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Pericardial fat has been associated with metabolic risk factors and the severity of coronary artery disease&#44; through the release of pro-inflammatory mediators&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> In addition&#44; it has been suggested that higher volumes of epicardial fat tissue are associated with the severity of sclerodermia&#44; regardless of other risk factors of cardiovascular disease or pulmonary fibrosis&#44; hypothesizing that the proximity of the mediastinal fat to the pulmonary artery may exert pro-inflammatory effects contributing to disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Translating this into the patient with IPF&#44; we hypothesized that anterior mediastinal fat &#40;AMF&#41; may have an influence in the prognosis of the disease&#44; irrespective of the changes in the pulmonary parenchyma&#46; We then sought to determine whether the amount of AMF in fibrotic patients&#44; candidates for LT&#44; could be used as a surrogate marker of severity of disease&#44; and therefore predict poor outcomes after the transplant procedure&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design</span><p id="par0030" class="elsevierStylePara elsevierViewall">The medical records from the pulmonary transplantation database of 360 LT patients transplanted between January 2009 and November 2018 at our Institution were retrospectively reviewed&#46; Ninety-two patients with pulmonary fibrosis receiving a single lung transplant from brain-death donors were selected for the study &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Fibrotic patients fulfilled the general accepted criteria for lung transplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> Patients were divided into two groups according to the amount of AMF volume&#44; calculated on the basis of radiological measurements obtained from the preoperative chest CT-scan&#58; low-AMF &#40;volume &#60;20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41; and high-AMF &#40;volume &#62;20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41;&#46; The present study followed the WMA Declaration of Helsinki-Ethical Principles for Medical Research involving human subjects&#46; All patients signed the Informed Consent at the time of inclusion in waiting list and our Institutional Review Board approved this study&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Lung transplantation procedure</span><p id="par0035" class="elsevierStylePara elsevierViewall">Lungs were retrieved from brain death donors using our standard protocol of cardiopulmonary harvesting previously reported&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> Either a right or left single LT was performed in all cases through a standard posterolateral thoracotomy or through an anterior thoracotomy&#46; The surgical procedure and the postoperative standard of care for LT recipients were performed as previously reported by our Institution&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Imaging analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">A pre-transplant chest CT-scan with intravenous contrast was performed in all patients&#44; as part of the routine assessment of LT candidates&#46; Scans were obtained at 10<span class="elsevierStyleHsp" style=""></span>mm intervals in the supine position at end inspiration&#46; The CT scan Digital Imaging Communications in Medicine &#40;DICOM&#41; format was used for assessment of axes and AMF volume&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A standardized manual tracing on the chest CT-scan was performed by two independent readers&#44; blinded to each other&#46; The radiological measurements of AMF included&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Anteroposterior axis &#40;AP&#41;&#58; from the posterior wall of sternum to the anterior wall of pulmonary artery&#44; measured in the CT-axial plane &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Transverse axis &#40;<span class="elsevierStyleItalic">T</span>&#41;&#58; distance between both mediastinal pleurae&#44; obtained at the same level of AP axis&#44; and measured in the CT-axial plane &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Height &#40;<span class="elsevierStyleItalic">H</span>&#41;&#58; from posterior wall of the sternal notch to the main pulmonary artery trunk&#44; measured in the sagittal plane &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">AMF volumes &#40;<span class="elsevierStyleItalic">V</span>&#41; were calculated by using the formula&#58; AP<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">T</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">H</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3&#46;14&#47;6&#44; following a similar method to calculate prostatic volumes&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Data collection</span><p id="par0070" class="elsevierStylePara elsevierViewall">Donor data included those variables required to define optimal vs&#46; extended donors&#46; Recipient preoperative data included&#58; age&#44; gender&#44; need of ventilation at the time of LT&#44; body mass index &#40;BMI&#41;&#44; mean pulmonary artery pressure measured at induction of anaesthesia through a Swan-Ganz catheter&#44; Lung Allocation Score &#40;LAS&#41; calculated at the time of LT as a surrogate marker of severity of illness&#44; and radiological measurements of AMF &#40;AP axis&#44; transverse axis&#44; height and volume&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Surgical and immediate postoperative data included&#58; use of intraoperative extracorporeal life support &#40;ECLS&#41; &#40;CPB or ECMO&#41;&#44; ischaemic time&#44; duration of mechanical ventilation&#44; primary graft dysfunction &#40;PGD&#41; at 72<span class="elsevierStyleHsp" style=""></span>h post-transplant&#44; ICU stay&#44; and 30-day mortality&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Late postoperative data included&#58; overall mortality&#44; airway complications&#44; and survival&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Lung Allocation Score was calculated by using the Eurotransplant LAS calculator &#40;<a href="http://www.eurotransplant.org/">www&#46;eurotransplant&#46;org</a>&#44; accessed&#58; December 5&#44; 2018&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Definitions</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients were diagnosed of idiopathic pulmonary fibrosis based on a pathological pattern of usual interstitial pneumonia and&#47;or the presence of a typical radiological pattern on a high resolution CT-scan&#46; In the absence of typical radiological findings&#44; a lung biopsy was performed in all cases&#44; excluding those patients with other interstitial lung diseases&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Recipients were considered on preoperative steroid therapy when receiving steroids at doses above 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg for 30 days just before transplantation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Extended donors were defined as those having&#44; at least&#44; two of the following criteria&#58; &#40;1&#41; age &#62;55 years&#44; &#40;2&#41; PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span> &#60;350<span class="elsevierStyleHsp" style=""></span>mmHg on 100&#37; oxygen with 5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O positive end-expiratory pressure&#44; &#40;3&#41; pulmonary infiltrates on chest radiograph&#44; &#40;4&#41; presence of purulent secretions on bronchoscopy&#44; &#40;5&#41; ischaemic times &#62;9<span class="elsevierStyleHsp" style=""></span>h&#44; and &#40;6&#41; tobacco history greater than 20 pack-years&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Primary graft dysfunction &#40;PGD&#41; was defined following the Statement of ISHLT&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> PGD grades 2&#8211;3 at 72<span class="elsevierStyleHsp" style=""></span>h post-transplant were included in the analysis&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Airway complication was defined as a finding of dehiscence&#44; stenosis&#44; or malacia of the anastomosis requiring either intervention &#40;surgery&#44; dilatation&#44; debridement&#44; laser therapy or stent placement&#41; or only conservative measures&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Urgent lung transplants were defined as those performed in candidates listed for transplant with rapid clinical deterioration requiring preoperative invasive mechanical ventilation at the time of the procedure&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical analysis</span><p id="par0120" class="elsevierStylePara elsevierViewall">The inter-reader agreement of radiological measurements was assessed by the Pearson correlation of the means of the two readers&#44; and by the intra-assay coefficient of variation&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">30-Day mortality and survival were compared by univariable and multivariable analyses &#40;logistic regression and Cox models&#41; adjusting for recipient age&#44; LAS&#44; BMI&#44; use of extended donor&#44; use of ECLS&#44; ischaemic time&#44; and PGD&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">A univariable analysis comparing low AMF vs&#46; high AMF was performed first&#58; either Pearson&#39;s <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> or Fisher&#39;s exact test was used&#44; when appropriate&#44; to assess differences between categorical variables&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Unpaired <span class="elsevierStyleItalic">t</span>-test was used to compare means between two quantitative variables from normally distributed data&#44; and Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test for non-normally distributed data&#46; Given the large sample size of the study population&#44; we assumed homogeneous variances and normal distribution in most of the analyses&#46; We used parametric tests when more than 30 cases for each group were compared and non-parametric tests when less than 30 cases for each group were compared&#46; Pre-tests for normality were not performed&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The relationship between radiological measurements and some demographic and functional variables was assessed by the Pearson correlation coefficient&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Survival was analyzed and compared using the Kaplan&#8211;Meier method and log-rank test&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">To determine independent predictors of mortality&#44; those variables exhibiting <span class="elsevierStyleItalic">p</span> values below 0&#46;1 in the univariable analyses entered into a multivariable Cox-regression analysis &#40;forward stepwise likelihood ratio&#41;&#46; Those variables with <span class="elsevierStyleItalic">p</span> values below 0&#46;05 in the final model were judged to be independent predictors of mortality&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Continuous variables are expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&#46; Categorical variables are expressed as counts and proportions with 95&#37; confidence intervals &#40;95&#37; CI&#41;&#46; Differences with <span class="elsevierStyleItalic">p</span> values &#60;0&#46;05 were considered significant&#46; The statistical analysis was performed using SPSS &#40;SPSS 20&#46;0 for Mac&#58; SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Overall patient series</span><p id="par0160" class="elsevierStylePara elsevierViewall">There were 92 patients&#44; 73 males &#40;79&#37;&#41;&#44; and 19 females &#40;21&#37;&#41;&#44; 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 &#91;14&#8211;68&#93; years old&#46; Twenty-eight patients &#40;30&#37;&#41; were under preoperative steroid therapy&#46; Overall AMF measurements were&#58; AP 22<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10 &#91;7&#8211;65&#93;<span class="elsevierStyleHsp" style=""></span>mm&#44; <span class="elsevierStyleItalic">T</span> 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28 &#91;7&#8211;150&#93;<span class="elsevierStyleHsp" style=""></span>mm&#44; <span class="elsevierStyleItalic">H</span> 33<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 &#91;9&#8211;70&#93;<span class="elsevierStyleHsp" style=""></span>mm&#44; <span class="elsevierStyleItalic">V</span> 31&#46;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38&#46;54 &#91;4&#46;61&#8211;274&#46;75&#93;<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#46; AMF measurements did not differ by gender or preoperative steroid therapy&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">General data of the patient series are depicted in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Inter-reader agreement</span><p id="par0170" class="elsevierStylePara elsevierViewall">The inter-reader agreement for radiological measurements was excellent&#44; both by Pearson coefficients of correlation &#40;AP axis&#58; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;98&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; <span class="elsevierStyleItalic">T</span> axis&#58; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;94&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; height&#58; <span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;97&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; and intra-assay coefficients of variation &#40;AP axis&#58; 0&#46;08&#59; <span class="elsevierStyleItalic">T</span> axis&#58; 0&#46;06&#59; height&#58; 0&#46;12&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Comparative analysis between right and left lung transplants</span><p id="par0175" class="elsevierStylePara elsevierViewall">To elucidate whether the side of LT could affect overall outcomes&#44; we compared right and left LT by univariate analysis&#46; No differences were observed when right or left lungs were transplanted&#46; Sixty-six patients underwent a right LT &#40;60&#37;&#41; and 26 underwent a left LT &#40;40&#37;&#41;&#46; Age &#40;right vs&#46; left LT&#41;&#58; 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 vs&#46; 52<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1 years&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;64&#46; Ischaemic time &#40;right vs&#46; left LT&#41;&#58; 312<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>63 vs&#46; 315<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>65<span class="elsevierStyleHsp" style=""></span>min&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;89&#46; Thirty-day mortality &#40;right vs&#46; left LT&#41;&#58; 15 &#40;23&#37;&#41; vs&#46; 5 &#40;19&#37;&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;47&#46; Primary graft dysfunction &#40;right vs&#46; left LT&#41;&#58; 6 &#40;9&#37;&#41; vs&#46; 0&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#46; High&#47;low AMF &#40;right vs&#46; left LT&#41;&#58; 31&#47;35 vs&#46; 16&#47;10&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;15&#46; Need of ECLS &#40;right vs&#46; left LT&#41;&#58; 12 &#40;18&#37;&#41; vs&#46; 5 &#40;19&#37;&#41;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;56&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Relationship between AMF volume and demographic and functional parameters</span><p id="par0180" class="elsevierStylePara elsevierViewall">Although the amount of AMF could be influenced by some factors such as nutritional status&#44; loss of respiratory function or recipient age&#44; on a preliminary analysis&#44; we did not observe a significant correlation between AMF volume and BMI &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;12&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;27&#41;&#44; or AMF volume and FVC &#40;&#37;&#41; &#40;<span class="elsevierStyleItalic">r</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;14&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;45&#41;&#46; Although there was a trend towards more AMF volume in older recipients&#44; this correlation was not significant &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Relationship between AMF volume and recipient perioperative factors</span><p id="par0185" class="elsevierStylePara elsevierViewall">AMF volumes did not differ between those patients receiving preoperative steroids &#40;27&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#46;3<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#59; 95&#37; CI&#58; 22&#46;5&#8211;33&#46;1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41; and those who did not &#40;35&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>52&#46;1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#59; 95&#37; CI&#58; 24&#46;5&#8211;45&#46;7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41;&#46; In addition&#44; no differences in AMF volumes were observed in patients requiring urgent LT or those developing bronchial complications &#40;data not shown&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">On the contrary&#44; it is noteworthy that those patients developing PGD at 72<span class="elsevierStyleHsp" style=""></span>h post-transplant&#44; and those dying within 30 days post-transplant presented significant higher volumes of AMF pre-transplant &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; These differences remained significant when grouping patients into low AMF volume and high AMF volume&#58; 15 patients with high AMF died within 30 days post-transplant&#44; as opposed to only 5 patients in the low-AMF group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46; In addition&#44; the high AMF group required more frequently ECLS than the low-AMF group&#46; Finally&#44; in the high-AMF group&#44; there was a tendency to be male&#44; older patients&#44; and with longer ischaemic times &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Analysis of 30-day mortality</span><p id="par0195" class="elsevierStylePara elsevierViewall">Focusing on potential causes of 30-day mortality in an unadjusted analysis&#44; we observed that patients dying within 30 days post-transplant were those in poor clinical condition&#44; with low BMI and higher LAS&#44; requiring an urgent LT under ECLS &#40;with longer ischaemic times&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Survival</span><p id="par0200" class="elsevierStylePara elsevierViewall">A significant worse post-transplant survival was observed in patients with higher AMF volumes&#46; Actuarial survival for low-AMF patients was 85&#37;&#44; 81&#37;&#44; and 78&#37; at 1&#44; 3&#44; and 5 years respectively&#44; with a median survival of 8&#46;3 years&#46; On the contrary&#44; actuarial survival for high-AMF patients was 55&#37;&#44; 40&#37;&#44; and 33&#37; at 1&#44; 3&#44; and 5 years respectively&#44; with a median survival of 2&#46;5 years &#40;<span class="elsevierStyleItalic">p</span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>A&#41;&#46; When we analyzed the survival&#44; conditional to survive 30 days&#44; these differences remained significant&#58; 95&#37;&#44; 91&#37;&#44; 88&#37; at 1&#44; 3&#44; and 5 years in the low-AMF group vs&#46; 81&#37;&#44; 59&#37;&#44; 49&#37; at 1&#44; 3&#44; and 5 years in the high-AMF group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Predictive factors of 30-day mortality and survival</span><p id="par0205" class="elsevierStylePara elsevierViewall">Factors predicting 30-day mortality were BMI &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;77&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;011&#41;&#44; AMF volume &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;04&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#41;&#44; ECLS &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;42&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; and ischaemic time &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Factors predicting survival were AMF volume &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;02&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; ECLS &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;17&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; and ischaemic time &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Discussion</span><p id="par0215" class="elsevierStylePara elsevierViewall">In the present study&#44; we were able to demonstrate that the AMF volume in IPF patients may play a role in predicting poor outcomes after LT&#46; Patients with high AMF volumes presented more 30-day mortality and poorer survival than those with low AMF volumes&#44; both in univariable and multivariable analyses&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first report aiming to analyze the volume of mediastinal fat tissue in fibrotic patients and its potential use as a surrogate marker of severity of disease&#44; and therefore&#44; as an individual risk factor in patients undergoing LT&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">For the purposes of this study&#44; we selected a homogeneous group of IPF patients undergoing single LT&#46; Even though bilateral LT have demonstrated better survival than single LT in IPF&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> in our Centre&#44; most of fibrotic patients underwent single procedures on the basis of optimizing the scarcity of donor resources&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">Parenchymal radiological findings of the chest CT scan play an essential role in the initial assessment and disease progression&#46; On the other hand&#44; some extraparenchymal radiological findings have been proposed as factors related to poor prognosis in IPF patients&#46; Tanizawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a> reported poor outcomes of LT in patients with pleuroparenchymal fibroelastosis&#46; Others have suggested that an increased amount of AMF and lymph node enlargement are associated to IPF progression&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> but current clinical guidelines do not include them as diagnostic or prognosis factors&#46; For this reason&#44; we hypothesized that an increased amount of AMF could be a predicting factor of post-transplant outcomes in IPF patients&#44; by making a simple measurement in the preoperative chest CT scan&#46; The calculation of AMF volume was obtained by using the formula widely used and validated for calculation of volumetric values in other organs&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Several factors&#44; such as coronary artery disease&#44; gastroesophageal reflux&#44; telomerase disorder&#44; and pulmonary hypertension have been associated with a poorer prognosis after LT in IPF patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2&#44;3&#44;15</span></a> In addition&#44; older recipients&#44; low exercise capacity&#44; poor functional parameters&#44; and high oxygen needs are additional risk factors&#46; To deal with an accurate method of patient severity of illness&#44; we used the LAS score&#44; calculated at the time of transplantation&#44; to establish a composite value of severity of illness that includes&#44; age&#44; gender&#44; anthropometric data&#44; diabetes&#44; ventilation needs&#44; forced vital capacity&#44; pulmonary artery pressures&#44; PCO<span class="elsevierStyleInf">2</span> changes&#44; 6-min walk distance and serum creatinine&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> In our Centre&#44; LAS score is not used to establish a priority on waiting list for LT&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">In our series&#44; higher AMF volumes did not correlate with BMI values&#44; steroid therapy or age&#44; although there was a trend to higher AMF volumes in older recipients &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; These findings might suggest that AMF changes in fibrotic patients are not influenced by these factors&#44; although opposite findings have been reported regarding the development of AMF in patients receiving high doses of steroids&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> Regarding novel antifibrotic treatments of IPF&#44; there is no evidence that nintedanib and pirfenidone could alter body fat distribution&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> In the present series&#44; a few numbers of patients were given antifibrotics and thus&#44; this parameter was not included in the analysis&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Although it has been suggested an association between AMF and IPF severity&#44; by a negative correlation with FVC and DLCO&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> we did not observe such a relationship&#44; possibly due to the subtle differences on AMF volumes and its small influence on lung volumes in the present series&#46; Therefore&#44; we could not demonstrate a fat substitution as a consequence of the lung loss of volume and elastic recoil in end-stage IPF patients&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Compared with other indications&#44; IPF presents the worst early and long-term outcomes after LT&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> In the present series&#44; patients dying within 30 days post-transplant were those in poor general condition&#44; with low BMI&#44; higher LAS&#44; ventilated patients and need of ECLS &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; These are well known risk factors that have been documented in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;19</span></a> To note that only 3 patients in the group of high AMF volume underwent CPB &#40;6&#37;&#41;&#44; as opposed to 27 patients undergoing ECMO &#40;94&#37;&#41; and none of CPB patients died within 30 days&#46; Potential subtle biases by grouping these methods of ECLS might be minimized by the low number of patients under CPB&#46; In the present series&#44; we also observed that LT patients with higher AMF volumes presented more PGD episodes and higher rates of 30-day mortality&#44; which suggest that AMF may be an additional risk factor of early pulmonary dysfunction and subsequent early mortality post-transplantation&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">To sustain this observation&#44; the adjusted risk model for 30-day mortality confirmed that AMF volume was independently associated to early mortality&#44; in addition to other well-known risk factors such as BMI&#44; need of ECLS or ischaemic times&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;18</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">IPF patients with high AMF volumes presented less survival than those with low AMF volumes&#46; These differences might be influenced by other confounding factors such as higher LAS&#44; PGD&#44; longer ischaemic times or the need of ECLS&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> However&#44; after the exclusion of those recipients dying within 30 days post-transplant&#44; the differences remained significant&#46; In addition&#44; the AMF volume remained an independent predictor&#44; as well as other risk factors such as the need of ECLS or longer ischaemic times&#46; It is possible that patients with higher AMF volumes were those in poor general condition&#44; requiring preoperative ventilation&#44; intraoperative ECLS&#44; with longer ischaemic times&#44; and developing PGD more frequently post-transplantation&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">The mechanisms involved in the possible deleterious effects of AMF on LT outcomes are unknown&#46; It has been well documented that visceral abdominal and epicardial fat are related with the pathogenesis of cardiovascular and systemic adverse events through the release of pro-inflammatory mediators by different mechanisms&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5&#44;19</span></a> On one hand&#44; abdominal mesenteric fat has a circulatory communication path to the liver via the portal circulation and it has been thus associated with hepatic production of inflammatory factors&#46; On the other hand&#44; intrathoracic and pericardial fat depots are substantially smaller than abdominal fat and are unlikely to release substances that could be detected systemically&#46; Therefore&#44; their role is more likely to be paracrine via their local effect on inflammation in the underlying tissue&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Accordingly&#44; it has been postulated that the close proximity of the epicardial fat tissue to the heart and vessels and the lack of a physical barrier between these structures allow for diffusion of pro-inflammatory cytokines that could play role in the development of cardiometabolic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">We hypothesize that the same local effects of epicardial fat tissue observed in patients with cardiac disease may be translated to the AMF for patients with IPF&#46; The role of AMF as a potential local source of pro-inflammatory mediators that could play a role in the natural history of IPF remains to be investigated&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">The present study has several limitations&#46; First&#44; the retrospective nature of this analysis&#46; Second&#44; the method used for the calculation of AMF volumes is imperfect&#46; Obtaining radiological measures from a chest CT scan to calculate volumes is subject of observer variability&#46; Despite the excellent inter-reader agreement between observers&#44; some bias in determining the exact dimensions of AMF is expectable&#44; and&#44; possibly&#44; other computed methods for assessing AMF values could have been desirable&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> In addition&#44; the election of a cut-point of 20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> of AMF to distribute patients into low and high AMF was arbitrary&#44; based on the median AMF values of the patient series&#46; Third&#44; there was a time-gap between the preoperative chest CT scan&#44; from which AMF measurements were obtained&#44; and the transplant procedure&#44; from which the LAS was calculated&#44; and it is possible that AMF volumes were underestimated in some severely ill IPF patients at the time of the LT&#46; Fourth&#44; we did not consider for the analysis some variables that could have had an impact on the results reported herein&#44; such as preoperative use of antifibrotic agents&#44; variations in the intraoperative anaesthetic management&#44; duration of ECLS&#44; the intraoperative use of blood products&#44; etc&#46; Finally&#44; although we observed an association between AMF volumes and LT outcomes in fibrotic patients&#44; we cannot demonstrate a cause-effect relationship&#46; Furthermore&#44; the possible mechanisms of this association remain unanswered&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">In conclusion&#44; we have observed that IPF patients with high volumes of AMF undergoing LT present poorer early and long-term outcomes than those with low volumes of AMF preoperatively&#46; Although the pathogenesis of this association is unknown&#44; we hypothesize that either a mediastinal fat substitution associated to the progressive lung volume reduction in IPF patients&#44; a paracrine effect of AMF by releasing pro-inflammatory mediators in these patients&#44; or both&#44; may be potential mechanisms involved&#46; Additional investigations are warranted to determine whether AMF has a role in predicting IPF progression and&#44; subsequently&#44; poor outcomes after LT&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interests</span><p id="par0285" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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              "titulo" => "Lung transplantation procedure"
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              "titulo" => "Imaging analysis"
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              "titulo" => "Overall patient series"
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              "titulo" => "Inter-reader agreement"
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              "identificador" => "sec0060"
              "titulo" => "Comparative analysis between right and left lung transplants"
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              "titulo" => "Relationship between AMF volume and demographic and functional parameters"
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              "titulo" => "Relationship between AMF volume and recipient perioperative factors"
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              "titulo" => "Analysis of 30-day mortality"
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              "titulo" => "Predictive factors of 30-day mortality and survival"
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    "fechaRecibido" => "2019-09-08"
    "fechaAceptado" => "2019-12-03"
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            0 => "Lung transplantation"
            1 => "Idiopathic pulmonary fibrosis"
            2 => "Mediastinal fat"
            3 => "Risk factors"
            4 => "Outcomes"
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            1 => "Fibrosis pulmonar idiop&#225;tica"
            2 => "Grasa mediast&#237;nica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Lung transplantation &#40;LT&#41; for pulmonary fibrosis is related to higher mortality than other transplant indications&#46; We aim to assess whether the amount of anterior mediastinal fat &#40;AMF&#41; was associated to early and long-term outcomes in fibrotic patients undergoing LT&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Retrospective analysis of 92 consecutive single lung transplants &#40;SLT&#41; for pulmonary fibrosis over a 10-year period&#46; AMF dimensions were measured on preoperative CT-scan&#58; anteroposterior axis &#40;AP&#41;&#44; transverse axis &#40;<span class="elsevierStyleItalic">T</span>&#41;&#44; and height &#40;<span class="elsevierStyleItalic">H</span>&#41;&#46; AMF volumes &#40;<span class="elsevierStyleItalic">V</span>&#41; were calculated by the formula&#58; AP<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">T</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">H</span><span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3&#46;14&#47;6&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">According to the radiological AMF dimensions&#44; patients were distributed into two groups&#58; low-AMF &#40;<span class="elsevierStyleItalic">V</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41; and high-AMF &#40;<span class="elsevierStyleItalic">V</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41;&#44; and early and long-term outcomes were compared by univariable and multivariable analyses&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">There were 92 SLT&#58; 73M&#47;19F&#44; 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 &#91;14&#8211;68&#93; years old&#46; 30-Day mortality &#40;low-AMF vs&#46; high-AMF&#41;&#58; 5 &#40;5&#46;4&#37;&#41; vs&#46; 15 &#40;16&#46;3&#37;&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#46; Patients developing primary graft dysfunction within 72<span class="elsevierStyleHsp" style=""></span>h post-transplant&#44; and those dying within 30 days post-transplant presented higher AMF volumes&#58; 21&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#46;8 vs&#46; 43&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41; and 24&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#46;2 vs&#46; 56&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>63&#46;6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; respectively&#46; Overall survival &#40;low-AMF vs&#46; high-AMF&#41; &#40;1&#44; 3&#44; and 5 years&#41;&#58; 85&#37;&#44; 81&#37;&#44; 78&#37; vs&#46; 55&#37;&#44; 40&#37;&#44; 33&#37; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Factors predicting 30-day mortality were&#58; BMI &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;77&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;011&#41;&#44; AMF volume &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;04&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;018&#41;&#44; CPB &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;42&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;002&#41;&#44; ischaemic time &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Factors predicting survival were&#58; AMF volume &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;02&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#44; CPB &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;17&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#44; ischaemic time &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;01&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Preoperative radiological assessment of mediastinal fat dimensions and volumes may be a useful tool to identify fibrotic patients at higher risk of mortality after single lung transplantation&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El trasplante de pulm&#243;n &#40;TP&#41; para el tratamiento de la fibrosis pulmonar est&#225; relacionado con una mayor mortalidad que otras indicaciones de trasplante&#46; Nuestro objetivo es evaluar si la cantidad de grasa mediast&#237;nica anterior &#40;GMA&#41; se asoci&#243; a los diferentes resultados tempranos y a largo plazo en pacientes con fibrosis a los que se les realiz&#243; un TP&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis retrospectivo de 92 trasplantes de pulm&#243;n unilaterales &#40;TPU&#41; consecutivos para el tratamiento de la fibrosis pulmonar durante un per&#237;odo de 10 a&#241;os&#46; Se midieron las dimensiones de la GMA en la TC preoperatoria&#58; eje anteroposterior &#40;AP&#41;&#44; eje transversal &#40;T&#41; y altura &#40;A&#41;&#46; Los vol&#250;menes de GMA &#40;V&#41; se calcularon mediante la f&#243;rmula&#58; AP<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>T<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>A<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3&#44;14&#47;6&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Seg&#250;n las dimensiones radiol&#243;gicas de la GMA&#44; los pacientes se distribuyeron en 2 grupos&#58; GMA baja &#40;V<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41; y GMA alta &#40;V<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span>&#41;&#44; y los resultados tempranos y a largo plazo se compararon mediante an&#225;lisis univariables y multivariables&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Se realizaron 92 TPU&#58; 73<span class="elsevierStyleHsp" style=""></span>V&#47;19<span class="elsevierStyleHsp" style=""></span>M&#44; 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11 &#40;14-68&#41; a&#241;os&#46; Mortalidad a 30 d&#237;as &#40;GMA baja frente a GMA alta&#41;&#58; 5 &#40;5&#44;4&#37;&#41; frente a 15 &#40;16&#44;3&#37;&#41;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;014&#46; Los pacientes que desarrollaron disfunci&#243;n precoz del injerto dentro de las 72<span class="elsevierStyleHsp" style=""></span>h posteriores al trasplante&#44; y los que murieron dentro de los 30 d&#237;as posteriores al trasplante presentaron mayores vol&#250;menes de GMA&#58; 21&#44;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>19&#44;8 frente a 43&#44;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#44;7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41; y 24&#44;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>24&#44;2 frente a 56&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>63&#44;6<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; respectivamente&#46; Supervivencia global &#40;GMA baja frente a GMA alta&#41; &#40;a los 1&#44; 3 y 5 a&#241;os&#41;&#58; 85&#44; 81 y 78&#37; frente al 55&#44; 40 y 33&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; respectivamente&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Los factores que predijeron la mortalidad a los 30 d&#237;as fueron&#58; IMC &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;77&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;011&#41;&#44; volumen de la GMA &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;04&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;018&#41;&#44; CEC &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;42&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#44; tiempo de isquemia &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;01&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;009&#41;&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Los factores que predijeron la supervivencia fueron&#58; volumen GMA &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;02&#59; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; CEC &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#44;17&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41; y tiempo de isquemia &#40;HR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44;01&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusi&#243;n</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La evaluaci&#243;n radiol&#243;gica preoperatoria de las dimensiones y los vol&#250;menes de la grasa mediast&#237;nica puede ser una herramienta &#250;til para identificar a aquellos pacientes con fibrosis con mayor riesgo de mortalidad despu&#233;s de un trasplante pulmonar &#250;nico&#46;</p></span>"
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Correlation between age and AMF in the anteroposterior axis&#44; and volume in fibrotic patients undergoing single lung transplantation&#46;</p>"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Post-transplant comparative survival between fibrotic patients with low AMF volumes vs&#46; patients with high AMF volumes&#46; &#40;B&#41; Post-transplant comparative survival between fibrotic patients with low AMF volumes vs&#46; patients with high AMF volumes among those surviving 30 days post-transplant&#46;</p>"
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          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; ECLS&#58; extracorporeal life support &#40;CPB or ECMO&#41;&#59; FVC&#58; forced vital capacity&#59; LAS&#58; Lung Allocation Score&#59; LT&#58; lung transplantation&#59; PGD&#58; pulmonary graft dysfunction at 72<span class="elsevierStyleHsp" style=""></span>h postop&#46; Quantitative variables are expressed as means<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD&#46; Qualitative variables are expressed as counts and proportions&#44; in parenthesis&#46; BMI and LAS were calculated at the time of transplantation&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95&#37; CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Gender &#40;M&#47;F&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">73&#47;19 &#40;79&#47;21&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Preop&#46; steroids&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">28 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#8211;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Urgent LT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#8211;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extended donor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;60&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">40&#8211;70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Need of ECLS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">30 &#40;32&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">23&#8211;41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Preop&#46; FVC &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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