Invited Commentary

Abstract

The current issue of The Annals features an insightful article from Kon and colleagues [1Kon Z.N. Bittle G.J. Pasrija C. Sanchez P.G. Griffith B.P. Pierson R.N. The optimal procedure for retransplantation after single lung transplantation.Ann Thorac Surg. 2017; 104: 170-175Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] from Maryland summarizing the strategies for lung retransplantation after a single lung transplant, their respective outcomes, and potential recommended approaches to early and late allograft failure. Of primary relevance, their data reinforce multiple database reviews that the incidence of lung retransplantation has increased over the past two decades, as late outcomes remain poor—emphasizing the need for an algorithm to manage patients towards successful retransplant. Kon and associates reviewed all single lung transplants (SLTs) from the Organ Procurement Transplant Network between 1994 and 2012. Three hundred twenty-five of these went on to require retransplantation. Redo lung transplant strategies were ipsilateral transplant (ILT, n = 50, 15%), contralateral (CLT, n = 175, 54%), and bilateral (BLT, n = 100, 31%). The indications and demographics were similar across cohorts. Timing of retransplant is essential to appreciate. Re-transplant was early (<30 days from primary SLT) in 26% of the ILTs, 2% of the CLTs, and 20% of the BLTs. Thirty-day, 1-year, and 5-year survivals were equivalent in the BLT (89%, 67%, 42%) and CLT groups (94%, 72%, 41%); both of these were superior to the rates from the ILT cohort (80%, 50%, 20%). These results highlight the known principle that early (<30 day) graft failure portends poor overall survival. Early graft failure implies both the transplanted lung and the native lung are both insufficiently functioning. This cohort often fails from the time of initial surgery and requires ventilator support. Both ILT and ventilator support were markers of poor outcomes in the study by Kon and colleagues. That being said, early failure is often less of a technical burden, with shorter immune-suppression burden, for retransplantation. In these cases, ILT and BLT were the strategies of choice. Both provide the maximum physiological support with less technical tour de force required. Late failure more commonly involves the challenge of scarring of the initial transplanted lung and hilum, and a cumulative impact of immunosuppression. Hence, 98% of CLT transplants were in this setting, avoiding the initially entered hemithorax. The outcomes from the Organ Procurement Transplant Network database that were reviewed were equivalent early and mid-term (5-year) with CLT to BLT. This is less intuitive in the contemporary era where bilateral transplantation is preferred for most all pathology. In the setting of retransplantation, however, limited donor organ resources, and the less-technical challenge of CLT (with similar mid-term outcomes), provide practical strength in this strategy for retransplantation of late graft failure. The Optimal Procedure for Retransplantation After Single Lung TransplantationThe Annals of Thoracic SurgeryVol. 104Issue 1PreviewRetransplantation has emerged as a therapeutic option for patients experiencing respiratory failure after single lung transplantation. However, outcomes associated with the surgical option (ipsilateral, contralateral, or bilateral lung retransplantation) has not been well evaluated. Full-Text PDF