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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.

Primary tuberculosis (TB) of tonsil is a rare form of extra-pulmonary tuberculosis. Most tonsillar TB cases present with coexistent pulmonary tuberculosis. It can simulate tonsillar malignancy and poses a diagnostic challenge. Histopathological examination is often needed for confirmation. Herein, we report a case of primary tonsillar tuberculosis in a 55-year-old gentleman mimicking carcinoma of the tonsil., (Copyright © 2019 Tuberculosis Association of India. Published by Elsevier B.V. All rights reserved.)