HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Julian A. Smith John Wallwork Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, J. A. Articles by Wallwork, J. Search for Related Content PubMed PubMed Citation Articles by Smith, J. A. Articles by Wallwork, J.

J Thorac Cardiovasc Surg 1995;109:818
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

Retransplantation in heart-lung recipients with obliterative bronchiolitis

The Transplant Unit
Papworth Hospital
Papworth Everard
Cambridge, CB3 8RE, United Kingdom

To the Editor:

We read with great interest the report by Adams and associates in the February 1994 issue of the JORUNAL (1994;107:450-9) discussing the results of retransplantation procedures (25 heart-lung between 1986 and 1990 and 9 single lung between 1988 and 1992) in 34 heart-lung recipients with obliterative bronchiolitis. Twenty-nine (85%) patients were receiving mechanical ventilatory support, 31 (91%) required enteral nutrition, and all except one were in the hospital before their retransplantation procedure. Poor early and long-term results were reported especially in the group receiving a second heart-lung transplant. Similar overall results were found in a combined North American–European multicenter series of 63 lung retransplantations. ¹

These suboptimal results question the merits of using scarce donor organs in patients who would otherwise not qualify for a primary heart-lung or lung transplant. The need for prolonged ventilatory support (more than 2 or 3 days) remains a relative contraindication to heart-lung and lung transplantation at some centers, including ours. ^2,3 There is concern about postoperative infection owing to the colonization of the airway during the period of mechanical ventilation and also about respiratory muscle deconditioning during this time. Mechanical ventilation does not represent a "bridge" to lung transplantation, and these patients are in an essentially moribund condition. In addition, profound malnutrition and the effect of chronic immunosuppression add considerably to the risk of this type of operation. Efforts should therefore be directed at performing transplantation when the patient is in a more optimal preoperative condition.

We recognize that there are no other therapeutic options for patients with end-stage obliterative bronchiolitis after heart-lung transplantation. The allocation of another heart-lung block to these patients represents inequitable organ allocation especially when up to three other patients could benefit from these donor organs. The procedure of repeat heart-lung transplantation carries an unacceptable early mortality, consumes excessive hospital resources including those of the blood bank, and fails to deliver an adequate quality of life at long-term follow-up. Only three of the 25 patients who underwent a second heart-lung transplantation were fully rehabilitated in New York Heart Association functional class I at the time of this report.

The results of single lung transplantation in this group are superior to those of repeat heart-lung transplantation. The prospects for acceptable long-term survival and rehabilitation appear much better although the reported experience is small. We have performed two such procedures without a successful long-term outcome. We agree with the authors that single lung transplantation appears to be the preferred surgical option, but we do not believe that it represents optimal usage of available donor organs.

Instead of pursuing retransplantation as the definitive treatment of obliterative bronchiolitis after heart-lung or lung transplantation, efforts should be directed toward prevention of this complication by improving the available immunosuppressive agents and also toward new pharmacologic therapies. In the future, pulmonary xenotransplantation may provide additional donor organs for these terminally ill patients.

References

1. Novick RJ, Kaye MP, Patterson GA, et al. Redo lung transplantation: a North American–European experience. J Heart Lung Transplant 1993;12:5-16.[Medline]
   
2. Marshall SE, Kramer MR, Lewiston NJ, Starnes VA, Theodore J. Selection and evaluation of recipients for heart-lung and lung transplantation. Chest 1990;98:1488-94.[Abstract/Free Full Text]
   
3. Dennis C, Wallwork J. Mechanical ventilation and lung transplantation. J Heart Lung Transplant 1994;13:22-3
   

This article has been cited by other articles:

				U. Bortolotti and H. Mayumi Simplified Technique for Aortic Annular Enlargement During Aortic Valve Replacement Ann. Thorac. Surg., May 1, 1996; 61(5): 1591 - 1592. [Full Text]

				J. P. A. Couetil, D. P. Houssin, O. Soubrane, P. G. Chevalier, B. E. Dousset, D. Loulmet, A. Achkar, M. J. Tolan, C. I. Amrein, A. Guinvarch, et al. COMBINED LUNG AND LIVER TRANSPLANTATION IN PATIENTS WITH CYSTIC FIBROSIS: A 4 1/2-year experience J. Thorac. Cardiovasc. Surg., November 1, 1995; 110(5): 1415 - 1423. [Abstract] [Full Text]

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Julian A. Smith John Wallwork Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smith, J. A. Articles by Wallwork, J. Search for Related Content PubMed PubMed Citation Articles by Smith, J. A. Articles by Wallwork, J.