A Review of 23 Human Lung Transplantations by 20 Surgeons

To assess the incidence of surgical complications after lung transplantation and its influence on early mortality and long-term survival.

Retrospective review of 792 lung transplants (LTs) performed from 1994 to 2022. Among them, 769 with complete data were selected. Patients with and without surgical complications were compared by univariable and multivariable analyses.

There were 385 single LTs (50%), 371 double LTs (48%), 8 bilobar LTs (1%), and 5 combined liver LTs (1%). Two hundred forty-nine patients presented surgical complications (32%) as follows: bronchial (n = 61), vascular (n = 55), pneumothorax (n = 33), and phrenic nerve palsy (n = 22). Thirty-day mortality (noncomplicated vs complicated) was 57 (41%) vs 80 (59%), P < .001. Transplants for bronchiectasis (58%), pulmonary hypertension (50%), and re-transplants (78%) presented more surgical complications (P < .001). Double LT (40%), bilobar LT (88%), and combined liver LT (100%) presented more surgical complications (P < .001). Complicated recipients were younger (49 ± 15 vs 45 ± 17 years; P = .001), with longer ischemic times (429 ± 67 vs 450 ± 76 min [2nd graft]; P = .007), and required extracorporeal support (ECLS) more often (43% vs 57%; P < .001). Survival at 1, 5, 10, 15, and 20 years (noncomplicated vs complicated): 78%, 63%, 52%, 41%, 31% vs 52%, 42%, 35%, 26%, 22%; P < .001). Predictors of mortality were the need for ECLS (odds ratio [OR] 4.14; P < .001), postoperative ventilation (hours) (OR 1.01; P < .001), and vascular complications (OR 4.78; P < .001).

Surgical complications remain an important source of morbidity and mortality after lung transplantation. Complex surgical procedures requiring ECLS develop frequent surgical complications needing long postoperative ventilation that are associated with early mortality and poorer long-term survival.

Lung transplantation is recommended for select patients with end-stage chronic obstructive pulmonary disease (COPD). However, a consensus has not been reached regarding the optimal choice of lung transplantation: single lung transplants (SLTs) vs bilateral lung transplants (BLTs). This meta-analysis aimed to evaluate the safety and efficacy of SLT compared with BLT in managing end-stage COPD.

Cochrane, Embase, PubMed, and Scopus were searched for articles by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022343408).

Seven studies of 311 screened met the eligibility criteria, with a total of 10,652 patients with end-stage COPD, SLT (n = 6233), or BLT (n = 4419). Overall survival rates of BLT group were more favorable than SLT group at 1 (odds ratio [OR] = 1.29, 95% CI: 1.16, 1.43, I² = 0%), 5 (OR = 1.46, 95% CI: 1.35, 1.58, I² = 23%), and 10 years (OR = 1.71, 95% CI: 1.57, 1.87, I² = 12%) as well as the hazard ratio (HR = 0.73, 95% CI: 0.70, 0.76, I² = 40%). Subgroup analysis on survival rates of alpha-1 antitrypsin deficiency also displayed a trend favoring BLT compared with SLT at 1 (OR = 1.60, 95% CI: 1.24, 2.08, I² = 28%), 5 (OR = 1.84, 95% CI: 1.50, 2.26, I² = 42%), and 10 years (OR = 1.98, 95% CI: 1.59, 2.48, I² = 47%) as well as the HR (HR = 0.67, 95% CI: 0.35, 1.28, I² = 82%).

Compared with SLT, BLT seems to demonstrate more favorable trends in survival rates for the management of end-stage COPD. Despite the promising results, the groups have significant heterogeneity in baseline characteristics. Further prospective studies with extended follow-up periods are needed to ascertain the efficacy of treatment.

Lung transplantation is an evolutionary procedure from its experimental origin in the twentieth century and is now recognized as an established and routine life-saving intervention for a variety of end-stage pulmonary diseases refractory to medical management. Despite the success and continuous refinement in lung transplantation techniques, the widespread application of this important life-saving intervention is severely hampered by poor allograft quality offered from donors-after-brain-death. This has necessitated the use of lung allografts from donors-after-cardiac-death (DCD) as an additional source to expand the pool of donor lungs. Remarkably, the lung exhibits unique properties that may make it ideally suitable for DCD lung transplantation. However, primary graft dysfunction (PGD), allograft rejection and other post-transplant complications arising from unavoidable ischemia-reperfusion injury (IRI) of transplanted lungs, increase morbidity and mortality of lung transplant recipients annually. In the light of this, nitric oxide (NO), a selective pulmonary vasodilator, has been identified as a suitable agent that attenuates lung IRI and prevents PGD when administered directly to lung donors prior to donor lung procurement, or to recipients during and after transplantation, or administered indirectly by supplementing lung preservation solutions. This review presents a historical account of clinical lung transplantation and discusses the lung as an ideal organ for DCD. Next, the author highlights IRI and its clinical effects in lung transplantation. Finally, the author discusses preservation solutions suitable for lung transplantation, and the protective effects and mechanisms of NO in experimental and clinical lung transplantation.

The use of cardiopulmonary bypass (CPB) was necessary for the early success of lung transplantation. In more recent years, the rate of utilization has decreased due to advances in surgical technique and the rising utilization of intraoperative extracorporeal membrane oxygenation (ECMO). This chapter will focus on the use of CPB specifically in the setting of lung transplantation. Surgical approaches and cannulation strategies will be discussed for both single and bilateral lung transplantations. Furthermore, specific scenarios in which CPB is particularly advantageous will be discussed along with a review of published outcomes for lung transplants performed using CPB. Finally, the option of hybrid CPB/ECMO setups will be reviewed.

Patient-centered outcomes are defined as outcomes that are important to the patient. In this article, we focus on patient-centered outcomes relevant to lung transplantation. Patient-centered outcomes as it pertains to lung transplantation encompass a variety of domains including survival, quality of life, symptom burden, physical and mental well-being, and quality of life years gained.

Chronic Obstructive Pulmonary Disease is the leading cause of death amongst chronic respiratory diseases. Because of its protracted course, COPD is the most important contributor to the number of years lived with disability. Over the last 40 years lung transplantation has emerged as the predominant surgical treatment for patients with end stage respiratory diseases. The interplay of variable lung function decline, comorbidities and overlap with other respiratory diseases hinder easy selection of COPD candidates for transplantation. Post-transplantation, perioperative mortality continues to decrease but chronic allograft dysfunction, infections and complications of immunossupresive regimens continue to be major barriers to long term survival.