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Heart-lung transplantation in 1990--indications, surgical technique, postoperative complications and outcome
B Reichart1, H Reichenspurner, B Meiser
1Department of Cardiac Surgery, Ludwig-Maximilians University, Munich, FRG.
Insights
Cyclosporine A enables long-term heart-lung transplants. Survival rates improved, with 30-day mortality below 20% and 1-year survival at 61% between 1986-1988.
Area of Science:
- Cardiology
- Thoracic Surgery
- Immunology
Background:
- Heart-lung transplantation is a treatment for end-stage cardiac and pulmonary diseases.
- Cyclosporine A (CyA) has enabled long-term outcomes since its introduction.
Purpose of the Study:
- To review the long-term results and complications of heart-lung transplantation.
- To detail the standard surgical procedure and immunosuppression protocols.
Main Methods:
- Analysis of 761 registered clinical heart-lung transplantations.
- Standard surgical procedure involving three anastomoses.
- Immunosuppression regimen including CyA, azathioprine, and rabbit antithymocyte globuline (RATG), with subsequent adjustments.
Main Results:
- Early complications include acute pulmonary rejection, pneumonia, and multiorgan failure.
- Late complications involve infections and chronic obliterative bronchiolitis.
- 30-day mortality decreased to below 20%; 1-year survival was 61% (1986-1988).
Conclusions:
- Heart-lung transplantation outcomes have improved significantly with advancements in immunosuppression and surgical techniques.
- Careful patient selection and management of postoperative complications are crucial for successful long-term survival.
Abstract:
Using cyclosporine A (CyA), long-term results after heart-lung transplantation became possible. Since 1981, 761 clinical heart lung transplantations have been registered at the International Society for Heart Transplantation. Candidates for this operation reveal signs of irreversible heart and lung diseases which are caused by cardiac lesions (e.g. valvular disease, Eisenmenger reaction due to congenital malformation) or pulmonary disorders (e.g. primary pulmonary hypertension, emphysema, fibrosis). The standard surgical procedure necessitates three anastomoses which combine donor and recipient tracheae, right atria and aortae. Immunosuppression consists of CyA (blood levels of 300-500 ng/ml), azathioprine (1-2 mg/kg/d) and rabbit antithymocyte globuline (RATG) (IgG: 2-4 mg/kg/d). After the first 2 postoperative weeks, RATG is replaced by low dose methylprednisolone (0.3-0.1 mg/kg/d). As an alternative, RATG may be omitted completely. Postoperatively, a variety of complications may evolve. Early problems (within the first month) comprise acute pulmonary rejection, bacterial pneumoniae, and multiorgan failure. Diagnosis of acute lung rejection proves difficult; it includes clinical signs, chest radiographic appearances and cytoimmunological monitoring of the peripheral blood. Transbronchial lung biopsies are for precise diagnosis of similar value to endomyocardial biopsies after heart transplantation. Late postoperative complications comprise viral, bacterial, fungal, and protozoal infections and chronic obliterative bronchiolitis. With increasing experience, the 30 day mortality fell to below 20% according to the International Society for Heart Transplantation. The one-year survival rate between 1986 und 1988 was reported to be 61%. The results of some individual groups are even better.
