Should we perform bilateral-lung or heart–lung transplantation for patients with pulmonary hypertension?

Prognosis factors in heart-lung transplantation: 30 years experience in a reference center

INTRODUCTION

Heart-lung transplantation has shown a progressive decrease in the number of procedures. There is a lack of information about this field in Spain. The main goal of this study is to analyze the experience of a national reference hospital.

METHODS

We performed a retrospective study of a historical cohort of heart-lung transplanted patients in a single center, during a 30 years period (from 1990 to 2021). The associations between variables were evaluated using the χ2 test or Fisher's exact test. Survival was analyzed using the Kaplan-Meier method. Differences were evaluated using the log-rank test and multivariate analysis with the Cox method.

RESULTS

A decrease in the number of procedures performed in the last decade was observed [2000-2009: 19 procedures (44.2%); 2010-2021: 15 procedures (34.8%)]. Early postoperative mortality was 23.3%, falling to 13.3% from 2010. In-hospital mortality was 41%, falling to 33% from 2010. Main factors related to higher mortality: previous thoracic surgery, corticosteroid therapy, extracorporeal circulation (ECLS) greater than 200 min, ischemia time greater than 300 min, and tracheal dehiscence (p < 0.005). Overall survival at one, five, and ten years was 58%, 44.7%, and 36.1%, respectively. Factors associated with lower survival rates: previous thoracic surgery, male donor, extracorporeal circulation greater than 200 min, ischemia time greater than 300 min, tracheal dehiscence and weight difference (p < 0.005).

CONCLUSIONS

There has been a progressive decrease in the number of heart-lung transplantations, being more evident in the last decade, but showing an improvement in both mortality and survival.

Double-lung versus heart-lung transplantation for end-stage cardiopulmonary disease: a systematic review and meta-analysis

We compared posttransplant outcomes following double-lung transplantation (DLTx) and heart-lung transplantation (HLTx), based on a search of PubMed, Cochrane Library, and Embase, from inception to March 8, 2022, for studies that report outcomes of these procedures. We then performed a meta-analysis of baseline characteristics and posttransplant outcomes. Subgroup analyses were implemented according to indication, publication year, and center. This study was registered on PROSPERO (number CRD42020223493). Ten studies were included in this meta-analysis, involving 1230 DLTx patients and 1022 HLTx patients. The DLTx group was characterized by older donors (P = 0.04) and a longer allograft ischemia time (P < 0.001) than the HLTx group. The two groups had comparable 1-year, 3-year, 5-year, 10-year survival rates (all P > 0.05), with similar results identified in subgroup analyses. We found no significant differences in 1-year, 5-year, and 10-year chronic lung allograft dysfunction (CLAD)-free survival, length of intensive care unit stay and hospital stay, length of postoperative ventilation, in-hospital mortality, or surgical complications between the groups (all P > 0.05). Thus, DLTx provides similar posttransplant survival to HLTx for end-stage cardiopulmonary disease. These two procedures have a comparable risk of CLAD and other posttransplant outcomes.

Transplantation for pulmonary arterial hypertension with congenital heart disease: Impact on outcomes of the current therapeutic approach including a high-priority allocation program

Patients with end-stage pulmonary arterial hypertension due to congenital heart disease have limited access to heart-lung transplantation or double-lung transplantation. We aimed to assess the effects of a high-priority allocation program established in France in 2007. We conducted a retrospective study to compare waitlist and posttransplantation outcomes before versus after implementation of the high-priority allocation program. We included 67 consecutive patients (mean age at listing, 33.2 ± 10.5 years) with pulmonary arterial hypertension due to congenital heart disease listed for heart-lung transplantation or double-lung transplantation from 1997 to 2016. At one month, the incidences of transplantation and death before transplantation were 3.5% and 24.6% in 1997-2006, 4.8% and 4.9% for patients on the regular list in 2007-2016, and 41.2% and 7.4% for patients listed under the high-priority allocation program (p < .001 and p = .0001, respectively). Overall survival was higher in patients listed in 2007-2016 (84.2% and 61.2% at 1 and 10 years vs. 36.8% and 22.1%, p = .0001). Increased incidence of transplantation, decreased waiting list mortality, and improved early and long-term outcomes were observed in patients with pulmonary arterial hypertension due to congenital heart disease listed for transplantation in the recent era, characterized by implementation of a high-priority allocation program.

Heart-lung transplant in congenitally corrected transposition of the great arteries and dextrocardia patient

A 53-year-old male patient was presented to our institution with the clinical picture of biventricular failure. The echocardiogram revealed congenitally corrected transposition of the great arteries, dextrocardia with situs solitus, atrioventricular discordance and ventriculoatrial discordance, severe systemic and mitral valves regurgitation, and severe pulmonary hypertension (mean pulmonary artery pressure: 51 mm Hg). He underwent heart–lung transplant. He was discharged on postoperative day 25 with left ventricular ejection fraction of 60%–65%, and with oxygen independency.

Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist

Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.

Not All Septal Defects Are Equal: Outcomes of Bilateral Lung Transplant With Cardiac Defect Repair vs Combined Heart-Lung Transplant in Patients With Eisenmenger Syndrome in the United States

BACKGROUND

Thoracic transplantation is considered for patients with Eisenmenger syndrome (ES) who have refractory right ventricular failure despite optimal therapy for pulmonary arterial hypertension. This study compared the outcomes of bilateral lung transplantation (BLT) with cardiac defect repair vs combined heart-lung transplantation (HLT).

RESEARCH QUESTION

This study presents an updated analysis using a US national registry to evaluate the outcomes of patients diagnosed with ES who underwent HLT or BLT with repair of cardiac defects.

STUDY DESIGN AND METHODS

This study identified patients with ES who underwent thoracic transplantation from 1987 to 2018 from the United Network for Organ Sharing database. Survival curves were estimated by using the Kaplan-Meier method and were compared by using the log-rank test.

RESULTS

During the study period, 442 adults with ES underwent thoracic transplantation (316 HLTs and 126 BLTs). Following BLT, overall survival 1, 5, and 10 years' posttransplant was 63.1%, 38.5%, and 30.2%, respectively. Following HLT, overall survival 1, 5, and 10 years' posttransplant was 68.0%, 47.3%, and 30.5% (P = .6). When survival analysis was stratified according to type of defect, patients with an atrial septal defect had better survival following BLT than following HLT (88.3% vs 63.2% 1 year posttransplant, P < .01; 71.1% vs 49.8% 3 years' posttransplant, P < .01; and 37.4% vs 29.9% 10 years' posttransplant, P = .08). Patients with a ventricular septal defect (VSD) exhibited better survival following HLT than following BLT (78.2% vs 49.6% 1 year posttransplant, P < .01; 55.6% vs 34.3% 5 years' posttransplant, P < .01; and 35.7% vs 26.5% 10 years' posttransplant, P = .03). The most common cause of mortality in patients with VSD undergoing BLT was cardiac ventricular failure.

INTERPRETATION

This study suggests that the best transplant option for patients with VSD remains HLT, which prevents subsequent development of ventricular failure. BLT with cardiac defect repair should be considered as the first-line treatment option in patients with ES due to an uncorrected atrial septal defect. These patients can be considered to have isolated and reversible right ventricular failure akin to patients with advanced pulmonary arterial hypertension.

Pulmonary Hypertension and Right Ventricular Failure: Lung Transplant Versus Heart-Lung Transplant

Pulmonary arterial hypertension is a highly morbid disease with limited treatment options that improve survival and currently the only curative treatment is transplantation. There is a small body of literature comparing the efficacy of lung and heart-lung transplantation in this population. The bulk of evidence suggests that most patients with severe right ventricular failure undergoing transplant will have recovery of right ventricular function after lung transplantation. Existing data suggest that, in the absence of complex congenital heart disease or significant left ventricular dysfunction, double-lung transplant is the surgical procedure of choice.

Assessment and treatment of the failing right heart: considerations for transplantation referral

Long considered an insignificant chamber, the right ventricle has been recently under spotlight, especially with emerging data supporting its critical role in disease progression. The right ventricle is a triangular heart chamber with complex physiology and pathophysiology. In this review, we discuss the normal physiology of the right ventricle, right ventricular failure, and recent advances in treatment with emphasis on optimal timing for transplantation referral.

Heart-lung transplantation: current indications, prognosis and specific considerations

Heart-lung transplantation (HLTx) is currently the best treatment for patients who have end-stage heart and lung failure. Idiopathic pulmonary arterial hypertension (IPAH) was the main indication for HLTx in the 1980s. However, when studies showed resolution of right ventricular dysfunction after double-lung transplantation (DLTx), this last procedure became the preferred option for end-stage IPAH. Currently, the main indication of HLTx is congenital heart disease (CHD), followed by acquired heart disease combined with pulmonary hypertension and/or intrinsic lung disease. Although early posttransplant survival remains lower after HLTx than after lung transplantation, careful patient selection combined with surgical advances are producing improvements. Here, we review the practice patterns, trends, and outcomes of HLTx worldwide.

Overview of Lung Transplantation, Heart-Lung Transplantation, Liver-Lung Transplantation, and Combined Hematopoietic Stem Cell Transplantation and Lung Transplantation

Lung transplantation (LTx) has evolved to represent the therapy of choice for many patients with end-stage lung diseases. Appropriate candidate selection for LTx is an important determinant of a positive outcome from transplantation. Posttransplantation survival has steadily improved, but long-term survival continues to be a challenge with a median survival of 5.8 years. Similarly, combined heart-lung transplantation and simultaneous liver-lung transplantation has been performed successfully in select patients who are not expected to survive either organ transplant alone. Moreover, LTx has been performed in patients who develop end-stage pulmonary complications following hematopoietic stem cell transplantation.

State of the Art of Combined Heart-Lung Transplantation for Advanced Cardiac and Pulmonary Dysfunction

Over the last several decades, significant advances and improvements in care of transplant patients have resulted in markedly improved outcomes. A number of options are available for patients with advanced cardiopulmonary dysfunction requiring transplantation. There is a debate about when isolated heart or isolated lung transplantation is no longer possible or advisable and combined heart-lung transplantation is justified. Organ availability and allocation severely limit the latter option to very few well-selected patients. We review practice patterns, trends, and outcomes after triple-organ heart-lung transplant (HLTx) worldwide, as well as our own experience with heart-lung transplant in the modern era.

Multidetector computed tomography shows reverse cardiac remodeling after double lung transplantation for pulmonary hypertension

OBJECTIVE

To use multidetector computed tomography (MDCT) to evaluate the structural changes in the right heart and pulmonary arteries that occur in patients with severe pulmonary hypertension treated by double lung transplantation.

MATERIAL AND METHODS

This was a retrospective study of 21 consecutive patients diagnosed with severe pulmonary hypertension who underwent double lung transplantation at our center between 2010 and 2014. We analyzed the last MDCT study done before lung transplantation and the first MDCT study done after lung transplantation. We recorded the following variables: diameter of the pulmonary artery trunk, ratio of the diameter of the pulmonary artery trunk to the diameter of the ascending aorta, diameter of the right ventricle, ratio of the diameter of the left ventricle to the diameter of the right ventricle, and eccentricity index. Statistical analysis consisted of the comparison of the means of the variables recorded.

RESULTS

In all cases analyzed, the MDCT study done a mean of 24±14 days after double lung transplantation showed a significant reduction in the size of the right heart chambers, with improved indices of ventricular interdependency index, and reduction in the size of the pulmonary artery trunk (p<0.001 for all the variables analyzed).

CONCLUSION

Patients with pulmonary hypertension treated by double lung transplantation present early reverse remodeling of the changes in the structures of the right heart and pulmonary arterial tree. MDCT is useful for detecting these changes.

A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

Left and Right Ventricular Functional Dynamics Determined by Echocardiograms Before and After Lung Transplantation

Impaired cardiac function is considered a contraindication for lung transplantation (LT). Because right ventricular (RV) function is expected to improve after LT, poor left ventricular (LV) function is often the determinant for LT eligibility. However, the changes in cardiac function before and after LT have not yet been elucidated. Therefore, we reviewed echocardiograms obtained from 67 recipients before and after LT. In a subset of 49 patients, both RV and LV longitudinal strains based on 2-dimensional speckle tracking echocardiography were analyzed. The cardiopulmonary exercise tests were also reviewed. All patients showed significant improvements in their exercise capacity after LT. RV echo parameters improved in all patients after LT (RV fractional area change: 36.7 ± 5.6% to 41.5 ± 2.7%, RV strain: -15.5 ± 2.9% to -18.0 ± 2.1%, RV E/E': 8.4 ± 1.8 to 7.7 ± 1.8; all p <0.05). Overall, the left ventricular ejection fraction (LVEF) did not change (58.7 ± 6.0% to 57.5 ± 9.7%, p = 0.385); however, 20 patients (30%) showed >10% decrease in LVEF after LT (61.5 ± 6.1% to 47.3 ± 4.2%, p <0.001) and an increase in LV E/E' (11.8 ± 1.8 to 12.9 ± 2.2, p = 0.049). Multivariate logistic regression analysis revealed that pre-LT LV E/E' was associated with decrease in LVEF after LT (odds ratio 1.381, 95% confidence interval 1.010 to 1.947, p = 0.043). Furthermore, patients with strain data showed that lower pre-LT LV strain was independently associated with LVEF decrease after LT (odds ratio 1.293, 95% confidence interval 1.088 to 1.614, p = 0.002). Although RV function improves after LT, LV systolic and diastolic functions deteriorate in a sizable proportion of patients. Impaired LV diastolic function before transplant appears to increase the risk of LVEF deterioration after LT.

Lung transplantation: an overview of candidacy and outcomes

BACKGROUND

Various factors must be taken into account when considering lung transplantation, including candidacy, contraindications, and outcomes.

METHODS

This article presents a review of the data and literature on lung transplantation, tracking the evolution of the treatment as it applies to different conditions, as well as an examination of patient survival rates in relation to pathology and treatment.

RESULTS

Timely referral and careful selection of candidates for lung transplantation maximize the outcomes of the procedure, resulting in a longer lifespan with improved physical health for patients.

CONCLUSION

Lung transplantation is a therapeutic option for patients with various lung diseases. Adapting treatment options and follow-up treatment to the individual patient's lifestyle and pathology optimizes patient survival rates after transplantation.