Clinical heart-lung transplantation

Combined lung and liver transplantation: the United States experience

BACKGROUND

Combined transplantation of the lungs and liver is indicated for patients who would not be expected to survive transplantation of either organ alone. No single center has accumulated a significant experience, and as a result the expectations for this operation in the current era are unknown.

METHODS

Patients that have undergone combined lung-liver transplantation in the United States were enrolled through the United Network for Organ Sharing Organ Procurement and Transplantation Network database. In addition, the English-language literature was searched for additional cases of combined lung-liver transplantation.

RESULTS

Eleven patients have undergone combined lung and liver transplantation in the United States at different centers. The 1- and 5-year patient survival rates are of 79% and 63%, respectively, and no patient has required retransplantation. These patient survival rates are equivalent to similar a combined lung-liver case series from the United Kingdom (P=0.37, log-rank test) and isolated orthotopic liver transplantation in the United States (P=0.59, log-rank test), and are comparable to patient survival rates following isolated lung transplantation in the United States.

CONCLUSIONS

Patient survival of combined lung-liver transplantation is comparable to that of isolated liver and isolated bilateral lung transplantation. This option should be considered for patients with end-stage lung disease and liver disease when transplantation of a single organ transplantation is precluded by severe disease in the other organ system.

Ten-year follow-up in patients with combined heart and kidney transplantation

BACKGROUND

Combined heart and kidney transplantation has been documented, although data regarding immunosuppression, rejection episodes, and graft or patient survival have not been detailed. We evaluated our experience and more than 10-year outcome with patients selected for combined heart and kidney transplantation.

METHODS

Eight patients aged 29 to 59 years were selected for combined heart and kidney transplantation. The indications were end-stage heart disease and underlying renal pathology, or secondary renal insufficiency, or renal failure. Six patients were dialysis dependent before transplantation. There were 7 simultaneous procedures and 1 staged procedure. The heart was transplanted first in all cases. All patients were maintained after transplantation on azathioprine (2 mg x kg(-1) x d(-1)) and whole-blood monoclonal cyclosporine levels at greater than 200 microg/L; prednisone was not decreased to less than 10 mg/d.

RESULTS

Seven (87.5%) patients have survived a mean duration of 100.4 months (range, 51-144 months), and each allograft has continued to function. The only death was due to pulmonary emboli and was not related to allograft rejection or failure. Only 4 cardiac and 4 kidney allograft rejections have occurred. Five patients have been free of kidney rejection, 1 patient has been rejection free for more than 8 years, and no patient has had simultaneous rejection.

CONCLUSIONS

In select patients, combined heart and kidney transplantation can provide long-term graft function and patient survival. The low rates of rejection support our current approach to immunosuppression. Our experience indicates that end-stage failure of either heart or kidney does not necessarily preclude dual-organ transplantation.

Bronchoalveolar lavage in lung transplantation. State of the art

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) has become a crucial tool in the management of lung transplant recipients. Detection of pulmonary infectious pathogens by culture, cytology, and histology of BAL, protected brush specimens, and transbronchial biopsies (TBB) is highly effective. Morphologic and phenotypological analyses of BAL cells may be suggestive for certain complications after lung transplantation. For interpretation of BAL findings, the natural course of BAL cell morphology and phenotypology after lung transplantation must be considered. During the first 3 months after pulmonary transplantation, elevated total cell count in BAL and neutrophilic alveolitis are common, representing the cellular response to graft injury and interaction of immunocompetent cells of donor and recipient origin. With increasing time after transplantation the CD4/CD8 ratio decreases due to lowered percentages of CD4 cells in BAL. During bacterial pneumonias, the cellular profile of BAL is characterized by a marked granulocytic alveolitis. Lymphocytic alveolitis with a decreased CD4/CD8 ratio is suggestive of acute rejection, but is also found in viral pneumonias and obliterative bronchiolitis. In the case of a combined lymphocytosis and neutrophilia without any evidence of infection, obliterative bronchiolitis should be considered. Functional analyses of BAL cells can give additional information about the immunologic status of the graft, even before histologic changes become evident but have not been established in routine transplant monitoring. However, functional studies suggest an important role of activated, alloreactive and donor-specific T lymphocytes in the pathogenesis of acute and chronic lung rejection. Investigations of soluble components in BAL have given further insight into the immunologic processes after lung transplantation. In this overview, the characteristics of BAL after lung transplantation will be summarized, and its relevance for the detection of pulmonary complications will be discussed.

Simultaneous transplantation of the heart and kidney

BACKGROUND

Multiple organ transplants have become frequent. Combined heart-and-kidney grafting has been reported recently and we have pursued this in selected cases.

AIMS

To devise a protocol for simultaneous heart-and-kidney transplantation, review our clinical experience with the procedure and the causes of cardiac and renal disease in this group.

METHODS

Seven patients with advanced cardiac failure (LV ejection fraction < 0.29 units; five with IDCM), and chronic renal failure (serum creatinine > 375 mumol/L) due to a variety of causes, were accepted for combined heart-and-kidney transplantation. Four males, of mean age 33 years, underwent the procedure. Each received his organs from a single cadaveric donor with ABO blood group compatibility and a negative 'current' lymphocytotoxic cross-match, but without regard to HLA-antigen matching. Cardiac ischaemic time averaged 3 hours 40 minutes, the renal first warm time was 0 minutes in all cases, and renal cold and second warm ischaemic times averaged 5 hours 17 minutes and 52 minutes respectively. The heart was grafted first and the kidney second in a procedure which averaged seven hours. Immunosuppression was achieved by induction with antithymocyte globulin, thence steroids, azathioprine and cyclosporin A.

RESULTS

No patient required post-operative dialysis. One patient had early urological complications requiring operative correction, but no serious opportunistic infections were observed. Early cardiac rejection on biopsy (ISHT grade 3a) was seen in three patients at four-ten weeks and responded promptly to increased steroids, but severe steroid-resistant rejection of both heart and kidney contemporaneously occurred in one of these three at 19 months and required a course of muromonab-CD3. All four patients developed hypertension. Mean creatinine clearance was 1.23 +/- 0.22 mL/second (74 +/- 13 mL/minute) at last follow-up. All four recipients were alive, well and rehabilitated 5, 20, 28 and 35 months after grafting. Two patients died while waiting for the double procedure and another patient eventually died after being taken off the dual waiting list and receiving a renal transplant only.

CONCLUSIONS

In experienced hands, combined heart-and-kidney transplantation is feasible and offers a compelling therapeutic solution in the treatment of advanced cardiac and renal failure. IDCM is a frequent cause of the heart failure in this group.

Reduction in bleeding after heart-lung transplantation. The importance of posterior mediastinal hemostasis

To reduce perioperative hemorrhage following heart-lung transplantation, several technical modifications were introduced in June 1988 to secure better posterior mediastinal hemostasis. The intraoperative and postoperative use of blood and blood products, as well as the chest tube drainage in the first 24 hours postoperatively, were compared in the seven patients operated on since June 1988 with the nine patients operated on before that date. Significant (p less than 0.05) reductions were demonstrated in the intraoperative and postoperative transfusion of packed cells, in the postoperative administration of fresh frozen plasma, and in the chest tube drainage within the first 24 hours postoperatively. The one-month and total hospital mortality rates were 6 percent and 12.5 percent, respectively. It is concluded that newer techniques to obtain optimal posterior mediastinal hemostasis have significantly reduced blood loss following heart-lung transplantation in our experience and have contributed to our excellent early postoperative results.

Organ procurement for pulmonary transplantation

Selection of suitable donors is critical to the success of clinical pulmonary transplantation. Requirements for lung donors, management before explantation, and methods of preservation were reviewed for the 70 heart-lung, eight double-lung, and two single-lung transplantations performed at the University of Pittsburgh since 1982. Careful observation of trends of hyperoxygenation studies, chest roentgenograms, and Gram stain and culture results of tracheal secretions, as well as findings on bronchoscopy, can help identify which lungs not only have adequate function but are acceptable for transplantation. In spite of the rigid criteria used, 76% of tracheal cultures from donors deemed acceptable grew organisms. The presence of oropharyngeal flora has been shown to correlate with the development of early intrathoracic infections in the recipient. Prophylactic broad-spectrum antibiotic treatment of the donor is desirable to treat microbial contamination that could cause focal injury to the donor lung and predispose to infection in the recipient. Acceptance of less than ideal donors is ill-advised even though rejection of such donors conflicts with the current shortage of organs.

Early experience of heart-lung transplantation

We report our experience of heart-lung transplantation for the treatment of children with terminal respiratory disease. Between May 1987 and October 1988 we performed heart-lung transplantation in five children under the age of 16 (age range 11-15). All the patients were severely disabled by dyspnoea and hypoxia. Two had primary pulmonary hypertension, two cystic fibrosis, and one had Eisenmenger's syndrome. All five children are alive and well five to 17 months after operation and have returned to activities normal for their age. Three of the five patients had episodes of infection after operation. These were staphylococcal pneumonia, herpes simplex pneumonitis and, in one of the patients with cystic fibrosis, persistent purulent sputum. The mean number of episodes of rejection per child was 2.7 per half year. Heart-lung transplantation is a practical treatment for children in these disease groups with terminal respiratory failure.

The pathology of combined heart-lung transplantation: an autopsy study

Clinical heart-lung transplantation (HLT) began at Stanford University (Stanford, CA) in 1981, and since then, over 40 HLTs have been performed. There is now a worldwide total of 250 HLTs. While much of the pathology that occurs in patients receiving an HLT is similar to that which develops in patients with other transplanted organ systems, these patients also develop unique clinical complications and pathologic processes that deserve emphasis. We report the autopsy findings of 20 HLT recipients, of whom 12 died in hospital one day to 4 months post-HLT. A major contributing factor in five of these postoperative deaths was pleural hemorrhage from adhesions due to prior chest surgery. Overwhelming viral and fungal infections accounted for six deaths. The seventh patient died as a result of adult respiratory distress syndrome (ARDS). Two patients showed histologic evidence of the reimplantation response. Six long-term survivors died (mean survival, 22 months) with obliterative bronchiolitis (OB). In four patients, OB was the immediate cause of death, while one patient died of an intercurrent myocardial infarct, and the other patient died of complications from an appendectomy. Two long-term survivors died without OB, one of iatrogenic causes at 63 months and the second due to unexplained ARDS at 52 months. Both patients without OB had virtually normal underlying pulmonary parenchyma. All of the long-term survivors had either coronary arterial or pulmonary vascular intimal sclerosis, and renal lesions attributable to cyclosporine A toxicity. Although histologic features of mild acute pulmonary and cardiac rejection were observed in four patients overall, these did not contribute to the cause of death in any case. Although OB is a major threat to its success, HLT is a viable option for patients with endstage pulmonary disease.

Immunologically mediated disease of the airways after pulmonary transplantation

Obliterative bronchiolitis has occurred in eleven of 30 recipients of cardiopulmonary allografts who survived at least 4 months after transplantation, has caused significant morbidity, and has been associated with four of eleven late deaths in this series. Although some improvement, or at least stability, of pulmonary function has followed augmented immune suppression, it appears that once the process is recognized clinically, much of the damage to the airways is irreversible. The histopathology, response to therapy, and, most important, the response of donor specific alloreactivity in the lymphocytes from the lung (bronchoalveolar lavage and peripheral blood) suggest immune- mediated basis for bronchiolitis obliterans. The presence of donor specific alloreactivity detected by primed lymphocyte testing predicted obliterative bronchiolitis in five of six recipients (83% sensitivity, 91% specificity) was absent in ten of eleven recipients who have not as yet developed the process (negative predicted value of 91%). Currently, the presence of a positive primed lymphocyte test in the bronchoalveolar lavage of the cardiopulmonary recipient is an indication for early treatment by augmented immune suppression.

Distant graft procurement for combined heart and lung transplantation using pulmonary artery flush and simple topical hypothermia for graft preservation

Although combined heart and lung transplantation has great potential for improving survival and rehabilitation in selected patients with pulmonary vascular disease, the lack of suitable donor organs has restricted the number of operations performed. We report a heart and lung transplantation operation for Eisenmenger's syndrome in which distant donor graft procurement was used with a simple system for preservation.

Effects of 24-Hour Hypothermic Storage on Isolated-Perfused Canine Heart-Lungs

Isolated-perfused canine heart-lungs were used as a model to measure the effects of 24-hour hypothermic storage on cardiopulmonary function and metabolism. Heart-lungs were stored at 4–7°C in Euro-Collins solution ( n = 6) or TP-V ( n = 6). a hyperosmolar colloid solution containing dextrose, sucrose. ATP and MgCl2. Lung inflation was maintained with 100% nitrogen. Following preservation, the heart-lungs were perfused with an albumin-mannitol perfusate for three hours at 37°C. for functional and laboratory determinations. Cold storage with TP-V soiution resulted in significantly lower enzyme activity for CPK ( p < 0·0005) and LDH ( p < 0·01) at 0, 1, and 3 hours of normothermic isolated perfusion. A significant reduction in lactate production ( p < 0·001) was also seen in the heart-lungs stored in TP-V. No apparent differences were seen in the pH, PCO2. and PO2 among the two groups, nor were there any significant haemodynamic changes. Histological specimens revealed that TP-V was less damaging to both cardiac and pulmonary tissue, as only moderate oedema and congestion was apparent. These results indicate that 24 hour hypothermic storage with TP-V may be a more appropriate preservation solution for canine heart-lungs.

Interactions between bronchoalveolar lymphocytes and macrophages in heart-lung transplant recipients

Bronchoalveolar lavages (BAL) were obtained from heart-lung transplant patients. Following transplantation, the number of lymphocytes and macrophages are considerably increased. BAL lymphocytes frequently exhibit donor specific secondary allogeneic proliferation measured in primed lymphocyte testing (PLT) assays. We report our findings regarding a persistence of donor derived macrophages and lymphocytes in BAL during the posttransplant period. The presence of donor specific macrophages causes a proliferative response of alloreactive BAL lymphocytes from the recipient. This "Bronchoalveolar Macrophage Lymphocyte Reaction," or "BMLR," may represent a unique aspect of in vivo interactions associated with lung allograft responses. Comparative studies showed considerably lower PLT responsiveness of peripheral blood lymphocytes than that of BAL lymphocytes. These studies suggest that functional assays on BAL cells may be useful in monitoring lung transplant rejection and other immunological phenomena that affect pulmonary function of heart-lung transplant patients.

Pathologic pulmonary alterations in long-term human heart-lung transplantation

Twenty-one patients with end-stage pulmonary hypertension underwent combined allograft heart-lung transplantation after 1980. Almost 80 per cent of these patients survived beyond the immediate postoperative period, with the longest survival period more than 3 1/2 years at the time of this report. Five patients died in the perioperative or immediate postoperative period, and 11 returned to normal lives with essentially normal pulmonary function. In the remaining five allograft recipients recurrent respiratory infections and progressive obstructive airway disease developed, with superimposed restrictive deficits in three of them. Two open lung biopsies, two autopsies, and one retransplantation were performed in these recipients. Morphologically, these allograft recipients showed extensive bronchiolitis obliterans, interstitial and pleural fibrosis, and accelerated arterial and venous arteriosclerosis. Bronchiolitis obliterans may prove to be a significant complication of heart-lung transplantation.

Long-term results, hemodynamics, and complications after combined heart and lung transplantation

During the first 31/2 years of the Stanford heart-lung transplant program, 23 transplants have been carried out in 22 patients with severe pulmonary vascular disease. Actuarial survival curves predict 1 and 2 year survival rates of 71% and 57%, respectively, for all patients. As a result of increasing experience, the early mortality of 26% has been reduced, with only one early death occurring in the last eight patients; prior cardiac surgery was a contributing factor in three of the six patients suffering early deaths. Two late deaths occurred in the series 14 and 15 months after operation. One patient died suddenly as a result of an acute myocardial infarct and the other patient died because of respiratory failure. At autopsy, both patients had severe proliferative coronary atherosclerosis with obliterative bronchiolitis affecting the lungs. An additional patient required a retransplant for obliterative bronchiolitis 37 months after the initial procedure, and he too was found to have severe coronary artery disease. Hemodynamics and left ventricular function were normal in patients studied 1 and 2 years after undergoing the transplantation procedure. Thus, the early mortality and morbidity of combined heart and lung transplantation has been significantly reduced, but the long-term complications, particularly graft atherosclerosis and obliterative bronchiolitis, are yet to be fully controlled.

Cyclosporine

Cyclosporine is an immunosuppressant used to prevent the rejection of transplanted kidneys, hearts, and livers. Cyclosporine suppresses T-lymphocyte function without causing myelosuppression, and its pharmacokinetics are highly variable. Compared with conventional immunosuppressive drug therapy, both patient and graft survival improved in patients treated with cyclosporine. Patients treated with cyclosporine also had less complicated hospital courses than patients receiving conventional immunosuppressants. The adverse effects from cyclosporine are reversible but include nephrotoxicity, hepatotoxicity, malignancies, hirsutism, and minor neurologic complications. Intravenous cyclosporine doses range from 2-9 mg/kg/d and oral doses range from 10-50 mg/kg/d; the dosage should be individualized based on the clinical status of the patient as well as blood concentrations of the drug. Monitoring cyclosporine blood concentrations is necessary in the postoperative management of transplant patients. Cyclosporine has contributed to the improved success of transplantation and the recognition of transplantation as a new therapeutic option for several diseases.

Primary pulmonary hypertension: natural history and the importance of thrombosis

A long-term retrospective follow-up study was made of 120 patients (33 male, 87 female patients) with primary pulmonary hypertension--diagnosed by strict clinical and hemodynamic criteria--to obtain a better understanding of the natural history and possible pathogenetic mechanisms of the disease. The mean age at diagnosis was 34 (3 to 64) years, but only 24 patients (21%) remained alive 5 years later. Lung tissue obtained at autopsy from 56 patients revealed two major pathologic types: thromboembolic pulmonary hypertension in 32 patients (57%) and plexogenic pulmonary arteriopathy in 18 (32%). Thus, in more than half the patients undergoing autopsy the major histologic feature was thrombi without any evidence of plexiform lesions. The two groups were similar with respect to their clinical and hemodynamic features and short survival. Of the variables tested for prognostic importance by stepwise multivariate analysis, only two were significant: pulmonary arterial oxygen saturation (p less than .00001) and anticoagulant therapy (p = .01). Anticoagulant therapy is recommended for patients with primary pulmonary hypertension.