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* From the Departments of Pulmonary and Critical Care Medicine (Drs. Khan, Mehta, and Arroliga), Internal Medicine (Dr. Salloum), Radiology (Dr. O'Donovan), and Biostatistics (Mr. Mascha), The Cleveland Clinic Foundation, Cleveland, OH; and The Cardiovascular Research Institute (Dr. Matthay), University of California, San Francisco, CA.
Correspondence to: Alejandro C. Arroliga, MD, FCCP, Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation—G62–156, 9500 Euclid Ave, Cleveland, OH 44195; e-mail: Arrolia{at}ccf.org
Background: Although the development of noncardiogenic pulmonary edema or pulmonary reimplantation response (PRR) after lung transplantation has been well described, the incidence has not been established and the relationship of PRR to clinical risk factors has not been analyzed.
Study objectives: (1) To describe the incidence of PRR in lung transplant recipients, (2) to identify the predictors of PRR, (3) to examine the correlation of suspected predictors with the severity of PRR, and (4) to evaluate the impact of PRR on morbidity and mortality of lung transplant recipients.
Design: Retrospective review of clinical records and radiographic studies.
Setting: Tertiary care referral center.
Patients: Ninety-nine consecutive patients with end-stage lung disease undergoing lung transplantation between February 1990 and October 1995.
Methods: Review of clinical records and postoperative chest radiographs of all lung transplant recipients to identify patients who experienced PRR. Chest radiographs of patients with PRR were graded for severity on a scale of 0 (none) to 5 (very severe). Demographic, pre- and perioperative factors were also evaluated along with short- and long-term survival of patients with PRR.
Results: Fifty-six of 99 lung transplant recipients (57%) experienced PRR. The median ischemia time of patients with and without PRR was 168 and 180 min, respectively (p = 0.62). The incidence of PRR was 51% in patients without preoperative pulmonary hypertension, 78% in mild to moderate pulmonary hypertension, and 58% in patients with severe pulmonary hypertension (p = 0.10). Incidence and severity of PRR was similar in patients receiving right, left, or double-lung transplantation. Similarly, age and sex of the recipients and underlying lung disease did not affect the incidence or severity of PRR. The incidence and severity of PRR was higher in patients undergoing cardiopulmonary bypass during lung transplantation. Patients with PRR had prolonged duration of mechanical ventilation and ICU stay. Overall, PRR did not affect the survival of the patients. However, survival of female lung transplant recipients was significantly better than male recipients (median survival, 60 vs 21 months; p = 0.02).
Conclusions: Acute pulmonary edema or PRR occurs frequently (57%) after lung transplantation. In this series, PRR was not associated with a prolonged ischemia time, preoperative pulmonary hypertension, the type of lung transplant, underlying lung disease, or age or sex of recipients. However, use of cardiopulmonary bypass during surgery was associated with increased incidence and severity of PRR. Also, the development of PRR resulted in prolonged mechanical ventilation and a longer ICU stay, but did not affect survival. Female lung transplant recipients survived significantly longer than male recipients. The reason for this difference in survival is unclear.
Key Words: acute pulmonary edema • lung transplantation • pulmonary reimplantation response
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