eMedicine Specialties > Transplantation > Surgery

Heart-Lung Transplantation: Differential Diagnoses & Workup

Author: Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Contributor Information and Disclosures

Updated: Nov 5, 2008

Differential Diagnoses

Other Problems to Be Considered

Patients with systemic disease must be carefully evaluated. Since certain disease states recur in the allograft, patients with such conditions may not be suitable candidates for the procedure.

Workup

Laboratory Studies

  • Hepatitis panel
    • If the patient does not have active antigenicity, these tests serve as a screen.
    • Thoracic transplantation remains controversial in the patient who has hepatitis C and is generally addressed on a center-to-center basis.
  • HIV screen: HIV positivity remains a contraindication to transplantation.
  • Viral screens, including Epstein-Barr virus (EBV), cytomegalovirus (CMV), and herpes simplex virus (HSV)
    • These tests are used to screen patients for past exposure and currently active disease. Past exposure indicates a risk of reactivity, and currently active disease should be treated before considering transplantation.
    • Recipients who are negative for CMV are generally treated with CMV immune globulin.
    • Immunizations are administered for diseases for which they are available (eg, rubella, hepatitis).
  • Fungal serologies and tuberculin (TB) skin testing
    • Pay particular attention to environmental exposure.
    • These tests are used to determine past exposure as a predictor of reactivation.
    • Patients with positive TB results are generally treated before listing for transplantation.
  • Prostate-specific antigen (PSA) in males: If results are positive, the appropriate workup and therapy are instituted before consideration for transplantation.
  • Papanicolaou test (Pap smear) in females: Findings should be negative before listing the patient for transplantation. If positive, refer the patient for appropriate evaluation and therapy.
  • Results from the following tests should be within reference ranges (excluding alpha1 antitrypsin), and any abnormalities should be assessed for reversibility:
    • CBC count with differential
    • Platelet count
    • Prothrombin time (PT)
    • Activated partial thromboplastin time (aPTT)
    • Complete chemistry profile, including liver panel, lipid profile, urinalysis, and tests specific to the pulmonary pathology (eg, alpha1 antitrypsin levels)
  • Blood type and screen, panel-reactive antibody (PRA), and tissue typing are used to determine the patient's immunologic suitability for transplantation and to enable donor matching.

Imaging Studies

  • Obtain a CT scan of the thorax to determine the thoracic size for donor matching and to detect disease processes that prohibit transplantation.
  • Conduct echocardiography and dynamic MRI to determine the patient's right ventricular ejection fraction (RVEF). An RVEF greater than 30% may indicate potential cardiac recovery, suggesting that the patient might benefit from pulmonary transplantation alone.
  • Bilateral mammograms in females should reveal no abnormalities prior to listing for transplantation. If abnormalities are revealed, refer the patient for appropriate evaluation and therapy.
  • Posteroanterior and lateral chest radiographs: This study determines the patient's chest size, which is needed for assessment of donor suitability and is also used as a screening test for other thoracic pathologies that may preclude transplantation.

Other Tests

  • Pulmonary function test results, including diffusion capacity of lung for carbon monoxide (DLCO) and maximal venous oxygen consumption (MVO2), are expected to be abnormal. If a patient has a forced expiratory volume in 1 second (FEV1) value greater than 1 and an MVO2 greater than 15, the condition may be treated by means other than transplantation.

Procedures

  • Cardiopulmonary evaluation
    • Right- and left-heart catheterization is used to determine whether the disease process is reversible or treatable by other means.
    • Careful evaluation of the patient's pulmonary vascular resistance: Resistance of fewer than 4 Wood units indicates that the patient may benefit from cardiac transplantation alone.
  • Biopsy
    • Biopsies of appropriate areas are necessary if the patient is manifesting systemic disease (eg, sarcoidosis).
    • Biopsy procedures determine the extent and activity of disease. Systemic involvement and active disease may be contraindications to transplantation.

More on Heart-Lung Transplantation

Overview: Heart-Lung Transplantation
Differential Diagnoses & Workup: Heart-Lung Transplantation
Treatment & Medication: Heart-Lung Transplantation
Follow-up: Heart-Lung Transplantation
Multimedia: Heart-Lung Transplantation
References
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References

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Further Reading

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Keywords

heart lung transplantation, heart lung transplant, heart-lung transplant, cardiopulmonary replacement, cardiopulmonary transplantation, cardiopulmonary allograft, heart-lung allograft, double-lung transplantation, end-stage cardiac disease, end-stage pulmonary disease, end-stage cardiopulmonary disease, Denton Cooley, cyclosporine A, immunosuppression, immunosuppressives, Eisenmenger syndrome, congenital heart defects, cystic fibrosis, end-stage bronchiectasis, allograft vascular disease, obliterative bronchiolitis, rejection

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Contributor Information and Disclosures

Author

Mary C Mancini, MD, PhD, Professor, Department of Surgery, Louisiana State University Health Sciences Center
Mary C Mancini, MD, PhD is a member of the following medical societies: American Heart Association, American Medical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, International College of Surgeons, International Society for Heart and Lung Transplantation, New York Academy of Sciences, Phi Beta Kappa, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Medical Editor

Richard Thurer, MD, B and Donald Carlin Professor of Thoracic Surgical Oncology, Miller School of Medicine, University of Miami
Richard Thurer, MD is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Medical Association, American Thoracic Society, Florida Medical Association, Society of Surgical Oncology, and Society of Thoracic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Shreekanth V Karwande, MBBS, Chair, Professor, Department of Surgery, Division of Cardiothoracic Surgery, University of Utah School of Medicine and Medical Center
Shreekanth V Karwande, MBBS is a member of the following medical societies: American Association for Thoracic Surgery, American College of Chest Physicians, American College of Surgeons, American Heart Association, Society of Critical Care Medicine, Society of Thoracic Surgeons, and Western Thoracic Surgical Association
Disclosure: Nothing to disclose.

CME Editor

Michael E Zevitz, MD, Assistant Professor of Medicine, Finch University of the Health Sciences, The Chicago Medical School; Consulting Staff, Private Practice
Michael E Zevitz, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other; AstraZeneca Grant/research funds Other

 
 
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