eMedicine Specialties > Transplantation > Surgery

Heart-Lung Transplantation: Follow-up

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

Updated: Nov 5, 2008

Follow-up

Further Inpatient Care

• Postoperative endomyocardial biopsies are performed at weekly intervals for 2-4 weeks to assess cardiac rejection.
• Chest radiographs and spirograms are routinely obtained to assess for the presence of pulmonary rejection or infection. If either entity is considered possible, bronchoalveolar lavage with transbronchial biopsy is performed to streamline the differential diagnosis and direct therapy.⁵

Further Outpatient Care

• Routine outpatient follow-up care is arranged at prescheduled intervals to monitor for immunosuppression and rejection and to evaluate overall clinical progress.
• The follow-up interval is determined by the center and may be as frequent as 3 times a week during the first several weeks after discharge. Visits become less frequent as the patient demonstrates stability with the medication regimens and as allograft acceptance (lack of rejection episodes) occurs.
• Long-term follow-up care can vary from every 3 months to yearly, depending on the patient's condition.
• Each outpatient visit may include the following:
  • Routine tests include biochemical screening (including electrolytes, cholesterol, glucose, and liver functions) and immunosuppressant drug levels.
  • Pulse oximetry and spirometry are monitored at each visit.
  • Cardiac evaluations are obtained at predetermined intervals and include echocardiography to assess the function of the allograft.

Inpatient & Outpatient Medications

• In addition to immunosuppressants, medications to treat concomitant conditions, including hypertension and diabetes, are ordered.

Deterrence/Prevention

• Because these patients are at risk for infection caused by their immunosuppressed state, behavioral modification must be encouraged to prevent exposure to certain conditions.
• Instruct the patient to wear a mask in crowds, particularly during the first year after transplantation.
• Because the lungs are particularly susceptible to injury, encourage the patient to avoid chemical sprays, noxious conditions, fires, and smoke.
• Stress good general hygiene, including rigorous housekeeping and monitoring of heating and air conditioning systems.
• Instruct the patient to avoid crowds and individuals who are ill.

Complications

• Rejection
  • Cardiac rejection is monitored by serial endomyocardial biopsies. However, this has proven to be an unsatisfactory method to assess pulmonary rejection because the two can occur discordantly.
  • Rejection is considered likely when radiographic changes in the lung fields are present. Examination of the cellular content of the bronchoalveolar lavage fluid is an appropriate surveillance method.
  • If rejection is suggested but not confirmed, treatment is nevertheless initiated. Treatment consists of steroid pulses (500-1000 mg of methylprednisolone qd for 3-5 d), monoclonal antibody treatment, or polyclonal antibody therapy. Cardiac rejection is treated in a similar fashion.
• Implantation response
  • This is a transient and reversible deterioration in compliance, gas exchange, and pulmonary vascular resistance. The process generally occurs immediately after surgery and persists for as long as 1 week after operation.
  • The etiology of the process is multifactorial, including lymphatic disruption, ischemia or reperfusion injury, denervation, surgical trauma, fluid overload, and inadequate preservation (to name a few).
  • Improvements in preservation techniques coupled with judicious postoperative diuresis leads to improved pulmonary function and resolution of the problem.
• Infection
  • The transplanted lung is extremely susceptible to injury and infection. Early mobilization of the patient and aggressive pulmonary therapy may reduce this postoperative complication. Bacteriologic culture of the donor and recipient trachea may demonstrate potential pathogens and guide appropriate prophylaxis. Diagnosis is confirmed by taking a careful history of the patient's exposure and by obtaining a bronchoalveolar lavage specimen for culture.
  • CMV infection represents a particular hazard. The infection may be a reactivation of recipient disease caused by the immunosuppression or de novo infection from donor tissue, transfused blood, or other sources. Radiographically, diffuse reticular infiltrates appear in the lung fields. The process proceeds rapidly to respiratory failure and death if aggressive treatment is not initiated. Patients are generally started on ganciclovir (5 mg/kg/d) prophylactically to prevent the problem. The same drug and dosage is used for treatment.
  • Late viral, fungal, and bacterial infections can occur based on exposure. Vigilance and careful historical documentation of the patient's activities and exposure often provide valuable clues to the infectious agent and guide therapy. Diagnosis and treatment must be prompt.
• Allograft vascular disease and bronchiolitis obliterans
  • Allograft vascular disease of the coronary arteries of the transplanted heart and obliterative bronchiolitis of the transplanted lung remain the main causes of late graft failure and death. The coronary arteries develop a progressive concentric myointimal hyperplasia. The lungs develop squamous metaplasia and fibrous replacement of the bronchioles. In both cases, the process is progressive.
  • The etiology of the process continues to be elusive. Current research indicates that initial ischemia or reperfusion injury of the allograft coupled with repeated rejection episodes may contribute to the process.
  • To date, the only available therapy is retransplantation.⁶

Prognosis

• The 1-year survival rate after a heart-lung transplant is 65%; the 5-year survival rate is 40%.
• Early mortality is secondary to surgical losses and acute allograft failure.
• The late attrition is due to obliterative bronchiolitis and rejection.⁷

Patient Education

• Patients are instructed to monitor temperature, blood pressure, and pulse oximetry.
• Symptoms of rejection are carefully discussed.
• At the first signs of an alteration in their usual state of health, patients are instructed to call the transplant center.
• Patients are instructed in detail about the immunosuppressive medications, their actions, and adverse effects.
• Careful dietary and rehabilitation education is provided.
• For excellent patient education resources, visit eMedicine's Heart Center and Lung and Airway Center. Also, see eMedicine's patient education article Heart and Lung Transplant.

Miscellaneous

Medicolegal Pitfalls

• A careful medical and psychosocial evaluation of the candidate must be performed according to established and published program criteria. These criteria are discussed with the patient and family before the initiation of the evaluation, and a candid discussion of issues that disqualify a patient from candidacy for transplantation must be addressed at the onset. A written contract is negotiated between the transplant center and the patient, with the stipulation that noncompliance with the guidelines is grounds for removal from the program. Both patient and physician must agree to these stipulations. Candid and frequent discussions concerning guidelines, issues, and waiting time should take place.

Special Concerns

• Candidates for heart-lung transplantation are generally younger persons with a fatal disease. The transplantation process offers hope to these individuals. However, the shortage of donor organs makes this lifesaving procedure unavailable to many individuals. Both patients and families need strong physician support, availability, and candor when dealing with issues as they arise.

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