A lung or heart-lung transplantation is an option for patients with respiratory failure and die despite optimal medical treatment the risk.
(See also Overview transplant.) A lung or heart-lung transplantation is an option for patients with respiratory failure and the risk of death despite optimal medical treatment. The most common indications for lung transplantation are COPD Idiopathic pulmonary fibrosis Cystic fibrosis alpha 1-antitrypsin deficiency Primary pulmonary hypertension Less common indications include interstitial lung disease (eg. As sarcoidosis), bronchiectasis, and congenital heart disease. The transplantation of one or both lungs are equally suitable for most lung diseases without cardiac involvement; with the exception of chronic diffuse infections (eg bronchiectasis.); In this case, the double-sided transplant is best. Indications for heart-lung transplantation is Eisenmenger’s syndrome Each lung disease with severe ventricular dysfunction is probably irreversible pulmonary heart disease often goes back alone after lung transplantation and therefore is rarely an indication for heart-lung transplantation; However, sometimes a heart-lung transplant is required. Relative contraindications are age (recipient of a lung must be <65 years old, recipient of two lungs <60 years of age and for a heart-lung transplant <55 years old), current cigarette smoking and previous thoracic surgery. Some clinics and for some patients with cystic fibrosis relative contraindications also represent lung infections with resistant strains of Burkholderia cepacia, which the mortality rate increases considerably. Transplantation of a single or both lungs are the same rate and at least eight times more frequently performed as a heart-lung transplants. Lung donor Nearly all lung donations come from brain-dead (deceased) donors with still existing cardiac function. Transplants from heart-dead donors, in English donation-after-cardiac-death (DCD) called, are increasingly being used as lungs of more suitable donors are missing. Transplants of adult lung from living donors (usually a parent-child transplant) are rarely carried out, namely when cadaver organs are not available. Donors must be <65, must never have smoked, and there must be no active lung disease are detected: Oxygenation: PaO 2 / FiO 2 (Fractional inspired O2)>. 250 to 300, with PaO2 in mmHg and FiO2 in decimal (eg 0, 5) lung compliance: Highest inspiratory pressure <30 cm H2O in tidal volume (VT) 15 ml / kg and positive end-expiratory pressure = 5 cm H2O External appearance: with bronchoscopy for donor and recipient are an anatomical ((by chest films) and physiological sizing total lung capacity) or both required. Time for transplantation recommendation at the time of transfer for transplantation should be determined by factors such as degree of obstructive defect: Forced expiratory volume in 1 s (FEV1) <25 to 30% of the target value in patients with COPD, alpha 1-antitrypsin deficiency, or Cystic fibrosis PaO 2 <55 mmHg PaCO2> 50 mmHg right atrial pressure> 10 mm Hg and systolic pressure> 50 mm Hg in patients with primary pulmonary hypertension rate of progression of clinical, radiological or physiological disease procedure the donor is first treated with anticoagulants. Subsequently, the lungs are perfused via the pulmonary artery with a cold, crystalloid, prostaglandins containing storage solution. The donor organs are cooled with an ice-cold solution of salt in situ or on cardiopulmonary bypass and removed. Often antibiotics are administered prophylactically. Single lung transplantation for the transplantation of a single lung is performed posterolateral thoracotomy. The original lung is removed; Bronchus, pulmonary artery and pulmonary veins of the donor lungs are anastomoses with the corresponding cuffs. The healing process is promoted by bronchial anastomoses intussusception or wrapping with omentum or pericardium. The benefits of the transplantation of a single lung lie in a simpler operation, the avoidance of cardiopulmonary bypass and systemic anticoagulation (usually) more flexibility in sizing and in the availability of the contralateral lung from the same donor for another recipient. The disadvantages lie in the possibility of not matching ventilation / perfusion between native and transplanted lungs and possibly in poor healing of the individual bronchial Anastomosen.Doppelte lung transplantation In the double-sided transplantation is a sternotomy or a front transverse thoracotomy required; the method is similar to two successive transplantations of individual lung. The main advantage is the complete removal of the diseased lung tissue to the recipient. A disadvantage is the poor healing of tracheal Anastomosen.Herz-lung transplantation is for a heart-lung transplant a median sternotomy must be performed with cardiopulmonary bypass. Aortic, right atrial and Trachealanastomosen are required, and the trachea is anastomosed directly over the bifurcation. The main advantages are an improved function of the graft and in a more independent healing process of anastomoses tracheal bronchial due to coronary collaterals within the heart-lung blocks. Disadvantageous to the long operating time with the need for a cardiopulmonary bypass, the need for a very accurate size adjustment and the need of three donor organs for a Empfänger.Immunsuppression prove A common immunosuppressive treatment with three drugs combined A calcineurin inhibitors (cyclosporine or tacrolimus) A purine metabolism inhibitor (azathioprine or mycophenolate mofetil) methylprednisolone or other Kortikostreoid First, the patients pre-operatively administered high doses; Methylprednisolone i.v. is often given intraoperatively before reperfusion of the transplanted lung. Lower doses are then added to the maintenance (see Table: immunosuppressants for the treatment of transplant rejection). Thymocyte globulin (ATG) or alemtuzumab are often given as induction therapy. These drugs can also minimize immunosuppressive therapy after transplantation. Often tacrolimus monotherapy is sufficient if induction therapy takes place. Abandoning corticosteroids promotes healing of bronchial anastomoses; they are replaced by higher doses of other drugs (eg. B. cyclosporine, azathioprine). Treatment with immunosuppressants is continued indefinitely. Complications rejection Despite immunosuppressive therapy occurs in most patients rejection reactions. The symptoms of hyperacute, acute and chronic form are similar and manifest themselves as fever, dyspnea, cough, decreased SaO2 (arterial O2 saturation) and reduced by> 10-15% FEV1 (see table: manifestations of liver transplant rejection by category). Hyperacute rejection crisis must be distinguished from an early graft dysfunction, which goes back to ischemic damage during transplant surgery. Acute rejection crisis must be distinguished from an infection. Interstitial infiltrates that are seen on a chest x-ray is typical in patients with accelerated or acute rejection. The rejection is usually diagnosed by bronchoscopy, including bronchoscopic transbronchial biopsy. When a rejection occurs, the biopsy is a perivascular lymphocytic infiltration into the small vessels; neutrophils in alveolar infiltrate and infectious agents suggest an infection. The i.v. administration of corticosteroids is usually effective in hyperacute, accelerated or acute rejection. The therapy is for recurrent or resistant cases different and consists in increased doses of corticosteroids, cyclosporin and ATG in Aerolsolform. A chronic rejection reaction (after> 1 year) occurs in up to 50% of patients; it manifests itself in the form of bronchiolitis obliterans or more rarely, an atherosclerosis. Acute rejection may increase the risk of chronic rejection. In patients with obliterative bronchiolitis occurs cough, dyspnoea and reduced FEF25-75% or FEV1 values ??with or without physical and radiographic evidence of a respiratory process. The differential diagnosis includes pneumonia. The diagnosis is usually done by bronchoscopic biopsy. There is no effective treatment, but one option is corticosteroids, ATG, the inhalation of cyclosporine and the re-transplantation. Manifestations of lung transplant rejection by category rejection category manifestations Hyper Acute poor oxygen supply, fever, cough, shortness of breath, decreased FEV1 Accelerates poor oxygen supply, fever, cough, dyspnea, in the X-ray image: Brustinfiltrate, reduced FEV1 acute therapy Same as accelerated Interstitial perivascular infiltrate (detected by transbronchial biopsy)Chronic bronchiolitis obliterans, cough, dyspnea, FEV1 = forced expiratory volume in 1 s Surgical complications The most common late complications of surgery are poor healing of the bronchial or tracheal anastomosis (diagnosed by air in the mediastinum or pneumothorax). Infection Up to 20% of recipients of a single lung develop a bronchial that leads to respiratory sounds and airway obstruction; they can be treated by dilation or stenting. Other surgical complications include hoarseness and diaphragmatic paralysis caused by damage to the recurrent laryngeal nerve laryngens or phrenic nerves; gastrointestinal dysmotility caused by injury to the thoracic vagus nerve innervating and pneumothorax. In some patients, occurs due to the line changes, caused by the seam between the pulmonary vein and the atrium to supraventricular arrhythmias. Prognosis survival rates of patients At 1 year: 84% of patients with a live donation and 83% with a corpse donation after 5 years 34% of patients with a live donation and 46% with a corpse donation patients with primary pulmonary hypertension, idiopathic pulmonary fibrosis or sarcoidosis have a higher mortality than those with chronic airway obstruction, or alpha-1 antitrypsin deficiency. Transplantation of a lung to go with a higher mortality associated as a double-sided transplants. The most common causes of death within one month: The primary failure of the donor organ ischemia and reperfusion, and infections (eg pneumonia.) Without cytomegalovirus between 1 month and 1 year old: Infection After 1 Year: bronchiolitis obliterans Risk factors that increase the mortality count incompatible cytomegalovirus (positive donors, negative receiver), incompatible human leukocyte antigen (HLA-DR), diabetes, and a former need for mechanical ventilation or inotropic support. In exceptional cases, reverses the original disturbance, especially some interstitial lung disease again. Due to a reaction hyperventilatorischen the physical load capacity is slightly restricted. The overall survival rate at a heart-lung transplant is after 1 year at 60% for both patients and grafts.