Recipient Selection

Lung transplantation is warranted for stable, ventilator-dependent recipients

BACKGROUND

Lung transplantation for patients on ventilators is a controversial use of scarce donor lungs. We have performed 500 lung transplants in 12 years and 21 of these have been in ventilator-dependent patients.

METHODS

A retrospective review of patient records and computerized database was performed. Living patients were contacted to confirm their health and functional status.

RESULTS

Patients included 13 men and 8 women with a mean age of 43 years. Sixteen patients were considered stable awaiting lung transplant, whereas 5 patients were unstable with acute graft failure after prior lung transplantation. Stable patients had been ventilated for a mean of 57 +/- 46 days whereas unstable patients had been supported for 10 +/- 9 days. Half of the patients required cardiopulmonary bypass support during the transplant, and there was no statistical difference in the frequency of CPB in stable and unstable patients (p = 0.61). Three hospital deaths included 0 of 16 of the stable patients and 3 of 5 of the unstable patients (p = 0.01). Long-term actuarial survival was significantly better in stable versus unstable patients (p = 0.02), with 5-year survival 40% for stable patients and 0% for unstable patients.

CONCLUSIONS

Lung transplantation can be successfully conducted in stable patients who have become ventilator dependent after listing for transplantation. Acute retransplantation for early lung dysfunction is high risk and has produced poor long-term results.

Single versus bilateral lung transplantation for idiopathic pulmonary fibrosis: a ten-year institutional experience

OBJECTIVE

Between July 1988 and July 1998, we performed 433 lung transplants. Forty-five patients had idiopathic pulmonary fibrosis, and operations for these patients included 32 single lung transplants and 13 bilateral sequential lung transplants. This study reviews this experience and compares single lung transplantation and bilateral lung transplantation for pulmonary fibrosis.

METHODS

We performed a retrospective review, including inpatient hospital charts, outpatient clinic records, and telephone contact with patients to verify current health status.

RESULTS

Perioperative mortality was 4 (8.9%) patients. One patient underwent redo bilateral lung transplantation for reperfusion injury and graft failure after single lung transplantation. The median hospitalization was 22 days. Actuarial survival at 1 and 5 years was 75.5% and 53.5%, respectively, which was not significantly different from our survival for all recipients (85.5% and 56.4%, respectively). Seventeen (41%) of 41 operative survivors have died. Late causes of death included obliterative bronchiolitis with respiratory failure (9), malignancy (3), and cytomegalovirus pneumonitis (2). Hospital mortality was 3 (9.4%) of 32 after single lung transplantation and 1 (7.7%) of 13 after bilateral lung transplantation. There was no difference between single and bilateral lung transplantation with regard to hospital stay. Four (12.5%) of the 32 patients undergoing single lung transplantation required tracheostomy, whereas 3 (23%) of 13 recipients undergoing bilateral lung transplantation required tracheostomy.

CONCLUSION

Single or bilateral lung transplantations offer viable therapy for patients with pulmonary fibrosis. We demonstrate no benefit of bilateral over single lung transplantation for patients with this diagnosis. Survival after transplantation appears better than that of historic control subjects receiving standard medical care at other institutions.

Lung transplantation: a decade of experience

OBJECTIVE

To review the 10-year clinical experience of a single institution's adult lung transplant program.

METHODS

Since July 1988, 450 lung transplants have been performed in 443 patients. Recipient diagnoses included emphysema in 229 patients, cystic fibrosis in 70 patients, pulmonary fibrosis in 48 patients, pulmonary hypertension in 49 patients, and miscellaneous end-stage lung diseases in 47 patients. Single-lung transplant was performed in 157 cases, bilateral sequential lung transplant in 283 cases, en bloc double-lung transplant in 8 cases, and heart-lung transplant in 2 cases. Graft lungs were obtained from local donors in 24% of cases and from distant donors in 76% of cases. Ideal donors were used in 74% of cases; in 26%, the donor was classified as marginal based on objective criteria.

RESULTS

Four hundred six (91.6%) lung transplant recipients survived to hospital discharge. There were 37 hospital deaths from cardiac events (n = 8), primary graft failure (n = 8), sepsis (n = 6), anastomotic dehiscence (n = 6), and other causes (n = 9). A diagnosis of chronic rejection (bronchiolitis obliterans syndrome [BOS]) was made in 191 patients (42.5%). BOS has not been improved by any specific therapy. Rates of freedom from BOS at 1, 3, and 5 years after the transplant are 82%, 42%, and 25%. One-, 3-, and 5-year actuarial survival rate for the entire group are 83%, 70%, and 54%. There is no statistical difference in survival according to diagnosis or type of lung transplant. Recipient waiting time was 116 days in the first 90 patients and 634 days in the most recent 90 patients.

CONCLUSIONS

Lung transplantation offers patients with end-stage lung disease acceptable prospects for 5-year survival. Chronic rejection and long waiting lists for donor lungs continue to be major problems facing lung transplant programs. The use of marginal and distant donors is a successful strategy in improving donor availability.

The therapeutic potential of nitric oxide in lung transplantation

Endogenously produced oxides of nitrogen appear to play important roles in tissue and organ homeostasis. Endogenous production of nitric oxide, which can be altered in response to various stimuli, can modulate vascular tone, oxyradical cascades, cell adhesion, and other aspects of inflammation. Because exogenously administered (inhaled) nitric oxide can mediate pulmonary vasodilatation and improve pulmonary function in some patients with lung injury, treatment of lung allograft recipients with inhaled nitric oxide may ameliorate ischemia-reperfusion injury, thereby improving perioperative pulmonary function and diminishing ventilatory support requirements. This review examines the biology of nitric oxide and present data that support its potential therapeutic effects for lung transplant recipients.