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Disruption of the aortic anastomosis after heart-lung transplantation
R D Dowling1, N Baladi, M Zenati
1Department of Surgery, University of Pittsburgh, Pennsylvania 15261.
Insights
Candida species in donor lungs can cause fatal aortic disruption after heart-lung transplants. Prophylactic amphotericin B and omental wrapping are now used to prevent this fungal infection.
Area of Science:
- Cardiology
- Infectious Diseases
- Transplant Surgery
Background:
- Heart-lung transplantation is a life-saving procedure for end-stage cardiopulmonary disease.
- Anastomotic site complications, including aortic disruption, can occur post-transplant.
- Fungal infections, particularly Candida species, pose a significant threat in immunocompromised patients.
Observation:
- Four of 66 heart-lung transplant recipients experienced aortic disruption at the anastomotic site, all resulting in mortality.
- Candida species were implicated in three cases, with fungal presence noted on suture lines or in aortic walls.
- Donor trachea cultures revealed Candida in two of these three patients, suggesting transmission.
Findings:
- Donor-derived Candida infection is a significant risk factor for fatal aortic anastomotic disruption post-heart-lung transplant.
- Complications included massive hemorrhage, right ventricular outflow tract obstruction, and pseudoaneurysm formation.
- Previous antifungal treatments were unsuccessful, highlighting the need for new preventive strategies.
Implications:
- A high index of suspicion for Candida in donor lungs is crucial for heart-lung transplant recipients.
- Prophylactic amphotericin B is now part of the regimen to prevent invasive fungal infections.
- Omental wrapping of the trachea and aorta may reduce mediastinal infection spread to the aortic suture line.
Abstract:
Disruption of the aorta at the anastomotic site occurred in 4 of 66 consecutive heart-lung transplant recipients and was associated with a 100% mortality. In 3 of these patients, Candida either was cultured from the suture line or was seen in the wall of the aorta at postmortem examination. In 2 of these 3 patients, cultures of material from the donor trachea taken at the time of explanation grew Candida species. Two patients were seen with sudden massive hemorrhage on postoperative day 26 and postoperative day 28. One patient experienced acute decompensation due to right ventricular outflow tract obstruction on postoperative day 30, and the remaining patient was seen 7 months postoperatively with obstruction of both the left main bronchus and the right pulmonary artery caused by extrinsic compression by an aortic pseudoaneurysm. A high index of suspicion should be maintained when transplanting lungs containing Candida species, as we believe there is substantial evidence of donor transmission of the fungal agents. We now include amphotericin B in our antibiotic prophylactic regimen in an attempt to prevent fungal infection because previous treatment has been uniformly unsuccessful. Furthermore, we wrap both the trachea and the aorta with omentum to lessen the likelihood of mediastinal spread of infection to the aortic suture line.