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Coronary risk stratification in patients with end-stage lung disease
Aditya K Kaza1, Jeffrey F Dietz, John A Kern
1Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia 22908-1359, USA.
Insights
Coronary artery disease (CAD) risk stratification helps identify lung transplant candidates needing further cardiac evaluation. This approach enables intervention, potentially allowing high-risk patients with severe CAD to undergo successful lung transplantation.
Area of Science:
- Cardiology
- Thoracic Surgery
- Transplantation Medicine
Background:
- Significant coronary artery disease (CAD) historically precluded lung transplantation.
- Coronary risk stratification may identify suitable candidates needing further cardiac assessment.
- This study investigates the utility of risk stratification in lung transplant candidates.
Purpose of the Study:
- To evaluate the effectiveness of coronary risk stratification in identifying lung transplant candidates with coronary artery disease (CAD).
- To determine the prevalence of CAD in high-risk lung transplant candidates.
- To assess the role of pre-operative cardiac intervention in this patient population.
Main Methods:
- Retrospective review of 72 lung transplant recipients (1995-2000) and 48 current candidates.
- Identification of CAD risk factors: smoking, diabetes, hypertension, hypercholesterolemia, prior CAD, congestive heart failure, age >50, arrhythmias.
- Classification into low-risk (≤1 factor) and high-risk (>2 factors) groups; assessment of coronary angiography (CA) and intervention.
Main Results:
- Of 72 prior recipients, 48 were high-risk; 5 had CAD diagnosed by CA, 1 received intervention.
- Of 48 current candidates, 28 were high-risk; 12 underwent CA, 2 received intervention.
- Pre-operative CA identified CAD in a significant proportion of high-risk candidates.
Conclusions:
- Coronary risk stratification effectively identifies lung transplant candidates with CAD.
- Pre-operative cardiac intervention can enable successful lung transplantation in high-risk patients.
- This strategy refines selection criteria, expanding eligibility for lung transplantation.
Background:
Significant coronary artery disease (CAD) has been a contraindication for listing patients for lung transplantation. We hypothesize that coronary risk stratification can help identify a sub-set of patients who need additional diagnostic tools and intervention.
Methods:
We performed a retrospective review of 72 consecutive patients who underwent lung transplantation at our institution from 1995 to 2000. Further, a review of patients who are currently listed for transplantation yielded 48 patients. We then identified the various risk factors for CAD, the diagnostic tools used, and pre-operative intervention. Risk factors identified included smoking history, diabetes, hypertension, hypercholesterolemia, CAD, congestive heart failure, age >50, and arrhythmias. Based on these risk factors, the patients were then classified into 2 groups: low risk (< or =1 risk factors) and high risk (> or =2 risk factors). We identified the patients in each group who underwent coronary angiography (CA), those with angiographic evidence of CAD, and those who received pre-operative intervention.
Results:
Of the 72 patients who underwent lung transplantation, 48 were identified as at high risk for CAD. Of these, 5 patients had CAD diagnosed before surgery using CA, and 1 patient received pre-operative intervention. Of the 48 patients currently on the lung transplant list, we identified 28 patients as high risk for CAD, 12 of whom were noted to have CA, and 2 of whom received pre-operative intervention.
Conclusions:
Although CAD was once a contraindication for lung transplantation, pre-operative risk stratification allows identification of CAD with CA in a high-risk group. We believe that by using appropriate pre-operative cardiac intervention, patients with severe CAD could successfully undergo lung transplantation.