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Ann Thorac Surg 1999;68:2020
© 1999 The Society of Thoracic Surgeons
a Division of Cardiovascular and Thoracic Surgery, London Health Sciences Centre, University of Western Ontario, University Campus, PO Box 5339, London, ON N6A 5A5, Canada
e-mail: rjnovick{at}julian.uwo.ca
Invited commentary
This paper by Dr Gammie and colleagues from the University of Pittsburgh is a retrospective review focusing on the effect of graft ischemic time on various outcomes after clinical lung transplantation. The study cohort was larger than most previous single-center reports on this issue, the authors’ experience spanned 10 years and the results were consistent and clear. Dr Gammie and his colleagues are correct in pointing out that although it is "generally accepted" that the upper limit for safe ischemia in clinical lung transplantation is in the range of 4 to 6 hours, this has not been supported by recent data. In fact, in a recently published multinational study, the duration of graft ischemia time was not an independent predictor of mortality in clinical lung transplantation [1]. Nonetheless, the interaction between donor age and graft ischemia time did predict 1 year mortality after lung transplantation, especially if donor age was greater than 55 years and the ischemic time was greater than 6 to 7 hours. These data indicated that how far to "push the envelope" when graft ischemic time was advanced and the lung graft was not otherwise optimal was still unresolved.
Although Dr Gammie’s paper addressed the effect of lung ischemia time on survival and early postoperative graft function, it did not provide data on several important secondary end-points in the intermediate-term postoperatively. Unfortunately, the incidence of rejection and of obliterative bronchiolitis was determined solely on the basis of histologic criteria, whereas no data were provided on the number of clinically-treated rejection episodes and on graft function in the intermediate-term. The manuscript would have been strengthened if the authors had reported serial FEV1 values, as well as bronchiolitis obliterans syndrome stages [2] of patients assigned to the three groups of ischemia time. In the final analysis, graft function and quality of life measurements are more important outcome variables for lung transplant recipients than the histologic results noted on transbronchial biopsy. Recent, as yet unpublished analyses from the International Society for Heart and Lung Transplantation database have confirmed that there is no significant effect of lung graft ischemia time on such secondary end-points as hospitalization for rejection or infection, FEV1 and a clinical diagnosis of obliterative bronchiolitis at 2 years after transplantation.
It is my hope that the University of Pittsburgh and other centers with a large experience in clinical lung transplantation will continue to analyze the effect of graft ischemic time and other donor variables on intermediate and long-term outcomes after lung transplantation, focusing not only on survival but also on lung function and quality of life measurements.
References
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