title: Strategies to Prevent Cast Formation in Patients with Plastic Bronchitis Undergoing Heart Transplantation.
abstract: Plastic bronchitis, a rare complication after Fontan palliation, carries a high morbidity and mortality risk. Heart transplantation is an effective treatment option, but casts may occur in the early post-operative period. We present a case series detailing peri-operative management strategies to minimize morbidity and mortality related to plastic bronchitis in patients undergoing heart transplantation. Patient 1 received no treatment pre-, intra-, or post-transplant for prevention of bronchial casts and developed severe respiratory acidosis 18 h following transplant. Emergent bronchoscopy was performed and a large obstructive cast was removed. The patient recovered and received inhaled tissue plasminogen activator (tPA) for 5 days. Patient 2 received inhaled tPA before, during, and for 5 days after transplantation and no bronchial casts developed. Patient 3 underwent intraoperative bronchoscopy just prior to implantation revealing no casts. The patient underwent non-urgent, preemptive bronchoscopy on post-transplant days 1, 3, and 4, removing several partially obstructive bronchial blood clots/casts, with no casts thereafter. Heart transplantation results in eventual resolution of plastic bronchitis. Residual bronchial casts can still be problematic in the peri-operative period. Airway clearance with inhaled tPA or bronchoscopy may prevent the need for prolonged mechanical ventilation and reduce post-operative morbidity in this unique population.
authors.affiliation: Division of Pediatric Cardiology, Indiana University School of Medicine - Riley Hospital, Indiana University Health, 705 Riley Hospital Drive, RR 127, Indianapolis, IN, 46202, USA. jjparent@iu.edu.
authors.forename: John J
authors.initials: JJ
authors.lastname: Parent
authors.affiliation: Division of Pediatric Cardiology, Indiana University School of Medicine - Riley Hospital, Indiana University Health, 705 Riley Hospital Drive, RR 127, Indianapolis, IN, 46202, USA.
authors.forename: Robert K
authors.initials: RK
authors.lastname: Darragh
authors.affiliation: Division of Pediatric Cardiology, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, USA.
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Gossett
authors.affiliation: The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Ryan
authors.affiliation: The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
authors.forename: Chet R
authors.initials: CR
authors.lastname: Villa
authors.affiliation: The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
authors.forename: Angela
authors.initials: A
authors.lastname: Lorts
authors.affiliation: The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
authors.forename: John L
authors.initials: JL
authors.lastname: Jefferies
authors.affiliation: The Heart Institute, Le Bonheur Children's Hospital, Memphis, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Towbin
authors.affiliation: The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
authors.forename: Clifford
authors.initials: C
authors.lastname: Chin
mesh_terms: D000280:Administration, Inhalation; D000402:Airway Obstruction / Q000517:prevention & control / Q000628:therapy*; D001991:Bronchitis / Q000209:etiology / Q000628:therapy*; D001999:Bronchoscopy; D002648:Child; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage; D018729:Fontan Procedure / Q000009:adverse effects; D006330:Heart Defects, Congenital / Q000150:complications / Q000601:surgery*; D016027:Heart Transplantation; D006801:Humans; D008297:Male; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Fontan; Pediatric heart transplantation; Plastic bronchitis; Single ventricle