Table 1:
Overview of the studies
| Authors, date, journal and country Study type (level of evidence) |
Patient group | Outcomes | Key results | Comments/weaknesses |
|---|---|---|---|---|
| Bando et al. (1994), J Thorac Cardiovasc Surg, USA [3] Prospective study (5-year period, January 1989–January 1994) (level 1b) |
Study group: all PH patients (n = 57) caused by PPH (n = 27) or ES (n = 30) SLTx (n = 11) BLTx (n = 22) HLTx (n = 24) |
Survival Haemodynamic and functional recovery Infection and rejection episodes |
Significantly lower overall survival and actuarial allograft survival in SLTx patients compared with BLTx and HLTx Significant post-transplant improvement in confidence interval, mean PAP and NYHA functional class for BLTx and HLTx in comparison with SLTx No difference SLTx vs BLTx vs HLTx |
Small sample Short follow-up of 3 months for the last included patients |
| Conte et al. (2001), Ann Thorac Surg, USA [4] Retrospective review (4- to 5-year period, July 1995–January 2000) (level 2a) |
Study group: BLTx patients Comparative group: SLTx patients PPH (n = 15) BLTx (n = 9) SLTx (n = 6) SPH (n = 40) BLTx: n = 21 of which n = 12 patients with mean PAP >40 mmHg SLTx: n = 19 of which n = 6 patients with mean PAP >40 mmHg |
Survival Infection Rejection Ventilation |
Better overall survival for BLTx in the indication of PPH No overall survival difference between SLTx and BLTx in SPH Patients with SPH and mean PAP >40 mmHg may benefit more from BLTx No difference SLTx vs BLTx No difference in BOS No difference |
The results can be considered relevant when addressing the difference between PPH and SPH. But in the subgroups of SPH, samples of patients become too small to actually lead to a definitive conclusion |
| Stoica et al. (2001), Ann Thorac Surg, UK [5] Retrospective review (15-year period, July 1984–August 1999) (level 2a) |
Study group: ES treated with HLTx (n = 51) Comparative group: Patients treated with HLTx for another indication than ES (n = 212) |
Survival | No survival difference between ES patients and other patients No survival difference between simple and complex ES patients |
No comparison made with ES patients undergoing BLTx |
| Pielsticker et al. (2001), J Heart Lung Transplant, USA [6] Prospective study (level 1b) |
Study group: 35 LTx centres worldwide (Europe, North America, Israel and Japan) | Tx practice patterns worldwide addressing PH |
Preferred procedure: USA/Ca: BLTx Europe/Israel: HLTx BLTx preferred by 83% of centres Criteria for HLTx: • In 45% of centres, RV function with RVEF measurement cut-off range 10–25% • In 76% of centres, LV function with LVEF measurement cut-off range 32–55% • Severity of tricupsid valve regurgitation in 24% of centres Longest waiting time for HLTx was in the USA, shortest was in Canada |
Heterogeneous practice pattern across the world. However, not exhaustive. Only 37 of the 46 surveyed centres answered the questionnaire |
| Waddell et al. (2002), J Heart Lung Transplant, Canada [7] and UNOS/ISHLT joint Transplant Registry Prospective registry (10-year period, 1988 and 1998) (level 1b) |
Patients: n = 605 end-stage ES ASD: (n = 171) VSD: (n = 164) MCA: (n = 68) PDA: (n = 32) Study group: HLTx n = 430 (71%) Comparative group: BLTx n = 106 (18%) SLTx n = 69 (11%) |
Survival | Overall, including any type of ES patients, significantly better survival for HLTx in comparison with LTx (P = 0.002) Highly significant benefit of HLTx for ES patients with VSD (p = 0.0001) VSD and MCA patients had the best prognosis and 96% of them were treated with HLTx Increased mortality risk for patients with VSD when treated with LTx (relative risk = 1.817, P = 0.035) All ES patients with more than ASD, PDA or perimembranous VSD are evaluated for HLTx |
Unequal sample size between patients who underwent HLTx or LTx. ES patients form a heterogeneous group according to the involved cardiac anomalies |
| Toyoda et al. (2008), Ann Thorac Surg, USA [8] Retrospective review (11-year period) (level 2a) |
Study group: all HLTx (n = 49) and LTx (BLTx = 11, SLTx = 7) performed for IPAH between 1982 and 1993 at the same institution Comparative group: all HLTx (n = 8) and LTx (BLTx = 20, SLTx = 2) performed for IPAH between 1994 and 2006 at the same institution |
Survival Incidence of BOS |
Survival improvement by era No overall difference in survival when comparing BLTx with HLTx Improved by era P < 0.01 No difference HLTx vs BLTx |
Vague criteria for choosing HLTx: chronically inotropic-dependent patients Small sample size and unequal repartition of the procedures from one era to the other |
| Fadel et al. (2010), Eur J Cardiothorac Surg, France [9] Retrospective review (10-year period, June 1998 and December 2008) (level 2a) |
Study group: HLTx (n = 152) performed for PH Decision for HLTx was made because of:
Comparative group BLTx (n = 67) performed for PH during the same period in all other patients |
Survival Waiting time Functional recovery Perioperative outcome |
No overall survival difference Freedom of BOS survival was significantly better in HLTx No significant difference in waiting duration for a suitable graft Significantly more PGD in BLTx patients (left heart failure on echocardiography with severe pulmonary oedema and recurrent PH during the first 24–36 h following Tx) Need for cardiopulmonary bypass (P = 0.55) Postoperative mortality (P = 0.24) Early surgical complication (P = 0.85) Mechanical ventilation: HLTx < BLTx (P = 0.02) Bronchial complications: HLTx < BLTx (P < 0.001) |
Unequal sample groups No cut-off definition for right heart failure such as RVEF measurement Different graft preservation methods over the study period No patient with left heart disease |
| Christie et al. (2011), J Heart Lung Transplant, ISHLT Registry [10] Prospective study (level 1b) |
Study groups: BLTx from 1994 to 2009 (n = 16 628) HLTx from 1982 to 2009 (n = 3303) IPAH patients from 1990 to 2009: LTx n = 1189 (67%) HLTx n = 578 (33%) |
Survival: half-life survival and conditional half-life survival (time to 50% survival for patients alive 1 year after Tx) |
BLTx: Half-life 6.8 years Conditional half-life 9.3 years HLTx:
|
No direct comparative test on survival data No information on criteria for the choice of the Tx procedure No information about waiting time on transplantation list for a suitable graft according to the procedure |
| De Perrot et al. (2012), J Thorac Cardiovasc Surg, Canada [11] Retrospective review (13-year period, January 1997—September 2010) (level 2b) |
All patients with PH Study group: Tx 1997–2004 Comparative group: Tx 2005–2010 BLTx patients n = 57 (72%) HLTx patients n = 22 (28%) |
Survival | No difference BLTx vs HLTx No difference regarding indication Majority of HLTx were performed for PH related to CHD |
Criteria for HLTx decision: LVEF<40% Previsible surgical obstacle to BLTx |
ASD: atrial septal defect; BLTx: bilateral lung transplantation; BOS: bronchiolitis obliterans syndrome; CHD: congenital heart disease; CSPS: congenital systemic-to-pulmonary shunt; ES: Eisenmenger's syndrome; HLTx: heart–lung transplantation; IPAH: idiopathic pulmonary artery hypertension; ISHLT: International Society for Heart–Lung Transplantation; LTx: lung transplantation; LV: left ventricle; LVEF: left ventricle ejection fraction; MCA: multiple congenital anomalies; NYHA: New York Heart Association; PAP: pulmonary artery pressure; PDA: patent ductus arteriosus; PGD: primary graft dysfunction; PH: pulmonary hypertension; PPH: primitive pulmonary hypertension; RV: right ventricle; RVEF: right ventricle ejection fraction; SLTx: single-lung transplantation; SPH: secondary pulmonary hypertension; Tx: transplantation; UNOS: United Network for Organ Sharing; VSD: ventricular septal defect.