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Ann Thorac Surg 1995;59:820-821
© 1995 The Society of Thoracic Surgeons
DR KIRK R. KANTER (Atlanta, GA): In view of your conclusions that patients with prior thoracic operations perhaps are not good candidates, it is striking that you do not mention that the 3 patients with obliterative bronchiolitis had been relisted for retransplantation. Would you exclude these patients from consideration for lung retransplantation, or were any of these 3 relisted at any time?
DR SPRAY: In fact, 2 of the 3 were relisted for lung transplantation but died before donor organs were available. I think the retransplantation issue is a very difficult one. Obviously one does not want to squander organs on patients who might not be expected to survive, and certainly the survival in retransplantation is lower than the initial survival. I do not think that the adhesions from a previous thoracic operation necessarily preclude retransplantation.
The most difficult patients, the ones who are most at risk for hemorrhage, are those patients who have pulmonary atresia with nonconfluent pulmonary arteries who have had attempts at unifocalization of aortopulmonary collateral vessels, usually with bilateral thoracotomies, and possibly a previous median sternotomy. These patients are cyanotic and have severe chest wall collaterals into the pulmonary parenchyma. The hemorrhage is not something that can be controlled with aprotinin or other agents. These patients may bleed so badly from the thin-walled collateral vessels that it is not possible to get the hemorrhage controlled. We have tried everything from aprotinin to epinephrine-soaked gauze packing of the chest to argon beam coagulators, and none of these approaches has been successful uniformly in this setting. I believe the real challenge is going to be to decide which patients with this diagnosis should be staged to lung transplantation and cardiac repair rather than having palliative attempts at reconstruction. Once you go down the road of multiple thoracotomies in these patients, I believe lung transplantation is precluded, and I consider previous multiple operations now a true contraindication to transplantation in cyanotic children.
DR THOMAS M. EGAN (Chapel Hill, NC): I congratulate you on really excellent results in a very challenging group of patients. From your perspective now that you have this experience with this patient population, if you could do heart-lung transplantations on these patients versus isolated lung transplantations, what do you think would be the determinants of which procedure should be used? Is the issue of airway complications fairly high on the list, or do you think that isolated lung transplantation is a reasonable option from that perspective? Also, when do you think the heart should be replaced rather than repaired?
DR SPRAY: From an airway standpoint, I do not believe heart-lung transplantation offers any benefit over bilateral sequential lung transplantation, even in very small infants. We have done double-lung transplantations in children in the age range of 3 to 4 months and have not seen any real problem with growth of the airways. So I do not think that concerns about airway size and healing in and of themselves should necessarily lead to heart-lung transplantation, which takes a donor away from a child who needs the heart.
However, I do think heart-lung transplantation should be used in patients who have a cardiovascular diagnosis where the reconstruction operation is not likely to produce a long-term good result or would require reintervention. Patients with any significant valvular abnormality might be precluded from lung transplantation and heart repair. For example, if there is concern about the capacity to achieve mitral valve competence in repair of atrioventricular canal, those patients might be better served by heart-lung transplantation.
From a practical standpoint, right now I think lung transplantation is a palliative operation in most patients because of the issue of bronchiolitis obliterans. Therefore, some decisions regarding the type of transplant used are a matter of weighing what you think the long-term survival of the child is going to be versus the risk of some reoperation required for additional reconstructive procedures on the heart.
DR CHARLES BRIDGES (Jacksonville, FL): I enjoyed your presentation, Dr Spray. I was wondering if irreversible pulmonary vascular obstructive disease would be an alternative way of describing the subgroup of patients that you operated on. With regard to that, as you know, with elevated pulmonary to systemic flow ratio it is possible to have pulmonary hypertension in the presence of normal pulmonary vascular resistance. Was there a specific cutoff in terms of Wood units that would cause you to propose that these patients be candidates for lung transplantation in addition to repair of their cardiac defect? Also, what was the criterion of irreversibility? In other words, did you increase the inspired oxygen concentration and then see if there was a change in pulmonary vascular resistance? Third, was there a correlation between the preoperative pulmonary vascular resistance and the outcome after lung transplantation?
DR SPRAY: To answer the last question first, there has not been a correlation between the pulmonary resistance before transplantation and outcome, possibly because a good number of these patients have an inadequate pulmonary vascular bed where pulmonary resistance is somewhat irrelevant; there is no pulmonary vascular bed for the cardiac output to go into. We have undertaken a study to evaluate patients with pulmonary hypertension sequentially in the catheterization laboratory, both at the time of transplant evaluation and subsequently while they are awaiting a transplant. We are using vasodilator testing in the catheterization laboratory, including inhaled nitric oxide in these patients, and we have identified a few patients with elevated resistance who were responders to some of these agents. In those patients we have tried vasodilators to see if exercise tolerance improves and symptoms are relieved; we may then delay placing them on the transplant list if they have favorable results.
I believe that these are very challenging patients, because it is difficult to decide when is the optimal time to list for transplantation. There are very few data on Eisenmenger syndrome in the literature to define when patients with Eisenmenger syndrome really need to be listed for transplantation, because they often can go for many years without significant problems. But once a patient becomes exercise intolerant, or when recurrent syncope occurs, we believe that irreversible pulmonary vascular changes are severe enough to warrant consideration for lung transplantation. We do not yet know which patients might respond to certain vasodilators, how long they will respond, and when they should be listed for transplantation, but we are trying to get some of that information now.
Related Article
Ann. Thorac. Surg. 1995 59: 813-820.
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