Acute native lung hyperinflation is not associated with poor outcomes after single lung transplant for emphysema

Donor quality assessment and size match in lung transplantation

Careful donor quality assessment and size match can impact long-term survival in lung transplantation. With this article, we review the conceptual and practical aspects of the preoperative donor lung quality assessment and size matching.

Postoperative Management of Hyperinflated Native Lung in Single-Lung Transplant Recipients with Chronic Obstructive Pulmonary Disease: A Review Article

End-stage chronic obstructive pulmonary disease (COPD) is the most common indication for single- or double-lung transplantation. Acute native lung hyperinflation (ANLH) is a unique postoperative complication of single-lung transplantation for COPD patients, with incidence varying in the medical literature from 15 to 30%. The diagnosis is made radiographically by contralateral mediastinal shift and ipsilateral diaphragmatic flattening. ANLH can deteriorate into hemodynamic instability, and respiratory impairment can result from compression of the allograft, which can precipitate atelectasis, hypoxemia, and hypercapnia, necessitating specific ventilatory intervention or volume reduction surgery. Currently, there is consensus for a therapeutic role of noninvasive positive pressure ventilation (NIPPV) in acute respiratory failure after lung transplantation as a well-tolerated measure to avoid re-intubation. This manuscript presents a concise review on the diagnosis and treatment of ANLH following unilateral lung transplant, along with a management algorithm created by the authors.

Lung transplantation for emphysema

Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.

Chronic Obstructive Pulmonary Disease and Lung Transplantation

Lung transplantation (LTx) has been a viable option for patients with end-stage chronic obstructive pulmonary disease (COPD), with more than 20,000 procedures performed worldwide. Survival after LTx lags behind most other forms of solid-organ transplantation, with median survival for COPD recipients being a sobering 6.0 years. Given the limited supply of suitable donor organs, not all patients with end-stage COPD are candidates for LTx. We discuss appropriate criteria for accepting patients for LTx, as well as contraindications and exclusionary criteria. In the first year post-LTx, infection and graft failure are the leading causes of death. Beyond this chronic graft rejection-currently referred to as chronic lung allograft dysfunction-represents the leading cause of death at all time points, with infection and over time malignancy also limiting survival. Referral of COPD patients to a lung transplant center should be considered in the presence of progressing disease despite maximal medical therapy. As a rule of thumb, a forced expiratory volume in 1 second < 25% predicted in the absence of exacerbation, hypoxia (PaO₂ < 60 mm Hg/8 kPa), and/or hypercapnia (PaCO₂ > 50 mm Hg/6.6 kPa) and satisfactory general clinical condition should be considered the basic prerequisites for timely referral. We also discuss salient issues post-LTx and factors that impact posttransplant survival and morbidity such as infections, malignancy, renal insufficiency, and complications associated with long-term immunosuppression.

Lung transplantation for chronic obstructive pulmonary disease: past, present, and future directions

PURPOSE OF REVIEW

Lung transplantation offers an effective treatment modality for patients with end-stage chronic obstructive pulmonary disease (COPD). The exact determination of when to refer, list, and offer transplant as well as the preferred transplant procedure type remains unclear. Additionally, there are special considerations specific to patients with COPD being considered for lung transplantation, including the implications of single lung transplantation on lung cancer risk, native lung hyperinflation, and overall survival.

RECENT FINDINGS

The International Society for Heart and Lung Transplantation's most recent recommendations rely on an assessment of COPD severity based on BODE index. Despite the lack of evidence supporting a mortality benefit of bilateral over single lung transplantation for COPD patients, the majority of transplants performed in this population remain bilateral. Some of the concerns specific to single lung transplantation remain the possibility of de novo native lung cancer and the hemodynamic and physiologic implications of acute native lung hyperinflation.

SUMMARY

COPD remains the most common worldwide indication for lung transplantation. Ongoing study is still required to assess the overall survival benefit of lung transplantation and assess the overall quality of life impact on the COPD patient population.

Transplant options for end stage chronic obstructive pulmonary disease in the context of multidisciplinary treatments

Lung transplantation (LTx) in advanced stage chronic obstructive pulmonary disease (COPD) patients is associated with significant improvement in lung function and exercise capacity. However, demonstration that the procedure also provides a survival benefit has been more elusive compared to other respiratory conditions. Identification of patients with increased risk of mortality is crucial: a low forced expiratory volume in 1 second (FEV₁) is perhaps the most common reason for referral to a lung transplant center, but in itself is insufficient to identify which COPD patients will benefit from LTx. Many variables have to be considered in the selection of candidates, time for listing, and choice of procedure: age, patient comorbidities, secondary pulmonary hypertension, the balance between individual and community benefit. This review will discuss patient selection, transplant listing, potential benefits and critical issues of bilateral (BLTx) and single lung (SLTx) procedure, donor-to-recipient organ size-matching; furthermore, it will describe LTx outcomes and its effects on recipient survival and quality of life.

Lung transplantation in chronic obstructive pulmonary disease: patient selection and special considerations

Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity. Lung transplantation is one of the few treatments available for end-stage COPD with the potential to improve survival and quality of life. The selection of candidates and timing of listing present challenges, as COPD tends to progress fairly slowly, and survival after lung transplantation remains limited. Though the natural course of COPD is difficult to predict, the use of assessments of functional status and multivariable indices such as the BODE index can help identify which patients with COPD are at increased risk for mortality, and hence which are more likely to benefit from lung transplantation. Patients with COPD can undergo either single or bilateral lung transplantation. Although many studies suggest better long-term survival with bilateral lung transplant, especially in younger patients, this continues to be debated, and definitive recommendations about this cannot be made. Patients may be more susceptible to particular complications of transplant for COPD, including native lung hyperinflation, and development of lung cancer.

Continued Utility of Single-Lung Transplantation in Select Populations: Chronic Obstructive Pulmonary Disease

BACKGROUND

The use of single lung transplantation (SLTx) for chronic obstructive pulmonary disease is often viewed as inferior therapy compared with bilateral lung transplantation (BLTx). We hypothesized from our experience that subpopulations of recipients with emphysema exist in which SLTx represents therapy that is equivalent to BLTx, therefore allowing more patients access to transplantation.

METHODS

Consecutive patients undergoing LTx for emphysema between 1992 and 2012 at a single institution were identified and analyzed retrospectively. A similar cohort from the United Network of Organ Sharing (UNOS) national database was identified for comparison. Five-year survival in patients receiving SLTx and those receiving BLTx were compared using Kaplan-Meier survival curves and log-rank tests.

RESULTS

Two hundred thirty-six patients meeting criteria were identified from our institution. Two hundred six underwent SLTx, and 30 underwent BLTx. Five-year survival for single-center SLTx (53.2% ± 3.6%) and BLTx (56.7% ± 10.2%) was not significantly different (p = 0.753). The national database included 7,256 patients meeting selection criteria, with 4,408 undergoing SLTx and 2,848 undergoing BLTx. Five-year survival among the national cohorts was lower for SLTx (46.4% ± 0.8%) compared with BLTx (55.9% ± 1.1%) (p < 0.0001). However, 5-year survival for our single-center SLTx experience (53.2% ± 3.6%) was comparable to the national BLTx cohort (55.9% ± 1.1%) (p = 0.539).

CONCLUSIONS

Five-year survival after SLTx for emphysema was comparable to that for BLTx in cohorts from our institution and from the UNOS national database. Further study should focus on the mechanism behind these improved outcomes. Given the potential for a larger number of life-years saved, SLTx should continue to be considered a therapeutic option in appropriately selected patients with chronic obstructive pulmonary disease (COPD).

Lung transplantation for emphysema: impact of age on short- and long-term survival

OBJECTIVES

Overall, emphysema (EMP) is the most common indication for lung transplantation. The majority of patients present with chronic obstructive pulmonary disease (COPD) and less frequently with alpha-1 antitrypsin deficiency (A1ATD). We analysed the results of lung transplants performed for EMP in order to identify the impact of age on short- and long-term outcome.

METHODS

A retrospective analysis was undertaken of the 108 consecutive lung transplants for EMP performed at our institution from November 1992 to August 2013 (77 COPD, 31 A1ATD). Retransplantations were excluded.

RESULTS

The median age was 56 years (range 31-68). Thirty-day mortality rate was 3.7%. One- and 5-year survival rates in COPD and A1ATD recipients were comparable (P = 0.8). The 1- and 5-year survival rates for recipients aged <60 years old were significantly better than the age group of ≥60 years (91 and 79 vs 84 and 54%, P = 0.05). Since 2007, the 1- and 5-year survival for these two age groups were 96 and 92 vs 86 and 44%, respectively, P = 0.04, log-rank test). For the following parameters, we were not able to find any difference to affect survival rates: use of intraoperative extracorporeal membrane oxygenation, waiting list time, sex, graft size reduction, body mass index and diagnosis. In multivariate analysis, age at transplantation (≥60 years old) (HR 2.854; 95% confidence interval (CI) 1.338-6.08, P = 0.008) and unilateral lung transplantation (HR 15.2; 95% CI 3.2-71.9, P = 0.009) were independent risk factors for mortality.

CONCLUSIONS

COPD and A1ATD recipients have similar overall long-term survival. Recipients aged ≥60 years and unilateral lung transplants were risk factors for mortality.

Size matching in lung transplantation: an evidence-based review

The evidence base for size matching between donors and recipients in lung transplantation has not recently been reviewed in a comprehensive manner. Our aim in this study was to assimilate published studies that have addressed size matching of donors to recipients and to establish a pragmatic understanding of the range of lung sizes that may be used for lung transplantation. A comprehensive literature search was performed using Medline and PubMed up to and including September 2012, to identify scientific articles that relate to size matching between donors and lung transplant recipients. Seventy-two articles were identified, of which 21 had addressed the question of the impact of size mismatching on outcomes in lung transplantation. No study has specifically tested the consequences of intentionally mismatching above or below the hypothetical limits for double lung transplantation of a predicted total lung capacity for the donor of between 75% and 125% of the recipient predicted total lung capacity as set out in the ISHLT consensus report on lung donor acceptability criteria. Research is lacking that has robustly defined limits for size mismatch for single lung transplantation and for recipients with restrictive lung pathologies such as pulmonary fibrosis. Published research on the impact of size mismatching between lung transplant donors and recipients is limited by study design and size. It is centered on addressing the issue of mismatch in double lung transplantation in cohorts with a diagnostically heterogeneous make-up and in single lung transplant patients with chronic obstructive pulmonary disease.

[Lung hyperinflation after single lung transplantation to treat emphysema]

Despite preventive measures, lung hyperinflation is a relatively common complication following single lung transplantation to treat pulmonary emphysema. The progressive compression of the graft can cause mediastinal shift and respiratory failure. In addition to therapeutic strategies such as independent ventilation, the treatment consists of the reduction of native lung volume by means of lobectomy or lung volume reduction surgery. We report two cases of native lung hyperinflation after single lung transplantation. Both cases were treated by means of lobectomy or lung volume reduction surgery.

Lung transplantation in advanced COPD: is it worth it?

Chronic obstructive pulmonary disease (COPD) is a condition of progressive airflow obstruction occurring primarily as a result of tobacco use that accounts for substantial worldwide morbidity and mortality. Medical therapy, with the exception of oxygen and smoking cessation, does not appreciably alter the natural progression of the disease. In contrast, when performed in carefully selected candidates, lung transplantation can provide substantial benefits in physiology, function, quality of life, and survival. Strict selection criteria limit transplant to highly compliant candidates with advanced disease but preserved functional status who are capable of successfully undergoing the operation. Although either single or bilateral lung transplant may be offered in COPD, recent evidence suggests that bilateral transplant is the preferred operation due to superior long-term outcomes. Regardless of the type of transplant operation, however, all lung transplant recipients are susceptible to numerous complications, including posttransplant infection and rejection. Despite these and other potential complications, advances in medical and surgical management now make lung transplantation a worthwhile therapeutic option in appropriately selected patients. In fact, lung transplant represents the only intervention that can substantially improve long-term outcomes in COPD patients with very advanced disease. Further work to refine recipient selection, improve lung allocation algorithms, and develop better treatments of chronic allograft dysfunction will lead to an even greater benefit to lung transplantation in this ill patient population.

Transplantation in Chronic Obstructive Pulmonary Disease

Lung transplantation is a surgical option for patients who fail optimization of medical treatment for the severe symptoms that result from COPD. This review will discuss patient selection, transplant listing, and the surgical technique for transplantation in COPD. Furthermore, it will describe transplant outcomes and its effects on recipient survival, pulmonary function, exercise capacity, respiratory muscle function, and quality of life. The respective roles of transplantation and lung volume reduction surgery as therapies for advanced disease will be outlined.

Early tracheal extubation in adults undergoing single-lung transplantation for chronic obstructive pulmonary disease: pilot evaluation of perioperative outcome

The objective of this pilot study was to evaluate the safety and success of early tracheal extubation (ETE) as compared to delayed tracheal extubation (DTE) in single-lung transplantation (SLT) for chronic obstructive pulmonary disease (COPD). This retrospective observational study was undertaken at a university hospital. Fifty-seven adult patients who underwent SLT for COPD (1998-2003) were enrolled. The study cohort was divided into an ETE subgroup (tracheal extubation in the operating room) or a DTE subgroup (tracheal extubation in the intensive care unit). There were no significant differences in perioperative outcomes between subgroups (in-hospital mortality; length of stay; prolonged mechanical ventilation; primary graft dysfunction; pneumonia; atrial fibrillation; renal dysfunction; and, sepsis). The anesthetic technique associated with ETE in SLT for COPD was characterized by limited systemic anesthetics and perioperative thoracic epidural analgesia. Appropriate ETE in SLT for COPD is not only safe but also results in equivalent perioperative outcome when compared to the traditional technique of DTE. Future studies should be powered to examine whether ETE reduces native lung complications such as hyperinflation, pneumonia and pneumothorax.

Native lung volume reduction surgery relieves functional graft compression after single-lung transplantation for chronic obstructive pulmonary disease

OBJECTIVE

Single-lung transplantation is an accepted treatment for end-stage lung disease caused by chronic obstructive pulmonary disease. A complication unique to single-lung transplantation for chronic obstructive pulmonary disease is graft dysfunction due to compression caused by native lung hyperinflation. We hypothesized that patients with functional compromise from native lung hyperinflation would benefit from native lung volume reduction surgery.

METHODS

The charts of all patients undergoing single-lung transplantation for chronic obstructive pulmonary disease were reviewed for lung volume reduction surgery of their native lung. Data regarding length of stay, surgical morbidity and mortality, overall survival, type of lung volume reduction surgery, and pulmonary function were recorded to evaluate the effect of lung volume reduction surgery.

RESULTS

Between February 1992 and May 2007, 206 single-lung transplantations were performed for chronic obstructive pulmonary disease. Ten (5%) patients had clinically significant graft compression from native lung hyperinflation. After excluding other causes for functional decline, these patients underwent a modified lung volume reduction surgery between 12 and 142 months after single-lung transplantation (mean, 50 months). Lung volume reduction surgery consisted of anatomic resection. Two (20%) of 10 patients died during their hospitalization. Of the remaining 8 patients, 7 (87.5%) have demonstrated functional improvement on the basis of forced expiratory volume in 1 second improving from 12% to 200% (mean improvement, 57%). Within 6 months of lung volume reduction surgery, mean 6-minute walk values improved significantly (866 to 1055 feet), whereas desaturation with exertion decreased significantly.

CONCLUSIONS

Lung volume reduction surgery by means of formal lobectomy in patients with native lung hyperinflation undergoing single-lung transplantation and significant graft compression appears feasible. Additionally, improvements in forced expiratory volume in 1 second can be accomplished in nearly all properly selected patients. Lung volume reduction surgery should be considered in patients with decreasing graft function caused by graft compression from native lung hyperinflation.

Predictors of independent lung ventilation: an analysis of 170 single-lung transplantations

OBJECTIVE

Single-lung transplantation for chronic obstructive pulmonary disease can cause unique postoperative problems that might require independent lung ventilation. We evaluated preoperative and immediate postoperative factors to predict the need for independent lung ventilation.

METHODS

We retrospectively studied 170 patients who received a single-lung transplant over a 15-year period, 20 (12%) of whom required independent lung ventilation.

RESULTS

Patients requiring independent lung ventilation were similar in age, sex, ischemic time, and donor characteristics to those who required conventional ventilation. Patients receiving independent lung ventilation had a greater degree of preoperative airflow limitation, more hyperinflation, lower postoperative PaO2/fraction of inspired oxygen ratios, more radiologic mediastinal shift, and more transplant lung infiltrate on the postoperative chest radiograph. Multivariate logistic regression analysis showed that independent lung ventilation was associated with increasing levels of recipient hyperinflation (percentage total lung capacity compared with predicted value; odds ratio, 1.04; 95% confidence interval, 1.01-1.07; P = .032) and reduced early postoperative PaO2/fraction of inspired oxygen ratio (odds ratio, 0.97; 95% confidence interval, 0.95-0.99; P = .005). Length of ventilation and intensive care unit stay and mortality were higher in the independent lung ventilation group. Among patients who survived to hospital discharge, there were no differences in long-term mortality between the 2 groups.

CONCLUSIONS

The need for independent lung ventilation in patients undergoing single-lung transplantation for obstructive lung disease is predicted by the combination of increased hyperinflation measured on recipients' preoperative lung function tests and a low PaO2/fraction of inspired oxygen ratio, indicating graft dysfunction in the immediate postoperative period.

Noninfectious Pulmonary Complications After Lung Transplantation

This article reviews several important noninfectious pulmonary complications that threaten survival, pulmonary function, and quality of life after lung transplantation. Topics reviewed include primary graft dysfunction (PGD), native lung hyperinflation, anastomotic complications, phrenic nerve injury, pleural complications, lung cancer, pulmonary toxicity associated with immunosuppressive medications, and exercise limitation.

Pulmonary Complications of Transplantation: Radiographic Considerations

The aim of this article is to clarify radiographic definitions associated with common parenchymal patterns encountered in the transplant population and to discuss the most common pathologic causes responsible for each pattern. The article also touches on radiographic findings signifying complications of other intrathoracic structures, including the airways, pleural space, and mediastinum.

Lung transplantation for emphysema. Lung hyperinflation: incidence and outcome

Lung transplantation, single or bilateral sequential, is the final option for patients with emphysema. This study analyzed the outcome of lung transplants for emphysema (single or double), and evaluates the incidence, predictive factors and prognosis of lung hyperinflation (LHI) in unilateral transplants. We prospectively studied patients undergoing lung transplantation for emphysema. On admission to the Intensive Care Unit (ICU) and at 12, 24, 48 and 72 h we tested the patients' respiratory function, oxygen arterial pressure (PaO2) and mean pulmonary arterial pressure (MPAP) before transplantation. LHI incidence, duration of mechanical ventilation and hypoxemia, ICU stay and mortality was also analyzed. We studied 34 consecutive patients undergoing lung transplantation for emphysema, 14 single and 20 bilateral. Single-lung transplantation had a higher mortality (50%) than double-lung transplantation (11%), with an odds ratio of 9.0 (1.3-48.7). Of the 14 patients who received a single graft, 9 patients (64%) developed LHI. No predictive factors for LHI could be established. Duration of mechanical ventilation (22 vs 3 days) and ICU stay (36 vs 6 days) was much longer in patients with LHI; however, only ICU stay reached statistical significance (P = 0.011). Mortality in patients with LHI was higher, 67% vs 20% (NS). We conclude that single-lung transplant in emphysema patients has a worse prognosis than bilateral transplant, with a 9-fold higher mortality rate. LHI is a common event in single-lung transplant for emphysema and is associated in our patients with a longer stay at the ICU.

Surgical advances in heart and lung transplantation

The successes of thoracic transplantation have led to the expansion of indications and a subsequent growth in demand for a short supply of organs. In response to this disparity, the criteria for organ donation have been liberalized. Despite these difficult challenges, with advances in surgical techniques and perioperative care of both the donor and recipient, outcomes have continued to improve over time. This article focuses on the more recent surgical advances in donor selection and management, procurement and implantation, and the impact of these advances on patient outcome.

Pulmonary complications of solid organ and hematopoietic stem cell transplantation

The ability to successfully transplant solid organs and hematopoietic stem cells represents one of the landmark medical achievements of the twentieth century. Solid organ transplantation has emerged as the standard of care for select patients with severe vital organ dysfunction and hematopoietic stem cell transplantation has become an important treatment option for patients with a wide spectrum of nonmalignant and malignant hematologic disorders, genetic disorders, and solid tumors. Although advances in surgical techniques, immunosuppressive management, and prophylaxis and treatment of infectious diseases have made long-term survival an achievable goal, transplant recipients remain at high risk for developing a myriad of serious and often life-threatening complications. Paramount among these are pulmonary complications, which arise as a consequence of the immunosuppressed status of the recipient as well as from such factors as the initial surgical insult of organ transplantation, the chemotherapy and radiation conditioning regimens that precede hematopoietic stem cell transplantation, and alloimmune mechanisms mediating host-versus-graft and graft-versus-host responses. As the population of transplant recipients continues to grow and as their care progressively shifts from the university hospital to the community setting, knowledge of the pulmonary complications of transplantation is increasingly germane to the contemporary practice of pulmonary medicine.

Lung transplantation for emphysema

Great strides have been made in lung transplantation in the past two decades. Changes in technique, immunosuppression regimens, and treatment of infectious complications have led to improvements in survival and functional results. Current areas of discussion concern the use of single lung transplantation versus bilateral sequential lung transplantation and the criteria for allocating donor lungs. This article reviews the current state of lung transplantation for emphysema and provides insight from more than one decade of experience with Washington University's lung transplant program.

Pulmonary resection following lung transplantation

BACKGROUND

The morbidity of lung transplantation is higher than other solid organ transplants. Little is known about the outcomes of patients who require pulmonary resection following lung transplantation. We reviewed our experience to evaluate and discern any variables affecting outcome of pulmonary resections performed following lung transplantation.

METHODS

A retrospective review of the lung transplant database was performed. Data are presented as mean +/- standard error (median).

RESULTS

A total of 136 lung transplants (80 single lung transplants [SLT], 55 bilateral lung transplants [BLT], and 3 heart-lung transplants [HLT]) were performed from August 1995 to February 2002. Twelve pulmonary resections, 7 lobectomies, and 5 wedge resections were performed on 11 patients. The indication for lobectomy was infection in 5 of 7 lobectomies (3 fungal, 2 bacterial), mass in 1 of 7, and infarction in 1 of 7. The indication for wedge resection was native lung hyperinflation in 4 of 5 wedge resections and mass in 1 of 5. The native lung was resected in 3 of 7 lobectomies and 4 of 5 wedge resections. An allograft lobectomy was performed following 1 SLT and 3 BLT and a wedge resection was performed after 1 SLT. The mean time to pulmonary resection was 12.4 +/- 3.9 (9.1) months. Survival postresection was 17.2 +/- 5.8 (8.3) months and 5 of 11 patients are still alive. There were no bronchial stump leaks following lobectomy.

CONCLUSIONS

Major pulmonary resections can safely be performed following lung transplant. We recommend early intervention to optimize outcomes.

Differential lung ventilation after single-lung transplantation for emphysema

OBJECTIVE

To review outcome and cardiovascular and respiratory function after initiation of differential lung ventilation for acute severe native lung hyperinflation in patients who have had a single-lung transplant for end-stage emphysema.

DESIGN

Retrospective review.

SETTING

Cardiothoracic tertiary referral center.

PARTICIPANTS

Thirteen patients who had differential lung ventilation for acute severe native lung hyperinflation, of a total of 132 patients who had a single-lung transplant for end-stage emphysema between 1988 and the end of 2000.

INTERVENTIONS

None. measurements and main results: Thirteen patients had differential lung ventilation for acute severe native lung hyperinflation; 7 survived to 1 year after transplant. There was a highly significant (p = 0.0006) improvement in mean PaO(2) from 8.23 (95% confidence interval [CI], 6.15 to 10.3) to 16.6 (95% CI, 12.84 to 20.45) 1 hour after start of differential lung ventilation. The average ratio of estimated dynamic compliance in the native lung compared with the transplanted (donor) lung was 2.69 (95% CI, 1.75 to 3.62).

CONCLUSION

In addition to previous case reports, this series shows that differential lung ventilation is an appropriate treatment for acute severe native lung hyperinflation. A difference in estimated effective dynamic compliance of > or = 2.69 between native and transplanted lung may require differential lung ventilation.

Single vs bilateral, sequential lung transplantation for end-stage emphysema: influence of recipient age on survival and secondary end-points

BACKGROUND

The appropriate age to perform bilateral, sequential lung transplants (BSLT) in patients with chronic obstructive pulmonary disease (COPD) remains controversial. Although single lung transplant (SLT) offers an advantage in terms of organ availability, the long-term survival may not warrant this strategy in all age groups.

METHODS

We analyzed 2,260 lung transplant recipients (1835 SLT, 425 BSLT) with COPD recorded in the International Society for Heart and Lung Transplantation/United Network for Organ Sharing thoracic registry between January 1991 and December 1997. To assess mortality, we performed univariate (Kaplan-Meier method and the chi-square statistic) and multivariate analyses (proportional hazards method). Because of incomplete morbidity data in the international registry, only data from U.S. centers (n = 1778, 1467 SLT, 311 BSLT) were used in the morbidity analysis.

RESULTS

Survival rates (%) computed using the Kaplan-Meier method at 30 days, 1 year, and 5 years for the patients aged < 50 years were 93.6, 80.2, and 43.6, respectively, for the SLT patients, and 94.9, 84.7, and 68.2, respectively, for the BSLT patients. For patients aged 50 to 60 years, survival rates (%) were 93.5, 79.4, and 39.8 for the SLT patients compared with 93.0, 79.7, and 60.5 for the BSLT patients. For those aged > 60 years, SLT survival (%) was 93.0, 72.9, and 36.4, compared with 77.8 and 66.0 for the BSLT group (a 5-year rate could not be completed in this group). The multivariate model showed a higher risk ratio for mortality in patients aged 40 to 57 years who received SLT vs BSLT. Recipient age and procedure type did not appear to affect the development of rejection, bronchiolitis obliterans, bronchial stricture, or lung infection.

CONCLUSIONS

Single lung transplant may offer acceptable early survival for patients with end-stage respiratory failure. However, long-term survival data favors BSLT in recipients until approximately age 60 years. These data suggest that a BSLT approach offers a significant survival advantage to recipients younger than 60 years of age.

Complications (excluding hyperinflation) involving the native lung after single-lung transplantation: incidence, radiologic features, and clinical importance

PURPOSE

To determine the incidence, importance, and radiologic features of native lung complications after single-lung transplantation.

MATERIALS AND METHODS

Seventeen (15%) of 111 single-lung transplant recipients developed native lung complications (excluding hyperinflation) 0-58 months (mean, 17 months) after transplantation. Complaints at presentation, culture or histopathologic results, diagnostic or therapeutic procedures, and outcome were recorded. Chest radiographs (n = 17) and computed tomographic (CT) scans (n = 8) obtained at time of diagnosis were reviewed. Serial radiographs were assessed for disease progression or improvement.

RESULTS

The most common complications were infection (n = 10), caused by bacteria (n = 4), fungi (n = 4), or mycobacteria (n = 2), typically manifested as lobar or segmental opacities on chest radiographs or CT scans. Lung cancer manifested as a solitary well-circumscribed nodule (n = 1), multiple nodules (n = 1), or a hilar mass (n = 1). Five (29%) of 17 patients died of native lung complications. Seven patients underwent mediastinoscopy (n = 3), lobectomy (n = 2), thoracoscopic wedge resection (n = 2), tube thoracostomy (n = 2), or pneumonectomy (n = 1) for diagnosis or treatment.

CONCLUSION

Native lung complications occurred in 17 (15%) single-lung transplant recipients, were most commonly due to infection or lung cancer, and caused serious morbidity or mortality in 12 (71%) of 17 patients affected.