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The transplant drama

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This document discusses organ procurement and transplantation procedures at the University of Minnesota. It provides details on evaluating and preparing donor organs, communicating with transplant teams, performing the organ harvest, and transporting organs. Key steps include evaluating donor cardiac and lung function, coordinating the procurement with recipient transplant teams, carefully removing the organs, and packing them for transport while maintaining acceptable ischemia times. The goal is to recover organs that are in good condition to be transplanted.

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The Transplant Drama N John Castro MD University of Minnesota Thoracic Transplant Programs
Disclosures • Consultant-Surgeon INOVATE HF
Organ Procurement University of Minnesota Thoracic Transplant Programs
Organ Procurement Organization and communication Behind the scenes Lifesource call: Blood type Age, sex, race, height, and weight Time of brain death mechanism of injury, thoracic trauma Pre hospital course: resuscitation, aspiration, intubation, joules PMHx: ETOH, drugs, smoking, HTN, diabetes, malignancy……. Serologies: hepatitis, HIV, CMV, syphilis
Organ Procurement Behind the scenes: Cardiac evaluation: Inotropes Hemodynamics and fluid status CVP Labs: troponin EKG ECHO Angiograms: men 35y, female 40y Acceptable ischemia times 4-5 hours for adults, 8 hours for infants
Organ Procurement Behind the scenes: Acceptable cardiac donors: Age: newborn to 60+ No history of active cardiac disease No history of severe thoracic trauma No prolonged CPR, hypotension, hypoxia Normal EKG Normal ECHO Inotrope < 10 mg/kg/h of dopa or dobuta with a CVP 8-12
Organ Procurement Behind the scenes: Lung evaluation: Oxygen challenge 100%/40% Vent settings CXR Sputum: gs/cx fungus Bronch Fluid status Acceptable ischemia time of 6-10
Organ Procurement Behind the scenes Acceptable lung donors: Age: newborn to 60+yrs No history of pulmonary disease No history of long term smoking >40py 100% FiO2 >300 PaO2, 40% FiO2 > 100 PaO2 normal serologies, normal paranchyma, acceptable oxygenation
Organ Procurement Organization and Communication Coordinator: Notifies patients and institutes travel plan Plans timing with lifesource coordinator Notifies admissions office and 6C/D Sets up OR and anesthesia times Notifies junior resident Clarifies immunosuppression orders and study patients Tracks down all charts, labs and x-rays Organizes fellows for donor run and OR Organizes transportation for donor run with Lifesource Verifies ABO and PRA
The transplant drama
The transplant drama
Organ Procurement The procurement site You represent the University of Minnesota Be polite The cardiac team needs to lead the coordinated effort of all the organ teams. Our organ must be removed first. We, with consideration of the other teams, need to set the cross clamp time.
Organ Procurement The Procurement Site Check the records: death note, blood type, all of the labs Check the films and angiograms Repeat the bronch at staff request Open the chest as soon as possible to inspect the organs Timing is everything, estimate cross clamp time Call transplant surgeon (1st call) Communicate plan with rest of procurement teams Keep an eye on anesthesia
Organ Procurement
Organ Procurement The Procurement Site Inspecting the organs Heart: contusions, coronary lesions, calcification, thrills, abnormal anatomy, pressure measurements Lungs: contusions, emboli, consolidated infection, bullae, lung trauma, masses
Organ Procurement
Organ Procurement The Procurement Site Preparing for cross clamp dissect completely the aorta, SVC, IVC, and PA loop the SVC place cannulation sutures in aorta and PA (prolene) open pleura widely dissect intra atrial groove Call transplant surgeon to confirm timing of cross clamp (2nd call)
Organ Procurement The Procurement Site Don’t forget to give the heparin Tie off SVC……stay away from the SA node Cut IVC…….keep an eye on the abdominal team Cross clamp and give plegia Cut off the tip of left atrium (even if we are not taking the lungs) Continue to ventilate the donor Cover heart and lungs with soft slush Suckers in the chest 2-3
Organ Procurement The Procurement Site Perfusion solution Cardiac Gopher cardioplegic solution (GCS) KCL 32.0 mEq/L bicarb 26 mEq/L Mannitol 13 gm/L Dextrose 10 mL of 50% Volume 1-2 liters for adults, 500-1000ml for children, and 250-500ml for infants Pressure bags set at 140 mm Hg
Organ Procurement The Procurement Site Perfusion solution Lung Perfadex and Prostaglandin Volume 60 ml/kg with pressure bag set at 140 mm/Hg
Organ Procurement The Procurement Site Don’t cut anything you can’t see Heart only: Divide SVC above tie Divide IVC Divide aorta at head and neck vessels Divide pulmonary artery at branches Open left atrium in the groove swing inferior, then up toward the appendage. Tip the heart superiorly and divide the roof of the left atrium Pack in container of iced saline solution, evacuate all air
Organ Procurement
Organ Procurement
Organ Procurement The Procurement Site Heart-lung block: Divide the SVC above the tie Divide the IVC Divide the aorta at the vessels Right lung divide the IPL, dissect posterior to the hilum in the pre esophageal plane Repeat on left side Inflate lungs staple trachea Pack in container of iced saline solution, evacuate all air
Organ Procurement Returning home Make sure to secure the cooler in the plane Have the Lifesource coordinator call the transplant surgeon or the U of M coordinator when you leave with the cross clamp time (3rd call) When you land, call the U of M coordinator or the OR (4th call) Accompany organs to the operating room to receive appropriate compliments on your surgical skills
The transplant drama
The transplant drama
The transplant drama
The transplant drama
Operative Techniques of Heart Transplantation Division of CVTS University of Minnesota
Recipient Set-UP • Reprogram PM or AICD • SG catheter to measure PAP • Prepare for groin cannulation in multiple redo or LVAD patients • TEE probe placement • CO2 tube in the operative field
Bypass Set-UP • Aortic cannulation as distal as possible, esp in previous CABGs and LVAD pts. • Bicaval cannulation at posterolateral cavoatrial junction, cava snares • Bypass initiation when donor heart lands in the airport • Cool to 28 to 30’ C • Aortic x-clamp when donor heart in OR
Recipient Cardiectomy
The transplant drama
The transplant drama
The transplant drama
The transplant drama
Recipient and Donor Heart Preparation • Trim the recipient cardiac chambers and great vessels based on the size of donor heart • Inspect donor cardiac chambers for debris or clots • Inspect PFO in donor heart • 400 cc retrograde cardiopleagia for donor heart
Implantation – biatrial anastomosis technique • Originally described by Lower and Shumway • 3-0 prolene sutures for both atrial anastomoses, 4-0 prolene sutures for both aorta and PA vessel anastomoses • Donor right atrial incision modified by Bernard
Left Atrial Anastomosis
Left Atrial Anastomosis
Atrial Conduction Pathways
Right Atrial Anastomosis
Right Atrial Anastomosis
PA Anastomosis
Aortic Anastomosis
Bicaval Anastomosis Technique • Described by Sarsam in 1993 • RA intact • LA shape preserved • Internodal conduction pathways preserved
Atrial Conduction Pathways
The transplant drama
The transplant drama
The transplant drama
The transplant drama
The transplant drama
The transplant drama
Biatrial vs Bicaval Anastomosis Techaniques • Biatrial: easy to perform, time tested technique, good long-term outcome for both cardiac function and patient survival. • Bicaval: less atrial rhythm disturbance, improved ECHO findings: smaller LA, RA; less TR, better atrial function; ? Shorter LOS, ? Less RV failure. Technically more challenge esp. in redo, AICD and LVAD pts, size mismatch, SVC stenosis • Lack of long-term study comparing both function and survivals in these two groups
The transplant drama
The transplant drama
The transplant drama
Technical Safeguards • Aggressive de-air measures. • Keep PA graft short to prevent kinking. • Keep Aortic graft long. • Enough reperfusion time for donor heart. • Double check anastomotic lines when partially supported by bypass
The transplant drama
The transplant drama
Lung Transplantation
History of Lung Transplantation • 1963 Hardy • 1963 – 1973 36 Patients Worldwide • 1973 – 1983 Hiatus • March 9, 1981 First Successful Heart-Lung Transplant • 1983 First Successful Single Lung Transplant Cooper in Toronto
Recipient Selection Guidelines • Clinically and physiologically severe disease • Medical therapy ineffective or unavailable • Substantial limitation in activities of daily living • Limited life expectancy • Adequate cardiac function without significant coronary artery disease • Ambulatory with rehabilitation potential • Acceptable nutritional status • Satisfactory psychosocial profile and emotional support system
Recipient Indications • Chronic Obstructive Pulmonary Disease – 36% • Antitrypsin – deficiency Emphysema – 7% • Cystic Fibrosis – 16% • Idiopathic Pulmonary Fibrosis – 21% • Primary Pulmonary Hypertension • Eisenmenger’s syndrome (with ASD or VSD) • Sarcoidosis • Occupational Lung Diseases • Interstitial Lung Disease Secondary to Chemotherapy or Radiation Therapy
Lung and Heart-Lung Donor Criteria • Conventional • ABO compatibility • Thoracic size match • Age less than 50 years (heart-lung) • Age less than 55 years (lung) • Normal troponin levels (heart-lung) • Lack of ventricular hypertrophy (heart-lung) • No history of respiratory disease • No significant smoking history
Lung and Heart-Lung Donor Criteria • No active pulmonary infection • No significant chest trauma or history of aspiration or cardiopulmonary resuscitation • No prior cardiac or pulmonary surgery • Short intubation time • Lack of purulent secretions; no gram-negative bacteria or fungi on gram stain • Clear chest X-ray without infiltrates • Challenge gas greater than 300mm Hg on 100% oxygen
Marginal Donors • Age over 55 years (lung) • Age over 50 years (heart-lung) • Tobacco history longer than 20 pack-years • Presence of infiltrate on chest X-ray • Donor ventilation time longer than 5 days • Donor use of inhaled drugs
Donor Operation • Check Chart Brain Dead, Blood Type, ABG • CXR • CT Scan • Bronchoscopy • Recruitment Measures • Serial ABGS • Pulmonary Vein Gases • Do no cut what you cannot see • Prostaglandin • Pneumoplegia • Gentle ventilation • Heart Excision after development of interatrial groove
Recruitment Maneuvers • Bronchoscopy • Diuresis • Bag lungs / Eviscerate as gently as possible • Peep 10 • Low dose Vasopressin 0.04
Recipient Operation • SLT • Older recipient • COPD or IPF • Groin available especially for LSLT • Amount of pulmonary hypertension • Snaring of PA or surgeon finger pinch • Patulous LA anastomosis
Recipient Operation • BSLT • Surgical Approaches • Bilateral transaxillary Toyoda at Pittsburgh • Bilateral posterolateral • Bilateral anterolateral Patterson at Wash U St. Louis • Clamshell • Use of CPB for left lung
CPB / ECMO • OR • Difficult Transport • Hemodynamically unstable • Unable to oxygenate • May have to crash on via femoral vessels, then position patient • Postoperatively Primary graft dysfucntion • Ischemia-reperfusion injury • Humoral rejection • Uncommon
Postoperative Resuscitation • Bicarbonate • Low dose epinephrine • Vasopressin • Neo • Levophed • FFP Avoid • Albumin • Dobutamine
Immunosuppression AZA and Prednisone RATG Cyclosporine OKT3 Cyclosporine, Prednisone, and AZA 1985 FK506 / Tacrolimus MMF Tacrolimus, Prednisone, and MMF Use of Induction Therapy
Registry 2009 Bilateral 69% of all lung transplants Survival 1994 – June 2007 89% at 3 months 79% at 1 year 64% at 3 years 52% at 5 years 29% at 10 years
Clinical Experience With a New Removable Tracheobronchial Stent in the Management of Airway Complications After Lung Transplantation S Fernandez-Bussy et al. JHLT July 2009 Between February 2007 and April 2008 24 patients underwent stent placement 49 stents were placed for 36 anastomoses at risk Airway complications in up to 27% of lung transplant recipients Indications: Bronchial stenosis 12 Bronchomalacia 12 Both 20 Partial bronchial dehiscence 5
Abdominal Complications after Lung Transplantation PC Smith et al. JHLT January/February 1995 January 1988 and July 1993 75 lung transplants Early Prolonged adynamic ileus (4) Diaphragmatic hernia after omental wrap (3) Ischemic bowel (2) Colitis with hemorrhage (1) Splenic injury after colonoscopy (1)
Abdominal Complications after Lung Transplantation PC Smith et al. JHLT January/February 1995 Colonic perforation (4) Late Cholilithiasis / choledocholithiasis (2) Mesenteric pseudoaneurysm (1) Fungal hepatic abscess (1) Intraabdominal hemorrhage (1)
Risk Factors For The Development of Bronchiolitis Obliterans Syndrome Acute Rejection Episodes Lymphocytic Bronchiolitis Cytomegalovirus Pneumonitis Medication Noncompliance Reperfusion Injury Bacterial Pneumonia Donor Antigen-Specific Reactivity Gastroesophageal Reflux Elevated Transforming Growth Factor-Beta Expression
Causes of Death First 30 days: Graft Failure Non-CMV Infections After First Year: BOS Non-CMV Infections Between 5 and 10 years: malignancy 12%
The transplant drama
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The transplant drama

  • 1. The Transplant Drama N John Castro MD University of Minnesota Thoracic Transplant Programs
  • 3. Organ Procurement University of Minnesota Thoracic Transplant Programs
  • 4. Organ Procurement Organization and communication Behind the scenes Lifesource call: Blood type Age, sex, race, height, and weight Time of brain death mechanism of injury, thoracic trauma Pre hospital course: resuscitation, aspiration, intubation, joules PMHx: ETOH, drugs, smoking, HTN, diabetes, malignancy……. Serologies: hepatitis, HIV, CMV, syphilis
  • 5. Organ Procurement Behind the scenes: Cardiac evaluation: Inotropes Hemodynamics and fluid status CVP Labs: troponin EKG ECHO Angiograms: men 35y, female 40y Acceptable ischemia times 4-5 hours for adults, 8 hours for infants
  • 6. Organ Procurement Behind the scenes: Acceptable cardiac donors: Age: newborn to 60+ No history of active cardiac disease No history of severe thoracic trauma No prolonged CPR, hypotension, hypoxia Normal EKG Normal ECHO Inotrope < 10 mg/kg/h of dopa or dobuta with a CVP 8-12
  • 7. Organ Procurement Behind the scenes: Lung evaluation: Oxygen challenge 100%/40% Vent settings CXR Sputum: gs/cx fungus Bronch Fluid status Acceptable ischemia time of 6-10
  • 8. Organ Procurement Behind the scenes Acceptable lung donors: Age: newborn to 60+yrs No history of pulmonary disease No history of long term smoking >40py 100% FiO2 >300 PaO2, 40% FiO2 > 100 PaO2 normal serologies, normal paranchyma, acceptable oxygenation
  • 9. Organ Procurement Organization and Communication Coordinator: Notifies patients and institutes travel plan Plans timing with lifesource coordinator Notifies admissions office and 6C/D Sets up OR and anesthesia times Notifies junior resident Clarifies immunosuppression orders and study patients Tracks down all charts, labs and x-rays Organizes fellows for donor run and OR Organizes transportation for donor run with Lifesource Verifies ABO and PRA
  • 12. Organ Procurement The procurement site You represent the University of Minnesota Be polite The cardiac team needs to lead the coordinated effort of all the organ teams. Our organ must be removed first. We, with consideration of the other teams, need to set the cross clamp time.
  • 13. Organ Procurement The Procurement Site Check the records: death note, blood type, all of the labs Check the films and angiograms Repeat the bronch at staff request Open the chest as soon as possible to inspect the organs Timing is everything, estimate cross clamp time Call transplant surgeon (1st call) Communicate plan with rest of procurement teams Keep an eye on anesthesia
  • 15. Organ Procurement The Procurement Site Inspecting the organs Heart: contusions, coronary lesions, calcification, thrills, abnormal anatomy, pressure measurements Lungs: contusions, emboli, consolidated infection, bullae, lung trauma, masses
  • 17. Organ Procurement The Procurement Site Preparing for cross clamp dissect completely the aorta, SVC, IVC, and PA loop the SVC place cannulation sutures in aorta and PA (prolene) open pleura widely dissect intra atrial groove Call transplant surgeon to confirm timing of cross clamp (2nd call)
  • 18. Organ Procurement The Procurement Site Don’t forget to give the heparin Tie off SVC……stay away from the SA node Cut IVC…….keep an eye on the abdominal team Cross clamp and give plegia Cut off the tip of left atrium (even if we are not taking the lungs) Continue to ventilate the donor Cover heart and lungs with soft slush Suckers in the chest 2-3
  • 19. Organ Procurement The Procurement Site Perfusion solution Cardiac Gopher cardioplegic solution (GCS) KCL 32.0 mEq/L bicarb 26 mEq/L Mannitol 13 gm/L Dextrose 10 mL of 50% Volume 1-2 liters for adults, 500-1000ml for children, and 250-500ml for infants Pressure bags set at 140 mm Hg
  • 20. Organ Procurement The Procurement Site Perfusion solution Lung Perfadex and Prostaglandin Volume 60 ml/kg with pressure bag set at 140 mm/Hg
  • 21. Organ Procurement The Procurement Site Don’t cut anything you can’t see Heart only: Divide SVC above tie Divide IVC Divide aorta at head and neck vessels Divide pulmonary artery at branches Open left atrium in the groove swing inferior, then up toward the appendage. Tip the heart superiorly and divide the roof of the left atrium Pack in container of iced saline solution, evacuate all air
  • 24. Organ Procurement The Procurement Site Heart-lung block: Divide the SVC above the tie Divide the IVC Divide the aorta at the vessels Right lung divide the IPL, dissect posterior to the hilum in the pre esophageal plane Repeat on left side Inflate lungs staple trachea Pack in container of iced saline solution, evacuate all air
  • 25. Organ Procurement Returning home Make sure to secure the cooler in the plane Have the Lifesource coordinator call the transplant surgeon or the U of M coordinator when you leave with the cross clamp time (3rd call) When you land, call the U of M coordinator or the OR (4th call) Accompany organs to the operating room to receive appropriate compliments on your surgical skills
  • 30. Operative Techniques of Heart Transplantation Division of CVTS University of Minnesota
  • 31. Recipient Set-UP • Reprogram PM or AICD • SG catheter to measure PAP • Prepare for groin cannulation in multiple redo or LVAD patients • TEE probe placement • CO2 tube in the operative field
  • 32. Bypass Set-UP • Aortic cannulation as distal as possible, esp in previous CABGs and LVAD pts. • Bicaval cannulation at posterolateral cavoatrial junction, cava snares • Bypass initiation when donor heart lands in the airport • Cool to 28 to 30’ C • Aortic x-clamp when donor heart in OR
  • 38. Recipient and Donor Heart Preparation • Trim the recipient cardiac chambers and great vessels based on the size of donor heart • Inspect donor cardiac chambers for debris or clots • Inspect PFO in donor heart • 400 cc retrograde cardiopleagia for donor heart
  • 39. Implantation – biatrial anastomosis technique • Originally described by Lower and Shumway • 3-0 prolene sutures for both atrial anastomoses, 4-0 prolene sutures for both aorta and PA vessel anastomoses • Donor right atrial incision modified by Bernard
  • 47. Bicaval Anastomosis Technique • Described by Sarsam in 1993 • RA intact • LA shape preserved • Internodal conduction pathways preserved
  • 55. Biatrial vs Bicaval Anastomosis Techaniques • Biatrial: easy to perform, time tested technique, good long-term outcome for both cardiac function and patient survival. • Bicaval: less atrial rhythm disturbance, improved ECHO findings: smaller LA, RA; less TR, better atrial function; ? Shorter LOS, ? Less RV failure. Technically more challenge esp. in redo, AICD and LVAD pts, size mismatch, SVC stenosis • Lack of long-term study comparing both function and survivals in these two groups
  • 59. Technical Safeguards • Aggressive de-air measures. • Keep PA graft short to prevent kinking. • Keep Aortic graft long. • Enough reperfusion time for donor heart. • Double check anastomotic lines when partially supported by bypass
  • 63. History of Lung Transplantation • 1963 Hardy • 1963 – 1973 36 Patients Worldwide • 1973 – 1983 Hiatus • March 9, 1981 First Successful Heart-Lung Transplant • 1983 First Successful Single Lung Transplant Cooper in Toronto
  • 64. Recipient Selection Guidelines • Clinically and physiologically severe disease • Medical therapy ineffective or unavailable • Substantial limitation in activities of daily living • Limited life expectancy • Adequate cardiac function without significant coronary artery disease • Ambulatory with rehabilitation potential • Acceptable nutritional status • Satisfactory psychosocial profile and emotional support system
  • 65. Recipient Indications • Chronic Obstructive Pulmonary Disease – 36% • Antitrypsin – deficiency Emphysema – 7% • Cystic Fibrosis – 16% • Idiopathic Pulmonary Fibrosis – 21% • Primary Pulmonary Hypertension • Eisenmenger’s syndrome (with ASD or VSD) • Sarcoidosis • Occupational Lung Diseases • Interstitial Lung Disease Secondary to Chemotherapy or Radiation Therapy
  • 66. Lung and Heart-Lung Donor Criteria • Conventional • ABO compatibility • Thoracic size match • Age less than 50 years (heart-lung) • Age less than 55 years (lung) • Normal troponin levels (heart-lung) • Lack of ventricular hypertrophy (heart-lung) • No history of respiratory disease • No significant smoking history
  • 67. Lung and Heart-Lung Donor Criteria • No active pulmonary infection • No significant chest trauma or history of aspiration or cardiopulmonary resuscitation • No prior cardiac or pulmonary surgery • Short intubation time • Lack of purulent secretions; no gram-negative bacteria or fungi on gram stain • Clear chest X-ray without infiltrates • Challenge gas greater than 300mm Hg on 100% oxygen
  • 68. Marginal Donors • Age over 55 years (lung) • Age over 50 years (heart-lung) • Tobacco history longer than 20 pack-years • Presence of infiltrate on chest X-ray • Donor ventilation time longer than 5 days • Donor use of inhaled drugs
  • 69. Donor Operation • Check Chart Brain Dead, Blood Type, ABG • CXR • CT Scan • Bronchoscopy • Recruitment Measures • Serial ABGS • Pulmonary Vein Gases • Do no cut what you cannot see • Prostaglandin • Pneumoplegia • Gentle ventilation • Heart Excision after development of interatrial groove
  • 70. Recruitment Maneuvers • Bronchoscopy • Diuresis • Bag lungs / Eviscerate as gently as possible • Peep 10 • Low dose Vasopressin 0.04
  • 71. Recipient Operation • SLT • Older recipient • COPD or IPF • Groin available especially for LSLT • Amount of pulmonary hypertension • Snaring of PA or surgeon finger pinch • Patulous LA anastomosis
  • 72. Recipient Operation • BSLT • Surgical Approaches • Bilateral transaxillary Toyoda at Pittsburgh • Bilateral posterolateral • Bilateral anterolateral Patterson at Wash U St. Louis • Clamshell • Use of CPB for left lung
  • 73. CPB / ECMO • OR • Difficult Transport • Hemodynamically unstable • Unable to oxygenate • May have to crash on via femoral vessels, then position patient • Postoperatively Primary graft dysfucntion • Ischemia-reperfusion injury • Humoral rejection • Uncommon
  • 74. Postoperative Resuscitation • Bicarbonate • Low dose epinephrine • Vasopressin • Neo • Levophed • FFP Avoid • Albumin • Dobutamine
  • 75. Immunosuppression AZA and Prednisone RATG Cyclosporine OKT3 Cyclosporine, Prednisone, and AZA 1985 FK506 / Tacrolimus MMF Tacrolimus, Prednisone, and MMF Use of Induction Therapy
  • 76. Registry 2009 Bilateral 69% of all lung transplants Survival 1994 – June 2007 89% at 3 months 79% at 1 year 64% at 3 years 52% at 5 years 29% at 10 years
  • 77. Clinical Experience With a New Removable Tracheobronchial Stent in the Management of Airway Complications After Lung Transplantation S Fernandez-Bussy et al. JHLT July 2009 Between February 2007 and April 2008 24 patients underwent stent placement 49 stents were placed for 36 anastomoses at risk Airway complications in up to 27% of lung transplant recipients Indications: Bronchial stenosis 12 Bronchomalacia 12 Both 20 Partial bronchial dehiscence 5
  • 78. Abdominal Complications after Lung Transplantation PC Smith et al. JHLT January/February 1995 January 1988 and July 1993 75 lung transplants Early Prolonged adynamic ileus (4) Diaphragmatic hernia after omental wrap (3) Ischemic bowel (2) Colitis with hemorrhage (1) Splenic injury after colonoscopy (1)
  • 79. Abdominal Complications after Lung Transplantation PC Smith et al. JHLT January/February 1995 Colonic perforation (4) Late Cholilithiasis / choledocholithiasis (2) Mesenteric pseudoaneurysm (1) Fungal hepatic abscess (1) Intraabdominal hemorrhage (1)
  • 80. Risk Factors For The Development of Bronchiolitis Obliterans Syndrome Acute Rejection Episodes Lymphocytic Bronchiolitis Cytomegalovirus Pneumonitis Medication Noncompliance Reperfusion Injury Bacterial Pneumonia Donor Antigen-Specific Reactivity Gastroesophageal Reflux Elevated Transforming Growth Factor-Beta Expression
  • 81. Causes of Death First 30 days: Graft Failure Non-CMV Infections After First Year: BOS Non-CMV Infections Between 5 and 10 years: malignancy 12%