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(Chest. 2001;120:508-513.)
© 2001 American College of Chest Physicians

Pulmonary Complications in Cardiac Transplant Recipients*

Roberta Lenner, MD; Maria L. Padilla, MD; Alvin S. Teirstein, MD; Alan Gass, MD and Gregory J. Schilero, MD

* From the Bronx VA Medical Center and NYU-Mount Sinai Medical Center, New York, NY.

Correspondence to: Roberta Lenner, MD, 515 East 72nd, Apt. 10 L, New York, NY 10021


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Background: The incidence of pulmonary complications in heart transplant recipients has not been extensively studied. We report pulmonary complications in 159 consecutive adult orthotopic heart transplantations (OHTs) performed in 157 patients.

Materials and methods: Retrospective review of medical records.

Results: Forty-seven of 159 recipients (29.9%) had 81 pulmonary complications. Pneumonia was the most common (n = 27), followed by bronchitis (n = 15), pleural effusion (n = 10), pneumothorax (n = 7), prolonged respiratory failure requiring tracheotomy (n = 7), and obstructive sleep apnea syndrome (n = 6). All patients with late-onset (> 6 months after transplantation) community-acquired bacterial pneumonia presented with fever, cough, and a new lobar consolidation on the chest radiograph, and responded promptly to empiric antibiotics without undergoing an invasive diagnostic procedure. In contrast, early-onset nosocomial bacterial pneumonias carried a 33.3% mortality rate. A positive tuberculin skin test result was associated with a significantly higher rate of pulmonary complications (62.5% vs 26.8%, p = 0.007). Lung cancer and posttransplant lymphoproliferative disorder (PTLD) developed exclusively in 6 of the 61 patients (8.1%) who received induction immunosuppression with murine monoclonal antibody (OKT3).

Conclusion: Pulmonary complications are common following heart transplantation, occurring in 29.9% of recipients, and are attributed to pneumonia of primarily bacterial origin in one half of cases. Late-onset community-acquired pneumonia carried an excellent prognosis following empiric antibiotic therapy, suggesting that in the appropriate clinical setting invasive diagnostic procedures are unnecessary. Analogous to reports in other solid-organ transplant recipients, induction therapy with OKT3 was associated with an increased incidence of lung cancer and PTLD. Overall, the development of pulmonary complications after OHT has prognostic significance given the higher mortality in this subset of patients.

Key Words: cardiac • complications • pulmonary • transplantation


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Orthotopic heart transplantation (OHT) is an accepted treatment modality for end-stage heart disease.1 The pulmonary status of patients awaiting heart transplantation may be compromised by congestive heart failure, pulmonary emboli and infarction, pneumonia, sleep-disordered breathing, or obstructive sleep apnea syndrome (OSAS), restrictive pulmonary dysfunction, and diffusion abnormalities.2 3 4 5 While some of these conditions resolve following successful OHT, heart transplantation and the associated long-term immunosuppressive therapy may also result in various pulmonary complications. Of these, infectious pulmonary complications,1 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 OSAS,21 thromboembolic disease,22 exercise-induced hypoxemia,23 pulmonary malignancies,10 12 24 25 pneumothorax,16 pulmonary interstitial fibrosis,26 and diffusion abnormalities2 3 27 28 following OHT have been described. Despite these reports, limited information is available regarding the overall frequency of pulmonary complications specifically associated with OHT. The purpose of this study is to describe the pulmonary complications in 159 consecutive adult OHT recipients.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Study Population
Two hundred OHTs were performed in 196 patients between August 8, 1986, and September 6, 1998, at The Mount Sinai Medical Center, in New York City. The medical records of 157 adult (> 18 years old) patients undergoing 159 heart transplantation during this time interval were retrospectively reviewed. Pretransplant conditions (underlying heart disease, smoking history, positive tuberculin skin test result, and positive cytomegalovirus [CMV] serologic finding), the postoperative immunosuppressive regimen, as well as posttransplant pulmonary complications and cause of death were analyzed.

Pulmonary Complications
Pneumonia was defined as radiologic evidence of a new or increasing pulmonary infiltrate, accompanied by fever or hypothermia, productive cough, and confirmation of the pathogenic organism by stain or culture finding. In addition, the diagnosis of bacterial pneumonia was accepted in the presence of a new lobar infiltrate on the chest radiograph, associated with prompt symptomatic as well as radiographic resolution in response to antibiotic therapy. CMV pneumonia was diagnosed when the organism was cultured from BAL fluid or by lung biopsy in the appropriate clinical setting. Pneumonia was considered nosocomial if it developed during the initial hospitalization for transplantation. Acute bronchitis was defined by the presence of fever and cough with an unremarkable chest radiographic finding. A pleural effusion was considered a pulmonary complication if visible on a plain chest radiograph, warranting a diagnostic thoracentesis and/or specific therapeutic intervention with diuretics, antibiotics, or chest-tube insertion. The diagnosis of OSAS was confirmed by overnight polysomnography. With the exception of OSAS, only pulmonary complications that required hospitalization were reported.

Immunosuppression
The induction and maintenance immunosuppressive regimen consisted of cyclosporine, azathioprine, and prednisone in the majority of the patients (86.4%), while tacrolimus (FK-506) and prednisone were administered to the remainder. The induction regimen also included murine monoclonal antibody (OKT3) in 61 recipients.

Prophylactic Antimicrobial Chemotherapy
Prophylactic antimicrobial chemotherapy included ceftriaxone perioperatively, IV ganciclovir for 3 months postoperatively, oral acyclovir, and trimethoprim/sulfamethoxazole for the first year following transplantation. In addition, patients received influenza and pneumococcal vaccination prior to transplantation.

Statistical Methods
Categorical variables were compared using the {chi}2 test or Fisher’s Exact Test as appropriate. Continuous variables were compared by use of a Student’s t test. Statistical significance was accepted for p < 0.05.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Among the 157 adult patients (113 men and 46 women) who underwent 159 consecutive transplants, the most common indications were coronary artery disease (44%), idiopathic cardiomyopathy (38.4%), and viral cardiomyopathy (10.1%), as summarized in Table 1 . Other indications included amyloidosis, familial cardiomyopathy, myocarditis, sarcoidosis, intracardiac tumors, and rejection requiring retransplantation. The recipients’ age, smoking history, purified protein derivative status, and survival outcome are summarized in Table 1 . The mean ± SD follow-up period was 3.4 ± 2.4 years after transplantation (range, 0 to 12 years). The CMV serologic findings of both the recipient and the donor were available in 150 cases. Forty-six recipients were CMV negative, 23 of whom had a CMV-positive donor (CMV mismatch).


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  		Table 1.. General Data on 157 Consecutive Heart Transplant Recipients *

 
Pulmonary Complications
General: Of the 157 study patients, 47 patients (29.9%) had 81 pulmonary complications following OHT (Table 2 ). The most common pulmonary complication was pneumonia (17.2%), followed by bronchitis (9.5%), pleural effusion (6.7%), pneumothorax (4.4%), prolonged respiratory failure requiring tracheotomy (4.4%), and OSAS (3.8%). Of the 27 posttransplant pneumonias, the causative pathogen was bacterial in 18 cases, fungal (Aspergillus) in 4 cases, viral (CMV) in 4 cases, and Nocardia in 1 case. Bacterial pneumonias occurred with similar frequency in the first 6 months and after 6 months following transplantation. Late-onset pneumonias were contracted in the community and were characterized by fever, productive cough, and a new lobar consolidation on the chest radiograph. None of these nine patients with community-acquired pneumonia underwent bronchoscopy, and blood culture findings were negative in all cases. Empiric antibiotic treatment resulted in rapid symptomatic relief as well as resolution of pulmonary infiltrates in all patients, including two patients with neutropenia secondary to chemotherapy and one patient who was an active IV drug abuser. All patients were discharged home without any subsequent complications. While a causative pathogen was not identified in any of these cases, the clinical presentation, radiographic appearance of lobar consolidation, and rapid (48 h) response to antibacterial medications suggests a bacterial etiology. In contrast, bacterial pneumonias contracted during the first 6 months following transplantation were nosocomial in origin, and three of the nine infections were associated with a fatal outcome. A causative organism was identified in four of these cases: two cases of Klebsiella pneumoniae and two instances of Escherichia coli. Most fungal pneumonias developed in the first 6 months, while viral pneumonias, bronchitis, OSAS, posttransplant lymphoproliferative disorder (PTLD), and solid pulmonary malignancies were diagnosed more frequently in the late posttransplant period.


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  		Table 2.. Pulmonary Complications After OHT

 
The etiology of the pleural effusion was found to be parapneumonic in four cases: one empyema and three uncomplicated exudates in association with early nosocomial pneumonia. The pleural effusion was thought to be a transudate in three heart transplant recipients: two of these effusions resolved following diuretic therapy, while the third patient died from cardiogenic shock in the setting of severe rejection. One patient with PTLD developed pleural effusion coincident with E coli sepsis and died shortly thereafter. Thoracentesis revealed hemothorax in one patient with Aspergillus pneumonia, and chylothorax was found in another patient at the time PTLD was diagnosed.

Prognostic Factors: There was no association between the presence or absence of pulmonary complications and recipient age, gender, underlying cardiac disease, and smoking history. Infectious pulmonary complications were not associated with CMV serologic findings, including among CMV-mismatched donor-recipient pairs. Of the 83 patients who were tested before transplantation, those with a positive tuberculin skin test result (16 patients) were more likely to develop pulmonary complications (62.5% vs 26.8%, p = 0.007). In subgroup analysis, posttransplant malignancy was the only statistically significant pulmonary complication associated with pretransplant tuberculin skin test reactivity (p = 0.047). Patients whose immunosuppression regimen included FK-506 rather than cyclosporine tended to have fewer pulmonary infections (5.6% vs 29.6%, p = 0.072) and posttransplant malignancies (0% vs 4.3%, p = not significant), but given the small number of recipients who received FK-506 (18 subjects), these differences did not reach statistical significance. Overall, with the exception of one case of bacterial pneumonia, all cases of pneumonia, bronchitis, bronchogenic carcinoma, and PTLD occurred in the cyclosporine group. However, a higher incidence of posttransplant malignancy (8.1% vs 0%, p = 0.043) occurred in the 61 patients whose induction immunosuppression included OKT3.

Outcome: Pulmonary complications directly contributed to mortality in 11 of the 37 patients who died after OHT during the follow-up period. The cause of death in these 11 patients is summarized in Table 3 . All cases of Aspergillus pneumonia, nosocomial bacterial pneumonia, and pneumothorax occurred in the first 6 months, while lung cancer, PTLD, and OSAS developed > 6 months following transplantation. Patients who developed pulmonary complications following OHT were more likely to have a fatal outcome (56.7% vs 23.7%, p = 0.001). Specifically, the mortality rate was significantly higher in patients who suffered pulmonary infections (45.9% vs 17.2%, p = 0.001), and in patients who developed posttransplant pulmonary malignancies (8.1% vs 1.6%, p = 0.0048). The presence of Aspergillus pneumonia, posttransplant malignancy, and nosocomial bacterial pneumonia carried the highest mortality risks (75%, 50%, and 33%, respectively).


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  		Table 3.. Pulmonary Complications Contributing to Mortality in 11 of 37 Deaths Among 159 OHT Recipients

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Heart transplantation is a widely accepted treatment for end-stage heart failure. Pulmonary complications following OHT may develop in association with the surgical procedure and the initial hospitalization, or from long-term immunosuppression. In this study, pulmonary complications developed in nearly one third of cardiac transplant recipients during an average follow-up period of 3.4 years; the most common pulmonary complications were pneumonia and bronchitis.

The diagnostic criteria of pneumonia in the solid-organ transplant recipient vary widely in the literature. Many studies6 7 8 11 16 required positive respiratory culture findings obtained by an invasive diagnostic procedure. In one early study of pulmonary infections in cardiac transplant recipients, Mammana et al16 reported a 60% incidence of pneumonia in 16 patients. Most of these were bacterial in origin and occurred in the first 6 months following transplantation. Transtracheal aspiration was performed in all patients, and percutaneous lung aspiration was performed in 72% of the patients. This latter diagnostic procedure was associated with a 46% complication rate. To establish the diagnosis of bacterial pneumonia, Hofflin and colleagues11 also required the demonstration of positive respiratory culture findings obtained by either transtracheal aspiration, bronchoscopic lavage, or transthoracic needle aspiration. Dummer et al8 studied the incidence of early infections following kidney, heart, and liver transplantation. The diagnosis of pneumonia was made by the presence of fever, radiographic abnormalities, and the demonstration of a respiratory pathogen on culture. In two additional reports,6 7 cultures obtained from fiberoptic bronchoscopy were the primary means of diagnosing pneumonia. An unanticipated finding in one of these studies6 was the occurrence of several late-onset pneumonias (mean, 19.7 months after OHT) diagnosed on clinical grounds alone with nondiagnostic respiratory culture findings.

In the current study, a diagnosis of pneumonia was accepted if the following criteria were fulfilled: radiologic evidence of a new or increasing pulmonary infiltrate accompanied by a compatible clinical course that included fever or hypothermia, productive cough, with or without confirmation of the pathogenic organism by cytologic staining techniques or culture. With these broader criteria, we had nine patients with late-onset community-acquired pneumonia. None of these patients underwent an invasive diagnostic procedure, and all had an excellent prognosis following empiric antibiotic therapy. These findings suggest that late-onset bacterial pneumonia in the cardiac transplant recipient may be treated safely without an invasive diagnostic procedure. Other pulmonary infections requiring hospitalization in the late posttransplant period included 12 cases of bronchitis, 4 cases of CMV pneumonitis, and 1 case of Nocardia pneumonia. None of the late-onset infections contributed to mortality. Since the majority of patients who survive the first 6 months after transplantation can be maintained on lower doses of immunosuppressive medication with preservation of allograft function, the spectrum of infectious disease encountered in this population more closely mirrors that seen in the general community.9 Our finding that most (21 of 26 complications) of the late-onset infectious pulmonary complications consisted of bronchitis and community-acquired pneumonia is in accordance with this observation. In contrast, most of the early-onset pulmonary complications consisted of nosocomial bacterial and fungal pneumonias, and these carried a high mortality risk. This finding was in accordance with other published data.6 7 8 11 In keeping with the observation of Fishman and Rubin,9 the routine use of trimethoprim/sulfamethoxazole prophylaxis in our population effectively eliminated Pneumocystis carinii pneumonia as a potential complication. Pleural effusion (9 of 10 cases) and pneumothorax (7 of 7 cases) occurred almost exclusively in the early posttransplant period, reflecting the prevalence of these complications shortly following transplant surgery.

The incidence of sleep-disordered breathing may be as high as 45% among patients with end-stage heart failure.5 Central sleep apnea associated with a Cheyne-Stokes respiratory pattern has been found to be the primary sleep disorder in this population. Cardiac failure, prolonged circulatory time, as well as the resultant central sleep apnea are expected to resolve following successful cardiac transplantation. Following OHT, however, sleep-disordered breathing is not limited to central sleep apnea. Klink et al21 reported five heart transplant recipients who developed clinically significant OSAS. Similarly, we found six patients with OSAS in the late posttransplant period. One of the patients had a cardiopulmonary arrest 2 days after the diagnosis of severe OSAS was established. His death may have been precipitated by hypoxemia and cardiac ectopy associated with apneic episodes previously documented by polysomnography. Obesity is a known risk factor for the development of OSAS. It may be that the use of cyclosporine and prednisone, both of which may result in substantial weight gain in transplant recipients, predisposes to the development of OSAS in this population. Heart transplant recipients may be at special risk for complications associated with OSAS, especially increased arrhythmogenicity associated with obstructive events. Our findings together with those of others21 suggest that OSAS may be a significant and relatively unrecognized pulmonary complication following OHT.

The incidence of solid tumors specifically following OHT has only been recently reported. Goldstein et al24 found a 3.4% incidence of de novo malignancies after cardiac transplantation; of these, lung cancer was the most common. All three patients in whom lung cancer developed in our study had significant smoking histories. This finding is similar to that reported by others.24 29 In the study by Goldstein et al,24 lung cancer was diagnosed in 7 of 712 heart transplant recipients; 6 of the 7 patients had significant smoking histories, and the 1 nonsmoking patient was found to have a carcinoid tumor. The fact that cigarette smoking is a major risk factor for the development of bronchogenic carcinoma and ischemic heart disease, the latter being the most frequent indication for heart transplantation, suggests strongly that a prior smoking history coupled with an immunosuppressive environment following OHT predisposes to the development of lung cancer in this population.

The incidence of PTLD reported by Chen and colleagues30 was 6.2%. When restricted to pulmonary involvement, we found an incidence of 1.8% of both PTLD and lung cancer in our study population. All cases occurred in the late posttransplant period. PTLD developed a mean of 29.3 months (range, 7 to 44 months) after transplantation, and lung cancer developed a mean of 43.3 months (range, 26 to 55 months) after transplantation.

The association of PTLD and other transplant malignancies with the use of immunosuppressive medication including OKT3 has long been established. Our finding of a significant association between the administration of OKT3 and the development of posttransplant malignancies is in accordance with other studies.25

We found no association between the presence or absence of pulmonary complications and recipient age, gender, underlying cardiac disease, smoking history, and CMV serologic findings. The lack of an association between posttransplant pneumonia and CMV serologic findings, including among CMV-mismatched donor-recipient pairs, is similar to that reported by Corensek et al.31

Regarding smoking history, significant smoking-related obstructive pulmonary disease precludes consideration for heart transplantation at our institution. With the exception of posttransplant pulmonary malignancies, the absence of association between smoking and pulmonary complications is therefore not surprising.

However, patients with a positive pretransplant tuberculin skin test result were more likely to develop pulmonary complications, in particular pulmonary malignancies. We can offer no definitive explanation for this association. The average age of patients with a positive tuberculin skin test result was not significantly different from those of the study population (52.5 ± 6.3 years vs 50.12 ± 12.3 years). Complications of surgery, such as abscess formation and pneumonia, have been associated with an anergic response to the tuberculin antigen. In cardiac transplant recipients, the incidence of pulmonary infections as well as mortality were found to be higher in anergic patients. In contrast, those with skin test reactivity had significantly more episodes of moderate-to-severe graft rejection.32 The treatment of rejection requires intensification of the immunosuppressive regimen, which in turn may predispose to the development of PTLD and other malignancies. Although we did not examine associations between positive tuberculin skin test results, the intensity of immunosuppressive therapy, and frequency of rejection, a plausible explanation for our findings might be that positive tuberculin skin test results were also associated with more severe rejection episodes. In this instance, the increased intensity of immunosuppression to combat rejection might predispose to an increased incidence of posttransplant malignancies.

Aspergillus pneumonia was found to be the pulmonary complication with the highest mortality in our study. Pneumonia caused by various Aspergillus species has uniformly been cited as an infectious complication carrying a grave prognosis in cardiac transplant recipients, as well as in recipients of other solid-organ transplants. In the study of Cisnernos et al,7 the overall mortality rate associated with pneumonia was 30.8% in 307 OHT recipients. Thirteen of the 307 patients developed Aspergillus pneumonia (incidence of 4.3%); 8 of these patients died (mortality rate of 62%). The factors associated with the worst prognosis in patients with pneumonia were infection by Aspergillus and bilateral infiltrates in the multivariate analysis. Aspergillus pneumonia carried a similarly high mortality rate in another study33 of 64 heart transplant recipients.

To our knowledge, this is the first study specifically addressing pulmonary complications in a large number of heart transplant recipients from a single center. The retrospective design of the study, however, may limit firm conclusions, and warrants the need for prospective, long-term studies.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Nearly one third of patients undergoing OHT had pulmonary complications, including pneumonia of bacterial origin in one half of the patients. Late-onset community-acquired pneumonia carried an excellent prognosis following empiric antibiotic therapy, suggesting that in the appropriate clinical setting invasive diagnostic procedures are unnecessary. Positive pretransplant tuberculin skin test results were associated with a higher incidence of pulmonary complications after transplantation. Analogous to reports in other solid-organ recipients, induction therapy with OKT3 was associated with an increased incidence of lung cancer and PTLD. Patients who developed post-OHT pulmonary disease have a higher mortality than patients without pulmonary complications.


   Footnotes
 
Abbreviations: CMV = cytomegalovirus; FK-506 = tacrolimus; OHT = orthotopic heart transplantation; OKT3 = murine monoclonal antibody; OSAS = obstructive sleep apnea syndrome; PTLD = posttransplant lymphoproliferative disorder

Received for publication October 11, 2000. Accepted for publication March 1, 2001.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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