The use of intraoperative mechanical support during lung transplantation has traditionally been a controversial topic. Trends for intraoperative mechanical support strategies swing like a pendulum. Historically, cardiopulmonary bypass (CPB) was the modality of choice during transplantation. It provides full hemodynamic support including oxygenation and decarboxylation. Surgical exposure is improved by permitting the drainage of the heart and provides more permissive retraction. CPBs contain drainage reservoirs with hand-held pump suction catheters promoting blood conservation through collection and re-circulation. But CPB has its disadvantages. It is known to cause systemic inflammation and coagulopathy. CPB requires high doses of heparinization, which increases bleeding risks. As transplantation progressed, off-pump transplantation began to trend as a preferable option. ECMO, however, has many of the benefits of CPB with less of the risk. Outcomes were improved with ECMO compared to CPB. CPB has a higher blood transfusion requirement, a higher need for post-operative ECMO support, a higher re-intubation rate, high rates of kidney injury and need for hemodialysis, longer ICU stays, higher incidences of PGD grade 3, as well as overall in-hospital mortality when compared with ECMO use. The focus now shifts to using intraoperative mechanical support to protect the graft, helping to reduce ischemia-reperfusion injury and allowing for lung protective ventilator settings. Studies show that the routine use of ECMO during transplantation decreases the rate of primary graft dysfunction and many adverse outcomes including ventilator time, need for tracheostomy, renal failure, post-operative ECMO requirements, and others. As intraoperative planned ECMO is considered a safe and effective approach, with improved survival and better overall outcomes compared to both unplanned ECMO implementation and off-pump transplantation, its routine use should be taken into consideration as standard protocol.

Provided advancements in Lung Transplantation (LT) survival, the efficacy of Lung Retransplantation (LRT) has often been debated. Decades of retrospective analyses on thousands of LRT cases provide insight enabling predictive patient criteria for retransplantation. This review used the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines. The PubMed search engine was utilized for articles relating to LRT published through August 2023, and a systematic review was performed using Covidence software version 2.0 (Veritas Health Innovation, Australia). Careful patient selection is vital for successful LRT, and the benefit leans in favor of those in optimal health following their initial transplant. However, the lack of a standardized approach remains apparent. Through an in-depth review, we will address considerations such as chronic lung allograft dysfunction, timing to LRT, surgical and perioperative complexity, and critical ethical concerns that guide the current practice as it relates to this subset of patients for whom LRT is the only therapeutic option available.

Introduction: The optimal treatment for Secondary Pulmonary Hypertension from End-Stage Lung Disease remains controversial. Double Lung Transplantation is widely regarded as the treatment of choice as it eliminates all diseased parenchyma and introduces a large volume of physiologically normal allograft. By comparison, the role of single lung transplantation for pulmonary hypertension (PAH) is less clear. The remaining diseased lung will limit clinical improvements and permit downstream sequelae; including residual cough, recurrent infection, and continued pulmonary hypertension. But not every patient can undergo DLT. Advanced age, frailty, co-morbid conditions, and limited availability of organs will all affect surgical candidacy and can offset the benefits of double lung procedures. Studies that compare SLT and DLT do not commonly explore the utility of single lung procedures even though multiple theoretical advantages exist; including reduced waiting times, less waitlist mortality, fewer surgical complications, and lower operative mortality. Worse, multiple forms of publication and selection bias may favor DLT in registry-based studies. In this review, we present the prevailing literature on single and double lung transplants in patients with secondary pulmonary hypertension and clarify the potential utility of these procedures. Materials and Methods: A PubMed search for English-language articles exploring single and double lung transplants in the setting of secondary pulmonary hypertension was conducted from 1990 to 2023. Key words included “single lung transplant”, “double lung transplant”, “pulmonary hypertension”, “rejection”, “complications”, “extracorporeal membranous oxygenation”, “death”, and all appropriate Boolean operators. We prioritized research from retrospective studies that evaluated clinical outcomes from single centers. Conclusions: The question is not whether DLT is better at resolving lung disease; instead, we must ask if SLT is an acceptable form of therapy in a select group of high-risk patients. Further research should focus on how best to identify recipients that may benefit from each type of procedure, and the clinical utility of perioperative VA ECMO.

Background: The Martini and Melamed criteria for diagnosing multiple primary lung cancers (MPLCs) have remained in use for half a century despite substantial changes in lung cancer epidemiology, risk factors, imaging technologies, and treatment approaches. Correspondingly, the landscape of MPLC has likely changed, necessitating revisions to their diagnostic guidelines. Research Question: What are the clinicopathologic profiles of modern-day MPLC patients, and can these features be used to identify a subset of patients classified as MPLC that may warrant additional investigation as intrapulmonary metastasis (IPM)? Study Design and Methods: We conducted a retrospective cohort study using electronic medical record data from patients who underwent multiple lung cancer resections at Mount Sinai Hospital. Patient demographics, tumor characteristics, and surgical treatments were compared with those reported in the original Martini and Melamed series. We then proposed a reclassification framework incorporating a CT-based assessment of synchronous versus metachronous tumors and contemporary clinicopathologic features documented in imaging and pathology reports. Results: Ninety-one patients underwent successive lung cancer resections. Among first nodules treated with surgical resection, 46% exhibited pathologic features suggestive of metastasis within the lung, including visceral pleural invasion (18%), vascular invasion (24%), lymphatic invasion (36%), and/or lymph node positivity (3%). In contrast, among second nodules (second temporal surgery), 45% demonstrated ground-glass opacity (GGO) supportive of a diagnosis of MPLC. Using the original criteria, 83 patients (91%) were classified as having MPLC; this proportion decreased to 53 patients (58%) under the reclassification criteria. Regardless of the criteria applied, contemporary MPLCs were more likely to occur in older patients, women, those with adenocarcinoma histology, and treated with sublobar resections compared with MPLCs described in the Martini and Melamed era. Conclusions: MPLCs are increasingly recognized, and their clinical presentation has changed substantially over time. Modern imaging and pathologic assessment may be useful tools for diagnosing MPLCs, but this requires future validation. This has important implications for staging and treatment decision-making, as patients may be undertreated by not being offered multimodal treatments or over-treated with systemic therapy when surgery alone may be sufficient.