A global perspective of lung transplantation: Part 1 - Recipient selection and choice of procedure

Abstract

Lung transplantation has grown considerably in recent years and its availability has spread to an expanding number of countries worldwide. Importantly, survival has also steadily improved, making this an increasingly viable procedure for patients with end-stage lung disease and limited life expectancy. In this first of a series of articles, recipient selection and type of transplant operation are reviewed. Pulmonary fibrotic disorders are now the most indication in the U.S., followed by chronic obstructive pulmonary disease and cystic fibrosis. Transplant centers have liberalized criteria to include older and more critically ill candidates. A careful, systematic, multi-disciplinary selection process is critical in identifying potential barriers that may increase risk and optimize long-term outcomes.

Figure 1.. Bronchial arteriogram showing recipient left internal thoracic arteries perfusing both right and left bronchial arteries from a common trunk.

(From reference # with permission.)

Figure 2.. Number of adult and pediatric lung transplant reported to the International Society for Heart and Lung Transplantation by year (ishlt.org/registries/slides.asp?slides=heartLungRegistry, 2014).

Figure 3.. Kaplan-Meier survival of adult lung transplants by era as reported to the ISHLT (ishlt.org/registries/slides.asp?slides=heartLungRegistry, 2014).

Figure 4.. Number of lung transplants per year by diagnostic category in the United States.

Group A: Obstructive Lung Disease; Group B: Pulmonary Vascular Disease; Group C: Cystic Fibrosis; Group D: Restrictive Lung Disease. (From reference # with permission.)

Figure 5.. Chest radiograph of a 71 year old recipient 5 months after left single lung transplant for IPF.

The allograft is well expanded with mediastinal shift towards the native lung. The forced vital capacity was 72% of predicted and FEV₁ was 87%.

Figure 6.. Perfusion (A) and ventilation (B) radionucleotide scan images of patient from Figure 5.

The left lung allograft accounts for 95% of perfusion and 97% of ventilation.

Figure 7.. Survival after single or bilateral lung transplant for Idiopathic Pulmonary Fibrosis in 795 propensity matched pairs.

(From reference # with permission.)

Figure 8.. Distribution of single and bilateral lung transplants for different indications by year as reported to the ISHLT.

AT Def: alpha-1 anti-trypsin deficiency (ishlt.org/registries/slides.asp?slides=heartLungRegistry, 2014).

Figure 9.. Survival effect of bilateral lung transplant in COPD according to quartiles of FEV₁% predicted.

Black areas of bars represent difference between expected median survival with and without transplant of > 1 yr (gain of life), white areas a loss of > 1 yr and shaded areas gain or loss of < 1 yr. Dashed lines separate between gain and loss of survival (taken from reference # with permission).

Figure 10.. 55 year-old male with Idiopathic Pulmonary Arterial Hypertension and severe refractory right heart failure despite therapy with intravenous epoprostenol, requiring continuous ambulatory dopamine infusion for inotropic support.

Apical 4-chamber echocardiographic view (A) demonstrates massive dilatation of the right atrium (RA) and right ventricle (RV) impairing left ventricular (LV) filling. The patient underwent a combined heart-lung transplant (B) and is asymptomatic with normal cardiac and pulmonary function 2 years post-transplant. Chest radiograph pre (C) and post (D) transplant.

Figure 11.. Lung transplant recipient age distribution by era (ishlt.org/registries/slides.asp?slides=heartLungRegistry, 2013).

Figure 12.. A non-ventilated patient ambulating with veno-venous ECMO while awaiting lung transplantation (http://vesta.cumc.columbia.edu/surgery/residency/Applicants/Research/ Cardiothoracic.php; accessed 10/10/15).