Clinical lung and heart/lung transplantation
Pulmonary Retransplantation: Is it Worth the Effort? A Long-term Analysis of 46 Cases

Presented at the 27th annual meeting and scientific sessions of the International Society for Heart and Lung Transplantation, April 2007, San Francisco, CA.
https://doi.org/10.1016/j.healun.2007.09.023Get rights and content

Background

Pulmonary retransplantation remains the only therapeutic option in some cases of severe primary graft dysfunction (PGD), advanced bronchiolitis obliterans sydrome (BOS), and in some cases of severe airway problems (AWP), mainly cicatriceal stenosis. However, its value has been questioned due to the overall scarcity of donor organs and reports indicating unsatisfactory outcome. We analyzed our institutional experience with pulmonary retransplantation to evaluate its value for different indications.

Methods

We retrospectively analyzed all 46 patients undergoing pulmonary retransplantation from the 567 consecutive primary lung or heart–lung transplantations performed in our department from August 1995 to August 2006. We stratified patients according to indication for retransplantation and analyzed the outcome.

Results

Forty-six patients (mean age 41 ± 16 years, 18 men and 28 women) underwent pulmonary retransplantation (14 bilateral lung transplantations, 32 single-lung transplantations) for primary graft dysfunction (n = 23), bronchiolitis obliterans syndrome (n = 19) and airway problems (n = 4). Mean time to retransplantation was 26 ± 27 days in the PGD group, 1,069 ± 757 days in the BOS group and 220 ± 321 days in the AWP group. Thirty-day, 1-year and 5-year survival rates after retransplantation were 52.2%, 34.8% and 29.0% in the PGD group and 89.2%, 72.5% and 61.3% in the BOS group, respectively. All 4 patients in the AWP group are presently alive (BOS vs PGD: p = 0.02; BOS vs AWP: p = 0.27; PGD vs AWP: p = 0.06).

Conclusions

Pulmonary retransplantation for bronchiolitis obliterans offers long-term survival rates in the range of primary lung transplantation for selected patients. Long-term survival rates for retransplantation due to PGD are significantly lower, warranting restrictive use in this setting. In our experience with a limited number of patients, retransplantation for airway problems has shown excellent results. Pulmonary retransplantation for chronic problems is a plausible approach, provided that patients are carefully selected. Retransplantation for PGD should be avoided.

Section snippets

Methods

We retrospectively analyzed all 46 patients undergoing pulmonary retransplantation from among 567 consecutive primary lung or heart–lung transplantations performed in our department from August 1995 to August 2006. We stratified patients according to indication for retransplantation and analyzed the outcome. Indications for primary lung transplantation were chronic obstructive pulmonary disease (COPD; n = 15), pulmonary fibrosis (n = 12), cystic fibrosis (CF; n = 10), primary pulmonary

Results

Forty-six patients underwent pulmonary retransplantation (10 double-lung, 30 single-lung, 5 lobar and 1 split-lung transplantation). The types of primary transplantation and retransplantation are summarized in Table 1. Indications for retransplantation were PGD (n = 23), BOS (n = 19) and AWP (n = 4, which included 1 patient with cicatriceal stenosis at the right anastomosis and 3 patients with more peripheral obstructions of the airway without possibility for stenting) (Table 2). The

Discussion

Pulmonary retransplantation remains a highly controversial procedure, mainly due to ethical concerns over fair distribution of scarce donor organs. Although the ethical questions can never be answered by medical data alone, we tried to identify which patients would benefit most from retransplantation to establish a refined approach toward this topic. Aside from the many ethical questions it is impossible to fully address all legal, financial and logistic issues related to this field. We have

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