Evaluation of Risk Factors for Heart-Lung Transplant Recipient Outcome: An Analysis of the United Network for Organ Sharing Database.

BACKGROUND: Heart-lung transplantation (HLTx) is an effective treatment for patients with advanced cardiopulmonary failure. However, no large multicenter study has focused on the relationship between donor and recipient risk factors and post-HLTx outcomes. Thus, we investigated this issue using data from the United Network for Organ Sharing database. METHODS: All adult patients (age ≥18 years) registered in the United Network for Organ Sharing database who underwent HLTx between 1987 and 2017 were included (n=997). We stratified the cohort by patients who were alive without retransplant at 1 year (n=664) and patients who died or underwent retransplant within 1 year of HLTx (n=333). The primary outcome was the influence of donor and recipient characteristics on 1-year post-HLTx recipient death or retransplant. Kaplan-Meier curves were created to assess overall freedom from death or retransplant. To obtain a better effect estimation on hazard and survival time, the parametric Accelerated Failure Time model was chosen to perform time-to-event modeling analyses. RESULTS: Overall graft survival at 1-year post-HLTx was 66.6%. Of donors, 53% were male, and the mean age was 28.2 years. Univariable analysis showed advanced donor age, recipient male sex, recipient creatinine, recipient history of prior cardiac or lung surgery, recipient extracorporeal membrane oxygenation support, transplant year, and transplant center volume were associated with 1-year post-HLTx death or retransplant. On multivariable analysis, advanced donor age (hazard ratio [HR], 1.017; P=0.0007), recipient male sex (HR, 1.701; P=0.0002), recipient extracorporeal membrane oxygenation support (HR, 4.854; P<0.0001), transplant year (HR, 0.962; P<0.0001), and transplantation at low-volume (HR, 1.694) and medium-volume centers (HR, 1.455) in comparison with high-volume centers (P=0.0007) remained as significant predictors of death or retransplant. These predictors were incorporated into an equation capable of estimating the preliminary probability of graft survival at 1-year post-HLTx on the basis of preoperative factors alone. CONCLUSIONS: HLTx outcomes may be improved by considering the strong influence of donor age, recipient sex, recipient hemodynamic status, and transplant center volume. Marginal donors and recipients without significant factors contributing to poor post-HLTx outcomes may still be considered for transplantation, potentially with less impact on the risk of early postoperative death or retransplant.

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.

Combined heart-lung transplantation: a perspective on the past and the future.

During the last 20 years, there has been a shift away from combined heart-lung transplantation (HLT) in favor of bilateral lung transplantation. This paradigm shift allowed for the donor heart to be transplanted to another patient. However, HLT remains to be the definitive surgical treatment for certain congenital heart disorders and Eisenmenger's syndrome. With a growing population of adult patients with congenital heart disease, there remains a need for HLT. This article provides a perspective on the past and the future of HLT.

The impact of the COVID-19 pandemic on cardiac surgery and transplant services in Ireland's National Centre.

BACKGROUND: Irish health services have been repurposed in response to the COVID-19 pandemic. Critical care services have been re-focused on the management of COVID-19 patients. This presents a major challenge for specialities such as cardiothoracic surgery that are reliant on intensive care unit (ICU) resources. AIM: The aim of this study was to evaluate the impact of the COVID-19 pandemic on activity at the cardiothoracic surgical care at the National Cardiothoracic Surgery and Transplant Centre. METHODS: A comparison was performed of cardiac surgery and transplant caseload for the first 4 months of 2019 and 2020 using data collected prospectively on a customised digital database. RESULTS: Cardiac surgery activity fell over the study period but was most impacted in March and April 2020. Operative activity fell to 49% of the previous years' activity for March and April 2020. Surgical acuity changed with 61% of all cases performed as inpatient transfers after cardiology admission in contrast with a 40% rate in 2019. Valve surgery continued at 89% of the expected rate; coronary artery bypass surgery was performed at 61% of the expected rate and major aortic surgery at 22%. Adult congenital heart cases were not performed in March or April 2020. One heart and one lung transplant were performed in this period. CONCLUSIONS: In March and April of 2020, the spread of COVID-19 and the resultant focus on its management resulted in a reduction in cardiothoracic surgery service delivery.

Current status of lung transplantation for cystic fibrosis.

Lung transplantation has emerged as an acceptable option for the management of cystic fibrosis patients with endstage lung disease. Heart-lung transplantation and, more recently, double lung transplantation have been successfully performed in this group of patients. The choice of operation, so far, has been based on the surgeon's preference and experience as well as the cardiac function of the patient. Each of the procedures has advantages and disadvantages. This article reviews the current worldwide experience in lung transplantation for patients with cystic fibrosis and highlights the controversies involved in the selection of patients and procedure.

Pediatric lung transplantation: expanding indications, 1985 to 1993.

The application of lung transplantation to the pediatric population was a natural extension of the success realized in our adult transplant program, which began in 1982. Thirty-two pediatric patients (age range 1 to 18 years) have undergone heart-lung (n = 16), double-lung (n = 14), and single-lung (n = 2) transplantation procedures. The cause of end-stage lung disease was primary pulmonary hypertension (n = 7), congenital heart disease (n = 7), cystic fibrosis (n = 9), pulmonary arteriovenous malformation (n = 2), desquamative interstitial pneumonitis (n = 2), graft-versus-host disease (n = 1), emphysema (n = 1), rheumatoid lung (n = 1), cardiomyopathy (n = 1), and Proteus syndrome (n = 1). Six patients (19%) underwent pretransplantation thoracic surgical procedures. The survival rate was 78% at a mean follow-up of 1.8 years. The survival rate in the 23 recipients without cystic fibrosis was 87% (95% since 1985). The actuarial 1-year survival rate in the nine recipients with cystic fibrosis was 55%. Immunosuppression was cyclosporine (n = 9) or FK 506 (n = 23)-based therapy with azathioprine and steroids. Children were followed up by spirometry, transbronchial biopsy, and primed lymphocyte testing of bronchoalveolar lavage fluid. The mean number of treated episodes of rejection per patient in the groups treated with cyclosporine and FK 506, respectively, was 1.0 and 1.2 at 30 days, 0.67 and 0.38 at 30 to 90 days, and 2.33 and 0.46 at greater than 90 days (p < 0.001, Fisher exact test).(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanical Circulatory Support device database of the International Society for Heart and Lung Transplantation: first annual report--2003.

Over the last 2 decades, mechanical circulatory support devices have been developed with the goal of supporting patients with advanced heart failure as a bridge to cardiac transplantation, a bridge to recovery, and an alternative to transplantation (also called chronic or destination therapy). The current generation of devices provides a differentiated spectrum of circulatory support. The major limitations of mechanical circulatory support devices are infection, coagulopathies and device dysfunction. The Scientific Council on Mechanical Circulatory Support of the International Society for Heart and Lung Transplantation has established an international database to generate critical data to advance knowledge about the effectiveness of mechanical circulatory support device therapy for one of the most difficult and costly contemporary medical problems, the malignant syndrome of advanced heart failure.

Indications. Unilateral, bilateral, heart-lung, and lobar transplant procedures.

Indications for unilateral, bilateral, heart-lung, and lobar transplant procedures for emphysema, cystic fibrosis, primary pulmonary hypertension, and pulmonary fibrosis are presented, and a brief historical perspective of the procedures is supplied.

The past, present, and future of lung transplantation.

BACKGROUND: The history of lung transplantation from the first human transplant performed in 1963 to the present is reviewed with particular focus on the added challenges because of the contaminated bronchus, exposure of the graft to airborne organisms, the poor blood supply to the bronchus, and the problem of reperfusion pulmonary edema. METHODS: The technical aspects of single and double sequential lung transplantation are reviewed, as are the current indications for single, double sequential, and heart/lung transplantation. Criteria for lung transplant recipients, in addition to their primary disease are noted, as are absolute and relative contraindications. The standard criteria for donor selection are also reviewed. RESULTS: The results of single, double sequential, and heart-lung transplantation over the past 10 years as reported by the International Society for Heart and Lung Transplantation Database are reviewed. In addition, the statistics of the lung and heart-lung transplantation program at the University of Colorado Health Sciences Center are reviewed, including the current immunosuppressive regimens and early and late monitoring for infection and rejection. This experience includes 3 early deaths in the first 53 patients for an operative mortality of 5.6%, with a 1-year actuarial survival of 90%. CONCLUSIONS: During the past decade remarkable improvement in the result of single and double sequential lung transplantation have occurred. As 1-year, actuarial survival is now approaching 90% at some institutions. Living related lobar transplantation, new antirejection agents, chimerism, and xenograft transplantation are areas for continuing and future investigation. The shortage in donor organ supply continues to be a very significant factor in limiting human lung transplantation.

Heart-lung transplantation in cystic fibrosis: predictions for the next decade in England and Wales.

Heart-lung transplantation has become an established treatment for end stage respiratory failure secondary to cystic fibrosis. The success of this form of treatment, and the increasing survival of such patients, suggests there will be an increased need for transplantation over the next decade. We have used cystic fibrosis population predictions and all cause mortality data to estimate the number of cardio-pulmonary deaths, due to cystic fibrosis, over the next decade and to estimate the number of such patients who are likely to benefit from heart-lung transplantation. We estimate that there will be between 85 and 127 potential transplant recipients with cystic fibrosis each year over the next decade. During 1990, 1991 and 1992 there were less than 40 transplants each year in such patients. These data emphasize the need to expand transplantation services and to maintain the availability of donor organs.

The development of heart and heart-lung transplantation at Stanford. Honored guest's lecture.

Transplantation of the heart is now accepted and perhaps even routine therapy for patients near death from heart disease. Better, more specific, less toxic molecules are under investigation for the control of rejection. The Holy Grail of tolerance is not beyond the realm of possibility. The mini-chimera concept almost certainly raises the specter of potentially successful xenografts. If not in this decade, certainly in this generation. Transplantation of the heart and both lungs constituted the first successful lung transplant of any kind. The ultimate division of indications for single lung, sequential bilateral lung, or heart-lung transplantation will be settled only by the accumulation of more clinical data. With respect to pulmonary transplantation, a few technical points have become clear. First, the double lung transplant with a tracheal anastomosis has been abandoned owing to the complications of tracheal stenosis and tracheal dehiscence. Second, there is no need to wrap the bronchial anastomosis with omentum; there is no need to "telescope" the donor bronchus. Finally, simple, continuous polypropylene suture technique should be used for any tracheal (heart-lung transplantation) or bronchial anastomosis.

Thoracic organ transplantation in children. The state of heart, heart-lung, and lung transplantation.

Heart, heart-lung, and lung transplantation have become accepted modalities for treatment in children with serious cardiopulmonary disease. Although early deaths secondary to infection and/or acute rejection have been reduced dramatically, there is still an early mortality related to cardiac complications and a late mortality related to rejection and infection. The management of hypoplastic left heart syndrome remains a special problem and is outlined in the review. There is much less experience in the newer modalities of heart-lung and lung transplantation in children and the results of these operative procedures are similar to what was seen in heart transplantation some 10 years ago. Ongoing and significant improvement continues, however, in all forms of transplantation dealing with the lung.

Heart-lung transplantation in India: initial experience.

Heart-lung transplantation is a well accepted and standard form of therapy for the surgical management of patients with end-stage cardiopulmonary disorders. The first heart-lung transplant in India was performed at our institution on May 3, 1999 and, subsequently, 2 more patients have undergone this procedure. The initial experience is encouraging and heralds a new era of thoracic organ transplantation in India.

[The present and future of heart-lung transplantation]. / Presente y futuro del trasplante cardiopulmonar.

Heart-lung transplantation is nowadays a controversial point in scientific meetings. Shortage of donors and the appearance of new options, specially the successful results with lung transplantation in Pulmonary Hypertension (PHT) and other lung diseases, mark new trends in the development of these pathologies.

Current concepts and controversies in lung transplantation.

This article reviews the history of organ transplantation, specifically focusing on the advances leading to the first successful human lung transplant. It also provides an overview of the com-mon indications and general selection criteria for lung transplant recipients, highlights areas of current controversy in pulmonary transplantation, reviews current approaches to posttransplantation immunosuppression, and discusses common complications seen intransplant recipients.

[Present international status and basic approach of lung and heart-lung transplantation].

Lung transplantation has been established as an optional treatment for variable irreversible diffuse lung diseases. To date, more than 5,000 patients have underwent lung transplantation, and nearly 1,000 procedures a year are performed recently. Although heart-lung transplantation has also been technically established, this procedure is confined to quite limited conditions due to the severe shortage of donors and many difficulties in operative procedure and the patient management. Preservation, post-transplantation edema, diagnosis of rejection, chronic rejection, shortage of donor organs, are principal problems in clinical lung transplantation, 24-hour preservation proved to be possible in several recent experimental studies, and the reperfusion injury has been revealed to be one of causes of post-transplantation edema. Establishment of methods for long-term pulmonary preservation and for the treatment of post-transplantation edema may be promising in the near future. Shortage of donor lung is one of major limiting factors. Research works on xenotransplantation and cadaver lung transplantation are on going, and these may help in solving this problem.