Lung Transplantation and Coronary Artery Disease

doi:10.1016/j.athoracsur.2011.04.021

The Annals of Thoracic Surgery

Volume 92, Issue 1, July 2011, Pages 303-308

https://doi.org/10.1016/j.athoracsur.2011.04.021 Get rights and content

Background

Coronary artery disease (CAD) remains a relative contraindication to lung transplantation. We have offered lung transplantation and coronary revascularization to selected patients with discrete CAD and preserved left ventricular function. The purpose of this report is the following: (1) to examine the short-term and medium-term outcome of patients after coronary revascularization and lung 3transplantation; and (2) to compare the short-term and medium-term outcome of this cohort to a matched group of lung transplant recipients without CAD.

Methods

From January 2000 to March 2010, 27 patients with CAD underwent coronary revascularization and lung transplantation. The control group was matched based on age, diagnosis, lung allocation score, and type of procedure.

Results

Lung transplant recipients with CAD and the control group had similar incidence of primary graft dysfunction (grade III). The duration of mechanical ventilation, intensive care unit stay, and hospital stay were the same. At a mean follow-up of 3 years, the incidence of composite adverse cardiac events was similar in the 2 groups.

Conclusions

Lung transplant recipients with CAD and the control group also had similar medium-term survival. Lung transplantation can be considered in patients with preexistent CAD with acceptable early and medium-term outcomes.

Section snippets

Patients and Methods

This study was approved by the Institutional Review Board. The records of all patients who underwent lung transplantation at the University of California-Los Angeles from January 2000 to March 2010 were reviewed. During this period, 27 patients underwent lung transplantation and coronary revascularization and are the subject of this study.

Perioperative Characteristics of Patients With CAD and the Control Group

During the study period, 27 patients with critical coronary artery lesions and preserved left ventricular function underwent lung transplantation and coronary revascularization, and are therefore the subjects of this study. The perioperative characteristics of this group of patients are shown in Table 1. The waiting time for patients with CAD and the control group was similar. Thirteen of 27 patients were deemed suitable candidates for single lung transplantation and were therefore referred for

Comment

The findings of this study demonstrate that selected patients with CAD can undergo coronary revascularization and lung transplantation with acceptable short-term and medium- term outcomes. Our results are comparable with lung transplant recipients without CAD.

Several reports have examined the role of coronary revascularization in lung transplant recipients with CAD [7, 8, 9, 10]. Snell and colleagues [7] were the first group to report on 5 patients with clinically significant CAD who underwent

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Cited by (34)

Prior and Perioperative Revascularization Does Not Affect Survival in Lung Transplant Patients
2020, Annals of Thoracic Surgery
Citation Excerpt :
Support for revascularization with LTx has been suggested by several authors.12,13 Sherman and colleagues7 compared 27 lung recipients who had undergone PCI or concomitant CABG with 81 control recipients, and, much like our findings, demonstrated similar survival and perioperative adverse events in the 2 groups. Parekh and colleagues12 found that in LTx with concomitant cardiac procedures, predominantly foramen ovale or atrial septal defect surgeries, similar 5-year survival was observed compared with that for patients without these concomitant procedures.
Coronary artery disease is common in lung transplant patients and has historically been viewed as a contraindication to the procedure. Although this mindset is changing, the effect of prior or perioperative revascularization on lung transplant survival outcomes is not adequately established.
We performed a single-center retrospective analysis of all single and double lung transplant patients from 2012 to 2018 (n = 468). Patients were split into 4 groups: (1) patients who received a preoperative percutaneous coronary intervention (n = 34), (2) those who received coronary artery bypass grafting (CABG) before transplantation (n = 25), (3) those that received concomitant CABG during transplantation (n = 29), and (4) those who had lung transplantation with no need for revascularization (n = 380). Groups were compared for demographics, surgical procedure, and survival outcomes.
The no-revascularization group was statistically younger than the rest (P = .001). The lung allocation score trended toward being higher in the concomitant coronary artery bypass group (P = .03). All groups were predominantly diagnosed with idiopathic pulmonary fibrosis. The proportion of patients with chronic obstructive pulmonary disease was greatest in the group not requiring revascularization (P = .001). Patients with previous CABG were more likely to receive a single lung transplant than a double one (21 versus 4; P = .054). Length of stay, posttransplant survival, and postoperative adverse events were similar among all groups.
Results suggest that preoperative or intraoperative revascularization does not negatively affect survival in lung transplant patients; lung recipients with coronary artery disease have comparable survival when adequately revascularized.
How important is coronary artery disease when considering lung transplant candidates?
2016, Journal of Heart and Lung Transplantation
Coronary artery disease (CAD) remains a relative contraindication for lung transplantation, but should it be if amenable to effective palliation?
From January 2005 to July 2010, 356 adults undergoing primary lung transplantation had no significant (<50%) coronary arterial stenosis and 70 had significant (≥50%) CAD requiring prior or concomitant revascularization. Propensity matching on 38 pre-transplant patient characteristics identified 61 well-matched pairs (87% of possible matches) and 295 no-CAD unmatched patients to compare post-operative morbidity, graft function, and time-related pulmonary function and survival.
Compared with no-CAD patients, those with CAD intervention were older, more likely to be male, had more comorbidities, and were more likely to have idiopathic pulmonary fibrosis. Among propensity-matched patients, 5 died in-hospital in the CAD intervention group and 6 in the no-CAD group (p = 0.7). Intensive care unit stay (5 vs 7 days), post-operative stay (14 vs 15 days), tracheostomy requirement (12 vs 11 patients), primary graft dysfunction scores (p >0.8), and early longitudinal post-transplant pulmonary function (p = 0.2) were similar, as was time-related mortality (20% vs 22% and 51% vs 52% at 1 and 4 years, respectively; p = 0.6). Unmatched no-CAD patients had fewer comorbidities and lower mortality than matched patients (15% and 39% at 1 and 4 years, respectively; p = 0.01).
CAD is an important risk factor in lung transplant candidates, but its influence can be minimized in experienced centers by effective palliation. Surprisingly, however, CAD is a marker for an unfavorable patient phenotype with worse than typical post-transplant survival, irrespective of whether CAD is present.
Lung transplantation following coronary artery bypass surgery—improved outcomes following single-lung transplant
2016, Journal of Heart and Lung Transplantation
Prior coronary artery bypass grafting (CABG) has been a contraindication to lung transplantation (LTx) because of disease severity and technical considerations. Although patients increasingly are being referred for and receiving LTx, whether it should remain a contraindication is unknown. We sought to define the prevalence of LTx after CABG and determine the effect on outcomes.
The United Network for Organ Sharing Standard Transplant Analysis and Research data set was queried during the period 2004–2013 for adult LTx patients, as prior CABG became a mandatory reporting field in 2004. The primary end-points were 30-day and 1-, 3-, and 5-year survivals.
The study cohort included 14,791 patients, of whom 292 patients had previously undergone CABG (single left, n = 68; single right, n = 181; bilateral, n = 43), representing 2% of all transplants. For the entire cohort, 30-day survival was 97%, and survival at 1, 3, and 5 years was 88%, 79%, and 74%. CABG was a predictor of mortality at all time points, with hazard ratios ranging from 1.97 (confidence interval, 1.23–3.16; p < 0.01) at 30 days to 1.38 (confidence interval, 1.12–1.69; p < 0.01) at 5 years. When stratified by type of transplant, CABG strongly predicted mortality at all time points for patients receiving bilateral, but not single, transplants.
Although LTx after CABG is uncommon, it is increasingly performed in the current era. Single right LTx is the most common procedure performed in patients with prior CABG. CABG before LTx is an independent predictor of mortality at all time points and is driven by increased mortality in patients receiving bilateral LTx.
Lung transplantation and concomitant cardiac surgery: Is it justified? Read at the 95th Annual Meeting of the American Association for Thoracic Surgery, Seattle, Washington, April 25-29, 2015.
2016, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Some of these patients had undergone pretransplantation percutaneous coronary intervention, and many had required concomitant CABG. Sherman and colleagues3 reported on 27 patients who had undergone concomitant CABG or pretransplantation percutaneous coronary intervention. Medium-term survival of this cohort was similar to that for historical cohorts.
Increasing numbers of lung transplant candidates have cardiac conditions that affect their survival after transplantation. Our objective was to determine if patients who undergo concomitant cardiac surgery (CCS) during the lung transplant procedure have similar outcomes, as a cohort of isolated lung transplant recipients.
This was a retrospective, observational, matched-cohort analysis. The records of lung transplant recipients who underwent CCS from August 2000 to August 2013 were reviewed. A cohort of isolated lung transplant recipients, matched on the basis of age, lung allocation score, diagnosis, type of procedure, and era, was identified. The primary endpoint of this trial was 5-year survival. The secondary endpoints were primary graft dysfunction, grade III, at 72 hours, intensive care unit and hospital length of stay, and 5-year major adverse cardiac event rates.
A total of 120 patients underwent lung transplantation and CCS. Compared with the isolated lung transplant group, the donor, recipient, and operation characteristics were similar. No difference was found in the survival of the 2 groups for up to 5 years, or in the incidence of primary graft dysfunction Grade III at 72 hours, intensive care unit length of stay, invasive ventilation, hospital length of stay, or incidence of 5-year major adverse cardiac events.
Lung transplant recipients undergoing CCS have early and midterm clinical outcomes similar to those of isolated lung transplant recipients. Given that this report is the largest published experience, offering cardiac surgery at the time of lung transplantation, to selected patients, remains justified.
Impact of pre-operative coronary artery disease on cardiovascular events following lung transplantation
2016, Journal of Heart and Lung Transplantation
Citation Excerpt :
The interval between coronary angiography and lung transplantation was calculated from the date of the left-heart catheterization procedure to the transplant date. Given the evidence showing acceptable clinical outcomes in lung transplant recipients with sub-clinical CAD irrespective of pre-operative coronary revascularization,9–13 none of our patients with sub-clinical CAD underwent coronary revascularization before or at the same time as lung transplant. Clinical events were examined by searching through the medical record database, lung transplantation registry records, and the Social Security Death Index.
This study examined the correlation between pre-operative coronary artery disease (CAD) and post-operative cardiovascular events in lung transplant recipients.
Consecutive isolated lung transplant recipients from 2007 to 2013 in our institution were identified and categorized as having significant CAD (≥ 50% coronary stenosis in at least 1 artery or history of coronary revascularization) or no–mild CAD. Patient records and death index data were analyzed for a median of 2 years for death or cardiovascular events, including coronary, cerebrovascular, and peripheral artery events.
The study comprised 280 patients (62% male) with mean age of 60 ± 10 years. Cardiovascular events occurred in 5.7% (16 of 280) of the entire cohort. Patients with significant CAD had a higher annualized rate of cardiovascular events than those with no–mild CAD (11.9% vs 0.6%; p < 0.001). Significant CAD was an independent predictor of cardiovascular events (hazard ratio, 20.32; 95% confidence interval, 5.79–71.26; p < 0.001) but not all-cause mortality (log-rank p = 0.66). Adding significant CAD to clinical risk factors gave incremental prognostic performance compared with clinical risk factors alone (p < 0.001 for increase in global chi-square).
Selected lung transplant candidates with significant CAD can undergo transplantation with equal mortality risk to those without CAD but are at a higher risk of non-fatal cardiovascular events. These data support the current practice of accepting a selected group of patients with CAD for lung transplantation and suggest that they should be monitored early and treated to prevent cardiovascular complications.
Contra-indications of lung transplantation: Evolving limits?
2014, Revue de Pneumologie Clinique
L’augmentation en France du taux de prélèvements pulmonaires et les évolutions techniques chirurgicales et d’anesthésie-réanimation, ont augmenté le nombre de transplantations pulmonaires (TP) et amélioré le pronostic au moins à court terme. La liste des contre-indications classiques de la transplantation pulmonaire peut donc être reconsidérée à la lumière de cette évolution. Cet article remet en perspective certaines des contre-indications médicales de la TP au regard notamment de l’expérience acquise dans d’autres transplantations d’organe ou par certains centres de TP. Les problèmes posés par des antécédents de cancer, l’infection VIH, les hépatites virales, les troubles nutritionnels, les complications aiguës et l’âge sont notamment détaillés. Les contre-indications chirurgicales ne sont pas abordées.
In France, the higher frequency of pulmonary sample in organ donors and the enhancement of surgical and perioperative life support techniques, have increased the number procedures and the short term prognosis of lung transplantation (LT). In this setting, the classical contraindications of LT need to be reconsidered. In this article, some of the classical contraindication of LT are confronted to the experience acquired in other solid organ transplantations or from some LT centers. Specific situations such as LT in patients with previous cancer, HIV infection, viral hepatitis, nutritional disorders, acutely ill LT candidates and aging candidates are addressed. Surgical contraindications are not reviewed.

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Original articleGeneral thoracicLung Transplantation and Coronary Artery Disease

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Perioperative Characteristics of Patients With CAD and the Control Group

Comment

Am J Cardiol

J Am Coll Cardiol

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Heart Lung Transplant

Original article
General thoracic
Lung Transplantation and Coronary Artery Disease