic islet-lung transplantation from a single donor in patients with CFRD, terminal respiratory failure, and poorly controlled diabetes. Islets were infused via the portal vein under local anesthesia, 1 week after lung transplantation. At 1 year, the primary outcome was transplant success as evaluated by a composite score including four parameters (weight, fasting glycemia, HbA1c, and insulin requirements). Ten participants (age: 24 years [17-31], diabetes duration: 8 years [4-12]) received a combined islet-lung transplant with 2892 IEQ/kg [2293-6185]. Transplant success was achieved in 7 out of 10 participants at 1-year post transplant. Fasting plasma C-peptide increased from 0.91 μg/L [0.56-1.29] to 1.15 μg/L [0.77-2.2], HbA1c decreased from 7.8% [6.5-8.3] (62 mmol/mol [48-67]) to 6.7% [5.5-8.0] (50 mmol/mol [37-64]), with 38% decrease in daily insulin doses. No complications related to the islet injection procedure were reported. In this pilot study, combined pancreatic islet-lung transplantation restored satisfactory metabolic control and pulmonary function in patients with CF, without increasing the morbidity of lung transplantation.

Summary A best evidence topic was constructed according to a structured protocol. The question addressed was whether size-reduced or lobar lung transplantation (LLTx) offers the same benefit as classic lung transplantation (LTx). Of the 147 papers found using the reported search, 9 were selected to provide the best evidence. Details of the studies regarding authors, date, journal, country of publication, study type, group studied, relevant outcomes and results are given. All studies reported survival rates of LLTx and most compared it with classical LTx. No statistical differences were reported in medium term and long term. Two of the studies reported a higher incidence of postoperative complications, such as the need for cardiopulmonary bypass, reperfusion oedema or primary graft dysfunction, and longer intubation or intensive care unit stay times. Although the largest study showed a significantly worse 1-year survival in LLTx, a sub-analysis considering patients successfully discharged showed similar outcomes at 1, 3 and 5 years when compared with classic LTx patients. We conclude that LLTx is a valid therapeutic option for recipients with significant donor size mismatch, offering similar outcomes as classical LTx in the medium term and long term.

Ex vivo lung perfusion (EVLP) is a valuable method for expanding the lung donor pool. Its indications currently differ across centers. This national retrospective cohort study aimed to describe the profile of donors with lungs transplanted after EVLP and determine the effectiveness of EVLP on lung utilization. We included brain-dead donors with at least one lung offered between 2012 and 2019 in France. Lungs transplanted without or after EVLP were compared with those that were rejected. Donor group phenotypes were determined with multiple correspondence analysis (MCA). The association between donor factors and lung transplantation was assessed with a multivariable multinomial logistic regression. MCA revealed that donors whose lungs were transplanted after EVLP had profiles similar to the donors whose lungs were declined and quite different from those of donors with lungs transplanted without EVLP. Donor predictors of graft nonuse included age ≥50 years, smoking history, PaO

Bronchiolitis obliterans syndrome (BOS) is the main limitation to long-term survival following lung transplantation. Several studies generated promising results regarding the efficacy of extracorporeal photopheresis (ECP) in BOS management. We aimed to compare FEV1 evolution in ECP-treated versus non-ECP treated patients among BOS recipients.Overall, 25 BOS patients were included after receiving optimized treatment. Data were collected retrospectively. Twelve patients with moderate and refractory BOS received ECP treatment.Among non-ECP treated control patients (n = 13), six experienced persistent decline without undergoing ECP for various reasons. ECP stabilized pre-ECP lung function during the subsequent 6 to 24 months (repeated measures one-way Anova, p = 0.002), without any significant impact observed by either FEV1 decline speed prior to ECP or time between BOS diagnosis and ECP onset. ECP-treated patients displayed a similar risk of an additional permanent 20% or higher drop in FEV1 after BOS onset compared to controls, but a lower risk compared to control decliners (p = 0.05). ECP quickly stabilized FEV1 decline in refractory BOS patients compared to non-treated decliners.We confirmed that this therapeutic option against refractory BOS can be managed in a medium-size LTx center, with a satisfactory efficacy and an acceptable tolerance.

Initially described in 1992 (1), thoracoscopic (VATS) lobectomy is unquestionably the greatest upheaval in thoracic surgery community since the introduction of one-lung ventilation by Carlens in 1949 (2).In the last twenty years, after several initial uncertainty about its adoption, VATS lobectomy slowly but constantly propagates worldwide and, nowadays, most international guidelines suggest the adoption of this minimally invasive approach for early-stage lung cancer, over the traditional “open” approaches (3,4). Indeed, several single- and multi-institutional studies, as well as national registry analysis, showed that VATS lobectomy adoption permits a shorter chest tube duration, a shorter length of hospital stay, fewer postoperative complications, and a lower or comparable perioperative mortality vs. classic thoracotomy (5-13). Moreover, the recent results of UK multicentric VIOLET randomized controlled trial corroborated these statements, demonstrating an association between VATS lobectomy and enhanced short-term clinical outcomes when compared with open surgery for non-small cell lung cancer (NSCLC) (14,15).

BACKGROUND Although central airway stenosis (CAS) is a common complication after lung transplantation, its consequences have been poorly evaluated. The objective of our study was to evaluate the impact of CAS on lung function after lung transplantation. MATERIAL AND METHODS All lung transplant recipients from June 2009 to August 2014 in a single center (Strasbourg, France) were retrospectively reviewed. RESULTS A total of 191 lung transplantations were performed: 175 bilateral, 15 single, and 1 heart-lung transplantation. Of the 161 bilateral lung-transplanted patients who survived >3 months, 22 (13.6%) developed CAS requiring endobronchial treatment. All these patients were treated by endoscopic balloon dilatation, and 9 additionally needed endobronchial stents. Respiratory function tests demonstrated persistent obstructive ventilatory pattern despite endoscopic treatment in recipients with CAS compared to those without CAS at 6, 12, and 18 months post-transplant. At 18 months, CAS patients had significantly lower post-transplant FEV1 (1.96±0.60 L versus 2.57±0.76 L, p=0.001) and FEV1/FVC (61±14% versus 81±13%, p

Background Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare but serious dermatologic diseases. They can be associated with systemic manifestations such as bronchiolitis obliterans syndrome (BOS). SJS/TEN-induced BOS is associated with a poor prognosis, and no guidelines exist regarding its management. Several case reports have described the association between SJS/TEN and BOS, with few patients undergoing lung transplantation as a last resort therapy. Unfortunately, in the published reports, none of the transplanted patients were observed for a long period of time after the transplantation; therefore, the long-term mortality as well as the risk of recurrence of BOS could not be inferred from these reports. Case report We present the case of a young patient diagnosed with SJS complicated by BOS and end-stage respiratory failure refractory to corticosteroid therapy. She underwent bilateral lung transplantation with an outstanding outcome at 5-year follow-up. Conclusion SJS/TEN-induced BOS might have a favorable evolution and long-term outcomes following lung transplantation. However, prospective studies are needed to confirm this finding.

International audience; Background. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non -Hodgkin lymphoma in the posttransplant setting. Treatment is based on chemotherapy; surgery is still debated and should be performed in very select cases. Methods. We observed 2 patients out of 300 who underwent lung transplantation in the Nouvel Hopital Civil between 2013 and 2019 with primary hepatic lymphoma. Chemotherapy with a rituximab-cyclophosphamide, hydroxydaunorubicin, vincristine, prednisone protocol was performed in all patients. Mycophenolate mofetil was interrupted before treatment, and everolimus was introduced after chemotherapy by associating tacrolimus withdrawal. Results. One patient showed complete remission; after 7 years, no recurrence has been noticed. The second is still undergoing chemotherapy with no signs of disease progression. Conclusions. DLBCL risk is higher in solid organ transplant recipients than in the general population. Primary hepatic lymphoma diagnosis is often difficult and based on histologic findings after initial clinical and radiological suspicion of primary or secondary liver neoplasia. Diagnosis is challenging because no clinical, radiological, or biological features exist. Biopsy is always indicated for histologic confirmation. Chemotherapy is the mainstay of therapy, but surgery may be indicated in very select patients.

OBJECTIVES Resection of thymic tumours including the removal of both the tumour and the thymus gland (thymothymectomy; TT) is the procedure of choice and is recommended in most relevant articles in the literature. Nevertheless, in recent years, some authors have suggested that resection of the tumour (simple thymomectomy; ST) may suffice from an oncological standpoint in patients with early-stage thymoma who do not have myasthenia gravis (MG) (non-MG). The goal of our study was to compare the short- and long-term outcomes of ST versus TT in non-MG early-stage thymomas using the European Society of Thoracic Surgeons thymic database. METHODS A total of 498 non-MG patients with pathological stage I thymoma were included in the study. TT was performed in 466 (93.6%) of 498 patients who had surgery with curative intent; ST was done in 32 (6.4%). The completeness of resection, the rate of complications, the 30-day mortality, the overall recurrence and the freedom from recurrence were compared. We performed crude and propensity score-adjusted comparisons by surgical approach (ST vs TT). RESULTS TT showed the same rate of postoperative complications, 30-day mortality and postoperative length of stay as ST. The 5-year overall survival rate was 89% in the TT group and 55% in the ST group. The 5-year freedom from recurrence was 96% in the TT group and 79% in the ST group. CONCLUSION Patients with early-stage thymoma without MG who have a TT show significantly better freedom from recurrence than those who have an ST, without an increase in postoperative morbidity rate.

Korrektur zu 10.1093/ejcts/ezab224

Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.

International audience; Long term survival post lung transplantation (LTx) is limited by the occurrence of bronchiolitis obliterans syndrome (BOS). One mechanism involved is the epithelial-mesenchymal transition (EMT). Membrane microparticles (MPs) are known to be involved in some respiratory diseases and in other organs allograft rejection episodes. We hypothesized that leukocyte-derived MPs likely contribute to EMT. To emphasize this physiological concept, our objectives were to: (1) confirm the presence of EMT on explanted lungs from patients who underwent a second LTx for BOS; 2) characterize circulating MPs in transplanted patients, with or without BOS; (3) evaluate in vitro the effect of monocyte-derived MPs in EMT of human bronchial epithelial cells. Our IHC analysis on explanted graft lungs revealed significant pathological signs of EMT with an inhomogeneous destruction of the bronchial epithelium, with decreased expression of the epithelial protein E-cadherin and increased expression of the mesenchymal protein Vimentin. The immunophenotyping of MPs demonstrated that the concentration of MPs carrying E-cadherin was lower in patients affected by BOS (p = .007). In vitro, monocyte-derived MPs produced with LPS were associated with decreased E-cadherin expression (p < .05) along with significant morphological and functional cell modifications. MPs may play a role in EMT onset in bronchial epithelium following LTx.

Cystic fibrosis-related diabetes (CFRD) is a major determinant of morbi-mortality in all stages of the disease, especially following lung transplantation. CF patients with end-stage respiratory failure and severe CFRD may thus benefit from beta-cell replacement. Combined pancreatic islet-lung transplantation bears the advantage of grafting autoregulated islets from the same donor using percutaneous transhepatic puncture. Islet post-lung transplantation proves to be a good therapeutic option for patients unable to undergo simultaneous islet-lung allotransplantation, whilst enabling a sufficient amount of pancreatic islets to be grafted. Current pilot studies involving a small number of CF patients suggest pancreatic islet graft to be feasible, with metabolic and nutritional parameter improvement 1-year post-lung islet transplantation, yet without additional morbidity. Further studies are needed to determine the procedure’s long-term benefits and enable us to select the best candidates for this procedure so as to ensure an optimal outcome.

Lymph node metastasis is an important prognosis factor in non-small cell lung cancer (NSCLC) patients. The aim of this study was to investigate the role of epithelial to mesenchymal transition (EMT) in lymph node progression in the early stages of NSCLC. We studied a retrospective cohort of 160 consecutive surgically treated NSCLC patients with available frozen tumor samples for expression of EMT markers (CDH1, CTNNB1, CDH2, and VIMENTIN), inducers (TGFB1, c-MET, and CAIX), and transcription factors (EMT-TF: SNAI1, SNAI2, ZEB1, TWIST1, and TWIST2). Partial EMT was more frequent in N1-2 (N+) vs N0 patients (P < .01). TGFB1 (P = .02) as well as SNAI2 (P < .01) and TWIST1 (P = .04) were the most differentially expressed genes in N+ tumors. In this group, ZEB1 was correlated with all EMT inducers and other EMT-TFs were overexpressed depending on the inducers. CAIX was an independent prognostic factor for overall survival (IC 95% HR: 1.10-5.14, P = .03). Partial EMT is involved in lymph node progression of NSCLC patients and depends on the TGFβ pathway. EMT-TFs are differentially expressed depending on EMT inducers. CAIX might be a relevant prognostic marker in early stage NSCLC.

A best evidence topic was constructed according to a structured protocol. The question addressed was whether pulmonary grafts from donors deceased from hanging offer the same benefit as grafts from donors deceased from other causes in lung transplantation. Of the 17 papers found, 4 provided the best evidence to answer the question. The authors, date, journal, country of publication, study type, group studied, relevant outcomes and results of these papers are tabulated. One study reported a large cohort of donors and analysed the outcomes by cause of death, reporting no differences in survival. The remaining 3 papers analysed observational studies on the outcomes of lung transplantation using pulmonary grafts from donors deceased from hanging, compared with donors deceased from other causes. No differences in the rates of post-transplantation pulmonary graft dysfunction and long-term overall survival were reported. Although the cohort of donors deceased from hanging is small, we conclude that these donors are an important contribution to the donor pool. Ex vivo lung perfusion may have a role in assessing graft viability in this scenario.

Il trauma toracico rimane la seconda causa di mortalita traumatica dopo il trauma cranico. Tre tipi di meccanismi possono essere descritti per i traumi chiusi del torace: le lesioni da compressione/schiacciamento, le lesioni da decelerazione e le lesioni da scoppio. I fattori di gravita da ricercare sono un’eta superiore ai 65 anni, una patologia cronica polmonare o cardiovascolare, un disturbo della coagulazione congenito o acquisito e un meccanismo a cinetica elevata. Questi fattori aumentano il rischio di decesso legato al trauma di un fattore 2-3. Una volta completato il bilancio lesionale e stabilizzato il paziente, le tecniche di osteosintesi toracica si applicano tanto ai traumi acuti che a quelli antichi (pseudoartrosi). I molteplici scopi dell’osteosintesi toracica comprendono il controllo del dolore, il ripristino dell’espansione toracica e della meccanica respiratoria normale e l’emostasi del sanguinamento dalla frattura.

Resume Introduction En chirurgie thoracique, l’ extracorporeal life support (ECLS) represente un arsenal therapeutique indique en cas de defaillance de l’appareil respiratoire ou comme support mecanique pour un acte therapeutique. Les objectifs de cette revue generale sur l’ECLS en chirurgie thoracique sont de decrire le rationnel des techniques d’ECLS disponibles, de presenter les indications d’ECLS lors de defaillances de l’appareil respiratoire et aussi de demontrer l’interet de l’ECLS pour pratiquer l’ECLS en chirurgie thoracique selon une medecine fondee sur les preuves. Etat des connaissances L’ECLS doit se pratiquer dans des centres experts. Dans le syndrome de defaillance respiratoire aigue severe et refractaire, l’ECLS permet de mettre au repos les poumons en pratiquant une ventilation protectrice. En transplantation pulmonaire, l’ECLS peut etre pratiquee avec de bons resultats en pont a la transplantation pulmonaire, en temps que support cardiorespiratoire peroperatoire et en pont a la recuperation en cas de dysfonction primaire du greffon pulmonaire. L’ECLS en tant que support a un acte therapeutique tracheobronchique et/ou chez un insuffisant respiratoire severe est faisable sans majorer significativement le risque perioperatoire. Perspectives Les indications d’ECLS vont accroitre dans le temps sous l’impulsion des centres experts. Dans les annees a venir, les progres des techniques et de l’ingenierie ainsi que des connaissances approfondies permettront l’amelioration du pronostic des patients atteints de defaillance respiratoire sous assistance mecanique. Des etudes prospectives multicentriques et randomisees affineront les indications et les strategies de prise en charge globale de ces patients. Conclusion L’ECLS est un moyen therapeutique ameliorant le pronostic de patients atteints ou soumis aux risques de defaillance respiratoire.

Background Postpneumonectomy acute respiratory distress syndrome (ppARDS) is a life-threatening condition with a disastrous prognosis. This study assessed the efficacy of venovenous extracorporeal membrane oxygenation (VV-ECMO) in adult patients with unresponsive severe ppARDS. Methods We retrospectively reviewed data of all patients treated with VV-ECMO for ppARDS from January 2009 to December 2015. We calculated the Sequential Organ Failure Assessment score before ECMO insertion and monitored the subsequent mechanical ventilation settings. The primary end point was hospital survival. The secondary end point was the ability to achieve a protective ventilatory strategy allowing lung recovery on ECMO. Results VV-ECMO was indicated in 8 ppARDS patients for refractory hypoxemia (median partial pressure of arterial oxygen/fraction of inspired oxygen: 68 [range, 60 to 75] mm Hg). Median Sequential Organ Failure Assessment before ECMO was 15 (range, 12 to 17), predicting a mortality rate greater than 80%. Median duration of ECMO was 9.5 (range, 5 to 16) days. Tidal volumes and plateau pressures both decreased on ECMO (pre-ECMO tidal volume: 412 [range, 250 to 450 mL] vs ECMO tidal volume: 277 [range, 105 to 367 mL], p = 0.0156; pre-ECMO plateau pressure: 34 [range, 32 to 40] cm H 2 O vs ECMO plateau pressure: 24.5 [range, 23.3 to 27.3] cm H 2 O, p = 0.0195). ECMO could be weaned in 7 patients (87.5%). Hospital survival was 50%. Conclusions Hospital survival was better than predicted before ECMO insertion. In severe and refractory ppARDS, VV-ECMO allows lung recovery and therefore increased survival.

Resume Introduction Dans certains cas de tumeur primitive intra-abdominale, la chirurgie de cytoreduction suivie d’une chimiotherapie hyperthermique peritoneale permet d’ameliorer la survie des patients se presentant au stade de carcinomatose peritoneale. Nous decrivons un cas de paralysie diaphragmatique consecutive a ce type d’intervention. Observation Dans les suites d’une chirurgie et d’une chimiotherapie hyperthermique pour un pseudomyxome intra-abdominal, une patiente de 60 ans a developpe une insuffisance respiratoire. Les explorations fonctionnelles respiratoires ont montre un syndrome restrictif. Des scanners thoraciques successifs ont mis en evidence un amincissement musculaire des coupoles diaphragmatiques. L’atteinte respiratoire a evolue vers le deces de la patiente. Conclusion Nous concluons a une degenerescence du muscle diaphragmatique liee a la reduction chirurgicale et a l’effet cytotoxique de la chimiotherapie. Devant le caractere unique de ce type de complication, nous n’avons pas evoque cette hypothese suffisamment tot dans l’histoire de notre patiente. Nous pensons que ce cas doit etre connu pour permettre un diagnostic plus precoce de ce type de complications et recommandons la realisation d’une biopsie musculaire pour attester l’atteinte du diaphragme.

Background Atrial arrhythmias (AAs) are frequent after lung transplantation (LT) and late postoperatively. Several predictive factors of early postoperative AAs after LT have been identified but those of late AAs remain unknown. Whether AA after LT affects mortality is still being debated. This study assessed in a large cohort of LT patients the incidence of AAs early and late after surgery, their predictive factors and their effect on mortality.Methods and Results:We studied 271 consecutive LT patients over 9 years. Mean follow-up was 2.9±2.4 years. 33% patients developed postoperative AAs. Age (odds ratio (OR) 2.35; confidence interval (CI) [1.31-4.24]; P=0.004) and chronic obstructive pulmonary disease (OR 2.13; CI [1.12-4.03]; P=0.02) were independent predictive factors of early AAs. Late AAs occurred 2.2±2.7 years after transplant in 8.8% of the patients. Pretransplant systolic pulmonary arterial pressure (PTsPAP) was the only independent predictive factor of late AA (OR 1.028; CI [1.001-1.056]; P=0.04). Double LT was associated with long-term freedom from atrial fibrillation (AF) but not from atrial flutter (AFL). Early and late AAs after surgery had no effect on mortality. Double LT was associated with better survival. Conclusions Early AA following LT is common in contrast with the low occurrence of late, often organized, AA. Early and late AAs do not affect mortality. PTsPAP is an independent predictor of late AA. Double LT protects against late AF but not AFL.

INTRODUCTION Enriching the diet with Omega-3 for several weeks improves myocardial resistance to ischemia-reperfusion (IR) in rats. However, patients with myocardial infarction requiring an emergency reperfusion cannot be pretreated with such a diet. The objective of our study was to describe the effects of an intravenous Omega-3 bolus before reperfusion in a rat model of myocardial IR. METHODS In a rat model of acute myocardial IR, an intravenous Omega-3 bolus (EPA:DHA 6:1), associated or not with iodinated contrast media, was administered after a 30-min ischemia, before reperfusion. Hemodynamic parameters were assessed. Circulating procoagulant microparticles were phenotyped. Vascular and heart inflammation, superoxide anion, and nitric oxide were measured. Ex vivo vascular reactivity was performed with a pharmacological selective inhibitor of inductible nitric oxide synthase. Cardiac troponin I (cTn-I) plasma levels were measured. RESULTS Compared with untreated IR rats, an Omega-3 bolus before reperfusion significantly decreased the IR syndrome, improving mean arterial pressure (114 ± 9 vs. 61 ± 17 mmHg 4 h after reperfusion, P

In origine, l’extracorporeal membrane oxygenation (ECMO) era una tecnica di assistenza respiratoria che utilizzava uno scambiatore gassoso a membrana. Per estensione, l’ECMO è diventata una tecnica respiratoria e cardiopolmonare utilizzata in caso di deficit respiratorio e/o cardiaco nell’attesa della restaurazione della funzione deficitaria o di un eventuale trapianto. Il supporto emodinamico può essere parziale o totale. Gli accessi vascolari possono essere periferici o centrali. Questo tipo di assistenza utilizza il concetto di circolazione extracorporea (CEC) sanguigna che in epoca moderna si è estesa con l’utilizzo di polmoni artificiali a membrana. Il circuito di base è semplice e comprende una pompa, un ossigenatore (che permette al sangue di caricarsi di O2 e di eliminare CO2) e delle vie d’accesso (una di drenaggio e una di reinfusione). La sua attuazione è facile, veloce e può essere avviata al letto del malato. Il miglioramento delle attrezzature, una migliore conoscenza delle tecniche e delle indicazioni, e le politiche di salute pubblica hanno reso popolare questa tecnica. Alcuni centri di chirurgia toracica la utilizzano di routine come assistenza alla realizzazione di un intervento terapeutico (soprattutto trapianto) assieme a team di rianimazione per il trattamento della sindrome da distress respiratorio acuto. Nel quadro della malattia polmonare dell’adulto, l’idea principale è quella di sviluppare il concetto di strategia minimalista con l’uso di una CEC adiuvante parziale – più che sostitutiva totale – che permetterebbe il recupero metabolico ad integrum del paziente. Nei prossimi anni, i progressi della tecnologia e dell’ingegneria così come le conoscenze approfondite permetteranno il miglioramento della prognosi dei pazienti colpiti da deficit respiratorio sotto assistenza meccanica.

Lung transplantation is the only life-saving treatment for end stage respiratory disease. The immediate outcome is still hampered by primary graft dysfunction. The latter is a form of acute lung injury occurring within the 30min following the unclamping of the pulmonary artery that prompts ischemia reperfusion injury. Severe forms may need prolonged mechanical ventilation and extra-corporeal membrane oxygenation. Overall, primary graft dysfunction accounts for at least one third of the deaths during the first post-operative month. Despite increasing experience and knowledge on the underlying cellular events, there is still a lack of an early marker of ischemia reperfusion graft injuries. Microparticles are plasma membrane vesicles that are released from damaged or stressed cells in biological fluids and remodeling tissues, among which the lung parenchyma during acute or chronic injury. We recently evidenced alveolar microparticles as surrogate markers of strong ischemia injury in ex-vivo reperfusion experimental models. We propose herein new insights on how microparticles may be helpful to evaluate the extent of lung ischemia reperfusion injuries and predict the occurrence of primary graft dysfunction.

Objective: Our study aims at assessing the outcomes and survival after completion pneumonectomy (CP) for non-small cell lung cancer (NSCLC). Methods: We restrospectively recorded all CP performed in our centre for NSCLC from January 1st,1999 to December 31st, 2015. Immediate post-operative outcome and overall survival were studied. Results: A total of 48 patients underwent CP. All patients had a previous pulmonary resection for NSCLC except for one with previous benign disease. Most of patients were male (81,3%), and weaned smoker (70.8%). Ten (20,8%) patients received neo-adjuvant chemotherapy. A post-operative complication occurred in 62,5% patients: haemorrhage requiring blood transfusion (33,3%), lung infection (16,7%), recurrent nerve paralysis (10,4%), and atrial fibrillation (8,3%). Only 6,3% of patients required a re-operation for bleeding. None of the patients presented with bronchopleural fistula as a post-operative complication of CP. Inhospital mortality occurred in four (8,3%) patients. Despite the need for CP, 35,4% of patients had a stage I disease, and 43.8% had a stage II disease. Recurrence occurred in 47,9% of patients with a mean disease-free survival of 11 months. Mean overall survival following CP reached 45 months (>3 years). Conclusions: In experienced hands, CP is a safe curative treatment for NSCLC. Despite its complications, the mortality rate was low. A further prolonged overall survival was offered by CP to patients who already had a previous NSCLC treated with surgery.

Background: Surgical repair has demonstrated a beneficial effect on outcome for patients presenting with flail chest or with multiple rib fractures. We hypothesized that benefit on outcome parameters concerns predominantly patients being extubated within 24 hours post-operatively. Methods: We prospectively recorded all patients presenting with chest traumatism eligible for surgical repair with anticipated early extubation according to our institutional consensus (flail chest, major deformity, poor pain control, associated lesions requiring thoracotomy). We compared outcomes of patients extubated within 24 hours post-operatively to those who required prolonged ventilator support. We tested predictive factors for prolonged intubation with univariate and multivariate analysis. Results: From 2010 to 2014, 132 patients required surgical repair. Two thirds were extubated within 24 hours following surgical repair. Pneumonia was the main complication and occurred in 30.3% of all patients. Patients extubated within 24 hours following surgical repair had significantly shorter ICU stay and shorter in-hospital stay (P