**2. A management algorithm for concomitant severe CAD in end-stage lung disease**

As mentioned above, the optimal treatment strategy for high-risk patients with advanced CAD and end-stage lung disease remains controversial, requires complex decision-making, and is evolving. The author [SHB] presents an algorithm for management of these high-risk patients (**Figure 1**). Severe CAD is defined as an angiographically significant lesion (>70% stenosis) in at least one of the main coronary artery branches and/or when clinical or physiologic criteria demonstrate significant coronary flow limitation. An experienced interventional cardiologist and two cardiac surgeons jointly review the CAD severity of these patients upon referral for lung transplantation evaluation. Individualized treatment options are then formulated using the presented algorithm. For example, patients who become clinically unstable are hospitalized and urgently evaluated and are either listed for concomitant lung transplantation and CABG or CABG versus PCI, if deemed feasible, followed by lung transplantation depending on relative disease severity. If PCI prior to lung transplantation is deemed necessary, coronary lesion complexity and coronary stent characteristics determine the duration of dual antiplatelet therapy (DAPT) required to prevent in-stent restenosis. In general, more complex lesions require a longer duration of DAPT. Recommended DAPT duration by stent type is as follows: (i) Bare metal stent (ideal for patients anticipated to have a short wait list time)- one (1) month; (ii) Synergy stent- three (3) months; and (iii) typical second generation

**97**

*Perioperative Care for Lung Transplant Recipients: A Multidisciplinary Approach*

drug eluting stent- six (6) months. However, should lung transplantation become necessary before completion of DAPT, we proceed to lung transplantation albeit at a higher risk of perioperative bleeding. Close follow-up by the cardiologist and

*Algorithm for management of patients with concomitant severe CAD and end-stage lung disease. LTX, lung* 

Preemptive management strategies that include meticulous and continuous cardiorespiratory monitoring, prompt initiation of vasoactive pharmacotherapy, volume administration, and institution of extracorporeal support are of critical importance during specific phases of intraoperative care. During these intraoperative phases of care (described below), there is a high risk of hemodynamic instability, lung derecruitment, worsening ventilation/perfusion mismatch, and alveolar hypoventilation leading to hypoxemia and hypercarbia in varying degrees of severity. The goals of perioperative ventilator support in lung transplantation rely on providing adequate minute ventilation while preventing oxygen toxicity, barotrauma, and volutrauma. Specific problems that may occur during various intraoperative phases, and the

Specific problems: acute RV decompensation due to (i) volume overload, (ii) decreased right ventricular (RV) preload and low cardiac output especially in the hypovolemic patient caused by increased intrathoracic pressure on

pulmonologist is maintained regardless of the treatment option.

**3. Perioperative care of the lung transplant recipient**

recommended management strategies, are highlighted below:

**3.1 Intraoperative management**

*transplant; PCI, percutaneous coronary intervention.*

**Figure 1.**

*3.1.1 Induction of anesthesia*

*DOI: http://dx.doi.org/10.5772/intechopen.85277*

*Perioperative Care for Lung Transplant Recipients: A Multidisciplinary Approach DOI: http://dx.doi.org/10.5772/intechopen.85277*

#### **Figure 1.**

*Perioperative Care for Organ Transplant Recipient*

ment of the highly sensitized patient are presented.

**lung disease**

**2. A management algorithm for concomitant severe CAD in end-stage** 

As mentioned above, the optimal treatment strategy for high-risk patients with advanced CAD and end-stage lung disease remains controversial, requires complex decision-making, and is evolving. The author [SHB] presents an algorithm for management of these high-risk patients (**Figure 1**). Severe CAD is defined as an angiographically significant lesion (>70% stenosis) in at least one of the main coronary artery branches and/or when clinical or physiologic criteria demonstrate significant coronary flow limitation. An experienced interventional cardiologist and two cardiac surgeons jointly review the CAD severity of these patients upon referral for lung transplantation evaluation. Individualized treatment options are then formulated using the presented algorithm. For example, patients who become clinically unstable are hospitalized and urgently evaluated and are either listed for concomitant lung transplantation and CABG or CABG versus PCI, if deemed feasible, followed by lung transplantation depending on relative disease severity. If PCI prior to lung transplantation is deemed necessary, coronary lesion complexity and coronary stent characteristics determine the duration of dual antiplatelet therapy (DAPT) required to prevent in-stent restenosis. In general, more complex lesions require a longer duration of DAPT. Recommended DAPT duration by stent type is as follows: (i) Bare metal stent (ideal for patients anticipated to have a short wait list time)- one (1) month; (ii) Synergy stent- three (3) months; and (iii) typical second generation

immunosuppression and understanding of transplant immunobiology, stringent posttransplant surveillance for infection, rejection, and the perioperative use of extracorporeal membrane oxygenation (ECMO) [1] used to bridge decompensating patients to lung transplantation and ex vivo lung perfusion (EVLP) to facilitate optimization and transplantation of marginal donor lungs with outcomes considered equivalent to those from lungs transplanted using standard criteria [2, 3]. Given the aging population, older patients with a higher comorbid burden are being referred for lung transplant evaluation. In the United States, national registry data reveal a progressively increasing number of lung transplant recipients over age 70 years [4]. Advanced CAD is one such comorbidity that is no longer considered an absolute contraindication to lung transplantation. Excellent early outcomes have been reported with concomitant coronary artery bypass grafting (CABG) and lung transplantation [5]. However, the optimal treatment strategy for patients with concomitant advanced CAD and end-stage lung disease remains controversial, requires complex decision-making, and is evolving [6]. Highly sensitized transplant candidates, i.e., those with a high titer of preexisting HLA donor-specific antibodies (DSA), present unique challenges requiring specialized perioperative management. Antibody-mediated rejection (AMR) remains a problem without a reliable treatment in the care of lung transplant patients. AMR is usually mediated by anti-HLA DSA, and both pretransplant and posttransplant DSAs in lung transplant recipients are associated with acute rejection, chronic allograft dysfunction, and decreased survival [7, 8]. Patients transplanted with pretransplant DSAs are at a higher risk of hyperacute/accelerated acute ABMR, chronic rejection, and allograft loss across all solid organs [9]. Although several desensitization protocols have been reported for lung transplant candidates, the guidelines for protocol selection as well as criteria for successful response to treatment remain unclear [10–12]. In this chapter, an overview of general perioperative management of the lung transplant recipient is presented, including specific management strategies for concomitant advanced CAD and end-stage lung disease and perioperative manage-

**96**

*Algorithm for management of patients with concomitant severe CAD and end-stage lung disease. LTX, lung transplant; PCI, percutaneous coronary intervention.*

drug eluting stent- six (6) months. However, should lung transplantation become necessary before completion of DAPT, we proceed to lung transplantation albeit at a higher risk of perioperative bleeding. Close follow-up by the cardiologist and pulmonologist is maintained regardless of the treatment option.
