Single Lung Transplant Remains a Viable Option for Patients With Severe Secondary Pulmonary Hypertension

Abstract

Background. Although double lung transplant is recommended in patients with severe secondary pulmonary hypertension (SPH), our institutional experiences suggest a role for single lung transplant in these patients. Here, we review our experience prioritizing single lung transplant in patients with SPH to minimize their surgical burden. Methods. We conducted a retrospective review of our lung transplant database to identify patients with SPH who underwent single lung transplant. Patients were stratified as either mild SPH (mean pulmonary artery pressure 25–40 mm Hg) or severe SPH (mean pulmonary artery pressure >40 mm Hg). Singe lung recipients without PH transplanted over the same time were also examined. Results. Between January 2017 and December 2019, 318 patients underwent single lung transplantation; 217 had mild SPH (68%), and 59 had severe SPH (18.5%). Forty-two patients without PH underwent single lung transplant. When the groups were compared, significantly higher pulmonary vascular resistance was noted in the severe SPH group, and obesity was noted in both the mild and severe SPH groups. Although the severe SPH group required more intraoperative cardiopulmonary support (37.3% versus 10.3% versus 4.7%, P < 0.05), there were no significant differences in most major postoperative parameters, including the duration of postoperative mechanical ventilation or the incidence of severe primary graft dysfunction. Survival 1 y posttransplant was not significantly different among the groups (93.2% versus 89.4% versus 92.9%, P = 0.58). Conclusions. Our experience supports the option of single lung transplantation with appropriate intraoperative mechanical circulatory support in patients with SPH. This strategy is worth pursuing, especially with ongoing donor lung shortages.

Lung Transplantation for COVID-19 Pulmonary Sequelae

“…In a recently published study, we demonstrated that SLT yields excellent outcomes for patients with severe pulmonary hypertension in whom DLT had been the preferred surgical option for several decades at most transplant centers. 19 Of note, the mortality of lung transplant recipients who contract COVID-19 after lung transplantation remains as high as 20% to 40%. 11 , 20 Given the high risks inherent to COVID-19 infection in lung transplant recipients, the option for an SLT with the goal of reducing the patient’s surgical burden should be strongly considered‚ particularly for elderly patients and patients with outstanding comorbidities.…”

“…We speculate that‚ during the lung transplant procedure in particular in patients with severe pulmonary hypertension, intraoperative MCS plays a preemptive role in stabilizing hemodynamics and better preserving organ function, in particular in the kidneys, which is also discussed in our recently published article. 19 …”

“…We speculate that‚ during the lung transplant procedure in particular in patients with severe pulmonary hypertension, intraoperative MCS plays a preemptive role in stabilizing hemodynamics and better preserving organ function, in particular in the kidneys, which is also discussed in our recently published article. 19 Whereas most prior reports detailing lung transplantation for COVID-19-related lung failure advocate close monitoring for 4 to 6 wk after the onset of COVID-19 infection before considering a patient for lung transplantation, essential questions regarding the reversibility of lung injuries associated with COVID-19 infection remain largely unanswered. 3,4,7,10 Approximately half of the patients who underwent SLT in our study were noted to have an improvement in their remaining native fibrotic lung postoperatively.…”

Single Lung Transplant for Secondary Pulmonary Hypertension: The Right Option for the Right Patient

“…In practice, this normalizes functional capacity, pulmonary vascular resistance (PVR), and right ventricular systolic function [1][2][3]. Additionally, though contentious in the literature, DLT recipients are reported to be more resistant to the effects of reflux, bronchiolitis obliterans, and both acute and chronic rejection [3][4][5][6][7][8][9]. However, DLT is also associated with higher rates of perioperative complications, including bleeding, bronchial dehiscence, dialysis, increased length of stay, and early post-operative death [4,10].…”

“…Advanced age, frailty, co-morbid conditions, and the limited availability of organs will all affect surgical candidacy and can offset the benefits of double lung procedures [1,6,[9][10][11]. Studies that compare SLT and DLT do not commonly explore the utility of single lung procedures even though multiple theoretical advantages exist; including reduced waiting times, less waitlist mortality, fewer surgical complications, and lower operative mortality [6,9]. Worse, multiple forms of publication and selection bias may favor DLT in registry-based studies.…”