Double‐lung versus heart‐lung transplantation for precapillary pulmonary arterial hypertension: a 24‐year single‐center retrospective study

Abstract

Summary Transplant type for end‐stage pulmonary vascular disease remains debatable. We compared recipient outcome after heart‐lung (HLT) versus double‐lung (DLT) transplantation. Single‐center analysis (38 HLT–30 DLT; 1991–2014) for different causes of precapillary pulmonary hypertension (PH): idiopathic (22); heritable (two); drug‐induced (nine); hepato‐portal (one); connective tissue disease (four); congenital heart disease (CHD) (24); chronic thromboembolic PH (six). HLT decreased from 91.7% [1991–1995] to 21.4% [2010–2014]. Re‐intervention for bleeding was higher after HLT; (P = 0.06) while primary graft dysfunction grades 2 and 3 occurred more after DLT; (P < 0.0001). Graft survival at 90 days, 1, 5, 10, and 15 years was 93%, 83%, 70%, 47%, and 35% for DLT vs. 82%, 74%, 61%, 48%, and 30% for HLT, respectively (log‐rank P = 0.89). Graft survival improved over time: 100%, 93%, 87%, 72%, and 72% in [2010–2014] vs. 75%, 58%, 42%, 33%, and 33% in [1991–1995], respectively; P = 0.03. No difference in chronic lung allograft dysfunction (CLAD)‐free survival was observed: 80% & 28% for DLT vs. 75% & 28% for HLT after 5 and 10 years, respectively; P = 0.49. Primary graft dysfunction in PH patients was lower after HLT compared to DLT. Nonetheless, overall graft and CLAD‐free survival were comparable and improved over time with growing experience. DLT remains our preferred procedure for all forms of precapillary PH, except in patients with complex CHD.

Pulmonary endarterectomy in a 12‐year‐old boy with multiple comorbidities

“…16 However, one should realize that PEA significantly outperforms the results of double lung transplantation for CTEPH. 7,11,16 Therefore PEA remains the first and only curative option and transplantation can only be considered as a rescue therapy. Hesitating to refer children for surgical consideration, or attempting to treat them by medication, only postpones the single potentially curable treatment and may worsen their prognosis post PEA.…”

“…Long-term results of double lung vs heart-lung transplantation for precapillary PH are comparable and given the donor organ shortage, that is even more pronounced in children, our center's preference for CTEPH goes to a double lung transplantation. 16 However, one should realize that PEA significantly outperforms the results of double lung transplantation for CTEPH. 7,11,16 Therefore PEA remains the first and only curative option and transplantation can only be considered as a rescue therapy.…”

Transplante Cardiopulmonar: Quando Indicar?

“…Outro ponto a ser verificado é se o receptor tem painel imunológico positivo, pois, devido a procedimentos prévios com transfusões, o paciente pode ser sensibilizado. 5 …”

Heart-lung transplantation: a necessity

“…In 2016, 58 HLTs were performed. That decline reflects advances in other treatments for pulmonary hypertension and heart failure, as well as the use of heart or lung transplantation alone 4 , 5 ; for example, patients with severe pulmonary hypertension and poor right ventricular function usually undergo bilateral lung transplantation and not HLT, because the right ventricle generally improves rapidly following lung transplantation. 6 There are several tests to determine when right ventricular dysfunction becomes irreversible, a condition that is an indication for HLT.…”