Combining Tricuspid Valve Repair With Double Lung Transplantation in Patients With Severe Pulmonary Hypertension, Tricuspid Regurgitation, and Right Ventricular Dysfunction

doi:10.1378/chest.10-2929

Chest

Volume 140, Issue 4, October 2011, Pages 1033-1039

https://doi.org/10.1378/chest.10-2929 Get rights and content

Background

Concomitant tricuspid valve repair (TVR) and double lung transplantation (DLTx) has been a surgical option at our institution since 2004 in an attempt to improve the outcome of DLTx for end-stage pulmonary hypertension, severe tricuspid regurgitation, and right ventricle (RV) dysfunction. This study is a review of that single institutional experience.

Methods

Consecutive cases of concomitant TVR and DLTx performed between 2004 and 2009 (TVR group, n = 20) were retrospectively compared with cases of DLTx alone for severe pulmonary hypertension without TVR (non-TVR group, n = 58).

Results

There was one in-hospital death in the TVR group. The 90-day and 1- and 3-year survival rates for the TVR group were 90%, 75%, and 65%, respectively, which were not significantly different from those for the non-TVR group. The TVR group required less inotropic support and less prolonged mechanical ventilation in the ICU. Follow-up echocardiography demonstrated immediate elimination of both volume and pressure overload in the RV and tricuspid regurgitation in the TVR group. Notably, there was a significantly lower incidence of primary graft dysfunction following transplantation in the TVR group (P < .05). Pulmonary functional improvement shown by an FEV₁ increase after 6 months was also significantly better in the TVR group (40% vs 20%, P < .05).

Conclusions

Combined TVR and DLTx procedures were successfully performed without an increase in morbidity or mortality and contributed to decreased primary graft dysfunction. In our experience, this combined operative approach achieves clinical outcomes equal or superior to the outcomes seen in DLTx patients without RV dysfunction and severe tricuspid regurgitation.

Section snippets

Patients

Human subject approval for this study was obtained from the University of Pittsburgh Medical Center prior to obtaining data (IRB approval number 000511). From January 2004 to April 2009, we performed primary LTx in 558 patients with end-stage lung disease at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, exclusive of heart-lung transplantation cases. Of these, 82 recipients with severe pulmonary hypertension underwent DLTx. The diagnosis of severe pulmonary hypertension

Operative Data

Intraoperative data are shown in Table 4. The operative time was longer in the TVR group than in the non-TVR group (P < .05). Ischemic time was not significantly different between the TVR and non-TVR groups (362 min vs 352 min). There were no significant differences in cardiopulmonary bypass time between the groups. In the non-TVR group, 49 patients (84%) required a bypass; among these cases, the mean bypass time was 195 min.

Postoperative Outcomes

Postoperative outcomes are shown in Table 5. The TVR group required

Discussion

Presently, there are only two surgical options available for patients with end-stage severe pulmonary hypertension disease: DLTx and heart-lung transplantation. Appropriate surgical options for patients with severe pulmonary hypertension have been a topic of longstanding debate. Throughout most of the 1990s, we performed single LTx for pulmonary hypertension.10, 11 After reviewing outcomes in 1998, however, we changed to a DLTx or heart-lung transplantation procedure for affected patients.²

Acknowledgments

Author contributions: Dr Shigemura had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Shigemura: contributed to the data collection, data analysis, and the writing of the manuscript.

Dr Sareyyupoglu: contributed to the data collection and analysis and final approval of the manuscript.

Dr Bhama: contributed to the data collection and final approval of the manuscript.

Dr Bonde: contributed to the data

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Cited by (12)

Regression of Tricuspid Valve Regurgitation After Lung Transplant: A Single-Center Experience
2022, Transplantation Proceedings
Although tricuspid regurgitation (TR) is common in candidates for lung transplant, no data or established guidelines exist regarding the need for surgical repair at the time of transplant. We aimed to evaluate the natural course of TR by assessing the incidence and extent of TR regression among patients who did not undergo tricuspid valve repair (TVR) concomitantly with lung transplant.
We retrospectively identified adult patients who underwent lung transplant without TVR at our institution from 2001 through 2017. Pretransplant and posttransplant echocardiograms were reviewed to assess severity of TR, tricuspid annular plane systolic excursion, central venous pressure, mean pulmonary arterial pressure, and right ventricular size and function.
Among 553 included patients, 324 (58.7%) were men, the mean (SD) age was 61.9 years (12.7), and 417 (75.4%) had a double lung transplant. TR before transplant was reported as trivial in 265 patients (47.9%), mild in 235 (42.5%), moderate in 40 (7.2%), and severe in 13 (2.4%). After transplant, TR improved significantly overall (P < .001). TR improved in 193 patients: 158 patients (81.9%) by 1 grade and 35 patients (18.1%) by 2 or more grades. Additionally, of 53 patients with pretransplant moderate or severe TR, 44 (83%) had improvement to mild, trivial, or no TR. After transplant, 12 patients (2.2%) had no remaining TR.
The severity of TR improved or showed no change in most patients after lung transplant, which obviates the need for TVR among most lung transplant recipients.
Single Lung Transplantation With Concomitant Cardiac Surgery in a Patient With Cystic Fibrosis: A Case Report
2020, Transplantation Proceedings
Citation Excerpt :
However, our case required switching between these 2 devices, as the patient required ECMO during preparation of the pulmonary hilum followed by CPB support in order to perform removal of the masses from the RA. After successful completion of this part, blood flow was provided by the ECMO circuit in order to finish the LT. Cardiac operations concomitant with LT do not seem to increase a risk of death as reported by Shigemura et al, who noted several cases of patients who underwent tricuspid valvuloplasty followed by LT [8]. Their oxygenation and circulation support was provided by CPB during the valvuloplasty and implantation of the first lung.
Cystic fibrosis is a congenital, progressive disease affecting many organs. It frequently leads to severe respiratory failure, which can be treated by means of a double lung transplantation. Single lung transplantation is justified only in certain cases.
This is a case report describing a 20-year-old female patient who became the recipient of a single lung transplant as a result of cystic fibrosis. The transplant was performed during cardiothoracic surgery, which included an intervention in the right atrium. At the age of 14, the patient underwent left pneumonectomy. In addition, the patient had a percutaneous endoscopic gastrostomy placed and a vascular port implanted. During preoperative evaluation, she presented with clinical symptoms of chronic respiratory failure. The patient was approved for lung transplantation at the age of 16. After 2 years on the national lung transplant waiting list, in 2018, the patient underwent right lung transplantation and removal of numerous thrombi in the right atrium during 1 procedure. This surgery was accomplished with the use of extracorporeal circulation, which is an extracorporeal membrane oxygenator combined with cardiopulmonary bypass. The patient was discharged 3 weeks after the procedure in good general condition. Presently, her pulmonary function is excellent and she presents with normal respiratory capacity.
Patients with cystic fibrosis often require double lung transplantation. Under normal circumstances, performing only a single lung transplantation would be considered medical malpractice. However, in certain cases, a single lung transplant is a life-saving procedure.
Extracorporeal Membrane Oxygenation as a Postoperative Left Ventricle Conditioning Tool After Lung Transplantation in Patients With Primary Pulmonary Artery Hypertension: First Polish Experience
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This finding indicates that tricuspid valve plasty is not always necessary among such patients. On the other hand, the study by Shigemura et al assessed that combined tricuspid valve plasty and bilateral lung transplantation were successfully performed without an increase in morbidity or mortality and contributed to decreased primary graft dysfunction [19]. This study describes the first Polish experience with consecutive intra- and postoperative prolonged VA-ECMO as a tool of heart conditioning.
Primary pulmonary hypertension can lead to hypertrophy of the right ventricle and ultimately to its insufficiency. Lung transplantation remains the only viable treatment for patients with certain forms of this disease. Usage of extracorporeal membrane oxygenation in veno-arterial form (VA-ECMO) after transplantation is both protective for left ventricle (enables adaptation to increased blood flow) and right ventricle (provides time to return to appropriate dimensions and in some cases to correct tricuspid regurgitaion).
The case study describes 4 patients who were treated with VA-ECMO as a perioperative support. Three patients were diagnosed with idiopathic form of precapillary primary pulmonary hypertension. A fourth patient was a 49-year old woman diagnosed with hypoplastic pulmonary veins representing the postcapillary form of pulmonary hypertension. In all of the cases, VA-ECMO was introduced during the surgery (femoral vein/internal jugular vein and femoral artery) and maintained for several days after the transplantation. Regular echocardiographic and biochemical assessment in postoperative course revealed that cardiac function improved during and after such treatment among all patients. They were successfully weaned off ECMO and finally surgically explanted without any local complications. One patient was treated with awake ECMO protocol.
VA-ECMO was proved to be a useful tool during the transplantation and postoperative period. It helps to restore proper cardiac function, as well as prevent adverse effects of aforementioned pathologic changes of a heart.
Geometric remodeling of tricuspid valve in pulmonary hypertension and its correlation with pulmonary hypertension severity: a prospectively case-control study using four-dimensional automatic tricuspid valve quantification technology
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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Original ResearchTransplantationCombining Tricuspid Valve Repair With Double Lung Transplantation in Patients With Severe Pulmonary Hypertension, Tricuspid Regurgitation, and Right Ventricular Dysfunction

Background

Methods

Results

Conclusions

Section snippets

Patients

Operative Data

Postoperative Outcomes

Discussion

Acknowledgments

J Heart Lung Transplant

Ann Thorac Surg

Am J Cardiol

Chest

J Am Soc Echocardiogr

J Thorac Cardiovasc Surg

J Heart Lung Transplant

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Original Research
Transplantation
Combining Tricuspid Valve Repair With Double Lung Transplantation in Patients With Severe Pulmonary Hypertension, Tricuspid Regurgitation, and Right Ventricular Dysfunction