Clinical lung and heart/lung transplantation
Lung Transplantation Outcome in Cystic Fibrosis Patients With Previous Pneumothorax

https://doi.org/10.1016/j.healun.2004.05.024Get rights and content

Background

High perioperative mortality that results from hemorrhage from pleural adhesions was reported in the early experience of heart-lung transplantation. This led to previous pleural procedures becoming a relative/absolute contraindication to transplantation in some centers, despite the advent of bilateral lung transplantation. Has this lead to a more conservative approach to pneumothorax management in patients with cystic fibrosis (CF)? And what is the effect of previous pleural procedures on surgical outcome of lung transplantation?

Methods

We reviewed 3 groups of patients transplanted at this center from 1989 to 2002, matched for year of lung transplantation. Group A comprised 16 patients with CF with a history of previous pneumothorax with or without pleural procedure. Group B comprised 16 patients with CF with no history of pneumothorax. Group C comprised 16 noninflammatory/nonbronchiectatic patients with no history of pneumothorax. Measured outcomes included blood products provided intraoperatively; operation and cardiopulmonary bypass times; postoperative hemorrhage; times to extubation, discharge from the intensive care unit and hospital discharge; forced expiratory volume at 1 second at 6 months; 30-day mortality; pleural adhesions graded descriptively; and previous pneumothorax management (Group A only). There were 35 pneumothorax episodes in the 16 patients in Group A. Nine episodes were managed with observation alone. Nine patients required invasive management, 25 chest drains were placed, 3 patients received medical pleurodesis, and 2 underwent thoracic surgical intervention.

Results

No significant difference was observed between the 3 groups regarding blood products intraoperatively or duration of procedure. Pleural adhesions found at operation were significantly more in Group A, with dense adhesions found only in Group A (p < 0.05). Group C was significantly more likely to be free from adhesions, with 13 patients clear (p < 0.01 Group C vs Group A, Group C vs Group B). No statistically significant difference was found in the other measured parameters.

Conclusions

Pneumothorax is treated conservatively in a potential lung transplant population. Patients with CF and previous pneumothorax with or without pleural procedures undergoing lung transplantation have dense pleural adhesions; however, this does not affect surgical outcome significantly. Patients with emphysema, fibrosing alveolitis, or obliterative bronchiolitis were significantly more likely to be free of pleural adhesions, suggesting that the inflammatory/chronic infective component of CF independently contributes to the increased pleural adhesions. Previous pleural procedures for pneumothorax should not be considered a contraindication in the assessment of suitability for lung transplantation.

Section snippets

Patients and Controls

Transplantation for CF began at the Cardio-Thoracic Centre at the Freeman Hospital, Newcastle Upon Tyne, in 1989.13 Up to April 2002, a total of 98 patients with CF have undergone single sequential lung transplantation, 16 of whom had had at least 1 episode of previous pneumothorax; these 16 patients made up our primary group of interest (Group A). We identified 2 control groups matched for time of surgical procedure to account for changes in surgical technique and experience over the 13 years.

Pneumothorax Episodes and Management

There were 35 episodes of pneumothorax in the 16 patients with CF. Ten patients had a single episode; the remaining 6 patients experienced recurrent problems, with 1 subject having 7 pneumothoraces. The first episode of pneumothorax occurred on average 3.25 years before lung transplantation (median 4.5 years, range 1–6 years). Three patients were on the active lung transplantation list at the time of a pneumothorax. Average age of patients at initial pneumothorax was 25.6 years (median 24.5

Discussion

Our study shows that in lung transplantation for patients with CF and previous pneumothorax with or without invasive intervention, there are increased pleural adhesions, but this has no effect on surgical outcome. We also showed that patients with CF with no history of pneumothorax have increased pleural adhesions at transplantation when compared with a control group free from chronic infection or inflammation.

References (18)

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