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Lung transplantation after prior cardiothoracic surgery: To transplant or not to transplant
Author’s Accepted Manuscript Lung transplantation after prior cardiothoracic surgery: to transplant or not to transplant Lorriana Elizabeth Leard
http://www.jhltonline.org
PII: DOI: Reference:
S1053-2498(16)30288-1 http://dx.doi.org/10.1016/j.healun.2016.08.007 HEALUN6341
To appear in: Journal of Heart and Lung Transplantation Accepted date: 17 Cite this article as: Lorriana Elizabeth Leard, Lung transplantation after prior cardiothoracic surgery: to transplant or not to transplant, Journal of Heart and Lung Transplantation, http://dx.doi.org/10.1016/j.healun.2016.08.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Lung transplantation after prior cardiothoracic surgery: to transplant or not to transplant Lorriana Elizabeth Leard, M.D.
The question is whether a patient who has undergone a prior cardiothoracic surgical procedure is a candidate for lung transplantation. This clinical dilemma faces many lung transplant programs around the world. As the age of lung transplant recipients increases, more and more patients who are being considered as potential candidates for lung transplantation are likely to have undergone prior cardiothoracic procedures. Re-entering a chest where the sternum has been disrupted and adhesions are present can be far more technically challenging. Thus, patients undergoing lung transplantation after prior cardiothoracic surgery are at increased risk of major bleeding, extended surgical times, and theoretically prolonged ischemic times. As a result, transplant programs are often faced with the question as to whether these risks are considerable enough to affect overall outcomes, and in turn, should certain prior surgical procedures affect a patient’s candidacy for lung transplantation. In the case of prior coronary artery bypass grafting (CABG), additional factors, such as underlying coronary artery disease or technical challenges related to performing surgery without disrupting grafts utilizing internal mammary arteries, often pose additional challenges when considering a patient’s candidacy for lung transplantation. Although these potential risks are well described, a certain number of patients with prior cardiothoracic surgery, including prior CABG, do undergo lung transplantation each year. In the United States, the United Network for Organ Sharing (UNOS) database has included documentation of prior CABG as a mandatory reporting field since 2004, indeed recognizing that patients with a history of CABG are undergoing lung transplantation. In the most recent version of the International Society for Heart and Lung Transplantation consensus document for the selection of lung transplant candidates, Weill and colleagues1 discuss the issue of prior cardiothoracic surgery under special surgical considerations. It is noted that up to 40% of lung transplant recipients have undergone some type of prior chest procedure, with many being diagnostic or therapeutic procedures related to their underlying lung diseases. The guidelines note that the published literature in this area is very limited, with the majority of the reported experience consisting of very small, single center retrospective studies. There is one previous larger retrospective single center study published in 2012 by Shigemura et al.2 which describes the survival of 238 patients who had undergone cardiothoracic surgical procedures (including chest-tube insertion alone in 115 patients) prior to lung transplantation. Although the long-term survival was not significantly different when compared to patients who had not had prior cardiothoracic procedures, there were higher rates of postoperative bleeding, nerve injury, respiratory and renal failure reported in those lung transplant recipients with prior cardiothoracic procedures. In this issue of the Journal of Heart and Lung Transplantation, two new articles provide much needed data in this area to help guide our selection of appropriate lung transplant recipients following cardiothoracic procedures, and in addition, perhaps provide some guidance in selecting the optimal transplant procedure in situations where patients have undergone prior CABG.
Omara and colleagues3 in their article entitled “Lung transplantation in patients who have undergone prior cardiothoracic procedures” describe their single center experience of 206 lung transplant recipients with prior cardiothoracic procedures (which for the purposes of this study included procedures more extensive than chest-tube insertion alone.) In this group of recipients who underwent lung transplantation between January 2005 and July 2010, the short- and longterm survival is similar between recipients with and without prior cardiothoracic procedures. And although prior cardiothoracic procedure is associated with a longer ICU stay, it is not associated with longer post-transplant hospital stay, lower FEV1%, or higher primary graft dysfunction grade. This study includes 17 patients with a history of prior CABG, but specific details about this group of patients are not analyzed given the small sample size. In the study by McKellar and colleagues4, the specific issue of CABG prior to lung transplant is examined. The authors use the UNOS STAR database to evaluate the incidence of lung transplantation following CABG and to compare the outcomes of patients undergoing single left, single right and bilateral lung transplant with and without a history of prior CABG. The authors report that 2% of the 14,791 patients undergoing lung transplantation in the United States between 2004 and 2013 had previously undergone CABG, with an increasing incidence of lung transplantation following CABG over the study period. In their analysis, CABG is identified as an independent predictor of mortality at 1, 3, and 5-years driven primarily by the increased mortality observed among patients undergoing bilateral lung transplantation. Remarkably, a history of prior CABG is not observed to be a predictor of mortality in either single left or single right lung transplant. Thus, this study suggests that perhaps patients with a history of prior CABG should only be candidates for single lung transplant. Both of these studies are retrospective and thus analysis is limited to the patients who were deemed to be an acceptable surgical risk to be listed and survived to undergo lung transplant surgery. We will never know how individual teams selected these patients. As a result, we do not have the complete data to fully appreciate the risks for the patients who were not given the chance to proceed with lung transplantation. Yet, these two noteworthy studies provide much needed data to help guide our decisions and enable the expansion of recipients to whom we can offer lung transplantation. Perhaps as a result of these studies, we now will have more opportunities to study the outcomes as more future potential candidates will be considered eligible for lung transplantation even if they have undergone prior cardiothoracic surgery. Disclosure statement The views expressed in this editorial are those of the author alone and do not represent those of the editors or leadership of the Journal of Heart and Lung Transplantation. The author has no conflicts of interest to disclose. No funding support was received in regard to this commentary.
1. David Weill, Christian Benden, Paul A. Corris, John H. Dark, R. Duane Davis, Shaf Keshavjee, David J. Lederer, Michael J. Mulligan, G. Alexander Patterson, Lianne G. Singer, Greg I. Snell, Geert M. Verleden, Martin R. Zamora, Allan R. Glanville, A consensus document for the selection of lung transplant candidates: 2014—An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation, The Journal of Heart and Lung Transplantation, 2015, 34, 1, 1 2. Shigemura N, Bhama J, Gries CJ, et al. Lung transplantation in patients with prior cardiothoracic surgical procedures. Am J Transplant 2012;12:1249-55. 3. Mohamed Omara, Toshihiro Okamoto, Amr Arafat, Lucy Thuita, Eugene H. Blackstone, Kenneth R. McCurry. Lung transplantation in patients who have undergone prior cardiothoracic procedures. The Journal of Heart and Lung Transplantation, 2016. 4. Stephen H. McKellar, Megan E. Bowen, Bradley C. Baird, Sanjeev Raman, Barbara C. Cahill, Craig H. Selzman. Lung transplantation following coronary artery bypass surgery— improved outcomes following single-lung transplant. The Journal of Heart and Lung Transplantation, 2016.
http://www.jhltonline.org
PII: DOI: Reference:
S1053-2498(16)30288-1 http://dx.doi.org/10.1016/j.healun.2016.08.007 HEALUN6341
To appear in: Journal of Heart and Lung Transplantation Accepted date: 17 Cite this article as: Lorriana Elizabeth Leard, Lung transplantation after prior cardiothoracic surgery: to transplant or not to transplant, Journal of Heart and Lung Transplantation, http://dx.doi.org/10.1016/j.healun.2016.08.007 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Lung transplantation after prior cardiothoracic surgery: to transplant or not to transplant Lorriana Elizabeth Leard, M.D.
The question is whether a patient who has undergone a prior cardiothoracic surgical procedure is a candidate for lung transplantation. This clinical dilemma faces many lung transplant programs around the world. As the age of lung transplant recipients increases, more and more patients who are being considered as potential candidates for lung transplantation are likely to have undergone prior cardiothoracic procedures. Re-entering a chest where the sternum has been disrupted and adhesions are present can be far more technically challenging. Thus, patients undergoing lung transplantation after prior cardiothoracic surgery are at increased risk of major bleeding, extended surgical times, and theoretically prolonged ischemic times. As a result, transplant programs are often faced with the question as to whether these risks are considerable enough to affect overall outcomes, and in turn, should certain prior surgical procedures affect a patient’s candidacy for lung transplantation. In the case of prior coronary artery bypass grafting (CABG), additional factors, such as underlying coronary artery disease or technical challenges related to performing surgery without disrupting grafts utilizing internal mammary arteries, often pose additional challenges when considering a patient’s candidacy for lung transplantation. Although these potential risks are well described, a certain number of patients with prior cardiothoracic surgery, including prior CABG, do undergo lung transplantation each year. In the United States, the United Network for Organ Sharing (UNOS) database has included documentation of prior CABG as a mandatory reporting field since 2004, indeed recognizing that patients with a history of CABG are undergoing lung transplantation. In the most recent version of the International Society for Heart and Lung Transplantation consensus document for the selection of lung transplant candidates, Weill and colleagues1 discuss the issue of prior cardiothoracic surgery under special surgical considerations. It is noted that up to 40% of lung transplant recipients have undergone some type of prior chest procedure, with many being diagnostic or therapeutic procedures related to their underlying lung diseases. The guidelines note that the published literature in this area is very limited, with the majority of the reported experience consisting of very small, single center retrospective studies. There is one previous larger retrospective single center study published in 2012 by Shigemura et al.2 which describes the survival of 238 patients who had undergone cardiothoracic surgical procedures (including chest-tube insertion alone in 115 patients) prior to lung transplantation. Although the long-term survival was not significantly different when compared to patients who had not had prior cardiothoracic procedures, there were higher rates of postoperative bleeding, nerve injury, respiratory and renal failure reported in those lung transplant recipients with prior cardiothoracic procedures. In this issue of the Journal of Heart and Lung Transplantation, two new articles provide much needed data in this area to help guide our selection of appropriate lung transplant recipients following cardiothoracic procedures, and in addition, perhaps provide some guidance in selecting the optimal transplant procedure in situations where patients have undergone prior CABG.
Omara and colleagues3 in their article entitled “Lung transplantation in patients who have undergone prior cardiothoracic procedures” describe their single center experience of 206 lung transplant recipients with prior cardiothoracic procedures (which for the purposes of this study included procedures more extensive than chest-tube insertion alone.) In this group of recipients who underwent lung transplantation between January 2005 and July 2010, the short- and longterm survival is similar between recipients with and without prior cardiothoracic procedures. And although prior cardiothoracic procedure is associated with a longer ICU stay, it is not associated with longer post-transplant hospital stay, lower FEV1%, or higher primary graft dysfunction grade. This study includes 17 patients with a history of prior CABG, but specific details about this group of patients are not analyzed given the small sample size. In the study by McKellar and colleagues4, the specific issue of CABG prior to lung transplant is examined. The authors use the UNOS STAR database to evaluate the incidence of lung transplantation following CABG and to compare the outcomes of patients undergoing single left, single right and bilateral lung transplant with and without a history of prior CABG. The authors report that 2% of the 14,791 patients undergoing lung transplantation in the United States between 2004 and 2013 had previously undergone CABG, with an increasing incidence of lung transplantation following CABG over the study period. In their analysis, CABG is identified as an independent predictor of mortality at 1, 3, and 5-years driven primarily by the increased mortality observed among patients undergoing bilateral lung transplantation. Remarkably, a history of prior CABG is not observed to be a predictor of mortality in either single left or single right lung transplant. Thus, this study suggests that perhaps patients with a history of prior CABG should only be candidates for single lung transplant. Both of these studies are retrospective and thus analysis is limited to the patients who were deemed to be an acceptable surgical risk to be listed and survived to undergo lung transplant surgery. We will never know how individual teams selected these patients. As a result, we do not have the complete data to fully appreciate the risks for the patients who were not given the chance to proceed with lung transplantation. Yet, these two noteworthy studies provide much needed data to help guide our decisions and enable the expansion of recipients to whom we can offer lung transplantation. Perhaps as a result of these studies, we now will have more opportunities to study the outcomes as more future potential candidates will be considered eligible for lung transplantation even if they have undergone prior cardiothoracic surgery. Disclosure statement The views expressed in this editorial are those of the author alone and do not represent those of the editors or leadership of the Journal of Heart and Lung Transplantation. The author has no conflicts of interest to disclose. No funding support was received in regard to this commentary.
1. David Weill, Christian Benden, Paul A. Corris, John H. Dark, R. Duane Davis, Shaf Keshavjee, David J. Lederer, Michael J. Mulligan, G. Alexander Patterson, Lianne G. Singer, Greg I. Snell, Geert M. Verleden, Martin R. Zamora, Allan R. Glanville, A consensus document for the selection of lung transplant candidates: 2014—An update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation, The Journal of Heart and Lung Transplantation, 2015, 34, 1, 1 2. Shigemura N, Bhama J, Gries CJ, et al. Lung transplantation in patients with prior cardiothoracic surgical procedures. Am J Transplant 2012;12:1249-55. 3. Mohamed Omara, Toshihiro Okamoto, Amr Arafat, Lucy Thuita, Eugene H. Blackstone, Kenneth R. McCurry. Lung transplantation in patients who have undergone prior cardiothoracic procedures. The Journal of Heart and Lung Transplantation, 2016. 4. Stephen H. McKellar, Megan E. Bowen, Bradley C. Baird, Sanjeev Raman, Barbara C. Cahill, Craig H. Selzman. Lung transplantation following coronary artery bypass surgery— improved outcomes following single-lung transplant. The Journal of Heart and Lung Transplantation, 2016.