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Heart-lung transplantation is indicated for patients with end-stage heart disease and lung disease. Given the complexity involved in the surgery and the post operative challenges, appropriate patient selection is key. Our study describes characteristics and short term outcomes in patients undergoing combined heart and double lung transplant (CHLTx) at our center. This is a retrospective study of patients who underwent CHLTx at our center in South India, from June 2021 to June 2022. CHLTx was performed on 14 patients during the study period. The majority of the patients were male (57%) with a mean age of 37.8 years (range 16-71 years). The most common indication for CHLTx was congenital heart disease (35.7%), followed by idiopathic pulmonary arterial hypertension (28.6%), Group 3 pulmonary hypertension due to interstitial lung disease (ILD, 21.4%) and ILD with ischemic heart disease in 14.2% patients. The mean 6MWT distance was 208 metres. Two patients were on pre-operative ECMO support but none required it post-operatively. No mortality was reported at 6-months. Post-operative sepsis was reported in 35.7% patients. Post-operative anastomotic complications developed in 14.2% patients, and both patients were managed with airway stenting (narrowing and dehiscence respectively). Overall, rejection was detected in 30.9% of 42 surveillance biopsies (at 1,3 and 6 months). Of these, 84.6% (n=11) were for grade 1 antibody-mediated rejection (AMR) and 2 biopsies showed acute cellular rejection (ACR). One patient was noted to have both AMR and ACR. The episodes of rejection correlated with high dd-cfDNA and dd-cfRNA levels along with high donor-specific antibodies. Combined HLTx is a viable option in patients with end stage heart and lung failure with acceptable outcomes, despite the challenges of a low-middle income country. [ABSTRACT FROM AUTHOR]

Tracheal dehiscence remains one of the feared complications after a heart-lung transplant because of its high mortality and morbidity despite surgical repair. Although it is very rare, treatment options are mainly focused on surgical re-exploration and patch repair. We present a case of partial anastomotic dehiscence 1 month after a combined heart-lung transplant. A 24-year-old gentleman, with a negative cross-match for donor-specific antibodies, underwent a combined heart-lung transplant for idiopathic pulmonary arterial hypertension and severe right ventricular dysfunction. His postoperative course was uncomplicated with no primary graft dysfunction, infection or airway complication. He was discharged on postoperative day 19. A routine CT chest before the 1st-month surveillance biopsy post-transplant showed a rent at the anterior tracheal anastomotic site (Figure 1A) with minimal bilateral pneumothoraces. Bronchoscopy showed partial dehiscence from 11 o clock to 2 o clock (25%-50% of circumference) in the cartilaginous part of the tracheal anastomotic site (Figure 1B). A covered metallic tracheobronchial Y stent measuring 18mm x 60 mm was inserted via a flexible bronchoscope under fluoroscopic guidance to stimulate neo-epithelization (Figure 1C). Bronchial washings for cultures were negative. Transbronchial lung biopsy was negative for acute cellular and antibody-mediated rejection. He was initiated on antibiotic and mucolytic therapy along with serial clean-up bronchoscopies and steroid reduction. Follow-up CT scan showed healed dehiscence and resolution of pneumothoraces. The Y stent was removed after 8 weeks of placement with the healed anastomotic area (Figure 1D). Twice monthly follow-up bronchoscopies for 3 months did not show any recurrence. Bronchoscopic metallic stent placement is a viable option for small tracheal dehiscence post-combined heart-lung transplant without the high risk of postoperative morbidity and mortality. [ABSTRACT FROM AUTHOR]

With the increasing prevalence of heart failure and end-stage lung disease, there is a sustained interest in expanding the donor pool to alleviate the thoracic organ shortage crisis. Efforts to extend the standard donor criteria and to include donation after circulatory death have been made to increase the availability of suitable organs. Studies have demonstrated that outcomes with extended-criteria donors are comparable to those with standard-criteria donors. Another promising approach to augment the donor pool is the improvement of organ preservation techniques. Both ex vivo lung perfusion (EVLP) for the lungs and the Organ Care System (OCS, TransMedics) for the heart have shown encouraging results in preserving organs and extending ischemia time through the application of normothermic regional perfusion. EVLP has been effective in improving marginal or borderline lungs by preserving and reconditioning them. The use of OCS is associated with excellent short-term outcomes for cardiac allografts and has improved utilization rates of hearts from extended-criteria donors. While both EVLP and OCS have successfully transitioned from research to clinical practice, the costs associated with commercially available systems and consumables must be considered. The ex vivo perfusion platform, which includes both EVLP and OCS, holds the potential for diverse and innovative therapies, thereby transforming the landscape of thoracic organ transplantation.

Lung transplantation is gaining widespread acceptance as the preferred therapeutic option for selected cases of end-stage lung disease in India. The indications of lung transplantation are increasing, with better post-operative survival, including the COVID affected lung, if we choose our patients well. The national acceptance of expanded criteria in lung donation, streamlining of the process of lung transplantation by governmental, and non-governmental organizations and significant increase in the number of organ donations in India have strengthened the lung transplantation program within the country. Through this article, we describe a brief history, the process, and our experience of lung transplantation since we started our program in 2017 until date., Competing Interests: Conflict of interestThe authors declare no competing interests., (© Association of Surgeons of India 2023, Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.)

Background: Lung transplantation (LTx) has come as hope for select patients with post-COVID acute respiratory distress syndrome (ARDS). It has a different phenotype with unique challenges. We aimed to bring out our experience with and outcomes of LTx for post-COVID ARDS., Methods: This study is retrospective case series from a single center in India. All the patients with post-COVID end stage lung disease (ESLD) who underwent bilateral LTx between 1st May 2020 and 30th August 2021 were included. LTx was performed following no improvement with optimal medical management with adequate time provided for recovery. Information relating to demographics, comorbidities, pretransplant status, perioperative parameters, gross and histopathological findings of explanted lungs, posttransplant morbidity, and mortality were analyzed., Results: This study included 23 patients. The median age of the patients in this study was 42 years and 20 participants were men (87%). The mean duration of intensive care unit stay was 15.83 ± 6.61 days. Mortality was observed among 8 participants (34.78%). Mean survival time was 34.54 weeks. Among the 8 patients who expired, the cause of death was sepsis for 6 patients (75.0%), neurologic cerebrovascular accident for 1 patient (12.5%), and cytomegalovirus for 1 patient (12.5%). All the deaths were reported in primary graft dysfunction grade 2 & 3 category. No rejections were observed on first and third month surveillance biopsies., Conclusions: LTx is the definitive option for survival in select patients with severe post-COVID-19-associated ESLD. This study brings out various challenges involved in such phenotypes and also observations in postoperative recovery., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Lung transplantation (LTx) is the definitive treatment for select progressive end-stage lung disease patients despite being on optimum medical therapy. Asian countries like China, Japan and India have started LTx programmes despite various odds and challenges. Some of these challenges seem to be unique to developing countries. We have elaborated the challenges of LTx in India and their proposed solutions and shared our experience in setting up a successful LTx programme., Competing Interests: Conflict of interestThe authors declare no competing interests., (© Indian Association of Cardiovascular-Thoracic Surgeons 2021.)

Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Worldwide, lung transplantation has been a therapeutic option for select end-stage lung disease patients who are on optimized medical regimens, but the underlying clinical condition continues to progress. For any successful lung transplantation program, it is important to have a robust donor lung management program. Lungs are commonly affected by the various factors related to trauma or neurogenic in brain stem death donors. This article would focus on the basic protocols to optimize donor lungs which would help in increasing donor pool. It would also elaborate COVID-specific points for donor lung evaluation. This article would also describe the criteria for ideal as well as marginal donor lungs. A comprehensive literature search was performed using PubMed to review various articles related to donor lung management., Competing Interests: None

Background: Lung transplantation (LT) has emerged as a definitive cure for a plethora of end-stage lung diseases (ESLDs). With improvements in immune-suppression protocols, the posttransplantation survival rates have gone up., Aim: The study reported the initial experience of the India's single largest lung transplant program on clinicopathological profile, procedures, challenges encountered, and outcomes., Settings and Design: A retrospective analysis was done from data available at three centers of Institute of Heart and Lung Transplant, Gleneagles Global Hospitals across Chennai, Bengaluru, and Mumbai., Materials and Methods: A total of 132 patients underwent lung (single or bilateral) or combined heart and lung transplant between April 2017 and March 2020. All the participants had 30 days' follow-up. Postoperative complications, graft rejection, and 30-day mortality were reported. Kaplan-Meier survival analysis and logistic regression analysis were performed., Statistical Analysis Used: Kaplan-Meier survival and binary logistic regression was performed., Results: Interstitial lung diseases, 65.91%, were the most common diagnosis. Bilateral LT (81.3%) was the most common type of LT performed. Grade III primary graft dysfunction was observed in 16 (12.1%). Distal airway stenosis (21.97%) was the most common complication followed by anastomotic stenosis (14.30%). Gram-negative bacterial sepsis (52%) was the leading cause of death. Cumulative probability of survival at 1 month was 0.85 (95% confidence interval [CI] 0.80-0.92), and at 1 year, it was 0.78 (95% CI, 0.72-0.86)., Conclusion: This study establishes the fact that despite multiple challenges, LT is a viable option for selected patients with ESLDs in India and should encourage early referrals to a transplant center., Competing Interests: None

Left ventricular assist devices (LVAD) have gained widespread use as an effective clinical therapy for patients with heart failure (INTERMACS 1-5) and are the standard of care for bridging patients to cardiac transplantation. Pre-implantation transesophageal echocardiography (TEE) allows interrogation of all cardiac structures and identifies potential problems such as intracardiac shunts, thrombi, aortic insufficiency, and right ventricular dysfunction that need palliation. Post-implantation exam helps in weaning from cardiopulmonary bypass (CPB) and successful LVAD initiation. ICU monitoring with TEE guides optimal intervention and should be considered in selected patients. TEE will continue to remain vital to successful outcomes in LVAD patients.

The Avalon elite bicaval dual-lumen cannula for single site VenoVenous Extracorporeal Membrane Oxygenation (VV ECMO) offers several advantages. Correct placement of the Avalon cannula is safe using image guidance and needs either fluoroscopy or Transesophageal echocardiography (TEE). We assessed our institutional ECMO performance, cannulation related complications, instances of cannula malposition among patients cannulated using the two imaging modalities. We reviewed all patients who had Avalon cannula placement for VV ECMO at our institute. Ten patients were included in the study. Patients were cannulated using either fluoroscopy (Group A, n = 5) or TEE (Group B, n = 5). Data included patient demographics, diagnosis, evidence of cannula malposition, ECMO performance, cannulation related complications. The primary outcomes ease of cannulation; cannula malposition and the need for repositioning were compared between the two groups. Visualisation of guidewire, Avalon cannula and the average number of attempts to cannulate were similar (P > 0.05) between the two groups. Four patients cannulated using fluoroscopy had low flows whereas none of the patients cannulated using TEE had flow problems which was statistically significant (P = 0.024). Four cannulas (80%) placed under fluoroscopy required repositioning whereas one cannula (20%) placed under TEE needed repositioning. This difference was not statistically significant though (P = 0.099). TEE is the ideal imaging modality to guide Avalon elite cannula placement for VV ECMO.