Thoracic surgery clinics
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Lung transplantation (LTx) is the definitive treatment of patients with end-stage lung disease. Availability of donor lungs remains the primary limitation and leads to substantial wait-list mortality. ⋯ Unique in its physiology, lung viability seems more tolerant to the variable durations of ischemia that occur in DCD donors. Initial experience with DCD LTx is promising and, in combination with ex vivo lung perfusion systems, seems a valuable opportunity to expand the lung donor pool.
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The number of patients listed for lung transplantation exceeds the number of available transplantable organs because of a shortage of organ donors and a low utilization rate of donated lungs. A novel strategy of donor lung management, called ex vivo lung perfusion (EVLP) can keep the organ in a physiologic protective condition, and promises to increase lung utilization by reevaluating, treating, and repairing donor lungs before transplantation. Preclinical studies have shown great potential for EVLP as a platform for the delivery of novel therapies to repair injured organs ex vivo and improve the success of lung transplantation.
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Airway complications after lung transplantation present a formidable challenge to the lung transplant team, ranging from mere unusual images to fatal events. The exact incidence of complications is wide-ranging depending on the type of event, and there is still evolution of a universal characterization of the airway findings. ⋯ Simple observation or simple balloon bronchoplasty is sufficient in many cases, but vigilance following more severe necrosis is required for late development of both anastomotic and nonanastomotic airway strictures. Furthermore, the impact of coexisting infection, rejection, and medical disease associated with high-level immunosuppression further complicates care.
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New oxygenator technologies widened the application of extracorporeal life support significantly in the last decade. Currently the use is still limited within intensive care units. Compared to ventricular assist devices for heart failure, lung replacement technology is lagging behind, not allowing discharge on device. Challenges to achieve a true artificial lung for long term use are discussed in this article.
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Since the advent of lung transplantation more than 5 decades ago, preoperative, surgical, and anesthetic management have improved. The growing experience with extracorporeal membrane oxygenation (ECMO) has enabled clinicians to expand its effective use to care for patients while bridging them to transplant (BTT). ⋯ In patients who continued to meet transplant criteria and were successfully transplanted, postoperative survival rates are acceptable. Larger studies are needed to inform decision algorithms for BTT patients and optimize outcomes.