Introduction: Donor-derived cell-free DNA has been validated in recipients of single organ transplants, either heart or lung. We looked into the clinical utility of detecting acute rejection in recipients of combined heart-lung transplants using a novel PCR-based assay that measures absolute dd-cfDNA levels. Material and Methods To analyse donor-derived cell-free DNA using a real-time PCR-based test, serum samples were collected concurrently with transbronchial and endomyocardial biopsies from 30 recipients of simultaneous heart-lung transplant recipients. Regression analyses were done to assess how donor-derived cell-free DNA levels were affected by the recipient and donor-derived characteristics. Results: The patients had a mean age of 38.87 years (range: 18-72 years), 60% of whom were male, and a BMI of 21.62. (range: 17.4- 27.2). Cyanosis of the heart was the most typical pre-transplant diagnosis (n=11, 36.7%). In comparison to healthy allografts (median 7.25 ng/l, interquartile range (IQR):-0.0- 43.3 ng/l), heart or lung allograft injuries had considerably higher absolute dd-cfDNA levels (median 37.0 ng/l, IQR:-12.5- 94.35 ng/l). With a 10 ng/mL threshold, the sensitivity and specificity were 63.6% and 66.7%, respectively, with positive and negative predictive values of 33.3% and 88.9%. The investigated metrics did not reach statistical significance for dd-cfDNA levels. Conclusion: The plasma levels of dd-cfDNA may be a less invasive technique to predict acute allograft injury even in combined heart-lung transplant recipients. Further studies are investigating organ-specific donor-derived cell-free RNA levels(heart-cfRNA & lung-cfRNA) to delineate organ injury.

Background. Lung transplantation (LTx) has come as hope for select patients with post-COVID acute respiratory distress syndrome (ARDS). It has a different phenotype with unique challenges. We aimed to bring out our experience with and outcomes of LTx for post-COVID ARDS. Methods. This study is retrospective case series from a single center in India. All the patients with post-COVID end stage lung disease (ESLD) who underwent bilateral LTx between 1st May 2020 and 30th August 2021 were included. LTx was performed following no improvement with optimal medical management with adequate time provided for recovery. Information relating to demographics, comorbidities, pretransplant status, perioperative parameters, gross and histopathological findings of explanted lungs, posttransplant morbidity, and mortality were analyzed. Results. This study included 23 patients. The median age of the patients in this study was 42 years and 20 participants were men (87%). The mean duration of intensive care unit stay was 15.83 6.61 days. Mortality was observed among 8 participants (34.78%). Mean survival time was 34.54 weeks. Among the 8 patients who expired, the cause of death was sepsis for 6 patients (75.0%), neurologic cerebrovascular accident for 1 patient (12.5%), and cytomegalovirus for 1 patient (12.5%). All the deaths were reported in primary graft dysfunction grade 2 & 3 category. No rejections were observed on first and third month surveillance biopsies. Conclusions. LTx is the definitive option for survival in select patients with severe post -COVID-19-associated ESLD. This study brings out various challenges involved in such phenotypes and also observations in postoperative recovery.

Pulmonary vein thrombosis (PVT) is a potentially fatal complication following lung transplantation (LT). The clinical presentation of PVT is nonspecific and mimics other common postoperative complications such as reperfusion injury, infection, and rejection. Transesophageal echocardiography (TEE) plays a pivotal role in detecting abnormalities of the pulmonary venous anastomosis in the perioperative period. Echocardiographic findings that warrant concern include a visible thrombus in pulmonary vein, pulmonary vein diameter <5 mm, turbulence on color Doppler, and peak systolic velocity >100 cm/s. Transplant centers should strongly consider TEE in individual patients with unexplained graft failure.

Lung transplantation (LTx) is the definitive treatment for select progressive end-stage lung disease patients despite being on optimum medical therapy. Asian countries like China, Japan and India have started LTx programmes despite various odds and challenges. Some of these challenges seem to be unique to developing countries. We have elaborated the challenges of LTx in India and their proposed solutions and shared our experience in setting up a successful LTx programme.

Background: Lung transplantation (LT) has emerged as a definitive cure for a plethora of end-stage lung diseases (ESLDs). With improvements in immune-suppression protocols, the posttransplantation survival rates have gone up. Aim: The study reported the initial experience of the India's single largest lung transplant program on clinicopathological profile, procedures, challenges encountered, and outcomes. Settings and Design: A retrospective analysis was done from data available at three centers of Institute of Heart and Lung Transplant, Gleneagles Global Hospitals across Chennai, Bengaluru, and Mumbai. Materials and Methods: A total of 132 patients underwent lung (single or bilateral) or combined heart and lung transplant between April 2017 and March 2020. All the participants had 30 days' follow-up. Postoperative complications, graft rejection, and 30-day mortality were reported. Kaplan–Meier survival analysis and logistic regression analysis were performed. Statistical Analysis Used: Kaplan–Meier survival and binary logistic regression was performed. Results: Interstitial lung diseases, 65.91%, were the most common diagnosis. Bilateral LT (81.3%) was the most common type of LT performed. Grade III primary graft dysfunction was observed in 16 (12.1%). Distal airway stenosis (21.97%) was the most common complication followed by anastomotic stenosis (14.30%). Gram-negative bacterial sepsis (52%) was the leading cause of death. Cumulative probability of survival at 1 month was 0.85 (95% confidence interval [CI] 0.80–0.92), and at 1 year, it was 0.78 (95% CI, 0.72–0.86). Conclusion: This study establishes the fact that despite multiple challenges, LT is a viable option for selected patients with ESLDs in India and should encourage early referrals to a transplant center.

Lung transplantation is a definitive treatment option for select end-stage lung disease patients. Post lung transplantation, immunosuppression plays a significant role in a successful outcome. Rejection and infection are commonly encountered where immunosuppression plays an important role. Many immunosuppressive strategies have been designed and their protocols might vary from center to center. This review will focus on these perspectives as well as emerging perspectives during COVID times.

Worldwide, lung transplantation has been a therapeutic option for select end-stage lung disease patients who are on optimized medical regimens, but the underlying clinical condition continues to progress. For any successful lung transplantation program, it is important to have a robust donor lung management program. Lungs are commonly affected by the various factors related to trauma or neurogenic in brain stem death donors. This article would focus on the basic protocols to optimize donor lungs which would help in increasing donor pool. It would also elaborate COVID-specific points for donor lung evaluation. This article would also describe the criteria for ideal as well as marginal donor lungs. A comprehensive literature search was performed using PubMed to review various articles related to donor lung management.

Left ventricular assist devices (LVAD) have gained widespread use as an effective clinical therapy for patients with heart failure (INTERMACS 1-5) and are the standard of care for bridging patients to cardiac transplantation. Pre-implantation transesophageal echocardiography (TEE) allows interrogation of all cardiac structures and identifies potential problems such as intracardiac shunts, thrombi, aortic insufficiency, and right ventricular dysfunction that need palliation. Post-implantation exam helps in weaning from cardiopulmonary bypass (CPB) and successful LVAD initiation. ICU monitoring with TEE guides optimal intervention and should be considered in selected patients. TEE will continue to remain vital to successful outcomes in LVAD patients.

Nonspecific interstitial pneumonitis.The cause of this difference may need to be evaluated further and possibly due to availability of effective treatment options for COPD compared to ILD in India.CLINICAL IMPLICATIONS: Referral patterns for lung transplantation in India

Purpose: Making an accurate diagnosis of specific forms of ILDs based on clinical and radiological features is extremely difficult and might lead to inappropriate treatment in some cases. We examined the correlation of preoperative diagnosis with the final histopathological diagnosis of the explanted lungs for patients referred for lung transplant at our center, Gleneagles Global Health City, CHENNAI, India Methods: We retrospectively analyzed the pre op radiological and post op histopathological diagnosis of all the ILD patients who underwent either single or double lung transplantation at our centre from Nov 2016 to September 2019. Results: A total of 46 patients with ILD underwent lung transplantation at our centre from Nov 2016 to Sept 2019. The pre transplant radiological diagnosis include Usual Interstitial Pneumonia-UIP( 24 cases ), Non Specific Interstitial Pneumonia-NSIP (07 cases ), Chronic hypersensitivity Pneumonitis-CHP ( 11 cases ), Sarcoidosis ( 03 cases ) and Lymphocytic Interstitial Pneumonia-LIP ( 01 cases ). The concordance between preop radiological and post explant histological diagnosis was analyzed (Table 1) Conclusion: Concordance between the radiological and histological diagnosis was seen in 95.8% cases of UIP, 72.7 % cases of CHP, 66.6% cases of sarcoidosis, 100% in LIP and in 14 % cases of NSIP respectively.

The Avalon elite bicaval dual-lumen cannula for single site VenoVenous Extracorporeal Membrane Oxygenation (VV ECMO) offers several advantages. Correct placement of the Avalon cannula is safe using image guidance and needs either fluoroscopy or Transesophageal echocardiography (TEE). We assessed our institutional ECMO performance, cannulation related complications, instances of cannula malposition among patients cannulated using the two imaging modalities. We reviewed all patients who had Avalon cannula placement for VV ECMO at our institute. Ten patients were included in the study. Patients were cannulated using either fluoroscopy (Group A, n = 5) or TEE (Group B, n = 5). Data included patient demographics, diagnosis, evidence of cannula malposition, ECMO performance, cannulation related complications. The primary outcomes ease of cannulation; cannula malposition and the need for repositioning were compared between the two groups. Visualisation of guidewire, Avalon cannula and the average number of attempts to cannulate were similar (P > 0.05) between the two groups. Four patients cannulated using fluoroscopy had low flows whereas none of the patients cannulated using TEE had flow problems which was statistically significant (P = 0.024). Four cannulas (80%) placed under fluoroscopy required repositioning whereas one cannula (20%) placed under TEE needed repositioning. This difference was not statistically significant though (P = 0.099). TEE is the ideal imaging modality to guide Avalon elite cannula placement for VV ECMO.

Pulmonary Alveolar Microlithiasis (PAM) is a rare autosomal recessive end stage lung condition characterized by widespread alveolar deposition of calcium microliths. It is worth emphasis india has reported 80 cases out of 1022 cases worldwide but there is no report on lung transplant and and anaesthetic management in this category of patient. This report present the anaesthetic challenge in management of first indian patient with the diagnosis of PAM, who underwent bilateral lung transplantation. Bilateral lung transplantation is one of the most challenging surgeries that require the care of a cardiothoracic anesthesiologist. Utilization of extracorporeal circulation has allowed a safer performance of this procedure in patients with severe cardiopulmonary compromise. Intraoperative management is a pivotal part of the patient's care, as it contributes to the patient's overall outcome.

Introduction: Heart transplant in India was started in 1994. The Indian transplant program differs from the West. In this study, we report the heart transplant experience from Gleneagles Global, Chennai. Materials and Methods: There were 55 patients who underwent a heart transplant during this period. Patients were induced with basiliximab, and the maintenance therapy was with tacrolimus, mycophenolate, and steroids. Results: Fifty patients underwent a heart transplant between 2017 and 2018. The age ranged from 21 to 66 years, and there were 45 males and 10 females. All patients were Class III and IV. Induction for transplant was with basiliximab 10 mg–20 mg. In 54 patients, tacrolimus was used, and low-dose tacrolimus plus everolimus 0.25 mg twice a day was given in five patients. Mycophenolate mofetil was given to all patients. Steroids were given to all patients. In 38 patients, renal function normalized by day 5, and in 12 patients, the renal recovery was delayed to day 10. Two patients needed postoperative dialysis. Three patients died of severe renal failure and sepsis. Fifteen patients had new-onset diarrhea in the 1st year with four having CMV[CE2] [CE2] antigen positivity, one with Clostridium difficile, and seven patients with diarrhea resolving with termination of mycophenolate. Four had Escherichia coli or Salmonella diarrhea which responded to oral antibiotics. One patient developed herpes zoster and another developed hepatic mucormycosis. Twelve patients developed sustained tremors and ten had severe headaches needing tricyclic antidepressants. Ten patients had episodes of leukopenia, eight of which resolved after temporary stoppage of valganciclovir and reduced dose of mycophenolate and two patients needed Granulocyte-colony stimulating factor therapy. Conclusions: This report covers the experience of 2 years and 55 patients. Mild side effects were noted in 30 patients after heart transplant. Side effects such as diarrhea, tremors, and headache were easily treated by clinical manipulation of drugs. Overall, 14 patients had significant bacterial or fungal or viral infections. Three patients died of sepsis ( first 15 days after transplant in 2 patients and 3–6 months in another).

The role of extracorporeal support in form of extracorporeal membrane oxygenation (ECMO) has been well established in cases of acute cardiopulmonary failure. The initial enthusiasm dampened, and there was no new development in this field before the recent H1N1 pandemic. Encouraging results in H1N1 patients saw a revised interest in use of ECMO. Gradually, the scope of ECMO widened and is now being used for various indications both in pediatric and adult patients. One of the newly added roles of ECMO is to provide interval support for organ retrieval in cases of donation after cardiac death (DCD). In this article, we will try to elaborate the concept and outcomes of the use of ECMO in donation after cardiac death.

Toxic myocarditis is a less explored indication of extracorporeal life support (ECLS) in our country. We present a case of use of ECLS in severe left ventricular dysfunction induced by aluminum phosphide (ALP) poisoning. As refractory arrhythmias and myocardial failure have been established as the primary cause of death in ALP poisoning, ECLS can prove to be a useful adjunct to the supportive management.

The bidirectional Glenn's shunt (BDG) is the first step in the systematic, staged approach to a Fontan operation for patients with univentricular hearts. For the BDG to function well, the flow of blood through the pulmonary circulation must be free from significant impediments so that systemic venous pressure does not reach physiologically unacceptable levels. High systemic venous pressures are associated with high morbidity because of persistent bilateral pleural effusions and pericardial effusions, low oxygenation, increased plasma transfusion requirements, albumin infusions to maintain plasma protein levels, and prolonged ICU stay. We present a case of BDG complicated by prolonged pleural effusions in the immediate postoperative period, which was managed successfully using a percutaneous catheter-based approach, and thereby avoiding the complications of a major redo cardiac surgery.