- Email: [email protected]
Lung Transplantation in Hungary From Cardiac Surgeons' Perspective
Lung Transplantation in Hungary From Cardiac Surgeons’ Perspective L. Fazekasa,b,*, Á. Ghimessyb,c, B. Gieszerb,c, P. Radeczkyb,c, L. Mészárosb,c, K. Törökb,c, L. Bogyób,c, I. Hartyánszkya, M. Pólosa, L. Daróczia, L. Agócsb,c, Á. Kocsisb,c, T. Bartókd, T. Dancsd, K. Kormosói Tóthd, N. Schönauerd, I. Madurkad, J. Elekd, B. Dömeb, F. Rényi-Vámosb,c, G. Langb,c, and A. Farkasb,c a Department of Cardiac Surgery, Semmelweis University, Budapest, Hungary; bDepartment of Thoracic Surgery, Semmelweis University, Budapest, Hungary; cDepartment of Thoracic Surgery, National Institute of Oncology, Budapest, Hungary; and dDepartment of Anaesthesiology and Intensive Care, National Institute of Oncology, Budapest, Hungary
ABSTRACT Thoracic organ transplantation made a fresh start in Hungary with the first double lung transplant in December 2015. This major leap in Hungarian transplantation was preceded by almost 10 years of preparation, new infrastructure development, and structural changes not only at the organizational level but in human resources as well. In the following years, until recently, altogether 47 lung transplants were performed on 24 men and 23 women. The underlying pathologies were as follows: chronic obstructive pulmonary disease, 25; cystic fibrosis, 11; idiopathic pulmonary fibrosis, 7; as well as other diseases, including bronchiectasis, eosinophilic granuloma, lymphangioleiomyomatosis, and primary pulmonary hypertension in 4 cases. The youngest recipient was 13 and the oldest was 65 years old. Overall survival rates at 30 days and at 1 year were 96% and 82%, respectively. No patients were lost in the cystic fibrosis and other diseases group, whereas the 1-year survival rates of the chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis groups were 73% and 71%, respectively. The results show the robustness and viability of the program, although there is still opportunity for further improvement. In this short paper, we summarize the fields of possible further cooperation of thoracic and cardiac teams as well as future challenges facing the new Hungarian lung transplant program.
T
HE FIRST double lung transplantation was performed in Hungary in December 2015 [1]. In the following 2.5 years, a total of 47 patients were implanted, showing the robustness and viability of the program. Since 1996 Hungarian end-stage lung disease patients have been transplanted in Vienna, and the new Hungarian program follows the same protocol in mutual collaboration with the lung transplant unit in Vienna. Transplant patients are referred by respiratory physicians and assessment is done by a multidisciplinary team that includes respiratory physicians, cardiologists, anesthetists, and thoracic surgeons. State-of-the-art surgical techniques are used that involve new instruments and devices, from the extracorporeal membrane oxygenator (ECMO) to the argon beam coagulator. The routine application of venoarterial ECMO in transplant cases has made both the anesthetic and thoracic surgical teams fully competent with this new device. Over just a short period, this confidence has enabled the thoracic team to undertake more ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 1263e1267 (2019)
complex general thoracic cases, such as tracheal resections using ECMO support. The successful initiation of lung transplantation in Hungary is a good example of thorough program planning and underlines the synergistic effect in different medical fields. The introduction of such complex procedures supports everyday activities and opens the caring team to new modalities. COOPERATION BETWEEN THORACIC TEAMS
Modern complex medicine needs cooperation and teamwork. However, the development of common language is a This publication was partially funded by National Research, Development and Innovation Office, Reference Number: KH126753. *Address correspondence to Levente Fazekas, MD, PhD, MSc, Department of Thoracic Surgery, Semmelweis University, Ráth György utca 7-9. H-1122 Budapest, Hungary. E-mail: fazekas. [email protected] 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.04.007
1263
1264
timely process. A multidisciplinary approach needs multidisciplinary centers where all the necessary facilities and therapeutic modalities coexist in one meaningful infrastructure. Significant progress in new medical fields can only be expected if these necessary structural changes and improvements are achieved. Unfortunately, unlike in the United Kingdom, the training of inter-related specialties such as thoracic and cardiac/cardiovascular surgery are separated in Hungary. Cardiac surgeons in Hungary have limited exposure to thoracic cases during their curriculum; the same is true for thoracic surgeons, who are generally less experienced in cardiac surgery. These disciplines are usually separated on the institutional level as well. Meanwhile, in many lung transplant programs over the world, lung transplantation is being performed by cardiac surgeons. The rationale behinddamong historical reasonsdmight have been the common use of heart-lung machines during procedures. However, this is not as obvious in today’s lung transplantations, as most procedures are performed using ECMO support or even off-pump. The thoracic approach has also shifted from median sternotomy to clam-shell and more recently to bilateral thoracotomy approach. However, ECMO centers are hardly viable without the mutual cooperation of cardiac and respiratory teams. Whether or not thoracic surgeons or cardiac surgeons are better at lung transplantation is hard to telldanastomotic techniques are the samedbut interesting developments have recently been achieved in both fields and are being incorporated into a new multidisciplinary lung transplant program. To emphasize the need for this team approach, we have collected some of the possible fields of cooperation in surgical management of severe heart and respiratory failure patients. ECMO AND ECMO CENTERS
Extracorporeal membrane oxygenation is an evolving technology that has become available in Hungary over the past 5 years. Indications for ECMO application vary, but as all of these centers are organized around cardiac surgical departments, this largely determines patient selection. Only a few patients with severe respiratory failure have been treated using ECMO, and most cases the outcome was poor. Respiratory ECMO patients in cardiac intensive therapeutic units are hard to manage, as care teams have limited experience with different time scales of lung recovery. While a severely damaged myocardium can recover within a few days, lungs need weeks. Cardiac venoarterial ECMO has a potential escape route by upgrading to left ventricular assist devices, thereby bridging to heart transplantation. Respiratory venovenous ECMO requires a lot of patience and time. In case of poor lung recovery, the only potential solution is lung transplantation. This is one of the reasons why respiratory teams should be involved in caring for these critically ill patients. At the same time, when using ECMO in severe respiratory failure, venovenous support may not provide sufficient support, rendering conversion to a venoarterial system necessary. Venoarterial ECMO management
FAZEKAS, GHIMESSY, GIESZER ET AL
requires vascular access and more cardiac skills as well as trans-thoracic or trans-esophageal echocardiography followup. Nevertheless, ECMO implantation and cannulation often requires vascular surgery support. ECMO is an excellent tool when used appropriately, but success depends on protocols, a key management team, and extensive education. Incorporating the multidisciplinary approach with involvement of cardiac and respiratory teams (among others) is mandatory in the routine work of modern ECMO units. RAPID RESPONSE ECMO TEAM AND OUTPATIENT ECMO
ECMO is increasingly implemented in refractory cardiogenic shock, although it also provides extra safety to transport critically ill cardiac or respiratory patients to specialized centers. However, the availability and readiness of ECMO team vary. Offering a 24/7 service requires significant human resources. Planning to provide outpatient service entails yet more resources in transportation and logistics. Initiation of ECMO therapydbe it venoarterial or venovenousdalways needs forward thinking as far as bridging strategy and further therapeutic possibilities. ECMO retrieval also needs robust intensive therapeutic unit resources in terms of space, beds, and staff. Preferably, a dedicated ECMO therapeutic unit should be established where adequately trained personnel are available. Taking into consideration the possible number of ECMO runs in a meaningfully reachable geographic area in Hungary, the cooperation of cardiac and respiratory ECMO teams seems reasonable. ECMO USE BEYOND CARDIAC SURGERY
There are several potential situations outside the cardiac surgery setting where ECMO could be successfully employed to provide cardiorespiratory support. These settings include high-risk structural heart interventions, ventricular tachycardia ablation, caesarean section, trauma, and non-cardiac elective procedures in patients at high risk for perioperative cardiac or respiratory complications [2]. The use of ECMO in trauma patients seems to have potential by stabilizing the patient during surgery and get better outcome. In the shock team approach, acute use of ECMO can restore cardiac output, thereby helping to normalize pH and lactate. Patient temperature can be easily controlled on ECMO. Cooling to reduce metabolism and provide cerebral and major organ protection is just as simple as rewarming to fight hypothermia. Correcting acidosis and hypothermia could also help in correcting coagulopathy with ECMO. With the use of heparin-coated tube sets, there is no need for systemic heparinization, and by offloading the venous circulation, ECMO can further help avoid severe intraoperative bleeding. Recently, the beneficial effects of venoarterial ECMO was shown in the event of a massive pulmonary embolism (PE). Aggressive institution of venoarterial ECMO appeared to be an effective method to triage and optimize patients with a massive PE to recovery or intervention [3].
LUNG TRANSPLANTATION IN HUNGARY
1265
Fig 1. (A) Heart and lung transplantation numbers in Hungary since 1992. (B) Survival of lung transplantation in Hungary. (C) Survival of heart transplantation patients in Hungary. HTX, heart transplants; LTX, lung transplants.
CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION
The incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after PE is considered to be around 1%-5% [4]. Taking into account the estimated incidence of PE being 1 in 1000, there are about 100 to 500 new CTEPH patients annually in Hungary. CTEPH is a devastating disease with an estimated mortality of 2 years without treatment, and the mean pulmonary artery pressure rate of more than 50 mm Hg is almost 80%. Surgical pulmonary thromboendarterectomy (PTE) and in inoperable cases balloon pulmonary angioplasty are the treatment of choice for CTEPH patients. Currently only 10e20 of these patients are being diagnosed yearly in pulmonary hypertension units all over Hungary. The few surgically operable candidates are referred to the Vienna Thoracic Surgery Department in Austria. PTE involves complex
surgery requiring a heart-lung machine and deep hypothermic circulatory arrest. During short periods of circulatory arrest, the thrombotic material is removed from pulmonary arteries. After successful surgery, lung recovery requires thorough respiratory management and sometimes temporary ECMO support. Hence, CTEPH management is a highly demanding multidisciplinary service where a number of different disciplines, from pulmonary and cardiac physicians and pulmonary imaging specialists to lung and cardiac surgeons should collaborate with anesthetists and intensive therapists [5].
HYBRID OPERATING ROOM AND ROBOTIC SURGERY
Among other surgical interventions, PTE is one of the modalities where hybrid procedures have great potential. Distal pulmonary artery branches unreachable by surgeons
1266
can be successfully treated by balloon pulmonary angioplasty [6]. Hybrid procedures and advanced intraoperative imaging could contribute to better outcomes. Imaging professionals, surgeons, and invasive radiologists should work together in a multidisciplinary team to perform these tasks. The emerging use of robotic techniques in thoracic surgery presents another unforeseeable perspective [7]. CONCOMITANT CARDIAC SURGERY
Patients who have end-stage lung disease with repairable cardiac diseases can be treated by lung transplantation and concomitant cardiac surgery (CCS) such as coronary artery bypass surgery, valve repair/replacement, or repair of congenital heart disease. In a recent retrospective, observational, matched-cohort analysis the authors suggested that lung transplant recipients who require CCS have early and midterm outcomes similar to those of isolated lung transplant recipients [8]. The incidence of CCS in their lung transplant cohort even reached 30% in 2013. However, they also stated that expansion of the recipient pool within the context of a limited supply of donor organs warrants further discussion. HEART-LUNG TRANSPLANTATION
Congenital heart surgery has made tremendous progress in Hungary over the last 10 years. Adult congenital heart patients generated a modest but increasing demand for heartlung transplantation (HLTX) for pulmonary arterial hypertension secondary to congenital heart disease. HLTX in this patient population incurs a high risk, but in selected patients with end-stage pulmonary arterial hypertension the outcome of transplantation seems reasonable [9]. Previously, idiopathic pulmonary hypertension was the most common indication for HLTX. However, it has been shown that right ventricular failure can be reversed after double lung transplantation. In some sporadic cases, acute exacerbation of right ventricular failure secondary to idiopathic pulmonary hypertension could even be successfully bridged to recovery on venoarterial ECMO and right ventricular assist device (unpublished case from our mechanical circulatory support database), but combined heart-lung transplantation remains the only definitive therapy for patients who have both endstage heart failure and end-stage lung failure [10]. RESULTS OF THORACIC ORGAN TRANSPLANTATION PROGRAMS IN HUNGARY
From December 2015 until recently, 47 lung and 133 heart transplants were performed in Hungary. Among the 47 lung recipients were 24 men and 23 women. The underlying pathologies were chronic obstructive pulmonary disease (25 cases), cystic fibrosis (11 cases), idiopathic pulmonary fibrosis (7 cases), and other diseases, including bronchiectasis, eosinophilic granuloma, lymphangioleiomyomatosis and primary pulmonary hypertension (4 cases). The youngest recipient was 13 and the oldest
FAZEKAS, GHIMESSY, GIESZER ET AL
was 65 years old. Overall survival at 30 days and at 1 year were 96% and 82%, respectively. No patients were lost in the cystic fibrosis and other diseases group, whereas the 1year survival rates of chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis group were 73% and 71%, respectively (Fig 1A,B). The heart transplant program that started in Hungary in 1992 made a significant quantity and quality improvement after joining the Eurotransplant network in 2012. The survival rates at 30 days and at 1 year have also increased from 85% to 90% and from 72% to 87%, respectively, in the last 3 years compared to the previous 2 decades (Fig 1A,C). With around 50 out of 10 million people undergoing heart implants every year, Hungary has reached and slightly exceeded the expected average Eurotransplant numbers. Extrapolating the promising numbers of the 26-year-old Hungarian heart transplant program, we expect our lung transplant numbers to further increase from an average of 20 to an average of 35 to 40 lung transplants per year. Based on our promising early results, we also aim to open to cases that are more complex. By joining the efforts and resources of the 2 thoracic organ transplant teams, we are planning to prepare for combined heart-lung transplantation within 3 years.
CONCLUSION
The introduction of multidisciplinary decision-making has significantly increased personal interaction between caregivers, although it does have a price in terms of workload and time by incorporating regular meetings and discussions into daily routine and requires major attitude adjustments on the organizational level as well. Nevertheless, it ensures superior patient care and outcomes, as described by Shah in the case of continuous flow left ventricular assist device recipients [11]. Non-hierarchical institutional models in Hungary are less common and cooperative teamwork patterns are yet to be developed. Modern team management tools, as well as the introduction of structured electronic medical records, can largely support these efforts. While a multidisciplinary approach also needs multidisciplinary leaders, the early success of lung transplantation in Hungary as an example may emphasize the need for deeper understanding these practices.
REFERENCES [1] Rényi-Vámos F, Radeczky P, Gieszer B, et al. Launching the Hungarian lung transplantation program. Transplant Proc 2017;49: 1535e7. [2] Monaco F, Belletti A, Bove T, et al. Extracorporeal membrane oxygenation: beyond cardiac surgery and intensive care unit: unconventional uses and future perspectives. J Cardiothorac Vasc Anesth 2018;32:1955e70. [3] Pasrija C, Shah A, George P, et al. Triage and optimization: a new paradigm in the treatment of massive pulmonary embolism. J Thorac Cardiovasc Surg 2018;156:672e81.
LUNG TRANSPLANTATION IN HUNGARY [4] Klok FA, Delcroix M, Bogaard HJ. Chronic thromboembolic pulmonary hypertension from the perspective of patients with pulmonary embolism. J Thromb Haemost 2018;16: 1040e51. [5] Jenkins D, Madani M, Fadel E, et al. Pulmonary endarterectomy in the management of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017;26:160111. [6] Lang I, Meyer BC, Ogo T, et al. Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017;26:160119. [7] Ricciardi S, Zirafa CC, Davini F, et al. How to get the best from robotic thoracic surgery. J Thorac Dis 2018;10: S947e50.
1267 [8] Biniwale R, Ross D, Iyengar A, et al. Lung transplantation and concomitant cardiac surgery: is it justified? J Thorac Cardiovasc Surg 2016;151:560e6. [9] Hascoet S, Pontailler M, Mercier O, et al. Outcome of heartlung or double-lung transplantation in pulmonary hypertension secondary to congenital heart diseases. J Heart Lung Transplant 2018;37:S241. [10] Toyoda Y, Toyoda Y. Heart-lung transplantation: adult indications and outcomes. J Thorac Dis 2014;6:1138e42. [11] Shah AM, Sims D, Madan S, et al. A multidisciplinary continuous support heart team approach improves survival in continuous flow LVAD recipients. J Heart Lung Transplant 2018;37:S84.
ABSTRACT Thoracic organ transplantation made a fresh start in Hungary with the first double lung transplant in December 2015. This major leap in Hungarian transplantation was preceded by almost 10 years of preparation, new infrastructure development, and structural changes not only at the organizational level but in human resources as well. In the following years, until recently, altogether 47 lung transplants were performed on 24 men and 23 women. The underlying pathologies were as follows: chronic obstructive pulmonary disease, 25; cystic fibrosis, 11; idiopathic pulmonary fibrosis, 7; as well as other diseases, including bronchiectasis, eosinophilic granuloma, lymphangioleiomyomatosis, and primary pulmonary hypertension in 4 cases. The youngest recipient was 13 and the oldest was 65 years old. Overall survival rates at 30 days and at 1 year were 96% and 82%, respectively. No patients were lost in the cystic fibrosis and other diseases group, whereas the 1-year survival rates of the chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis groups were 73% and 71%, respectively. The results show the robustness and viability of the program, although there is still opportunity for further improvement. In this short paper, we summarize the fields of possible further cooperation of thoracic and cardiac teams as well as future challenges facing the new Hungarian lung transplant program.
T
HE FIRST double lung transplantation was performed in Hungary in December 2015 [1]. In the following 2.5 years, a total of 47 patients were implanted, showing the robustness and viability of the program. Since 1996 Hungarian end-stage lung disease patients have been transplanted in Vienna, and the new Hungarian program follows the same protocol in mutual collaboration with the lung transplant unit in Vienna. Transplant patients are referred by respiratory physicians and assessment is done by a multidisciplinary team that includes respiratory physicians, cardiologists, anesthetists, and thoracic surgeons. State-of-the-art surgical techniques are used that involve new instruments and devices, from the extracorporeal membrane oxygenator (ECMO) to the argon beam coagulator. The routine application of venoarterial ECMO in transplant cases has made both the anesthetic and thoracic surgical teams fully competent with this new device. Over just a short period, this confidence has enabled the thoracic team to undertake more ª 2019 Elsevier Inc. All rights reserved. 230 Park Avenue, New York, NY 10169
Transplantation Proceedings, 51, 1263e1267 (2019)
complex general thoracic cases, such as tracheal resections using ECMO support. The successful initiation of lung transplantation in Hungary is a good example of thorough program planning and underlines the synergistic effect in different medical fields. The introduction of such complex procedures supports everyday activities and opens the caring team to new modalities. COOPERATION BETWEEN THORACIC TEAMS
Modern complex medicine needs cooperation and teamwork. However, the development of common language is a This publication was partially funded by National Research, Development and Innovation Office, Reference Number: KH126753. *Address correspondence to Levente Fazekas, MD, PhD, MSc, Department of Thoracic Surgery, Semmelweis University, Ráth György utca 7-9. H-1122 Budapest, Hungary. E-mail: fazekas. [email protected] 0041-1345/19 https://doi.org/10.1016/j.transproceed.2019.04.007
1263
1264
timely process. A multidisciplinary approach needs multidisciplinary centers where all the necessary facilities and therapeutic modalities coexist in one meaningful infrastructure. Significant progress in new medical fields can only be expected if these necessary structural changes and improvements are achieved. Unfortunately, unlike in the United Kingdom, the training of inter-related specialties such as thoracic and cardiac/cardiovascular surgery are separated in Hungary. Cardiac surgeons in Hungary have limited exposure to thoracic cases during their curriculum; the same is true for thoracic surgeons, who are generally less experienced in cardiac surgery. These disciplines are usually separated on the institutional level as well. Meanwhile, in many lung transplant programs over the world, lung transplantation is being performed by cardiac surgeons. The rationale behinddamong historical reasonsdmight have been the common use of heart-lung machines during procedures. However, this is not as obvious in today’s lung transplantations, as most procedures are performed using ECMO support or even off-pump. The thoracic approach has also shifted from median sternotomy to clam-shell and more recently to bilateral thoracotomy approach. However, ECMO centers are hardly viable without the mutual cooperation of cardiac and respiratory teams. Whether or not thoracic surgeons or cardiac surgeons are better at lung transplantation is hard to telldanastomotic techniques are the samedbut interesting developments have recently been achieved in both fields and are being incorporated into a new multidisciplinary lung transplant program. To emphasize the need for this team approach, we have collected some of the possible fields of cooperation in surgical management of severe heart and respiratory failure patients. ECMO AND ECMO CENTERS
Extracorporeal membrane oxygenation is an evolving technology that has become available in Hungary over the past 5 years. Indications for ECMO application vary, but as all of these centers are organized around cardiac surgical departments, this largely determines patient selection. Only a few patients with severe respiratory failure have been treated using ECMO, and most cases the outcome was poor. Respiratory ECMO patients in cardiac intensive therapeutic units are hard to manage, as care teams have limited experience with different time scales of lung recovery. While a severely damaged myocardium can recover within a few days, lungs need weeks. Cardiac venoarterial ECMO has a potential escape route by upgrading to left ventricular assist devices, thereby bridging to heart transplantation. Respiratory venovenous ECMO requires a lot of patience and time. In case of poor lung recovery, the only potential solution is lung transplantation. This is one of the reasons why respiratory teams should be involved in caring for these critically ill patients. At the same time, when using ECMO in severe respiratory failure, venovenous support may not provide sufficient support, rendering conversion to a venoarterial system necessary. Venoarterial ECMO management
FAZEKAS, GHIMESSY, GIESZER ET AL
requires vascular access and more cardiac skills as well as trans-thoracic or trans-esophageal echocardiography followup. Nevertheless, ECMO implantation and cannulation often requires vascular surgery support. ECMO is an excellent tool when used appropriately, but success depends on protocols, a key management team, and extensive education. Incorporating the multidisciplinary approach with involvement of cardiac and respiratory teams (among others) is mandatory in the routine work of modern ECMO units. RAPID RESPONSE ECMO TEAM AND OUTPATIENT ECMO
ECMO is increasingly implemented in refractory cardiogenic shock, although it also provides extra safety to transport critically ill cardiac or respiratory patients to specialized centers. However, the availability and readiness of ECMO team vary. Offering a 24/7 service requires significant human resources. Planning to provide outpatient service entails yet more resources in transportation and logistics. Initiation of ECMO therapydbe it venoarterial or venovenousdalways needs forward thinking as far as bridging strategy and further therapeutic possibilities. ECMO retrieval also needs robust intensive therapeutic unit resources in terms of space, beds, and staff. Preferably, a dedicated ECMO therapeutic unit should be established where adequately trained personnel are available. Taking into consideration the possible number of ECMO runs in a meaningfully reachable geographic area in Hungary, the cooperation of cardiac and respiratory ECMO teams seems reasonable. ECMO USE BEYOND CARDIAC SURGERY
There are several potential situations outside the cardiac surgery setting where ECMO could be successfully employed to provide cardiorespiratory support. These settings include high-risk structural heart interventions, ventricular tachycardia ablation, caesarean section, trauma, and non-cardiac elective procedures in patients at high risk for perioperative cardiac or respiratory complications [2]. The use of ECMO in trauma patients seems to have potential by stabilizing the patient during surgery and get better outcome. In the shock team approach, acute use of ECMO can restore cardiac output, thereby helping to normalize pH and lactate. Patient temperature can be easily controlled on ECMO. Cooling to reduce metabolism and provide cerebral and major organ protection is just as simple as rewarming to fight hypothermia. Correcting acidosis and hypothermia could also help in correcting coagulopathy with ECMO. With the use of heparin-coated tube sets, there is no need for systemic heparinization, and by offloading the venous circulation, ECMO can further help avoid severe intraoperative bleeding. Recently, the beneficial effects of venoarterial ECMO was shown in the event of a massive pulmonary embolism (PE). Aggressive institution of venoarterial ECMO appeared to be an effective method to triage and optimize patients with a massive PE to recovery or intervention [3].
LUNG TRANSPLANTATION IN HUNGARY
1265
Fig 1. (A) Heart and lung transplantation numbers in Hungary since 1992. (B) Survival of lung transplantation in Hungary. (C) Survival of heart transplantation patients in Hungary. HTX, heart transplants; LTX, lung transplants.
CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION
The incidence of chronic thromboembolic pulmonary hypertension (CTEPH) after PE is considered to be around 1%-5% [4]. Taking into account the estimated incidence of PE being 1 in 1000, there are about 100 to 500 new CTEPH patients annually in Hungary. CTEPH is a devastating disease with an estimated mortality of 2 years without treatment, and the mean pulmonary artery pressure rate of more than 50 mm Hg is almost 80%. Surgical pulmonary thromboendarterectomy (PTE) and in inoperable cases balloon pulmonary angioplasty are the treatment of choice for CTEPH patients. Currently only 10e20 of these patients are being diagnosed yearly in pulmonary hypertension units all over Hungary. The few surgically operable candidates are referred to the Vienna Thoracic Surgery Department in Austria. PTE involves complex
surgery requiring a heart-lung machine and deep hypothermic circulatory arrest. During short periods of circulatory arrest, the thrombotic material is removed from pulmonary arteries. After successful surgery, lung recovery requires thorough respiratory management and sometimes temporary ECMO support. Hence, CTEPH management is a highly demanding multidisciplinary service where a number of different disciplines, from pulmonary and cardiac physicians and pulmonary imaging specialists to lung and cardiac surgeons should collaborate with anesthetists and intensive therapists [5].
HYBRID OPERATING ROOM AND ROBOTIC SURGERY
Among other surgical interventions, PTE is one of the modalities where hybrid procedures have great potential. Distal pulmonary artery branches unreachable by surgeons
1266
can be successfully treated by balloon pulmonary angioplasty [6]. Hybrid procedures and advanced intraoperative imaging could contribute to better outcomes. Imaging professionals, surgeons, and invasive radiologists should work together in a multidisciplinary team to perform these tasks. The emerging use of robotic techniques in thoracic surgery presents another unforeseeable perspective [7]. CONCOMITANT CARDIAC SURGERY
Patients who have end-stage lung disease with repairable cardiac diseases can be treated by lung transplantation and concomitant cardiac surgery (CCS) such as coronary artery bypass surgery, valve repair/replacement, or repair of congenital heart disease. In a recent retrospective, observational, matched-cohort analysis the authors suggested that lung transplant recipients who require CCS have early and midterm outcomes similar to those of isolated lung transplant recipients [8]. The incidence of CCS in their lung transplant cohort even reached 30% in 2013. However, they also stated that expansion of the recipient pool within the context of a limited supply of donor organs warrants further discussion. HEART-LUNG TRANSPLANTATION
Congenital heart surgery has made tremendous progress in Hungary over the last 10 years. Adult congenital heart patients generated a modest but increasing demand for heartlung transplantation (HLTX) for pulmonary arterial hypertension secondary to congenital heart disease. HLTX in this patient population incurs a high risk, but in selected patients with end-stage pulmonary arterial hypertension the outcome of transplantation seems reasonable [9]. Previously, idiopathic pulmonary hypertension was the most common indication for HLTX. However, it has been shown that right ventricular failure can be reversed after double lung transplantation. In some sporadic cases, acute exacerbation of right ventricular failure secondary to idiopathic pulmonary hypertension could even be successfully bridged to recovery on venoarterial ECMO and right ventricular assist device (unpublished case from our mechanical circulatory support database), but combined heart-lung transplantation remains the only definitive therapy for patients who have both endstage heart failure and end-stage lung failure [10]. RESULTS OF THORACIC ORGAN TRANSPLANTATION PROGRAMS IN HUNGARY
From December 2015 until recently, 47 lung and 133 heart transplants were performed in Hungary. Among the 47 lung recipients were 24 men and 23 women. The underlying pathologies were chronic obstructive pulmonary disease (25 cases), cystic fibrosis (11 cases), idiopathic pulmonary fibrosis (7 cases), and other diseases, including bronchiectasis, eosinophilic granuloma, lymphangioleiomyomatosis and primary pulmonary hypertension (4 cases). The youngest recipient was 13 and the oldest
FAZEKAS, GHIMESSY, GIESZER ET AL
was 65 years old. Overall survival at 30 days and at 1 year were 96% and 82%, respectively. No patients were lost in the cystic fibrosis and other diseases group, whereas the 1year survival rates of chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis group were 73% and 71%, respectively (Fig 1A,B). The heart transplant program that started in Hungary in 1992 made a significant quantity and quality improvement after joining the Eurotransplant network in 2012. The survival rates at 30 days and at 1 year have also increased from 85% to 90% and from 72% to 87%, respectively, in the last 3 years compared to the previous 2 decades (Fig 1A,C). With around 50 out of 10 million people undergoing heart implants every year, Hungary has reached and slightly exceeded the expected average Eurotransplant numbers. Extrapolating the promising numbers of the 26-year-old Hungarian heart transplant program, we expect our lung transplant numbers to further increase from an average of 20 to an average of 35 to 40 lung transplants per year. Based on our promising early results, we also aim to open to cases that are more complex. By joining the efforts and resources of the 2 thoracic organ transplant teams, we are planning to prepare for combined heart-lung transplantation within 3 years.
CONCLUSION
The introduction of multidisciplinary decision-making has significantly increased personal interaction between caregivers, although it does have a price in terms of workload and time by incorporating regular meetings and discussions into daily routine and requires major attitude adjustments on the organizational level as well. Nevertheless, it ensures superior patient care and outcomes, as described by Shah in the case of continuous flow left ventricular assist device recipients [11]. Non-hierarchical institutional models in Hungary are less common and cooperative teamwork patterns are yet to be developed. Modern team management tools, as well as the introduction of structured electronic medical records, can largely support these efforts. While a multidisciplinary approach also needs multidisciplinary leaders, the early success of lung transplantation in Hungary as an example may emphasize the need for deeper understanding these practices.
REFERENCES [1] Rényi-Vámos F, Radeczky P, Gieszer B, et al. Launching the Hungarian lung transplantation program. Transplant Proc 2017;49: 1535e7. [2] Monaco F, Belletti A, Bove T, et al. Extracorporeal membrane oxygenation: beyond cardiac surgery and intensive care unit: unconventional uses and future perspectives. J Cardiothorac Vasc Anesth 2018;32:1955e70. [3] Pasrija C, Shah A, George P, et al. Triage and optimization: a new paradigm in the treatment of massive pulmonary embolism. J Thorac Cardiovasc Surg 2018;156:672e81.
LUNG TRANSPLANTATION IN HUNGARY [4] Klok FA, Delcroix M, Bogaard HJ. Chronic thromboembolic pulmonary hypertension from the perspective of patients with pulmonary embolism. J Thromb Haemost 2018;16: 1040e51. [5] Jenkins D, Madani M, Fadel E, et al. Pulmonary endarterectomy in the management of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017;26:160111. [6] Lang I, Meyer BC, Ogo T, et al. Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017;26:160119. [7] Ricciardi S, Zirafa CC, Davini F, et al. How to get the best from robotic thoracic surgery. J Thorac Dis 2018;10: S947e50.
1267 [8] Biniwale R, Ross D, Iyengar A, et al. Lung transplantation and concomitant cardiac surgery: is it justified? J Thorac Cardiovasc Surg 2016;151:560e6. [9] Hascoet S, Pontailler M, Mercier O, et al. Outcome of heartlung or double-lung transplantation in pulmonary hypertension secondary to congenital heart diseases. J Heart Lung Transplant 2018;37:S241. [10] Toyoda Y, Toyoda Y. Heart-lung transplantation: adult indications and outcomes. J Thorac Dis 2014;6:1138e42. [11] Shah AM, Sims D, Madan S, et al. A multidisciplinary continuous support heart team approach improves survival in continuous flow LVAD recipients. J Heart Lung Transplant 2018;37:S84.