Individuals with pulmonary hypertension (PH) experienced lower primary graft dysfunction following heart-lung transplantation compared with double-lung transplantation, according to a study published in Transplant International. Rates of chronic lung allograft dysfunction-free and graft survival improved with more surgical experience.
This retrospective, single-center study included 38 individuals with heart-lung transplants and 30 individuals with double-lung transplants that took place between 1991 and 2014. These transplants were undertaken as a result of chronic thromboembolic PH (n=6), congenital heart disease (n=24), and connective tissue disease (n=4) as well as hepatoportal (n=1), drug-induced (n=9), heritable (n=2), and idiopathic (n=22) causes of precapillary PH. Post-discharge follow-up included ≥3 annual check-ups. A 2-tailed t-test was used to compare continuous variables, while the chi-square test was used to compare categorical variables. The Kaplan-Meier method was used to examine graft survival and chronic lung allograft dysfunction-free survival.
The use of heart-lung transplantation decreased from 91.7% to 21.4% between the beginning and end of the study period. Double-lung transplants were associated with more grade 2 and grade 3 primary graft dysfunction (P <.0001), while post-discharge bleeding occurred more frequently among heart-lung transplants (P =.06). Graft survival for double-lung transplantation at 3 months was 93%, at 1 year was 83%, at 5 years was 70%, at 10 years was 47%, and at 15 years was 35%. For heart-lung transplantation, these rates were 82%, 74%, 61%, 48%, and 30%, respectively.
Rates of graft survival improved with surgical experience, with the 2010 to 2014 period showing significantly higher rates compared with the 1991 to 1995 period (P =.03). Chronic lung allograft dysfunction-free survival did not differ significantly, however, with double-lung transplantation 5- and 10-year rates at 80% and 28% vs heart-lung transplantation at 75% and 28% (P =.49). Heart-lung transplantation had a significantly longer follow-up than double-lung transplantation (234 vs 113 months, respectively; P <.0001).
This study was limited by its single-center, retrospective design; having a small population, a long study window, the potential for postoperative variables, and potential confounders that could not be retrieved as data. In addition, a changing indication for heart-lung transplantation over time which allowed for an imbalance in transplant type, longer follow-up for heart-lung transplantation that may have resulted in greater mortality rates, and a lack of analysis on risk-adjusted survival and risk factors may have also limited the study’s outcomes.
The study researchers concluded that they “did not find any significant difference in early mortality, overall graft survival, and [chronic lung allograft dysfunction]-free survival between [heart-lung transplantation] and [double-lung transplantation]. There was a trend for more re-interventions for bleeding after [heart-lung transplantation], while [primary graft dysfunction] was more frequent, but manageable after [double-lung transplantation]. Graft survival in this high-risk group of PH patients has improved significantly over time with growing experience.”
Brouckaert J, Verleden SE, Verbelen T, et al. Double-lung versus heart-lung transplantation for pre-capillary pulmonary arterial hypertension; a 24-year single-center retrospective study [published online February 8, 2019]. Transpl Int. doi:10.1111/tri.13409