Seminars in thoracic and cardiovascular surgery
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As a result of advances in surgical techniques, immunosuppressive therapy, and postoperative management, lung transplantation has become an established therapeutic option for individuals with a variety of end-stage lung diseases. The current 1-year actuarial survival rate following lung transplantation is approximately 75%. However, the processes of acute and chronic lung allograft rejection have limited the long-term success of lung transplantation. ⋯ Indeed, graft rejection, infection, and malignancy are the three principal causes of mortality for the lung transplant recipient. One should also keep in mind that graft loss in a lung transplant recipient is usually a fatal event, since there is no practical means of long-term mechanical support, and since the prospects of re-transplantation are low, given the shortage of acceptable donor grafts. This chapter reviews the current state of immunosuppressive therapy for lung transplantation, and suggests alternative paradigms for the management of future lung transplant recipients.
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Semin. Thorac. Cardiovasc. Surg. · Jan 2004
ReviewDonor management and selection for heart transplantation.
The success of cardiac transplantation has led to its widespread application for all etiologies of end-stage heart disease. As a result, this has resulted in a severe shortage of available donor organs. ⋯ This has translated into harvesting of older donor hearts, from more unstable donors as well as from more distant locations. Of utmost importance is that when the decision is made to proceed with cardiac transplantation, the risk/benefit ratio associated with cardiac transplantation in that particular patient must be weighed against the mortality and morbidity risk while remaining on the heart transplant waiting list.
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Better understanding of the mechanisms of ischemia-reperfusion injury, improvement in the technique of lung preservation, and the recent introduction of a new preservation solution specifically developed for the lungs have helped to reduce the incidence of primary graft dysfunction after lung transplantation. Currently, the limitation in extending the ischemic time is more often related to the increasing use of non-ideal lung donors rather than to poor lung preservation. In this review, we have focused our attention on the experimental and clinical work performed to optimize the methods of lung preservation from the time of retrieval to the period of reperfusion after graft implantation.
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As the complexity of congenital heart care increases, and expectations for improved outcomes grow, the limitations of current medical information management systems are exposed. Despite advances in information management technology, achieving a state of information resonance within a congenital heart team, where comprehensive patient data and real time program performance can be intuitively accessed on demand, remains an elusive goal. ⋯ We designed and implemented an Internet based information management system to collect, store and exchange comprehensive patient information, and measure clinical performance in real time. Use of this system has been associated with improved clinical outcomes for a congenital heart team.
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The widespread application of lung transplantation is limited by the shortage of suitable donor organs resulting in longer waiting times for listed patients with a substantial risk of dying before transplantation. To overcome this critical organ shortage, some transplant programs have now begun to explore the use of lungs from circulation-arrested donors, so called non-heart-beating donors (NHBDs). ⋯ Techniques for NHBD lung preservation and pretransplant functional assessment are reviewed. Ethical issues involved in transplanting lungs from asystolic donors are discussed.