Concomitant Cardiac Surgery During Lung Transplantation: A National Analysis

J. Hadaya¹, S. Kim², Y. Sanaiha³, S. Mallick², R. J. Shemin², P. Benharash^4
1David Geffen School of Medicine at UCLA, Los Angeles, California ²UCLA, Los Angeles, California ³University of California, Los Angeles, Los Angeles, California ⁴UCLA Division of Cardiac Surgery, Los Angeles, California

Purpose: Lung transplantation (LT) is the gold standard treatment for end-stage lung disorders in appropriate surgical candidates. Concomitant surgery (CCS) to address cardiac lesions at the time of LT remains controversial and large-scale data lacking. The present study utilized a national cohort to evaluate trends and outcomes of CCS during LT.

Methods: All adult LT recipients were abstracted in the 2012-2020 National Inpatient Sample (NIS). The NIS approximates 97% of hospitalizations in the United States across all hospital and payer types, and captures data on operations performed at the time of LT. CCS included repair of atrial septal defect (ASD) or patent foramen ovale (PFO), coronary artery bypass grafting (CABG), aortic, mitral, tricuspid or pulmonic valve repair or replacement, left atrial appendage occlusion (LAAO), and surgical ablation for atrial fibrillation. Generalized linear models were used to study the association between CCS and outcomes of interest. The primary outcome of the study was in-hospital mortality, while secondary outcomes included complications, length of stay, and hospitalization costs. Complications included neurologic (stroke or transient ischemic attack), tracheostomy, acute kidney injury (AKI), need for renal replacement therapy, blood transfusion, and re-exploration. We secondarily examined mortality rates by specific CCS performed.

Results: Of 19,690 patients undergoing LT, 995 (5.0%) underwent concomitant cardiac surgery. The rate of CCS remained stable from 4.4% in 2012 to 5.9% in 2020 (p=0.18). Patients undergoing CCS were of comparable age (62 vs 61 years, p=0.15) and sex distribution (35.2% vs 39.8% female, p=0.20). Patients undergoing CCS had a greater burden of cardiovascular comorbidities including congestive heart failure (23.6% vs 12.3%, p< 0.001), coronary artery disease (41.7% vs 24.5%, p< 0.001), and pulmonary hypertension (58.3% vs 38.2%, p< 0.001) relative to others. Patients who underwent CCS received rates of bilateral lung transplant (76.4% vs 72.6%, p=0.25) compared to others. Unadjusted rates of mortality and most complications were similar between the two groups (Table), while AKI was more prevalent in CCS (52.3% vs 39.7%, p< 0.001). After risk adjustment, there was no significant difference in mortality, complications, costs, or length of stay between the two groups (Table). The most commonly performed concomitant operation was ASD/PFO closure (41.7%) followed by CABG (28.6%) and left atrial appendage closure (14.6%). When examined independently, there was no association between each specific concomitant operation and in-hospital mortality (Figure). CCS during LT was performed at 17% of centers in 2012 and 30% of centers in 2020.

Conclusion: This study represents the first national analysis reporting the incidence and outcomes of CCS during LT. CCS during LT does not confer excess short-term morbidity or mortality. CCS should continue to be considered on an individualized basis dependent on the risk factors, underlying cardiac pathology, and institutional experience.

Identify the source of the funding for this research project: None.