Lung transplantation: early and long-term results

From May of 1982 to March of 2009, 1253 lung and heart-lung transplants were performed at the University of Pittsburgh Medical Center Presbyterian Hospital with over all survival of 91% at 30 days, 75% at 1-year, 52% at 5 years and 32% at 10 years. Over a wide span of time, our surgical techniques,
immunosuppression, infection prophylaxis and postoperative management have evolved. For donor lung procurement, we give a bolus injection of prostaglandin E1 500mcg into the main pulmonary artery immediately before cross-clamp and add additional prostaglandin E1 500mcg in the first bag of the preservation solution, which was started in 1994. We started to add nitroglycerin 50mg in the first bag in 1997. We introduced retrograde flush with preservation solution from the pulmonary veins at the donor back table in 1998. We switched the preservation solution from Euro-Collins to Perfadex in 2001. We give 70cc/kg of Perfadex antegradely through the main pulmonary artery in the operative field and 1 liter of Perfadex for each lung retrogradely through the pulmonary veins at the back table. During the recipient surgery, we give cold blood pneumoplegia and terminal warm blood pneumoplegia, which was started in 1996. The composition of our pneumoplegia includes dextrose, insulin, glutamate, aspartate, lidocaine, adenosine, nitroglycerine, verapamil, ascorbic acid, deferoxamine. Since 2000, we manage mechanical ventilation with low tidal volume (6cc/kg of the donor body weight) and high PEEP. For immunosuppression, we give alemtuzumab induction before reperfusion, which was started in 2003. For maintenance immunosuppression, we use tacrolimus and started to use mycophenolate mofetil in 1997. We use mycophenolate mofetil in half dose (750mg twice daily) and minimize steroid (5mg once daily). Because of alemtuzumab induction that causes profound T-cell depletion for 6 months, we give valganciclovir for cytomegalovirus prophylaxis for 6 months and voriconazole against fun-gus and yeast for 4 months. With these modifications, when compared 1982-1993 vs. 1994-2009, survival has improved from 85% to 93% at 30 days, from 65% to 79% at 1 year, from 44% to 55% at 5 years and from 28% to 33% at 10 years.Both early and long-term outcome after lung and heart-lung transplantation has been improving.

Keywords: Pulmonary Veins