BREATHING LUNG TRANSPLANTATION” - A ROAD TO RELIEF NEW LUNGS WITH OLD VESSELS
M.V.RaghavendraRao,VijaykumarChennamchetty,MMKarindas,IlieVasiliev,HiteshLakshmiBilla, 6 7 8 MohammedIsmailNizami ,JerrysonAmeworgbeGidisu,SaicharanGBodi
1DepartmentofMedicine,ApolloInstituteofMedicalSciencesandResearch,JubileeHills,Hyderabad,Telangana,India
2AssociateProfessor,DepartmentofPulmonaryMedicine,ApolloInstituteofMedicalScienceandResearch,Hyderabad,TS,India, 3Professor,DepartmentofOncology,WorldAcademyofMedicalsciences, 4Professor,Departmentof InternalMedicine, WorldAcademyofMedicalSciences, 5Registrar,InterventionalPulmonology,ApolloInstituteofMedicalScienceandResearch,Hyderabad,TS,India
6AssociateProfessor,PulmonaryMedicine,DepartmentofEmergencyMedicine,Nizam'sInstituteofMedicalSciences,Hyderabad, TS,India
7President,DepartmentofCardiothoracicsurgery,KingandQueenMedicalUniversityCollege,Ghana,Africa.
8AssociatestaffphysicianofPulmonology,Respiratoryinstitute,Clevelandclinic,AbuDhabi,UAE.
ABSTRACT
Alungtransplantisasurgerytoreplacediseasedlungswithhealthylungs.Thedisciplineoflungtransplanthasmadeextraordinaryinnovativeoverthelastdecades. Althoughadvances,morbidityandmortalityalsohighwhencomparedwithothersolidorgantransplants.Lungtransplantationisalife-savingtreatmentforpatients with advanced lung diseases of various nonmalignant etiologies. A lung transplant is a surgical procedure to replace an infected lung with healthy lung. Lung transplantationisaregeneratecureforpatientswithcessationstagelungdisease;however,itisrarelyaboutpatientwithacuterespiratorydistresssyndrome(ARDS) assigntoinfectiouscauses.Faultylungscanmakeitbotherforthebodytogettheoxygenitneedstopullthrough.Thesevereacuterespiratorysyndromecoronavirus2 pandemiccreatechallengesforlungtransplantrecipients. Adiversityofdiseasescandamageyourlungsandkeepthemfromfunctioningeffectively Bankonpatient's medicalcondition,alungtransplantmayinvolvereplacingoneofthesubject'slungsorbothofthem.Insomesituations,thelungsmaybetransplantedalongwitha donorheart.
KEYWORDS:Lungtransplantation;complications;mortality;Heart–lungtransplantation(HLT),patientselection,COVID-19;SARS-CoV-2.
INTRODUCTION:
In1999,Dr KMCherianperformedthefirstdouble-lungtransplantation(DLT) andthefirstcombinedheart–lungtransplantation(HLT)inIndia,therebyusheringinthebeginningoftheeraofLTinIndia(1).
Followingthisinitialenthusiasm,therewasadeclineinLTactivity,until2007, whenacombinedHLTwasperformedatApolloHospitals,Chennai(2)
In2011,singlelungtransplantation(SLT)wasfirstperformedininGlobalHospitalsinChennai(3)
ThefirstSLTinstateofMaharashtrawasdoneinHindujaHospital,Mumbai,on 11July2012(4)
ThefirstSLTinthestateofAndhraPradesh(nowTelangana)wasperformedin YashodaHospitalinSeptember2012(5)
ThefirstcombinedHLTwasperformedinMahatmaGandhiHospital,Jaipur,on 5December2016(6)
ThefirstcombinedHLTwasperformedinLissieHospital,Kochi,in6January 2017(7)
ThefirstDLTandthefirstcombinedHLTweredoneinNarayanaHrudayalaHospital,Bengaluru,on20June2018,and3Jan2019(8,9)
In India, the first LT for COVID-affected lungs was performed on 24 August 2020 in the city of Hyderabad , Telangana. In Tamil Nadu, the first LT for COVID-affectedlungswasperformedon27August2020(10,11)
ThiswasfollowedbyaLTforCOVID-affectedlungsinDelhi,whichalsohappenedtobethefirstLTtobedoneinNewDelhi(12)
Lungtransplantationnowadaysisawell-acceptedandroutinetreatmentforwell selectedpatientswithterminalrespiratorydisease.(13)
While lung transplants carry certain associated risks, they can also extend life expectancyandenhancethequalityoflifeforthosewithendstagepulmonarydisease(14)
AlthoughsporadiccasesoflungtransplantationforCOVID-19-associatedacute respiratorydistresssyndrome(ARDS)havebeenreported(15,16,17)
Theirheartraterespondslessquicklytoexertionduetothecuttingofthevagus nervethatwouldnormallyhelpregulateit(18)
Respiratorydiseasesimposeenormoushealthburdensworldwide,notleastdisabilityandearlydeath.(19,20)
HISTORY:
VladimirDemikhovandHenryMetras,duringthe1940sand1950s,firstdemonstratedthattheprocedurewastechnicallyfeasible.
James Hardy of the University of Mississippi performed the first human lung transplantonJune11,1963(21,22)
Followingasingle-lungtransplantation,thepatient,identifiedlaterasconvicted murdererJohnRichardRussellsurvivedfor18days(23)
Thefirstsuccessfultransplantsurgeryinvolvingthelungswasaheart-lungtransplant,performedbyDr BruceReitzofStanfordUniversityin1981onawoman whohadidiopathicpulmonaryhypertension(24,25)
1983:Firstsuccessfullong-termsinglelungtransplant(TomHall)byJoelCooper(Toronto)(26)
1986:Firstsuccessfullong-termdoublelungtransplant(AnnHarrison)byJoel D.Cooper(Toronto)(27)
1988:Firstsuccessfullong-termdoublelungtransplantforcysticfibrosisbyJoel Cooper(Toronto).
In1988,VeraDwyer,awomanfromCountySligoinIreland,wasdiagnosedwith anirreversible,chronicandfibroticlungdisease.Lateronthatyear,shereceived a single lung transplant in the UK. In November 2018, Ms. Dwyer was recognizedastheworld'slongestsurvivingsinglelungtransplantrecipientinanevent attheMaterHospitalinDublin(28,29)
Roadtorelief: India's first ever breathing lung transplant was performed in middle aged man withendstageinterstitiallungdisease.Thisrunsthelungsthroughadevicethat cools the organ while it breaths, nourishes it with a substrate enriched solution thatwillwipeouttracesofinfection.
Selectionofrecipient: Theselectionofappropriaterecipientsforlungtransplantationisanevolvingdiscipline.(30)
Bronchiolitis obliterans syndrome (BOS) is the most common form of chronic lungtransplantrejection.
Selectionofdonor:
1. Donorsshouldbewithin18to64yearsold.
2. Sexmaypassonaccomplishmenttoallfemalerecipientsespeciallyinmale tofemaletransplants. 3. Femaledonorstomalerecipientsmayproducenegativeoutcomes 4. Racematcheddonorshaveimprovedoutcomes 5. AfricanAmericandonorsexpressunsatisfactoryprojection 6. Smokingdonorsmaydecreaserecipientsurvivalpost-transplant 7. Chestradiographsareapoorindicatoroflungdonorfunction 8. Braindeaddonorsanddeceaseddonorshaveidenticaldiagnosis
9. Although there have been multiple trials on individual lung donor criteria thatfailtoshownegativerecipientprognosis,therearefewstudiesthatevaluate the effects of multiple extended criteria compounded together in one donorlung.(31)
Thesecompromisesinphysiologymayhaveuntoldeffectsonprimarygraftdysfunction(PGD) andoverallpatientmortality(32)
“Bridgetolungtransplantation” It refers to strategies to manage with artificial support the acutely decompensatingpatientuntilasuitableorganisavailable(33).
Mechanicalventilationtodayhasbeenthemostcommonlyusedbridgingstrategytolungtransplant,butventilatedpatientsareparticularlysusceptibletoventilator-induced lung injury and ventilator-associated pneumonia and requires patients to be bed-bound and often sedated, which reduces their ability to undergoadequatephysiotherapy (34)
Since the beginning of the lung transplant era, ECLS has been recognized as a potentialbridgetolungtransplantforpatientswithrespiratoryfailure.However, the initial clinical experience in the 1980's and 1990's was discouraging with a high mortality rate and a high incidence of complications associated with the applicationofECLS(35)
Mechanicalventilationtodayhasbeenthemostcommonlyusedbridgingstrategytolungtransplant(36)
WestBengal'sfirstlungtransplantationtakesplace
Therecipient,whodevelopedcomplicationsfollowingrecoveryfromCovid-19, isonECMOsupportasbothofhislungswerecompletelydamaged.WestBengal onTuesdaywitnesseditsfirstlungtransplantationafterdoctorsataprivatehospitalinKolkatasuccessfullyconductedamarathonsurgerytogiveanITprofessionalanewleaseoflife,anofficialofthemedicalestablishmentsaid.
One-year-oldundergoesbilaterallungtransplant BoyhadBronchopulmonarydysplasia
MGM Healthcare doctors have performed a bilateral lung transplant on a oneyear-oldboyfromChennai,whosufferedfrombronchopulmonarydysplasia,a chroniclungdiseaseaffectingnewborns.
Manundergoesbilaterallungtransplant Punjabfarmerwasdiagnosedwithinterstitiallungdisease
A 34-year-old man from Chandigarh, with a low body mass index, recently underwentlungtransplantsurgeryatacityhospitalhere.ThefarmerfromPunjab hadararefamilialinterstitiallungdisease.ILDisagroupofdisordersthatprogressivelyscarslungtissue.Itisbelievedtooccurinoneinonelakhpopulation.
Breathinglungtransplantationperformed
AbreathinglungtransplantationwasperformedbydoctorsattheKrishnaInstituteofMedicalSciences(KIMS),Secunderabad,onSaturday Doctorsclaimed that this was the first such procedure conducted in India.The surgery was performedbydirectoroftheLungTransplantprogrammeDr SandeepAttawarand histeamonamiddleagedpatientwithendstageinterstitiallungdiseasewith10
litresofoxygensupport.
Yashoda,CMRIlaunchoflungtransplantprogramme Yashoda Hospitals-Hyderabad and CMRI-Kolkata have taken an initiative to work together in providing Heart and Lung Transplantation Services, ECMO and Thoracic surgeries.Amemorandum of understanding (MOU) on this was signedbetweenthetwoinstitutions.
AIIMSsecond publichospitalinIndiatodolungtransplant AIIMShasbecomeonlythesecondpublichospitalinthecountrytoconducta lung transplant procedure after PGIMER, Chandigarh. The surgery involves removingoneorbothdiseasedlungsfromapatientandtheirreplacementbya healthyonefromacadaverdonor
Murali Manoharan,thedonor,asoldierintheIndianArmy,wasdeclaredbrain deadattheArmy(ResearchandReferral)Hospitalafteraroadtrafficaccident, accordingtoviceadmiralRajatDatta,directorgeneral,ArmedForcesMedical Services “Manoharan's wife, Kaushalya, consented to the donation lungswereusedforthetransplantatAIIMS.GroupcaptainSumeshKaisthaof theArmyhospitalsaidthatthiswasthefirsttimetheyretrievedthelungsfroma brain-dead donor She was on non-invasive ventilator support for almost two years,”saidKaistha.(37)
Man with lungs damaged by COVID undergoes transplant after donor organsbroughtfromAhmedabad
A55-year-old patient is a resident of Meerut in Uttar Pradesh, was suffering fromchronicobstructivepulmonarydisease(COPD).Hislungshadbeendamagedduetothecoronavirus.Heunderwentabilaterallungtransplantataprivate facilityhereafterdonororgansweretransported950kilometresinthreehours, accordingtoastatement.ThesurgerytookplaceatMaxHospital,Saket,andthe hospitalsaiditisthefirsttimeinNorthIndiathatabilaterallungtransplanthas beendonewiththehelpofextracorporealmembraneoxygenation,(ECMO)support.Atthehospital,hewasevaluatedbyaheartlungtransplantteamledbyDr RahulChandola,thestatementsaid.(38)
Extremely rare' double lung transplant saves Chicago man with terminal cancer
AlbertKhoury,54,underwentaseven-hoursurgerytoreceivehisnewlungsat Northwestern Medicine in Chicago on September 25, 2021.Albert Khoury - a 54-year-oldnon-smokerwithterminallungcancer -underwentaseven-hoursurgery to receive his new lungs in September 2021.Six months on, the lungs are workingwellandhehasnosignsofcancerinhisbody.Thesurgery,performedat Northwestern Medicine in Chicago, gives hope to others who have advanced stages of lung cancer.Ankit Bharat, chief of thoracic surgery at Northwestern Medicine,saidthe'extremelyuncommon'surgeryis'consideredacomplete"nogo"'forterminallungcancerpatients (39)
Family of unvaccinated Georgia man, 24, who underwent DOUBLE LUNG transplant after contracting COVID-19 says he regrets not getting a shotBlake Bargatze, 24, from Sugar Hill, Georgia, did not get a COVID-19 vaccine because he feared side effects. His lungs became so damaged that he needed a double lung transplant.He received his new pair of lungs on June 28 and now facessixtoeightmonthsofrecoveryandrehabilitation Contraindications:
LaboratoryStudies
Complicationsfromlungtransplantationare
Bleeding,Infection,Blockageofthebloodvesselstothenewlung(s),Blockage oftheairways.,Severepulmonaryedema(fluidinthelung)andBloodclots.
PrimaryGraftDysfunction
Primarygraftdysfunction(PGD)describesaformofacuteallograftinjurycharacterizedbydevelopmentofnoncardiogenicpulmonaryedemawithin72hours oftransplantationintheabsenceofidentifiablesecondarycauses(40)
isrecommendedbecausetheriskofCMVdiseaseishigh(50).
Aboutone-thirdoftheinfectionswithP cariniimayoccurafterthefirstpostoperativeyear(51)
Toxoplasma gondii pneumonitis has been described exclusively in heart-lung recipients(52)
SUMMARY:
Lungtransplantationistheonlyparadigmthatendeavoraeverlastingresolution forend-stagelungdiseases.Afewhospitalsaredoingvigorouslungtransplantations.Preoperativeandpostoperativeconsiderationsinlungtransplantationmay be different in the developing countries when compared to the developed world.(53)
CONCLUSION:
Blemishedlungscanmakeitdifficultfortogettheoxygenitneedstosurvive.A diversity of diseases damage lungs. Chronic obstructive pulmonary disease (COPD), including emphysema, Scarring of the lungs (pulmonary fibrosis),CysticfibrosisandHighbloodpressureinthelungs(pulmonaryhypertension) forced to obstruct exchange of air and produce air hunger Lung damage canoftenbetreatedwithmedicinesand breathingdevices.Butwhentheseprogramsareoutoffhandlungfunctionbecomeslife-threatening,doctorssuggest a single-lungtransplantoradouble-lungtransplant.
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