Lung transplantation in children and young adults with cardiovascular disease

Repair of congenital heart lesions combined with lung transplantation for the treatment of severe pulmonary hypertension: A 13-year experience

OBJECTIVE

In patients with severe pulmonary hypertension associated with congenital heart disease, we prefer to perform repair of the congenital heart disease and lung transplantation whenever feasible so as to augment the donor pool and avoid the cardiac complications associated with heart transplantation. We report our experience with repair of congenital heart disease and lung transplantation and compare the results with those of patients who underwent heart-lung transplantation during the same period.

METHODS

The records of patients who had repair of congenital heart disease and lung transplantation (n = 35) and heart-lung transplantation (n = 16) between 1990 and 2003 were reviewed.

RESULTS

The underlying congenital heart disease in the repair of congenital heart disease and lung transplantation group included transposition of great vessels (n = 2), atrioventricular canal defect (n = 2), ventricular septal defect (n = 9), pulmonary venous obstruction (n = 7), scimitar syndrome (n = 2), pulmonary arterial atresia or stenosis (n = 5), and others (n = 8). Thirteen of the patients undergoing repair of congenital heart disease and lung transplantation (37.1%) had the congenital heart disease repaired before lung transplantation; the remaining congenital heart disease repairs were performed concurrently with transplantation. Sixteen patients underwent heart-lung transplantation because of poor left ventricular function or single-ventricle anatomy. Freedoms from bronchiolitis obliterans at 1, 3, and 5 years were 72.9%, 54.7%, and 54.7% for the repair of congenital heart disease and lung transplantation group and 77.8%, 51.9%, and 38.9% for the heart-lung transplantation group, respectively. Survivals at 1, 3, and 5 years were 62.9%, 51.4%, and 51.4% for the repair of congenital heart disease and lung transplantation group and 66.5%, 66.5%, and 60% for the heart-lung transplantation group, respectively.

CONCLUSION

Repair of congenital heart disease and lung transplantation is a feasible treatment option. Long-term outcome is determined by associated complications related to lung transplantation. Despite the complexity of combined congenital heart disease repair with lung transplantation and the resulting perioperative morbidity, the patients had similar outcomes to those of patients who underwent heart-lung transplantation.

Surgical Treatments/Interventions for Pulmonary Arterial Hypertension

While considerable advances have been achieved in the medical treatment of pulmonary arterial hypertension (PAH) over the past decade, surgical and interventional approaches continue to have important roles in those patients for whom medical therapy is unavailable or has been unsuccessful. These techniques include pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension, thoracic transplantation, and atrial septostomy. This chapter will provide evidence-based recommendations for the selection and timing of surgical and interventional treatments of PAH for physicians involved in the care of these complex patients.

The Southern Thoracic Surgical Association 50th anniversary celebration: the impact of STSA pediatric cardiothoracic surgery manuscripts on surgical practice

BACKGROUND

Members of the Southern Thoracic Surgical Association (STSA) have presented important pediatric cardiothoracic surgery papers at the annual meetings over the last 50 years. In order to determine the influence of these presentations on the practice of surgery, a review was undertaken. Early papers were characterized by emerging advances in open-heart surgery, anatomic congenital heart studies, and electrophysiologic discoveries that extended life with pacemakers. Later years were characterized by innovative myocardial preservation methods, improved cardiopulmonary bypass techniques, expanded homograft availability, emphasis on accurate repairs, intraoperative transesophageal echocardiography, and cardiopulmonary transplantation.

METHODS

All but one of the scientific programs of the annual meetings (that of 1964) were located. The programs were reviewed and 180 presentations were identified on topics in congenital heart disease, pediatric thoracic disease, and pediatric thoracic wall abnormalities. Of those 180 oral presentations, 155 manuscripts (86%) were eventually published or in press and available for critical review and analysis. Manuscripts were grouped by diagnosis or therapeutic intervention. We determined a "cumulative citation frequency" (CCF), which measures the number of times an article is cited in the bibliography of related papers in the universe of participating journals. The selected manuscripts were compared with the historic landmark contributions and the existing trends at the time, and the number of articles both by individual authors and from institutions were tallied.

RESULTS

Grouping by authors and institutions showed that 100 of 155 pediatric cardiothoracic manuscripts (65%) originated from 13 institutions. The CCF for the 20 leading articles ranged from 26 to 93.

CONCLUSIONS

This historical STSA 50-year record of pediatric cardiothoracic advances was accomplished in a milieu of collegial respect and camaraderie. Our annual meetings over the years have provided a venue for thoracic surgeons to share their ideas, innovations, and scientific inquiry. These contributions have significantly affected the practice of pediatric cardiothoracic surgery. The STSA has worked for 50 years and we trust that it will work for another 50 years and beyond.

Lung transplantation for pulmonary vascular disease

BACKGROUND

Pulmonary hypertension (PHT) is a lethal condition resulting in markedly diminished life expectancy. Continuous prostaglandin I2 infusion has made an important contribution to symptom management, but it is not a panacea. Lung or heart-lung transplantation remains an important treatment option for end-stage PHT patients unresponsive to prostaglandin I2. This study reviews the outcomes after transplantation for PHT in our program.

METHODS

A retrospective chart review was performed for 100 consecutive patients with either primary PHT (48%) or secondary PHT (52%) transplants since 1989. Living recipients were contacted to confirm health and functional status.

RESULTS

Fifty-five adult and 45 pediatric patients underwent 51 bilateral lung transplants, 39 single lung transplants, and 10 heart-lung transplants. Mean age was 23.7 years (range, 1.2 months to 54.8 years) and mean pre-transplant New York Heart Association class was 3.2. Pre-transplant hemodynamics revealed a mean right atrial pressure of 9.6+/-5.4 mm Hg and mean pulmonary artery pressure of 64+/-14.4 mm Hg. Hospital mortality was 17% with early death predominantly because of graft failure and infection. With an average follow-up of 5.0 years, 1- and 5-year actuarial survival was 75% and 57%, respectively. Mean pulmonary artery pressure on follow-up catheterization was 22+/-6.0 mm Hg, and mean follow-up New York Heart Association class was 1.3 (p < 0.001 for both compared with pre-transplant). Diagnosis and type of transplant did not confer a significant difference in survival between groups.

CONCLUSIONS

Whereas lung or heart-lung transplant for PHT is associated with higher early mortality than other pulmonary disease entities, it provides similar long-term outcomes with dramatic improvement in both quality of life and physiologic aspects.

Diagnosis and treatment of severe pediatric pulmonary hypertension

Advances in the treatment of pulmonary hypertension during the past decade have dramatically improved patient survival. Many of these advances are based on improved understanding of the vascular biology of the normal and hypertensive pulmonary circulations. Pulmonary hypertension is an important determinant of morbidity and mortality in patients with many pediatric diseases, including congenital heart disease. This article describes current diagnostic strategies and treatments for patients with primary and secondary pulmonary hypertension.

Selective use of extracorporeal membrane oxygenation is warranted after lung transplantation

OBJECTIVES

Early allograft dysfunction after lung transplantation ranges from subclinical x-ray abnormalities to pulmonary edema, hypoxemia, hypercarbia, and pulmonary hypertension. Management may include extracorporeal circulation to allow recovery of the acute lung injury. We reviewed our experience with extracorporeal membrane oxygenation after lung transplantation to assess the utility of this therapy.

METHODS

A retrospective chart review was performed. Single or bilateral lung transplantation was performed in 444 adults from July 1988 to July 1998. Twelve (2.7%) patients experienced allograft dysfunction severe enough to require extracorporeal membrane oxygenation after failure of conventional therapy, including sedation, paralysis, and inhaled nitric oxide.

RESULTS

Seven of 12 patients requiring extracorporeal membrane oxygenation were discharged from the hospital. Mean and median times to extracorporeal membrane oxygenation support were 1.2 days and 0 days, respectively. Mean length of support was 4.2 days. Four patients died while receiving extracorporeal membrane oxygenation support. One patient was weaned from extracorporeal membrane oxygenation but died during the hospitalization. Two patients required acute retransplantation while receiving extracorporeal membrane oxygenation, and one survived to discharge. Three patients continued to receive extracorporeal membrane oxygenation support for more than 4 days, and all 3 died. All survivors had begun receiving extracorporeal membrane oxygenation support by post-transplantation day 1. Three of 7 patients discharged from the hospital died 12 months, 13 months, and 72 months after transplantation because of bronchiolitis obliterans syndrome (n = 2) or lymphoma (n = 1). Four patients are alive 2, 12, 25, and 54 months after transplantation.

CONCLUSIONS

Extracorporeal membrane oxygenation provides effective therapy for acute post-transplantation lung dysfunction. The frequency and pattern of our extracorporeal membrane oxygenation use reflects bias toward early extracorporeal membrane oxygenation support for isolated graft failure in otherwise intact and uninfected recipients.

Heart/single-lung transplant for a "failed Fontan" with pulmonary A-V malformation

Pulmonary arteriovenous malformation can occur in patients with functional single ventricle after a cavopulmonary connection. There is no effective medical treatment for this complication. Pulmonary arteriovenous malformations may regress over time after heart transplantation, but may be a source of significant perioperative morbidity. We report the case of a woman with single ventricle, ventricular dysfunction, and bilateral pulmonary arteriovenous malformations who had successful treatment of both cardiac and pulmonary failure with en bloc heart and right lung transplantation.

Lung transplantation and repair of complex congenital heart lesions in patients with pulmonary hypertension

Pulmonary vascular disease in conjunction with either a previously repaired or an unrepaired congenital heart defect is the third most common indication for lung transplantation in the pediatric age range. Because scarcity of donor organs remains a critical issue and heart-lung donor blocks are becoming diminishingly available, efforts must be directed towards other options such as combining lung transplantation with correction of the underlying congenital heart defect. Certain defects like congenital pulmonary vein stenosis are eradicated by removal of the diseased lungs, whereas others such as complete atrioventricular canal and pulmonary atresia with ventricular septal defect require cardioplegic arrest of the heart and intracardiac repair in conjunction with the lung transplantation. A breakdown of this patient population into subgroups may be helpful both in thinking about the pathophysiology and in determining appropriate indications and timing of transplantation. Earlier studies from our center showed the high-risk nature and formidable undertaking of caring for this complex group of patients. Through continued experience, there has been gradual improvement in early outcomes. As with all other groups of lung transplantation patients, obliterative bronchiolitis remains the major deterrent to long-term survival.

Hemodynamic data and survival in children with pulmonary hypertension

OBJECTIVES

Using data from a multi-institutional data base, we sought to determine whether hemodynamic data predict duration of survival in children with primary or secondary pulmonary hypertension.

BACKGROUND

Lung transplantation is a therapeutic option for children with pulmonary hypertension. Appropriate timing of lung transplantation requires reliable methods of predicting duration of survival in potential candidates.

METHODS

A regional data base was used to obtain cardiac catheterization data on 50 children with mean pulmonary artery pressure (mPAP) > 25 mm Hg and indexed pulmonary resistance (Rp) > 4.5 Wood units. Data on survival were obtained from the participating centers.

RESULTS

There were 15 patients without congenital heart disease (group 1) and 35 patients with congenital heart disease (group 2) for analysis. Actuarial survival at 1, 2 and 5 years was 86%, 69% and 69% in group 1 and 88% and 77% in group 2, respectively (p = NS). Hemodynamic variables that predicted survival on univariate analysis were mean right atrial pressure (mRAP) (p < 0.0001), mPAP (p = 0.034), Rp (p < 0.0001) and pulmonary flow (p = 0.003), as well as a variable that we generated-mRAP x Rp (p < 0.0001). On multivariate stepwise logistic regression analysis, mRAP x Rp was independently related to survival. A model using mRAP x Rp allows for the estimation of probability of death at 1 and 2 years after catheterization.

CONCLUSIONS

Hemodynamic variables can predict survival in children with pulmonary hypertension in the presence or absence of congenital heart defects. This information can be used to determine the optimal timing of listing for lung transplantation.

Pathology of lung allografts in children and young adults

Heart-lung and lung transplantation have become acceptable therapeutic modalities for end-stage lung and heart conditions in children and young adults, but the posttransplantation pulmonary pathology in this age-group is poorly characterized. We present our experience with the pathology of lung transplantation in a cohort of 11 patients with a median age of 12.5 years, and median posttransplantation follow-up of 8.3 months. The findings are based on histological examination of 98 specimens, including five autopsy specimens from patients 20 years of age or younger. Our experience, combined with the data in other pediatric series, suggest that there is not a significant difference in the prevalence or severity of acute rejection or bronchiolitis obliterans (BO) between adult and pediatric lung transplant recipients. Lymphocytic bronchitis/bronchiolitis showed a more prominent association with BO in our series than previously reported in adult studies. Chronic vascular rejection in the pediatric lung transplant recipients can occur earlier than reported in adults and is associated with a grave prognosis. Overwhelming infection was a major cause of death in our experience. In particular, our data combined with the previous reports indicate that adenoviral pneumonia is a relatively common pathogen in the pediatric population and is a major cause of mortality in this age-group.

Pediatric lung transplantation--are there surgical contraindications?

Lung transplantation has evolved as a successful treatment for end-stage cardiopulmonary disease in children; however, clear guidelines regarding surgical exclusion criteria for pediatric lung transplant candidates have not been well-established. Since December 1994, we have performed 10 bilateral lung transplants and 1 heart-lung transplant in 10 recipients (mean age, 7 years; range, 3 months to 19 years). Indications for transplantation included pulmonary vascular disease (n=6), bronchiolitis obliterans (n=2), bronchopulmonary dysplasia (n=1), graft failure due to viral pneumonitis (n=1), and cystic fibrosis (n=1). Among the 10 patients, 4 were evaluated elsewhere for lung transplantation; of these, 3 were rejected by 1 or more programs because of "high-risk" characteristics. We considered 8 of the 10 patients to have 1 or more "high-risk" characteristics, as follows: previous chest operations other than open lung biopsy (n=6 patients having 1-4 previous operations), ventilator-dependence with tracheostomy and high-dose corticosteroids (n=4), redo lung transplant (n=2), concomitant intracardiac repair (n=6), portal hypertension (n=1), and the use of extracorporeal membrane oxygenation (ECMO) at the time of transplant (n=1). Our standard operative approach was a bilateral thoracosternotomy. Cardiopulmonary bypass was used for explant of the recipient lungs and implant of the donor lungs, and during repair of coexisting congenital heart defects. Aprotinin and fresh whole blood were administered during the procedure to aid in hemostasis. Concomitant procedures were frequently performed and included repair of an intra-atrial baffle leak (prior Mustard procedure), closure of an atrial septal defect, repair of partial anomalous pulmonary venous return, reconstruction of the pulmonary venous confluence, ECMO decannulation, and splenectomy. There were no operative deaths, and no patient required re-exploration for bleeding. One patient had primary graft failure due to adenovirus infection of the donor lungs, and required prolonged mechanical ventilation and eventually ECMO support until retransplantation was performed. The mean hospital stay after transplant was 25+/-13 days (range, 10-56 days). All patients were discharged with a natural airway. Airway complications consisted of one bronchial anastomotic stricture which required dilation, for a complication rate of 5% per anastomoses at risk. One patient required reoperation for stenosis of the superior vena cava. There have been no late deaths, with a mean follow-up of 7+/-4 months (range, 1-13 months). We attribute this 100% operative and short-term survival in these "high-risk" pediatric lung transplant recipients to our operative methods, a multidisciplinary approach to postoperative management, and the enormous physiologic reserve of pediatric patients. Therefore, the standard exclusion criteria used for adult lung transplantation may not be applicable to the pediatric age group. We hope to use these data to expand the use of lung transplantation in pediatric patients.

Outcome of children with pulmonary hypertension referred for lung or heart and lung transplantation

We reviewed our institutional experience with 24 children with pulmonary hypertension, who were referred for lung or heart and lung transplantation. Diagnosis, age, and previously published predictive survival scores calculated at the time of referral were analyzed as predictors of pretransplant death. Among the 24 children, 7 did not meet criteria for listing and 17 were listed for transplantation. Of those listed, eight died waiting, two await transplantation, and seven were transplanted and are alive and well 7-20 months after transplantation. Poor functional status (New York Heart Association class 3 or 4) at the time of referral was significantly associated with death before transplant (P=0.05) in univariate analysis. Analysis of the predictive scores was possible in 21 of 24 patients; lower predictive scores were significantly associated with death before transplantation and shorter duration of survival without transplantation in univariate analysis. Multivariate analysis (Cox regression) confirmed that lower scores were significantly associated with poor survival. We conclude that children with pulmonary hypertension are often referred for transplantation too late in the course of their disease. Early complete hemodynamic evaluation before the onset of severe symptoms, followed by serial evaluations of disease progression and consultation with a transplant center, should result in earlier, more appropriate time of listing and improved survival. A systematic study of pretransplant mortality among all children listed for lung transplantation would provide a basis for clinical decision making and policies affecting organ allocation.

Lung transplantation for congenital pulmonary vein stenosis

BACKGROUND

Congenital pulmonary vein stenosis is a uniformly fatal disease when left untreated. Transcatheter techniques (for example, balloon dilation and stent placement) have proved to be only temporizing measures, and previous surgical attempts at treatment of this entity have provided little improvement and few survivors.

METHODS

Over the last 4 years, 6 patients with congenital pulmonary vein stenosis have been treated at our institution, 3 of whom underwent bilateral sequential lung transplantation.

RESULTS

The 3 patients who underwent bilateral lung transplantation are alive and well 6 to 24 months after transplantation. The other 3 died of complications of the disease before donor lungs became available.

CONCLUSIONS

Making the diagnosis of congenital pulmonary vein stenosis requires a high index of suspicion, and referral for lung transplantation should be made as soon as the diagnosis is reached. Lung transplantation has resulted in good-quality short to medium-term survival for 3 patients with this otherwise untreatable disease.