End-stage lung disease is a highly disabling pathology for which lung transplantation is the only possible therapeutic option in some cases. The median survival after lung transplantation at 5 and 10 years is 53% and 31%, respectively. Since the first successful lung transplant in the 1980s, the number of transplants had increased considerably all around the world (3600 in 2011). Lung transplantation includes lobar, single-lung, and double-lung transplants. The most commonly performed procedure is bilateral sequential lung transplant.
Lung transplantation may be indicated for patients with end-stage pathophysiology due to the following disorders:
Obstructive lung disease (COPD, alpha-1 antitrypsin deficiency)
Septic or suppurative disease (cystic fibrosis, bronchiolitis obliterans syndrome, bronchiectasis)
Restrictive lung disease (pulmonary fibrosis, sarcoidosis)
Vascular lung disease (primary or secondary pulmonary hypertension)
The most common indication for retransplantation is bronchiolitis obliterans syndrome.
Contraindications to lung transplantation include the following:
Malignancy in the last 2 years
Untreatable advanced dysfunction of another organ or system
Progressive neuromuscular disease
Noncurable chronic extra-pulmonary infection
Significant chest wall or spine deformity
Lack of compliance to medical therapy
Untreatable psychiatric or psychological conditions
Substance addiction in the last 6 months
Absence of a reliable social support system
Preoperative assessment consists of a complete multidisciplinary evaluation at the time of listing. The assessment is based on complete pulmonary, cardiac, hepatic, and renal function data, as well as physiological and social work evaluation (Table 50-1). Once listed, patients are followed by their pulmonologist and undergo intensive physiotherapy to maintain optimal overall condition.
TABLE 50-1Preoperative Evaluation for Lung Transplantation ||Download (.pdf) TABLE 50-1 Preoperative Evaluation for Lung Transplantation
|Respiratory ||Blood group and antibody screen and cross match |
| ||Arterial blood gas on room air |
| ||Pulmonary function testing (FEV1, FVC, DLCO, 6-MWT) |
| ||Chest X-ray, chest CT scan, Ventilation/perfusion scan |
|Cardiac ||ECG, 2D transthoracic echocardiogram, radionuclide angiography (multigated acquisition scan) |
|Patients > 40 years ||Cardiology consultation, nuclear cardiac stress testing |
|Men > 45 years, women > 50 years ||Coronary angiography and right heart catheterization for PAP |
|Infectious disease ||Viral serology, including HIV, hepatitis B, C, CMV, EBV; tuberculin skin test; sputum cultures |
|Hepatic and renal ||Liver enzymes, creatinine, urea |
|Osteoporosis ||Bone mineral densitometry |
Premedication—Standard premedication usually includes steroids and antibiotics. Therapy for any underlying condition should be continued until surgery, especially antibiotics, bronchodilators, steroids, and pulmonary vasodilators.
Monitoring—During lung transplantation, sudden hemodynamic instability due to mediastinal manipulation and pulmonary artery clamping is extremely common.
For this reason, routine anesthetic monitoring should include the following: