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Ann Thorac Surg 1985;40:488-493
© 1985 The Society of Thoracic Surgeons

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Articles

Asynchronous Rejection of Heart and Lungs Following Cardiopulmonary Transplantation

From the Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.

^* Address reprint requests to Dr. Griffith, Department of Surgery, University of Pittsburgh School of Medicine, 1084 Scaife Hall, Pittsburgh, PA 15261

Eighteen patients have received 19 combined heart-lung allografts since March, 1982. During the maturation of our program of heart-lung transplantation, we have learned that isolated rejection of the lung can occur frequently and that exclusive dependence on the cardiac biopsy can be misleading. Of the 18 patients who received allografts, 10 are the basis for this report. The other patients were excluded because of death from excessive bleeding (1), inadequate lung preservation (2), an inability to differentiate rejection from infection (3), or an absence of rejection of either the heart or the lungs (2). Rejection of the lung was suggested, in the absence of clinical evidence of infection, by the radiographic appearance of a diffuse pulmonary infiltrate. It was confirmed by a prompt response to augmentation of maintenance immunosuppression with an intravenous pulse of methylprednisolone. The presence or absence of cardiac rejection was determined by the standard endomyocardial biopsy. Direct biopsy of the involved lung through a thoracotomy was performed in 4 patients so that a definitive histological diagnosis of rejection would reinforce the anticipated clinical diagnosis. The clinical course in 6 of the 10 patients plus the results of the open lung biopsy in 3 of them suggest that isolated rejection of the lung developed in the absence of cardiac findings. Patients responded within 12 to 24 hours to augmented immunosuppression with a dramatic improvement in the abnormal chest radiograph. In all 10 patients, either isolated lung or synchronous heart and lung rejection episodes were confined to the first six weeks after operation unless a severe alteration in the immunosuppression was made (2 patients).

It is believed that in the absence of clinical infection, the appearance of a diffuse pulmonary infiltrate after the first postoperative week should be treated with a brief course of intravenous administration of steroid irrespective of the results of the endomyocardial biopsy.

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