Heart-lung transplantation: Cardiac clinicopathological correlations

Reports on heart-lung transplantation emphasize the pathology of the transplanted lungs. This study is a clinicopathological assessment of cardiac pathology in the hearts transplanted as part of the combined heart-lung block. Seventy-five consecutive heart-lung transplants (H-LTx) performed between 1981 and 1989 were studied. Endomyocardial biopsy, autopsy and clinical data were analyzed for information on cardiac rejection, graft coronary disease, transplant survival and the presence of obliterative bronchiolitis and compared with controls. The controls consisted of 391 heart transplants (HTx) performed in 361 recipients over the same time period. Sixty-three adults and nine children received H-LTx (48.6% male; 51.4% female). In this study, H-LTx were performed primarily for Eisenmengerʹs complex (3372) and primary pulmonary hypertension (2872). At 1 year H-LTx survival was 63.88%, versus 81.54% in HTx alone and 63.63% in lung transplant recipients without heart grafts. The results showed that H-LTx patients have less cardiac rejection compared to patients who undergo HTx alone (p < .005). Only 40% of H-LTx recipients developed acute cardiac rejection in the initial 3 months posttransplantation (post-Tx), compared with 80% of HTx controls. Only 4% of H-LTx recipients developed cardiac rejection after the initial 6 months. No cardiac rejection was observed in the initial 5 years post-Tx in 49.9% of H-LTx. Graft coronary disease was seen in 7.73% of H-LTx within the first 5 years post-Tx compared with 25.87% in HTx recipients alone (p < .005). Obliterative bronchiolitis (OB) was present in 71.43% of H-LTx with graft coronary disease, compared to OB in only 41.38% of H-LTx without graft coronary disease (p < .05). In conclusion, H-LTx recipients have less acute cardiac rejection episodes than HTx recipients alone (p < .005). Most cardiac rejection in H-LTx occurs within the initial 6 months. In addition, H-LTx recipients develop less graft coronary disease than HTx recipients (p < .005). Obliterative bronchiolitis and graft coronary disease may be the result of the same immunological process, as 71.43% of H-LTx with graft coronary disease also had OB. Survival for H-LTx patients is more similar to that of lung transplant (LTx) patients alone than that of heart transplants alone, suggesting that it is the pulmonary pathology portion, rather than the cardiac pathology portion, in combined H-LTx transplants that contributes more to H-LTx survival.