Lung transplantation (LT) plays an important role in improving the quality of life (QoL) for select patients with end-stage lung diseases and who are already dependent on supplemental oxygen or mechanical ventilation. The goal of any LT program is to improve QoL. Like QoL, HRQoL is multidimensional by definition and encompasses domains including symptoms, physical functioning, cognitive performance, psychosocial conditions, emotional status, and adaptation to disease, among others. HRQoL improvements after LT relative to their pretransplant HRQoL measures, and these improvements are sustained over long-term follow-up. The pulmonary function of transplant recipients is affected by pretransplant factors, operative factors (pleural or diaphragmatic injury), and post-transplant complications (bronchial strictures). In the first weeks after LT, pulmonary function is hampered by various factors including pain and early graft dysfunction, and the peak in pulmonary function is in general observed between 3 and 12 months following LT.

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 is an established therapeutic procedure for end stage lung diseases. Especially in cases of PF-ILD, patients can be referred to the transplant centre late and with significant comorbidities. PH associated with PF-ILD is an index of poor outcome and also is an indication for bilateral transplantation. Prevalence, severity and factors associated with PH among IPF v/s non-IPF is unknown. Objectives: To determine whether prevalence, severity and factors determining the pulmonary hypertension among IPF and Non-IPF is different. Methods: We conducted a retrospective observational study. We analysed Right Heart catheterisation studies, demographic data, Pulmonary function tests in a series of patients with diagnosed PF-ILD who underwent successful lung transplantation from 2020 to 2022. Results: We included 61 patients in the study(20 with IPF &41 with Non-IPF);Prevalence of PH was higher in the Non-IPF group(51.28%v/s48.7%,p-value<0.0001)whereas severity with IPF group(40%v/s 9.8%,p-value=0.005). Patients with 6MWT distance of <90m has severe PH (90m v/s 170m, p-value=0.007) whereas patients with walk distance of >180 meter did not have any PH(130m v/s 180m, p-value=0.009). Conclusion: Patients with Non-IPF diagnosis has higher prevalence of PH and IPF patients has more severe PH among PF-ILD. 6MWT is a good indicator of presence and severity of PH. References: Shorr AF, Wainright JL, Cors CS, et al. Pulmonary hypertension in patients with pulmonary fibrosis awaiting lung transplant. Eur Respir J 2007; 30: 715–721. Abbreviations: 6MWT-Six minute walk test, PH-Pulmonary hypertension, IPF-idiopathic pulmonary fibrosis

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.

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.

Aim: To study the effectiveness and safety of mycophenolate mofetil (MMF) in patients with connective tissue disease (CTD) associated interstitial lung disease (ILD). Methods: The retrospective observational study was carried out from Jan 2015 to Feb 2019. Symptomatic CTD-LD patients with (HRCT chest) documented ILD and abnormal pulmonary function test (forced vital capacity, FVC< 70%), who were treated with MMF were included. The treatment response was assessed clinically by pulmonary function test and radiology. Clinical assessment and PFT were done at baseline, 6, 12 and 24 months. HRCT chest was done at baseline and 24 months. Results and analysis: Out of 33 patients, 13 had MCTD, 12 had RA, and remaining 8 belonged to the systemic sclerosis (SSc)-predominant groups (3: diffuse cutaneous SSc, 2: SSc/myositis overlap, and 1 each with Sjogren’s syndrome, SLE/Sjogren’s overlap and interstitial pneumonia with autoimmune features). Increased female predominance was noted (90.9%). The mean FVC at baseline noted in MCTD, RA and SSc-predominant groups were 62±6.17, 64±4.17 and 59±6 respectively. Improvement was reported in 4 patients, each in MCTD and RA groups. Eight patients in the MCTD group and 7 each in RA and SSc- predominant groups had a stable lung disease. One patient each in all the groups reported worsening of the disease. There was a positive trend in FEV1 and FVC with treatment. No significant difference in FEV1 and FVC values with treatment was noted across the three groups. Numerical differences in the mean values of FEV1 and FVC between two groups (NSIP and UIP) were noted, but was not statistically significant. All the subjects completed 24 months of follow-up. They were on 2 g/day of MMF for the first 12 months, followed by a maintenance of 1.5- 2 g/day for the next 12 months. None of the subjects discontinued treatment due to intolerance or adverse effects.

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.

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 emergence of COVID-19 has impacted heart transplantation worldwide. The pandemic has impacted donor availability and also raised issues of safety of receipients and surgical teams. In these recommendations, the Indian Society of Heart and Lung Transplantation (INSHLT) has discussed the issues related to the testing and safety issues related to the donor and the recipient as well as the surgical teams. The INSHLT recommends COVID-19 testing once consent for organ donation is obtained of both the donor and the receipient. The INSHLT also recommends high-resolution computed tomography of the chest before organ donation, especially for lung donation.

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: Limited data exists regarding the burden and management of rare diseases like pulmonary alveolar microlithiasis (PAM) from developing countries. Improved access to lung transplantation in India in recent times has proved to be an advantage in the management of these patients. Methods: We present 3 cases of PAM, two of them had severe disease and ended up undergoing bilateral lung transplantation. The third patient, a young female, has a relatively milder disease and is currently on follow up. Cases: The first patient is a 54-year-old female who presented with progressive dyspnoea and eventually became oxygen and NIV dependent. She had severe restrictive defect on spirometry and raised PASP 80 mm Hg on echocardiography. Our second patient is a 25-year-old male presenting with recurrent spontaneous pneumothorax. Over 2 years of follow up, he became progressively dyspnoeic and oxygen dependent. Both the patients underwent bilateral lung transplantation and have returned to pre-disease lifestyle with no complications till recent follow up. The third patient is a sibling of our male patient of PAM and is likely suffering from a less severe genetic variant of PAM. She has radiological features suggestive of PAM and is asymptomatic with mild restriction on spirometry and is currently under follow up. We plan to list her for transplant if she deteriorates clinically. Conclusion: Our cases exhibit the heterogeneity in presentation and clinical course along with a familial predisposition of PAM in our population. It should also be emphasized that increased awareness and early referral to lung transplantation in presence of recurrent infections and pneumothorax is definitely life saving.

The science of lung transplantation has evolved from an experimental procedure, to be accepted as a legitimate mainstream therapy for patients with end-stage pulmonary disease.Now lung transplantation offers patients with end-stage lung disease acceptable quality of life and matches a 5-year survival rate of other solid organ transplants.In the present report, we present our initial experience in performing two single lung transplantations done in our centre.