Lung transplantation is a surgical procedure in which a patient's diseased lungs are partially or totally replaced by lungs which come from a donor. While lung transplants carry certain associated risks, they can also extend life expectancy and enhance the quality of life for end-stage pulmonary patients.
Qualifying conditions
Lung transplantation is the therapeutic measure of last resort for patients with end-stage lung disease who have exhausted all other available treatments without improvement. A variety of conditions may make such surgery necessary. As of 2005, the most common reasons for lung transplantation in the United States were:
- 27% chronic obstructive pulmonary disease (COPD), including emphysema;
- 16% idiopathic pulmonary fibrosis;
- 14% cystic fibrosis;
- 12% idiopathic (formerly known as "primary") pulmonary hypertension;
- 5% alpha 1-antitrypsin deficiency;
- 2% replacing previously transplanted lungs that have since failed;
- 24% other causes, including bronchiectasis and sarcoidosis.
Contraindications
Despite the severity of a patient's respiratory condition, certain preexisting conditions may make a person a poor candidate for lung transplantation. These conditions include:
- concurrent chronic illness (e.g. congestive heart failure, kidney disease, liver disease);
- current infections, including HIV and hepatitis;
- current or recent cancer;
- current use of alcohol, tobacco, or illegal drugs;
- age;
- psychiatric conditions;
- history of noncompliance with medical instructions.
History
The history of organ transplants began with several attempts that were unsuccessful due to transplant rejection. Animal experimentation by various pioneers, including Vladimir Demikhov and Dominique Metras, during the 1940s and 1950s, first demonstrated that the procedure was technically feasible. James Hardy of the University of Mississippi performed the first human lung transplant in 1963. Following a left lung transplantation, the patient survived for 18 days. From 1963-1978, multiple attempts at lung transplantation failed because of rejection and problems with anastomotic bronchial healing. It was only after the invention of the heart-lung machine, coupled with the development of immunosuppressive drugs such as cyclosporine, that organs such as the lungs could be transplanted with a reasonable chance of patient recovery.
The first successful transplant surgery involving the lungs was a heart-lung transplant, performed by Dr. Bruce Reitz of Stanford University on a woman who had idiopathic pulmonary hypertension.
- 1983: First successful single lung transplant (Tom Hall) by Joel Cooper (Toronto)
- 1986: First successful double lung transplant (Ann Harrison) by Joel Cooper (Toronto)
- 1988: First successful double lung transplant for cystic fibrosis by Joel Cooper (Toronto)
Transplant requirements
Requirements for potential donors
There are certain requirements for potential lung donors, due to the needs of the potential recipient. In the case of living donors, this is also in consideration of how the surgery will affect the donor.
- healthy;
- size match; the donated lung or lungs must be large enough to adequately oxygenate the patient, but small enough to fit within the recipient's chest cavity;
- age;
- blood type.
Requirements for potential recipients
While each transplant center is free to set its own criteria for transplant candidates, certain requirements are generally agreed upon:
- end-stage lung disease;
- has exhausted other available therapies without success;
- no other chronic medical conditions (e.g. heart, kidney, liver);
- no current infections or recent cancer. There are certain cases where preexisting infection is unavoidable, as with many patients with cystic fibrosis. In such cases, transplant centers, at their own discretion, may accept or reject patients with current infections of B. cepacia or MRSA .
- no HIV or hepatitis;
- no alcohol, smoking, or drug abuse;
- within an acceptable weight range (marked undernourishment or obesity are both associated with increased mortality);
- age (single vs. double tx);
- acceptable psychological profile;
- has social support system;
- financially able to pay for expenses;
- able to comply with post-transplant regimen. A lung transplant is a major operation, and following the transplant, the patient must be willing to adhere to a lifetime regimen of medications as well as continuing medical care.
Medical tests for potential transplant candidates
Patients who are being considered for placement on the organ transplant list must undergo an extensive series of medical tests in order to evaluate their overall health status and suitability for transplant surgery.
- blood typing; the blood type of the recipient must match that of the donor due to certain antigens that are present on donated lungs. A mismatch of blood type can lead to a strong response by the immune system and subsequent rejection of the transplanted organs;
- tissue typing; ideally, the lung tissue would also match as closely as possible between the donor and the recipient, but the desire to find a highly compatible donor organ must be balanced against the patient's immediacy of need;
- Chest X-ray - PA & LAT, to verify the size of the lungs and the chest cavity;
- pulmonary function tests;
- CT Scan (High Resolution Thoracic & Abdominal);
- Bone mineral density scan;
- MUGA (Gated cardiac blood pool scan);
- Cardiac stress test (Dobutamine/Thallium scan);
- ventilation/perfusion (V/Q) scan;
- electrocardiogram;
- cardiac catheterization;
- echocardiogram.
Lung allocation score
Main article: lung allocation scorePrior to 2005, donor lungs within the United States were allocated by the United Network for Organ Sharing on a first-come, first-serve basis to patients on the transplant list. This was replaced by the current system, in which prospective lung recipients of age of 12 and older are assigned a lung allocation score or LAS, which takes into account various measures of the patient's health. The new system allocates donated lungs according to the immediacy of need rather than how long a patient has been on the transplant list. Patients who are under the age of 12 are still given priority based on how long they have been on the transplant waitlist. The length of time spent on the list is also the deciding factor when multiple patients have the same lung allocation score.
Patients who are accepted as good potential transplant candidates must carry a pager with them at all times in case a donor organ becomes available. These patients must also be prepared to move to their chosen transplant center at a moment's notice. Such patients may be encouraged to limit their travel within a certain geographical region in order to facilitate rapid transport to a transplant center.
Types of lung transplant
Lobe
A lobe transplant is a surgery in which part of a living donor's lung is removed and used to replace part of recipient's diseased lung. This procedure usually involves the donation of lobes from two different people, thus replacing a single lung in the recipient. Donors who have been properly screened should be able to maintain a normal quality of life despite the reduction in lung volume.
Single-lung
Many patients can be helped by the transplantation of a single healthy lung. The donated lung typically comes from a donor who has been pronounced brain-dead.
Double-lung
Certain patients may require both lungs to be replaced. This is especially the case for people with cystic fibrosis, due to the bacterial colonisation commonly found within such patients' lungs; if only one lung were transplanted, bacteria in the native lung could potentially infect the newly transplanted organ.
Heart-lung
Main article: Heart-lung transplantSome respiratory patients may also have severe cardiac disease which in of itself would necessitate a heart transplant. These patients can be treated by a surgery in which both lungs and the heart are replaced by organs from a donor or donors.
A particularly involved example of this has been termed a "domino transplant" in the media. First performed in 1987, this type of transplant typically involves the transplantation of a heart and lungs into recipient A, whose own healthy heart is removed and transplanted into recipient B.
Procedure
While the precise details of surgery will depend on the exact type of transplant, there are many steps which are common to all of these procedures. Prior to operating on the recipient, the transplant surgeon inspects the donor lung(s) for signs of damage or disease. If the lung or lungs are approved, then the recipient is connected to an IV line and various monitoring equipment, including pulse oximetry. The patient will be given general anesthesia, and a machine will breathe for him or her.
It takes about one hour for the pre-operative preparation of the patient. A single lu
Lung Transplant Surgery
Heart and Lung Surgery: USC Department of Cardiothoracic Surgery
Lung Transplant, Lung Transplantation Patient Guide: Lung Transplant ...
Single or double lung transplantation may be performed, depending on whether the lung disease involves infection or damage without infection. When the new lung(s) arrives in the ...
Lung transplant surgery process
A single-lung transplant usually takes 4 to 8 hours. A double-lung transplant usually takes 6 to 12 hours.
Lung Infections: Heart Transplant Surgery Patient Guide
Patient's Guide to Heart Transplant Surgery . Lung Infections. Your lungs are the most common site for infections to develop after any transplant.
Lung Transplant Surgery - New York Presbyterian Hospital
One Hosptial affilitated with two Ivy League Medical Schools: Columbia University College of Physicians & Surgeons and Weill Medical College of Cornell University.
Lung transplant surgery
Implementation of a management guideline aimed at minimizing the severity of primary graft dysfunction after lung transplant The Journal of Thoracic and Cardiovascular Surgery, 11 ...
Lung Transplant Program - Cardiothoracic Surgery - SURGERY ...
Lung Transplant Program, Cardiothoracic Surgery, San Antonio - University of Texas Health Science Center at San Antonio. Outstanding cardiothoracic thoracic surgical residency and ...
Lung transplant - Surgery, Surgical Procedures & Surgery Recovery ...
Lung transplant Definition Lung transplant is surgery to replace one or both diseased lungs with healthy lungs from a human donor. Alternative Names
Lung Transplant - Surgery Procedures & Risks - NY Times Health ...
Free reference information and multimedia from The NY Times on surgical procedures, risks and prognosis, as well as links to related news and features.
WakeMed Raleigh, NC - Lung transplant. Lung transplant is surgery to ...
WakeMed Health & Hospitals, Greater Raleigh, Wake County, NC - Lung transplant. Lung transplant is surgery to replace one or both diseased lungs with healthy lungs from a human ...