BACKGROUND:In France, a priority rule called high-emergency lung transplantation (HELT) was implemented in 2007 to lower the risk of mortality while on the waitlist for LT for the sickest patients. However, allowing rapid access to LT and lowering the waitlist mortality was at the expense of worse outcomes compared with regular allocation. The aim of the study was to provide actualized data on the results of HELT in France. METHODS:Using exhaustive data from the French organ procurement organization, we performed a retrospective analysis by selecting patients who underwent LT from January 1, 2018, to December 31, 2023, across all 10 French LT centers. The main end point was 1-y post-LT survival in the HELT versus the standard LT allocation group. RESULTS:We selected 1085 patients who underwent LT according to HELT priority (n = 325, 30% of the LTs) or standard LT following a regular graft allocation (n = 760) during the study period. Survival at 3, 6, and 12 mo after LT was 90.3%, 86.7%, and 82.7% versus 87.7%, 83%, and 77.6% in the standard LT and the HELT groups, respectively ( P  = 0.046). On multivariable analysis, HELT was not found to be associated with increased risk of 1-y mortality but was found to be associated with increased postoperative morbidity. CONCLUSIONS:Although previous reports indicated that HELT was associated with a worse prognosis than standard LT, this appears to no longer to be the case.

Heart-lung transplantation (HLTx) is a life-saving intervention for patients with advanced cardiopulmonary disease. Its use has declined significantly in recent decades, and the pulmonary indications for HLTx remain unclear. This study aimed to explore current expert opinions and areas of agreement and disagreement on pulmonary indications for HLTx using a 2-round modified Delphi survey sent to 94 experts at 6 French HLTx centers, including pulmonologists, cardiologists, thoracic surgeons, cardiac surgeons, and anesthesiologists-intensivists. Items relevant to 9 key domains were selected by a working group based on literature reviews. Both surveys had 57 items. Consensus regarding each domain was evaluated by determining the intraclass correlation coefficient (ICC), with an ICC >0.8 indicating strong consensus. In round 1, 40/94 experts responded. The items were scored from 1 to 9: 11 scored >7, 7 scored <3, and 39 had intermediate scores and were reformulated for the second round. The wide interquartile ranges indicated significant variability in responses, and for no domain was the ICC above 0.8. In round 2, which was offered to all experts, the response rate dropped to 25, precluding further statistical analysis. Key areas of disagreement included HLTx indications in severe PAH, right ventricular dysfunction, and congenital heart disease. These findings highlight the absence of a shared consensus and reflect the intrinsic complexity, rarity of the procedure, and variability in institutional expertise. Rather than establishing prescriptive criteria, this expert review underscores the need for individualized, multidisciplinary, and center-specific decision-making, while acknowledging ethical considerations related to donor scarcity. Future efforts should focus on multicenter data collection and predictive models integrating clinical variables and expert judgment to better identify patients who may benefit from HLTx.

Some patients with pulmonary fibrosis (PF) can have severe and fixed chest wall retraction; others regain the shape of their original rib cage once the lungs are removed. These 2 possibilities determine the size of the lung graft to be allocated but are not predictable with classical respiratory tests or computed tomography (CT) scan. We first measured chest wall elastance (Ecw) with esophageal pressure on the day of transplantation (group 1) and then during pretransplant medical check-up, and used for donor selection (group 2). Twenty patients in group 1 had low pretransplantation actual total lung capacity/predicted total lung capacity (pTLC) ratio that was not correlated with Ecw. The amount of transplanted lung TLCtransplanted/pTLC was correlated to Ecw (R2 = 0.43, p = 0.003). Patient with higher Ecw required lung resection and had more primary graft dysfunction. In group 2, 20 patients' Ecw measurements allowed for increase in TLCtransplanted/pTLC from 79 ± 20% to 93 ± 18%, p = 0.023 with only 2 lung resections. Ecw can be measured before transplantation to optimize size mismatch and lung resection.

OBJECTIVE:Non-small-cell lung cancer (NSCLC) remains a major public health concern, with tobacco and environmental exposures to carcinogens (such as asbestos, radon, and silica) recognized as major risk factors. This study investigates the impact of occupational exposure, particularly to crystalline silica on peri‑ and postoperative outcomes in patients undergoing surgery for NSCLC. METHODS:A retrospective analysis was performed on 251 patients who underwent lobectomy or segmentectomy between 2018 and 2021, with occupational exposure data collected postoperatively. RESULTS:Our findings suggest that patients with occupational exposure, particularly to silica, asbestos, or multiple carcinogens, have more complex surgical courses, including longer operative times, higher rates of conversion from minimally invasive to open surgery, and increased postoperative complications (Clavien-Dindo grade II or higher). Preoperative lymph node staging was less accurate in exposed patients, in part because of inflammatory changes such as fibro-hyaline lesions, which can cause false-positive PET/CT findings. CONCLUSIONS:The study highlights the need for tailored surgical strategies and accurate lymph node staging in exposed individuals. Future research should focus on prospective studies to refine perioperative management and explore the biological mechanisms driving these complications.

OBJECTIVES:Acute kidney injury (AKI) requiring dialysis after lung transplantation is a significant source of morbidity. This study investigates the incidence, mortality, and variables associated with the need for dialysis. METHODS:This retrospective analysis included patients aged ≥15 years who underwent lung transplantation between 2014 and 2019 at 3 French institutions. Patients were grouped based on the need for dialysis in the postoperative period. Outcomes analysed included the incidence of AKI requiring dialysis and short- and long-term mortality. We also examined the association between recipient, donor, and intraoperative variables and the need for dialysis. RESULTS:The study population consisted of 478 patients, with a mean age of 49.7 (SD 14.3) years. Dialysis was required for 88 patients (18.4%). In multivariable logistic regression, recipient characteristics (diagnosis), donor characteristics (cardiac arrest), and intraoperative variables (total ischaemic time, norepinephrine dose at the end of the procedure, red blood cell and plasma transfusions) were independently associated with postoperative dialysis (P < 0.05). The median overall survival for patients requiring dialysis was 6.2 months (not reached for those without dialysis). Patients requiring dialysis had a higher risk of all-cause mortality (P < 0.01), with higher 30-day (29.5% vs 7.2%) and 1-year (63.6% vs 13.4%) mortality rates. CONCLUSIONS:AKI requiring dialysis after lung transplantation is associated with significantly higher 30-day and long-term mortality. Identifying high-risk patients for postoperative renal failure requiring dialysis may improve long-term outcomes after lung transplantation.

OBJECTIVES:Smoking is a modifiable risk factor for lung resections but to what extent preoperative smoking cessation reduces that risk remains unclear. The study hypothesis was that the potential benefit of smoking cessation can be assessed by measuring the risk difference between active and former smokers in a large cohort of patients. METHODS:Data were extracted from the French Society of Thoracic and Cardiovascular Surgeons (Société Française de Chirurgie Thoracique et Cardiovasculaire) database. The study cohort comprised patients who underwent lung resection for cancer from January 2002 to December 2020 and for which information on smoking status was available. The risk of overall and specific postoperative complications according to smoking status was defined by logistic regression models, and results were presented in terms of odds ratios (ORs) and relative 95% confidence intervals (CIs) adjusted for confounding factors. RESULTS:Of the 7204 analysed patients at the time of their operations, 20.2% were active smokers, 60.7% were ex-smokers and 19.1% were never smokers. Compared to former smokers, active smokers experienced a higher rate of respiratory complications (OR 1.5, CI 1.2-1.7) and infections (OR 1.6, CI 1.3-1.9). Postoperative atelectasis was significantly reduced in former smokers (3%) compared to active smokers (6.9%, P < 0.01). In active smokers, the risk was related to the level of exposure, being higher for smokers of more than 40 pack-year. CONCLUSIONS:After lung surgery, active smokers experience a higher risk of respiratory complications, infections and prolonged air leak compared to former smokers. This risk seems to be related to the level of exposure.

Introduction Non-small cell lung cancer (NSCLC) is often associated with compromised lung function. Real-world data on the impact of surgical approach in NSCLC patients with compromised lung function are still lacking. The objective of this study is to assess the potential impact of minimally invasive surgery (MIS) on 90-day post-operative mortality after anatomic lung resection in high-risk operable NSCLC patients. Methods We conducted a retrospective multicentre study including all patients who underwent anatomic lung resection between January 2010 and October 2021 and registered in the Epithor database. High-risk patients were defined as those with a forced expiratory volume in 1 s (FEV1) or diffusing capacity of the lung for carbon monoxide (DLCO) value below 50%. Co-primary end-points were the impact of risk status on 90-day mortality and the impact of MIS on 90-day mortality in high-risk patients. Results Of the 46 909 patients who met the inclusion criteria, 42 214 patients (90%) with both preoperative FEV1 and DLCO above 50% were included in the low-risk group, and 4695 patients (10%) with preoperative FEV1 and/or preoperative DLCO below 50% were included in the high-risk group. The 90-day mortality rate was significantly higher in the high-risk group compared to the low-risk group (280 (5.96%) versus 1301 (3.18%); p<0.0001). In high-risk patients, MIS was associated with lower 90-day mortality compared to open surgery in univariate analysis (OR=0.04 (0.02–0.05), p<0.001) and in multivariable analysis after propensity score matching (OR=0.46 (0.30–0.69), p<0.001). High-risk patients operated through MIS had a similar 90-day mortality rate compared to low-risk patients in general (3.10% versus 3.18% respectively). Conclusion By examining the impact of surgical approaches on 90-day mortality using a nationwide database, we found that either preoperative FEV1 or DLCO below 50% is associated with higher 90-day mortality, which can be reduced by using minimally invasive surgical approaches. High-risk patients operated through MIS have a similar 90-day mortality rate as low-risk patients.

Journal Article Accepted manuscript Giant thoracic calcinosis Get access Anaëlle Chermat, Anaëlle Chermat Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University, Pessac, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Hugues Begueret, Hugues Begueret Department of anathomopathology, Haut-Leveque Hospital, Bordeaux University, Pessac, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Jeremy Tricard, Jeremy Tricard Department of cardio-thoracic Surgery, Dupuytren Hospital, Limoges University, Limoges, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Jacques Jougon, Jacques Jougon Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University, Pessac, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Yaniss Belaroussi, Yaniss Belaroussi Department of anathomopathology, Haut-Leveque Hospital, Bordeaux University, Pessac, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Matthieu Thumerel Matthieu Thumerel Department of Thoracic Surgery, Haut-Leveque Hospital, Bordeaux University, Pessac, France Corresponding author: Dr Matthieu Thumerel, Service de chirurgie thoracique, cervicale et de transplantation pulmonaire, Hôpital Haut-Lévêque—CHU de Bordeaux, Avenue de Magellan, 33600 Pessac, France. Tel: +33-55-7656009, matthieu.thumerel@chu-bordeaux.fr Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, ezae170, https://doi.org/10.1093/ejcts/ezae170 Published: 11 May 2024 Article history Received: 10 January 2024 Revision received: 03 April 2024 Accepted: 17 April 2024 Published: 11 May 2024

BACKGROUND:Pleuroparenchymal fibroelastosis (PPFE) has no currently available specific treatment. Benefits of lung transplantation (LT) for PPFE are poorly documented. METHODS:We conducted a nation-wide multicentric retrospective study in patients who underwent lung or heart-lung transplantation for chronic end-stage lung disease secondary to PPFE between 2012 and 2022 in France. RESULTS:Thirty-one patients were included. At transplantation, median age was 48 years [IQR 35-55]. About 64.5% were women. Twenty-one (67.7%) had idiopathic PFFE. Sixteen (52%) had bilateral LT, 10 (32%) had single LT, 4 (13%) had lobar transplantation and one (3%) had heart-lung transplantation. Operative mortality was 3.2%. Early mortality (<90 days or during the first hospitalization) was 32%. Eleven patients (35.5%) underwent reoperation for hemostasis. Eight (30.8%) experienced bronchial complications. Mechanical ventilation time was 10 days [IQR 2-55]. Length of stay in intensive care unit and hospital were 34 [IQR 18-73] and 64 [IQR 36-103] days, respectively. Median survival was 21 months. Post-transplant survival rates after 1, 2, and 5 years were 57.9%, 42.6% and 38.3% respectively. Low albuminemia (p = 0.046), FVC (p = 0.021), FEV1 (p = 0.009) and high emergency lung transplantation (p = 0.04) were associated with increased early mortality. Oversized graft tended to be correlated to a higher mortality (p = 0.07). CONCLUSION:LT for PPFE is associated with high post-operative morbi-mortality rates. Patients requiring high emergency lung transplantation with advanced disease, malnutrition, or critical clinical status experienced worse outcomes. CLINICALTRIALS: GOV IDENTIFIER:NCT05044390.

Introduction Lung graft allocation can be based on a score (Lung Allocation Score) as in the USA or sequential proposals combined with a discrete priority model as in France. We aimed to analyse the impact of allocation policy on the outcome of urgent lung transplantation (LT).Methods US United Network for Organ Sharing (UNOS) and French Cristal databases were retrospectively reviewed to analyse LT performed between 2007 and 2017. We analysed the mortality risk of urgent LT by fitting Cox models and adjusted Restricted Mean Survival Time. We then compared the outcome after urgent LT in the UNOS and Cristal groups using a propensity score matching.Results After exclusion of patients with chronic obstructive pulmonary disease/emphysema and redo LT, 3775 and 12 561 patients underwent urgent LT and non-urgent LT in the USA while 600 and 2071 patients underwent urgent LT and non-urgent LT in France. In univariate analysis, urgent LT was associated with an HR for death of 1.24 (95% CI 1.05 to 1.48) in the Cristal group and 1.12 (95% CI 1.05 to 1.19) in the UNOS group. In multivariate analysis, the effect of urgent LT was attenuated and no longer statistically significant in the Cristal database (HR 1.1 (95% CI 0.91 to 1.33)) while it remained constant and statistically significant in the UNOS database (HR 1.12 (95% CI 1.05 to 1.2)). Survival comparison of urgent LT patients between the two countries was significantly different in favour of the UNOS group (1-year survival rates 84.1% (80.9%-87.3%) vs 75.4% (71.8%-79.1%) and 3-year survival rates 66.3% (61.9%-71.1%) vs 62.7% (58.5%-67.1%), respectively).Conclusion Urgent LT is associated with adverse outcome in the USA and in France with a better prognosis in the US score-based system taking post-transplant survival into account. This difference between two healthcare systems is multifactorial.

Introduction Lung transplantation (LTx) aims at improving survival and quality of life for patients with end-stage lung diseases. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used as intraoperative support for LTx, despite no precise guidelines for its initiation. We aim to evaluate two strategies of VA-ECMO initiation in the perioperative period in patients with obstructive or restrictive lung disease requiring bilateral LTx. In the control ‘on-demand’ arm, high haemodynamic and respiratory needs will dictate VA-ECMO initiation; in the experimental ‘systematic’ arm, VA-ECMO will be pre-emptively initiated. We hypothesise a ‘systematic’ strategy will increase the number of ventilatory-free days at day 28.Methods and analysis We designed a multicentre randomised controlled trial in parallel groups. Adult patients with obstructive or restrictive lung disease requiring bilateral LTx, without a formal indication for pre-emptive VA-ECMO before LTx, will be included. Patients with preoperative pulmonary hypertension with haemodynamic collapse, ECMO as a bridge to transplantation, severe hypoxaemia or hypercarbia will be secondarily excluded. In the systematic group, VA-ECMO will be systematically implanted before the first pulmonary artery cross-clamp. In the on-demand group, VA-ECMO will be implanted intraoperatively if haemodynamic or respiratory indices meet preplanned criteria. Non-inclusion, secondary exclusion and VA-ECMO initiation criteria were validated by a Delphi process among investigators. Postoperative weaning of ECMO and mechanical ventilation will be managed according to best practice guidelines. The number of ventilator-free days at 28 days (primary endpoint) will be compared between the two groups in the intention-to-treat population. Secondary endpoints encompass organ failure occurrence, day 28, day 90 and year 1 vital status, and adverse events.Ethics and dissemination The sponsor is the Assistance Publique–Hôpitaux de Paris. The ECMOToP protocol version 2.1 was approved by Comité de Protection des Personnes Ile de France VIII. Results will be published in international peer-reviewed medical journals.Trial registration number NCT05664204.

Thymic Epithelial tumors (TETs) are rare malignancies, with an annual incidence of 350 cases in France. The main prognostic factors are WHO histological classification, Masaoka-koga (MK) stage and, mainly, complete resection of primary tumor. The anatomopathological (AP) analysis could be a challenge, especially to define margins and histological subtypes, thus specific collaboration between surgeon and pathologist is needed. Moreover, an optimal approach by an expert thoracic group might be a differential factor due to the low frequency of TETs.

OBJECTIVES:A lung transplant is the final treatment option for end-stage lung disease. We evaluated the individual risk of 1-year mortality at each stage of the lung transplant process. METHODS:This study was a retrospective analysis of patients undergoing bilateral lung transplants between January 2014 and December 2019 in 3 French academic centres. Patients were randomly divided into development and validation cohorts. Three multivariable logistic regression models of 1-year mortality were applied (i) at recipient registration, (ii) the graft allocation and (iii) after the operation. The 1-year mortality was predicted for individual patients assigned to 3 risk groups at time points A to C. RESULTS:The study population consisted of 478 patients with a mean (standard deviation) age of 49.0 (14.3) years. The 1-year mortality rate was 23.0%. There were no significant differences in patient characteristics between the development (n = 319) and validation (n = 159) cohorts. The models analysed recipient, donor and intraoperative variables. The discriminatory power (area under the receiver operating characteristic curve) was 0.67 (0.62-0.73), 0.70 (0.63-0.77) and 0.82 (0.77-0.88), respectively, in the development cohort and 0.74 (0.64-0.85), 0.76 (0.66-0.86) and 0.87 (0.79 - 0.95), respectively, in the validation cohort. Survival rates were significantly different among the low- (< 15%), intermediate- (15%-45%) and high-risk (> 45%) groups in both cohorts. CONCLUSIONS:Risk prediction models allow estimation of the 1-year mortality risk of individual patients during the lung transplant process. These models may help caregivers identify high-risk patients at times A to C and reduce the risk at subsequent time points.

Baseline lung allograft dysfunction (BLAD) is predictor of death and chronic lung allograft dysfunction (CLAD) after lung transplantation. However, it may be distinct risk factors and prognosis depending on functional pattern of BLAD. Our objective was to verify these hypotheses. This retrospective study was conducted with lung transplants done in our center between 2010 and 2019. Forced expiratory volume in the first second [FEV1] and forced vital capacity [FVC] > 80% predicted defined normal baseline function. Failure to meet these criteria defined BLAD which was then characterized according to its functional pattern. Restrictive and obstructive groups were compared to non-BLAD group. Characteristics associated with death and CLAD were determined by multivariate regression. Of 171 recipients eligible for study, 111 (65%) had normal respiratory function, 22 (13%) had obstructive BLAD, 34 (20%) restrictive BLAD and 4 (2%) mixed BLAD. Patients with obstructive BLAD had older donor (55 ± 15 years vs 44 ± 16 years; p=0.007) with lower PaO2/FiO2 (386 ± 84 mm Hg vs 435 ± 84 mm Hg; p=0.03) than patients without BLAD, increased risk of death (hazard ratio [HR] 4.7; 95% confidence interval [CI] 2.11-10.5) but not of CLAD. Compared to patients without BLAD, patients with restrictive BLAD were more likely transplanted for fibrosis (30% vs 10%; p=0.053), had smaller implanted graft with smaller ratio of total lung capacity [TLC] implanted/ predicted TLC of recipient (0.88 ± 0.23 vs 1 ± 0.21; p<0.0001), had increased risks of death ([HR] 6.7 95% [CI] 3.23-13.9) and CLAD ([HR] 2.19 95% [CI] 1.25-3.84). There may be several kind of BLAD with distinct risk factors and prognosis. This need further invesigation.

Purpose Incidence and course of lung diseases differ by sex. While chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis are considered male-predominant diseases, women represent up to 44% of French lung transplant recipients. Data about impact of sex in lung transplantation (LT) are limited. This study aimed to evaluate sex differences in candidate characteristics, waitlist outcomes and post-transplant survival. Methods All adult candidates newly listed for LT between January 2017 and December 2021 (1 928) were included in the study. Main outcomes were 1-year cumulative incidence of LT, 1-year waitlist mortality or delisting for worsening medical condition, and 1-year post-LT survival. Cumulative incidence and Kaplan-Meier curves were compared using Gray's and log-rank test, respectively. Association of female sex with all outcomes were assessed using multivariable Cox models. Results Women (850) were younger, smaller in height, with less frequent history of smoking and more frequent previous cancer, had more COPD and pulmonary hypertension and more often positive HLA and CMV antibodies. Females received graft from older donors and underwent more frequently bilateral LT. While 1-year waitlist mortality did not differ between women and men (5% [4-7] and 6% [4-7], respectively) incidence of LT was lower in women (Figure 1). In multivariable Cox models, female sex remained associated with lower access to LT (HR 0.84 [0.73-0.96], p=0.014). One-year post-LT survival (Figure 2) tended to be better in women with Cox model (HR 0.79 [0.62-1.02], p=0.07). Conclusion Women have lower access to LT while they tend to have better post-LT survival.

PURPOSE Chest wall resections for lung cancer treatment remain difficult to plan using standard 2-dimensional computed tomography. Although virtual reality headsets have been used in many medical contexts, they have not been used in chest wall resection planning.DESCRIPTION We compared preoperative planning of a chest wall surgical resection for lung cancer treatment between senior and resident surgeons who used an immersive virtual reality device and a 2-dimensional computed tomography.EVALUATION Chest wall resection planning was more accurate when surgeons used virtual reality vs computed tomography analysis (28.6% vs 18.3%, P = .018), and this was particularly true in the resident surgeon group (27.4% vs 8.3%, P = .0025). Predictions regarding the need for chest wall substitutes were also more accurate when they were made using virtual reality vs computed tomography analysis in all groups (96% vs 68.5%, P < .0001). Other studied parameters were not affected by the use of the virtual reality tool.CONCLUSIONS Virtual reality may offer enhanced accuracy for chest wall resection and reconstruction planning for lung cancer treatment.

The substernal goitre is defined as a goitre for which >50% of the mass is located below the superior orifice of the thorax, surgical resection remains the reference treatment, the approach used is the cervicotomy, which often allows to extract the mediastinal portion of the plunging goitre, and we report a rare case of a huge cancerous plunging goitre whose complete resection required the enlargement of the cervicotomy in right hemi-clamshell, for the carcinological, vascular and recurrent control.

Editor—We analysed respiratory mechanics in a 33-yr-old female double-lung transplant recipient who experienced reverse-triggered (RT) breaths under volume-controlled ventilation while electrical activity of the diaphragm (EAdi) was continuously recorded. The patient, who had bronchiolitis obliterans, required tracheal intubation 4 yr after transplantation because of pneumonia causing acute respiratory failure with flow limitation and intrinsic PEEP (PEEPi). After 2 days of volume-controlled ventilation, sedation with propofol and sufentanil was stopped.