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Surgical management of heart-lung transplantation
1Department of Cardio-Thoracic Surgery, University of Cape Town Medical School, Groote Schuur Hospital, South Africa.
Insights
Cyclosporin A enables long-term survival in heart-lung transplant recipients by selectively suppressing the immune system while preserving tracheal wound healing. This immunosuppressive therapy has been vital for managing irreversible heart and lung diseases in over 500 patients.
Area of Science:
- Cardiovascular Surgery
- Immunology
- Pulmonology
Background:
- Heart-lung transplantation is a critical option for end-stage cardiac and pulmonary diseases.
- Cyclosporin A has emerged as a key immunosuppressant, improving survival rates.
- The International Society for Heart Transplantation has collected extensive clinical data since 1981.
Purpose of the Study:
- To evaluate the efficacy and complications of heart-lung transplantation using cyclosporin A-based immunosuppression.
- To detail the surgical procedure and immunosuppressive regimens.
- To identify early and late postoperative complications.
Main Methods:
- Analysis of 501 clinical cases from the International Society for Heart Transplantation registry.
- Standard surgical procedure involving tracheal, atrial, and aortic anastomoses.
- Immunosuppressive regimen including cyclosporin A, azathioprine, and rabbit antithymocyte globulin, followed by methylprednisolone.
Main Results:
- Cyclosporin A facilitates long-term survival and preserves tracheal wound healing.
- Early complications include acute lung rejection, multiorgan failure, and bacterial pneumonia.
- Late complications involve viral/fungal pneumonia, tuberculosis, and chronic obliterative bronchiolitis.
Conclusions:
- Cyclosporin A-based immunosuppression is effective for long-term heart-lung transplant survival.
- Accurate diagnosis of acute lung rejection requires clinical, radiographic, and cytoimmunological monitoring.
- Comprehensive management of early and late complications is crucial for patient outcomes.
Abstract:
Using cyclosporin A, long-term survival after heart-lung transplantation became possible. The drug blocks the immune system more selectively and leaves the tracheal wound healing unimpaired. Since 1981, 501 clinical cases have been collected by the registry of the International Society for Heart Transplantation. Candidates for heart-lung transplantation reveal signs of irreversible heart and lung diseases that may have been caused by cardiac lesions (valvular diseases, Eisenmenger reaction due to congenital malformations) or by pulmonic disorders (primary pulmonary hypertension, emphysema, fibrosis). The standard surgical procedure, which combines donor and recipient tracheas, right atria, and aortas, makes three anastomoses necessary. Immunosuppressive regimen includes cyclosporin A (blood trough levels of 300 to 500 ng/mL), azathioprine (1 to 2 mg/kg), and rabbit antithymocyte globulin (1 to 4 mg immunoglobulin G/kg). After the first two postoperative weeks, rabbit antithymocyte globulin is replaced by methylprednisolone (0.3 to 0.1 mg/kg; 500 mg are given intravenously after opening the aortic cross-clamp; 3 x 125 mg on postoperative day 1). After heart-lung transplantation an extreme variety of problems may evolve. Early postoperative complications (within the first postoperative month) comprise acute isolated lung rejection, multiorgan failure, and bacterial pneumonia. Diagnosis of acute lung rejection proves difficult; it includes clinical signs, chest radiographic appearances, and cytoimmunological monitoring. Transbronchial lung biopsies are of similar value for precise diagnosis as are endomyocardial specimens after heart transplantation. Late postoperative complications (after 1 postoperative month) comprise viral pneumonia, fungal infection, tuberculosis, and chronic obliterative bronchiolitis.(ABSTRACT TRUNCATED AT 250 WORDS)