Review of Heart-Lung Transplantation at Stanford

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Presentation transcript:

Review of Heart-Lung Transplantation at Stanford Tobias Deuse, MD, Ramachandra Sista, MD, David Weill, MD, Dolly Tyan, MD, Francois Haddad, MD, Gundeep Dhillon, MD, Robert C. Robbins, MD, Bruce A. Reitz, MD The Annals of Thoracic Surgery Volume 90, Issue 1, Pages 329-337 (July 2010) DOI: 10.1016/j.athoracsur.2010.01.023 Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 This timeline shows major changes in immunosuppressive therapy and antimicrobial prophylaxis regimens over almost three decades of heart-lung transplant. (Aza = azathioprine; CMV-IG = cytomegalovirus/immunoglobulin; CsA = cyclosporine A; Inh. Ampho B = inhaled amphotericin B; MMF = mycophenolate mofetil; OKT3 = monoclonal antibody OKT3; Pred = prednisone; RATG = rabbit antithymocyte globulin; RATG/ATGAM = rabbit antithymocyte globulin/antithymocyte globulin; TAC = tacrolimus; TBBx = transbronchial biopsies; TMP-SMX = trimethoprim /sulfamethoxazole.) The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Combined heart-lung transplants (HLTx) performed at Stanford between March 1981 and June 2008. Center volume over time (A). Annual numbers peaked around 1990 and again in the mid 1990s. Since the 2000s, a mean of 5.4 transplants is being performed each year. The distribution of patient age at the time of transplantation is shown in (B). Patient ages ranged from 49 days to 58 years. The indications for heart-lung transplantation have undergone changes over the years (C). (PPH = primary pulmonary hypertension.) The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Survival after heart-lung transplant (HLTx). The overall survival trended to improve between the 1980s and the 1990s (p = 0.07) and was significantly improved in the 2000s (p = 0.02; A). Plots for 1-, 5-, 10-, and 15-year survival are shown in (B). One-year survival started at 62.1% and has improved recently. Overall 5-year survival has plateaued at approximately 55%, whereas 10- and 15-year survival have steadily improved to approximately 40% and 30%, respectively. Conditional survival data for 5-, 10-, and 15-year survivors revealed an improvement of half-life from 5.3 years in the whole population to 12.5 years for the 5-year survivors and to an estimated 20 to 25 years for the 10-year survivors (C). Survival was similar for the three most common diagnoses (D). All survival graphs are shown with 95% confidence interval. (CF = cystic fibrosis; PPH = primary pulmonary hypertension.) The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Freedom from acute rejection (with 95% confidence interval) in heart-lung transplant (HLTx) patients, divided by affected organ. The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Infections in heart-lung transplant patients. The overall incidence of bacterial (p = 0.008) and viral infections (p = 0.017) was significantly decreased over time, whereas the reduction of fungal infections was more subtle (p = 0.630) (A). The spectrum of infections shifted toward more fungal and fewer viral infections (B). Due to a rigorous decrease of pseudomonas infections in the 2000s (p < 0.001), there was a trend toward more gram+ pathogens (p = 0.066, C). The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Long-term complications after heart-lung transplant (HLTx). Freedom from bronchiolitis obliterans syndrome (BOS) was 96.4%, 66.7%, and 50.2% after 1, 5, and 10 years (A). The incidence of BOS followed a nearly linear trend with approximately 5% per year. Freedom from graft vasculopathy was markedly higher at 99.3%, 94.1%, and 65.8% after 1, 5, and 10 years (B), respectively. Freedom from any type of malignancy was 98.5%, 94.4%, and 81.0% after 1, 5, and 10 years (C). Between 10 and 15 years, the rate doubled to approximately 40% (C). All outcome graphs are shown with 95% confidence interval. (CAD = coronary artery disease.) The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Comparison between pediatric and adult heart-lung transplant (HLTx) recipients. Survival data for the 188 (88.7%) adult patients and the 24 (11.3%) pediatric patients (< 18 years of age) were very similar. Survival half-lives were 5.9 years for the pediatric and 5.3 years for the adult population (p = 0.62). Survival graphs are shown with 95% confidence interval. The Annals of Thoracic Surgery 2010 90, 329-337DOI: (10.1016/j.athoracsur.2010.01.023) Copyright © 2010 The Society of Thoracic Surgeons Terms and Conditions