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Ann Thorac Surg 1990;49:333-340
© 1990 The Society of Thoracic Surgeons

Articles

Surgical management of heart-lung transplantation

B. Reichart, MD*, S. Vosloo, MMed, J. Holl, MD

Department of Cardio-Thoracic Surgery, University of Cape Town Medical School, Groote Schuur Hospital, Cape Town, South Africa

* Address reprint requests to Dr. Reichart, Department of Cardiac Surgery, University of Munich, Klinikum Grosshacern, FRG.

Using cyclosporin A, long-term survival after heart-lung transplantation became possible. The drug blocks the immune system more selectively and leaves the tracheal wound healing unimpaired. Since 1981, 501 clinical cases have been collected by the registry of the International Society for Heart Transplantation. Candidates for heart-lung transplantation reveal signs of irreversible heart and lung diseases that may have been caused by cardiac lesions (valvular diseases, Eisenmenger reaction due to congenital malformations) or by pulmonic disorders (primary pulmonary hypertension, emphysema, fibrosis). The standard surgical procedure, which combines donor and recipient tracheas. right atria, and aortas, makes three anastomoses necessary. Immunosuppressive regimen includes cyclosporin A (blood trough levels of 300 to 500 ng/mL), azathioprine (1 to 2 mg/kg), and rabbit antithymocyte globulin (1 to 4 mg immunoglobulin G/ kg). After the first two postoperative weeks, rabbit antithymocyte globulin is replaced by methylprednisolone (0.3 to 0.1 mg/kg; 500 mg are given intravenously after opening the aortic cross-clamp; 3 x 125 mg on postoperative day 1). After heart-lung transplantation an extreme variety of problema may evolve. Early postoperative complications (within the first postoperative month) comprise acute isolated lung rejection, multiorgan failure, and bacterial pneumonia. Diagnosis of acute lung rejection proves difficult; it includes clinical signs, chest radiographic appearances, and cytoimmunological monitoring, Transbronchial lung biopsies are of similar value for precise diagnosis as are endomyocardial specimens after heart transplantation. Late postoperative complications (after 1 postoperative month) comprise viral pneumonia, fungal infection, tuberculosis, and chronic obliterative bronchiolitis. With increasing experience, the 30-day mortality declined to below 20% according to the International Society for Heart Transplantation; 66.5% of the patients who were operated on worldwide between 1986 and 1988 are alive and well after 1 year. The results of some individual groups are even better. In 1989/1990, heart-lung transplantation seems to have become a clinical method with acceptable results. The donor shortage remains a major problem.






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