THERAPY AND PREVENTION CARDIAC TRANSPIANTATION Long-term results, hemodynamics, and complications after combined heart and lung transplantation

During the first 3/2 years of the Stanford heart-lung transplant program, 23 transplants have been carried out in 22 patients with severe pulmonary vascular disease. Actuarial survival curves predict 1 and 2 year survival rates of 71% and 57%, respectively, for all patients. As a result of increasing experience, the early mortality of 26% has been reduced, with only one early death occurring in the last eight patients; prior cardiac surgery was a contributing factor in three of the six patients suffering early deaths. Two late deaths occurred in the series 14 and 15 months after operation. One patient died suddenly as a result of an acute myocardial infarct and the other patient died because of respiratory failure. At autopsy, both patients had severe proliferative coronary atherosclerosis with obliterative bronchiolitis affecting the lungs. An additional patient required a retransplant for obliterative bronchiolitis 37 months after the initial procedure, and he too was found to have severe coronary artery disease. Hemodynamics and left ventricular function were normal in patients studied 1 and 2 years after undergoing the transplantation procedure. Thus, the early mortality and morbidity of combined heart and lung transplantation has been significantly reduced, but the long-term complications, particularly graft atherosclerosis and obliterative bronchiolitis, are yet to be fully controlled. Circulation 71, No. 5, 919-926, 1985. AFTER 20 years of laboratory experience with combined heart and lung transplantation,' the clinical heart-lung transplant program commenced at Stanford in 1981. Combined heart and lung transplantation in man appeared feasible after the long-term success of heart-lung transplantation in a primate preparation2; the development of cyclosporine as an immunosuppressive agent3 and the experience derived from our cardiac transplant program, in which more than 350 patients have now been treated, were other important factors making such a clinical program appear feasible. Furthermore, the results of simple lung transplanFrom the Departments of Cardiovascular Surgery, Pulmonary Medicine, and Pathology, Stanford University School of Medicine. Supported in part by research grant HL 13108-15 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda. Dr. Dawkins is supported by grants from The Peel Medical Research Trust, The Royal Society and Special Cardiac Fund, Brompton Hospital London. Address for correspondence: Dr. Keith D. Dawkins, St. George's Hospital, Blackshaw Rd., London, SW17 OQT. England. Received Dec. 4, 1984; accepted Jan. 10, 1985. Vol. 71, No. 5, May 1985 tation were so poor4 that development of an alternative approach appeared justifiable. During the early phase of the program the emphasis was on the surgical aspects of the procedure and early postoperative care, but with increasing experience and improved methods of selection of donors and recipients the focus has now shifted to the long-term sequelae of heart-lung transplantation. In man, the hemodynamic and pulmonary consequences of denervation of the cardiopulmonary axis, lymphatic interruption, rejection, infection, and drug toxicity are largely unknown. Laboratory data suggest that combined heart and lung transplantation is compatible with long-term survival,2 but abnormal pulmonary histology5 and hemodynamics6 have been observed in some of the animals studied. As part of the postoperative evaluation, recipients of heart-lung transplants have undergone cardiac catheterization on a regular basis and here we report the long-term results, hemodynamic characteristics, and