Effect of changes in postoperative spirometry on survival after lung transplantation.

OBJECTIVE: The decline in normalized forced 1-second expiratory volume after lung transplantation is inevitable; however, the effect of this change on survival is unknown. Additionally, the benefit of double versus single lung transplant is debated, particularly because pulmonary function is only slightly better after double lung transplant. Our goal was to determine the effect of the temporal pattern of post-transplant forced 1-second expiratory volume (percentage of predicted) on the risk of death after transplant and the differences in the sensitivity of single and double lung transplant to this relationship. METHODS: From February 1990 to January 2008, 622 adults underwent lung transplantation, of whom 315 (51%) received 2 lungs. Of the 509 patients (82%) with available data, 9471 longitudinal evaluations of forced 1-second expiratory volume (percentage of predicted) were analyzed. The temporal pattern was characterized for each patient, and the resulting curve was evaluated as a time-varying covariable function in the survival analysis. Differences in sensitivity of single and double lung transplant were assessed by interaction. RESULTS: Forced 1-second expiratory volume (percentage of predicted) increased from 50% immediately postoperatively to 55% at 1 year after single lung transplant and then gradually declined to 47% by 3 years. Although the pattern was similar after double lung transplant, the corresponding forced 1-second expiratory volume (percentage of predicted) at these points was greater--60%, 75%, and 65%. Lower post-transplant forced 1-second expiratory volume (percentage of predicted) was associated with a substantially increased risk of death after single lung transplant (P < .0001); however, this increase was far less after double lung transplant (P < .0001). CONCLUSIONS: The results of our study have demonstrated the effect of changing lung function after lung transplantation on survival. Survival after single lung transplant proved more sensitive to declining pulmonary function, demonstrating an advantage of the increased pulmonary reserve provided by double lung transplant.

Decortication after lung transplantation.

BACKGROUND: Compromise of a pulmonary allograft by restrictive or infectious pleural-space pathology may be amenable to surgical intervention; however, the role of decortication in this patient population has not yet been substantiated. To address this issue, indications and outcomes of decortication after lung transplantation were examined at our institution. METHODS: From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%). RESULTS: Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days. CONCLUSIONS: Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.