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Heart-Lung Transplantation in 1990Indications, Surgical Technique, Postoperative Complications and Outcome B. Reichart. If. Reichenspurner. and B. Meiser Department of Card iac Surgery. Klinikum GroBhad ern , Ludw ig-Maximilian s Unive rs ity. Munich. r HG

Using cyclospori ne A (eyA), long-term results afte r heart-lu ng tra nsplantation beca me possible. Since 198 1, 761 clinica l hear t lung tra nspla nta tions have been registered at the Intern ational Society for Hea rt Transplanta tion . Candidates for this operat ion reveal signs of irreversible hea rt and lung diseases which a rc ca used by cardiac lesions Ie.g . valvular disease, Eisenmenger reaction due to congenita l malformation) or pulmona ry disorders (e. g. primar y pulmonary hypertension, emp hysema, fibrosis). The standard surgical procedu re necessitates three anastomoses which combine donor and recipient trac heae, right atria and ao rtae . Immunosuppression cons ists of CyA (blood levels of 300-500 ng/ ml). azathio pri ne (1-2 rug/kg/d) a nd rabbit a ntithymocyte globu line (RATG) (IgG, 2-4 rug/ kg/d ). After the first 2 postoperative weeks , RATG is repla ced by low dose met hylpredni solone (0.3- 0 .1 rug/kg/d). As a n alternat ive, HATG may be omitted completely. Postoperatively, a variety of comp lications may evolve. Early problems (with in the first month) comprise acute pulmonary rejection , bacterial pneum oniae, a nd multiorgan failure. Diagnosis of acu te lung reject ion proves difficult; it includes clinical signs, ches t radiographic appearances and cytoimmun ological monitoring of the peripheral blood. Transbronchial lung biopsies are for precise diagnosis of sim ilar value to endomyocardial biopsies afte r heart tr a nsplan tat ion. Late postoperative complications comprise viral, bacter ial, fungal, an d protozoa l infections and chronic obliterative br onchiolitis . With increasing experience, the 30 day mortality fell to below 20 % accor ding to the Intern a tional Society for Hea rt Tran spla ntation. The one-year survival rate betwee n 1986 und 1988 was reported to be 61 'Yo. The results of so me individual gro ups arc even better.

Key word s Hea rt-lung trans plantation - Immunosuppression - Postoperative complications

Intruductian In 1981. the first successful combined heart-an d-lun g tr ansplantation was perform ed (12). Since then. 76 1 pati ents have undergo ne this operat ion . there by providing useful Head at the 19th Ann ual Meeting ofthe German Society for Thor acic a nd Cardiovascular Surgery , Bad Na uheim, Febr uary 22-24, 1990 Thorac. cardiovasc. Surgeon 38 (1 990) 271-275 © Georg Thieme VerlagStuttgart - New York

Herz-Lun ge n-Transpl a nta tion 1990 lndlk atlon. chir urgische Tech nlk, postopera ti ve Knmpllka flouen und Ergebnisse -c

Langzeiterfolge nach lIerz -Lungen-Transpla ntation sind erst seit der Einflihr ung von Cyclospor in A (CyAI mogltch. Seit 1981 wurden weltweit 761 EingrifTe dcr lnternationale n Gescllschaft fur Herztra nsplan ta tion gemeldet. Kandida ten Itlr diesen EingrifT weis en Symptome eines irreversib len Herz- und l.ungenversag ens a uf, welches prima r kar diale (z. B. Klappenerkrankungen, Eisenme nger Heaktion na ch kongen italen Vitie n) odcr pulmonale Iz. B. prim ar e pulmonal e Ilypertension, Emphyse m, Fibrose) Ursachen haben kan n. Die Sta nda rd-Opera tionsmethode beinhal tet 3 Anastom osen an Trac hea. rcchtom Vorhof und Aorta . Die immu nsu ppre ssive Thcrapie bosteh t in den ersten 2 Wochen aus einer Kombinat ion von CyA{e ntsp rcc hcnd einem Vollblutspieg el von 300-500 ng/mll. Azathiop rin (1- 2 mg/kg/d) und Kaninchen-A ntithymozyten Globu lin (ATG I UgG: 2-4 mg/kg/d): ab der dritten Wochc ersctzt ma n ATG mit niedr ig dosiertem Meth ylpred nisolon (0.3-0.1 mg/kg/dl. Als Alternative kcnn te auf ATGga nz verzic htet we rde n. Postopcrativ beobachtet man za hlreiche Komplikationen ; frilhzcitig lim ersten postoperativen Mc natt kan n es zu akute n Abston ungsrc aktionen der Lunge, bakteriellen Pneumc nien und Multiorgunversag en kommen . Die Diagnosestellung der akuten Lungcn abstoBung ist nicht einfach ; sie schlicllt klinische Symptome und Verand cru ngen des Thorax-Hdntgenbildes und des zytoimmunologischen Monitoring mit ein. Die tra nsbronchiale Biopsie ist fur eine exa kte Diagnose von a hnlichem Wert wie die Endomyokard biopsie nach Iler ztra nspla ntation . Typische Spa tkc mplikationen sind Virus -, Bakterien- , Pilz- und Protozoeninfektioncn sowie die chro nische oblite ra tive Bronchiolitis . Dcr Internat ionalen Gesellschaft fur Herxtransplan tation zufolge Itcgt die 30 Tage Letalitat dcrzei t unter 20 %. 1m Zeitraum zwische n 1986 und 1988 bet rug die Ein-Ja hres- Uberlebensratc 61 %. Die Erge bnisse einzelner Gruppen sind sogar noch hosse r.

infor mati on on patient se lection an d sh urt- resp ectively

long-term results (Fig. I ). Progr ess has been made in lung pr eservati on in orde r to allow sa fe long-distance ha rvesting; bot h the immuno-suppressive management as well as the diagnosis of acute isolated lung rejection ha s improv ed. Th is ar ticle will address recent ind icati ons, surgical tec hnique . postoperative manageme nt . results. and majo r complicat ions of combined heart- and lung tra nsplantation. Received for Publication, March 20. 199 0

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Summ a ry

IJ. Reichart , II. Reichenspurner, IJ. Meiser

Thome. cardiova s c. Surgt'o1l ,18 ( 1990)

200 180

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Heart-lung transplantation in 1990--indications, surgical technique, postoperative complications and outcome.

Using cyclosporine A (CyA), long-term results after heart-lung transplantation became possible. Since 1981, 761 clinical heart lung transplantations h...
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