Risk factors and outcomes of vocal cord paralysis after lung transplantation - a retrospective cohort study

Abstract

Summary Vocal cord paralysis (VCP) may complicate thoracic surgery and is associated with increased morbidity and mortality. Among lung transplant (LTx) recipients, chronic pulmonary aspiration can contribute to chronic allograft dysfunction (CLAD). We herein assessed the unknown incidence and clinical impact of VCP in a large LTx cohort. All first‐time bilateral LTx recipients, transplanted between January 2010 and June 2015 were included in a single‐centre retrospective analysis. Bronchoscopy reports were assessed for VCP. Patients exhibiting VCP were compared to propensity score‐matched negative controls regarding CLAD onset and graft survival and secondary end‐points, including inpatient duration and complications; lower respiratory tract infections (LRTI) within 24 months. In total, 583/713 (82%) patients were included in the analysis. A total of 52 (8.9%) exhibited VCP, which was transient in 34/52 patients (65%), recovering after median 6 months (IQR 2–12). Compared to 268 controls, 3‐year graft survival and CLAD‐free survival were non‐inferior in VCP [HR 0.74 (95% CI 0.35–1.57), and HR 0.74 (95% CI 0.39–1.41)] respectively. Duration of hospitalization was similar and no differences in LRTI rates or airway complications were observed. Lower pre‐Tx BMI increased risk for VCP [HR 0.88 (95% CI 0.79–0.99)]. Overall, VCP did not adversely affect graft and CLAD‐free survival and secondary outcomes including LRTIs and hospitalizations.

Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis

“…9,42 Dysphonia may present as hoarse or absent voice or weak cough and may indicate glottic incompetence, risk of aspiration with associated chest infection and potential for respiratory distress. 10 The potential mechanisms for dysfunction in swallowing and voice following transplantation in this population are discussed below (see also Figure 1).…”

“…This would appear to be supported by increased rates of left sided VFP. 10,14 In addition, Taeneka and colleagues report ventricular assist device implantation to be a high risk for severe VFP which they hypothesize to be potentially related to nerve compression from enlarged cardiovascular structures or direct manipulation and retraction of the heart. 20 Given an increasing proportion of patients with end stage cardiac failure are now being supported via ventricular assist device's, the implant/explant of these devices is likely to further the risk of RLN damage.…”

“…14 Higher rates of VFP are evident amongst the lung transplant population with incidence ranging from 8-34%. 9,10,12 Interestingly, Seeliger and colleagues 10 reported that half of their cohort diagnosed with VFP were asymptomatic. This phenomena has also been reported in other surgical procedures which place the RLN at risk.…”

“…In addition, formal screening of vocal fold function for all patients following lung transplantation is recommended. 10…”

“…21,22 The potential etiology of voice and swallowing complications in this patient population is poorly understood and has received little attention in the literature. Cardiothoracic transplant surgery and the post-operative course are inherently complex and can involve (1) compromised respiratory function, (2) prolonged intubation, [23][24][25][26] (3) damage to the recurrent laryngeal nerve (RLN), 10,14,27 (4) intensive care unit acquired weakness, 28 (5) alterations to neurological status 9,28 and (6) chronic gastro-oesophageal reflux. [29][30][31] All these factors are known to have a direct association with swallowing and voice dysfunction.…”