Combining Lung Transplant, Bypass Surgery
ATLANTA -- For patients who have been precluded from receiving a lung transplant because of their underlying coronary artery disease, Duke University Medical Center researchers have shown that they can achieve similar positive outcomes by performing revascularization procedures such as coronary bypass operations immediately prior to the transplant surgery.
Additionally, performing the evascularization procedures does not add additional time to the transplant procedure itself, they report. The surgeons performed the heart surgery while the patient was being prepared to receive the donor organ, which was en route to the hospital.
The researchers emphasize that this strategy is used for lung transplant patients who -- except for their heart disease -- do not have any other health problems or conditions that would preclude them from getting the transplant. They must have coronary artery disease that is amenable to a revascularization procedure, and their hearts must pump at least at 50 percent capacity.
"Typically, these patients have been turned down at most centers from having a lung transplant because of their coronary artery disease," said Vijay Patel, M.D., heart and lung transplant fellow at Duke. "Patient selection is critical; if the only medical reasons for a patient not to receive a lung transplant is the heart disease, they could be candidates for the combined procedure."
Patel prepared the results of the Duke study for presentation today (May 20) during 98th annual international conference of the American Thoracic Society.
The researchers analyzed the clinical records of the first 350 lung transplants performed at Duke and found that 18 patients had severe coronary artery disease and received either bypass surgery (12) or an angioplasty procedure (6) prior to transplant. The survival rate for these patients was 88 percent, compared to an 81 percent survival for all other transplant patients.
"This approach appears to be safe and effective for a group of patients who otherwise would not receive a transplant," Patel said. "We have shown that we can improve the quality of life of these patients without increasing the amount of time the patient is on the table. Also, their length of stay in the hospital was similar to those transplant patients who didn't get the revascularization."
This study is the largest to date, providing scientific support for combining a heart procedure with a lung transplant in this select group of patients, the researchers say.
"Insurance companies, for example, follow the dogma that coronary artery disease automatically makes it too risky to transplant lung patients," said R. Duane Davis, M.D. surgical director of Duke's lung
transplant program. "Now we have data that shows in this select population of patients, we can safely provide a life-extending procedure. This data should provide a comfort zone for physicians at other centers to consider these patients for transplant."
Davis points out that these types of patients represent a small percentage of lung transplant candidates, and placing them on the transplant waiting list would not lead to large increase patients awaiting new lungs. At Duke, which is currently the largest lung transplant center in the U.S., only about 5 percent of patients were appropriate candidates.
"Since there is such a limited supply of donor organs, we have an ethical obligation to make sure that when an organ becomes available, it has a high likelihood of surviving," Davis continued. "That is why patient evaluation and selection is vital."
Duke performed its first lung transplant procedure in 1992. In the ensuing 10 years, the Duke program has become the largest in the country, having performed more of the surgeries than any other program in each of the past two years.
The analysis was supported by Duke's department of surgery. Other members of the Duke team were study coordinator Robert Messier, M.D., Mark Steele, M.D., Charles Hoopes, M.D., and Scott Palmer, M.D.