Cardiac interventions in lung transplant patients: a narrative review with a focus on transcatheter valvular interventions

Introduction

Background

In patients with end-stage lung disease, lung transplant (LT) remains the gold standard treatment for appropriately selected candidates. The prevalence of LT continues to grow in the United States (US) and worldwide, with almost 3,000 US transplants recorded in 2022 and more than 4,600 performed worldwide now per year (1,2). Candidate selection for LT continues to evolve, with indications and contraindications that vary by institution. Relative contraindications include prior chest surgery such as coronary artery bypass grafting (CABG) and untreated cardiac disease such as coronary artery disease (CAD) and valvular disease; however, for years it has been noted that these may not contraindicate LT at highly experienced centers (3,4).

The presence of concomitant cardiac disease in LT candidates is not new. However, its prevalence will continue to rise as older patients are increasingly considered for transplantation. In 2020, 33.0% of patients awaiting transplant were older than 65 years of age, a significant increase from a decade earlier when only 19% of waitlisted patients were older than 65 years (5). Consequently, numerous centers have developed experience in management of coexisting cardiac disease, though these reports focus mainly on CAD management with CABG at the time of LT or percutaneous coronary intervention (PCI) (6).

There is less experience with the management of aortic and mitral valvular disease requiring intervention prior to or during LT (7). Previous authors have cited severe aortic stenosis (AS) as a contraindication to LT (8,9). Similarly, one survey reports that 19.4% of cardiothoracic surgeons and 34.2% of pulmonary physicians view the presence of significant mitral regurgitation (MR) as an absolute contraindication to LT (10). The evolution of transcatheter aortic valve replacement (TAVR) and transcatheter edge-to-edge repair (TEER) with MitraClip provides new treatment options for severe AS and MR in this patient population.

Rational and knowledge gap

Due to the growing population, there have been numerous reports over the past two decades of cardiac surgery in LT patients during their transplantation, preoperative cardiac optimization by percutaneous or surgical approaches, and postoperative surgical/percutaneous management of cardiac disease in LT survivors. The majority of these focus on CAD, with some data on concomitant repair of patent foramen ovale (PFO), atrial septal defect (ASD), and ventricular septal defect (VSD) (11,12). Additionally, a previous review by Fialka et al. pooled 12 manuscripts to further understand coronary disease among LT recipients (13). In their pooled analysis, they demonstrated increased mortality in LT patients who underwent CABG, but attributed this finding to advanced CAD. Moreover, they note that the most contemporary studies find no difference in outcomes among patients who undergo revascularization and those who do not. Lastly, the authors note there is no clear benefit between PCI and CABG in this patient population. However, this review does not mention valvular pathology. There remains a paucity of evidence on LT patients who require peri-transplant management of mitral or aortic valve disease.

Objective

The aim of this review is to discuss the available literature on cardiac intervention in LT patients, with a brief overview on CAD and then a focus on aortic and mitral disease. Although there are additional cardiac pathologies that arise in the LT patient, such as cardiac arrhythmias, the following review focuses on structural disease and interventions. We present this article in accordance with the Narrative Review reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-17/rc).

Methods

Published studies in English from January 1998 to April 2025 were reviewed. PubMed, JSTOR, ScienceDirect, and Web of Science search terms included: “cardiac surgery and lung transplant”, “aortic stenosis, aortic regurgitation, mitral regurgitation, tricuspid regurgitation and lung transplant”, “coronary artery disease, PCI, coronary artery bypass grafting and lung transplant”, “lung transplant and cardiac valve disease”, “TAVR and lung transplant”, and “TEER and lung transplant”. Forty-two publications were appropriate for inclusion and analyzed, including both original clinical reports and review articles. This is summarized in Table 1.

Discussion

Management of non-valvular cardiac disease

As previously described, the aging LT population has resulted in a growing prevalence of coexisting CAD in patients. Although this was once considered a contraindication to transplant candidacy, it is now considered a “risk factor with high or substantially increased risk” by the International Society for Heart and Lung Transplantation. There are three major questions at hand in this patient population: (I) is peri-transplant management of the coronary disease safe? (II) If so, does percutaneous or surgical management offer an advantage? (III) Does the timing of coronary intervention (pre-transplant vs. concomitant treatment) impact outcomes?

Previous studies have evaluated the safety of both pre-LT revascularization and concomitant CABG during LT (14,15). This was initially described in 1999 in five patients, of which three underwent concomitant CABG and two underwent preoperative PCI, with 1 death within 90 days of LT (13). Patel et al. evaluated 354 patients from 1992 to 2001 from a single center for the existence of CAD and related interventions (15). Six patients had undergone preoperative angioplasty or stenting, and 12 patients had combined CABG-LT. All patients in the first group remained alive at the time of publication, and nine out of 12 patients remained alive in the CABG group, with all three deaths related to lung complications. The concomitant CABG group had a greater length of stay (LOS). Overall, the revascularized group and non-revascularized group had equal survivability. The authors subsequently deemed that CAD should not be prohibitive of LT candidacy and can be addressed either preoperatively with PCI or concomitantly with CABG during LT. However, study limitations include a small sample size and a lack of evaluation of long-term outcomes, including graft patency. Seoane et al. similarly reported success with pre-LT revascularization in six patients with PCI, showing that patients with CAD who were revascularized with PCI before LT had a survival advantage vs. those with moderate coronary disease who were not revascularized; after analysis of survival up to 5 years post-LT, revascularized CAD patients had comparable survivability to those without CAD (16). In this study, six patients underwent PCI, and one patient underwent concomitant CABG who died due to dysrhythmia 14 days postoperatively.

In a follow-up of the study by Patel et al., Castleberry and colleagues record an increased rate of preoperative PCI and concurrent CABG in LT patients, with a jump from 2.8% to 6.0% in the former and from 4.0% to 8.3% in the latter (11). In total, 49 patients underwent concurrent CABG and 38 underwent preoperative PCI during their study period. Critically, they found no difference in mortality between LT patients with no revascularization, those with preoperative PCI, and those with concurrent CABG. However, in this study, CABG patients required longer intensive care unit (ICU) stay, hospital stay, and ventilator support than those with preoperative PCI or no revascularization at all. The authors conclude that prior or concomitant revascularization of CAD are reasonable therapeutic options in select LT patients with CAD.

The success of concomitant cardiac surgery during LT has been well established beyond CABG. In 2005, Parekh et al. reported the results of 35 patients who underwent LT with concomitant cardiac surgery (17). Eighteen patients underwent repair of PFO, nine underwent ASD repair, two underwent VSD repair, four underwent CABG, one underwent pulmonary artery aneurysmectomy, and 1 underwent ascending aortic replacement. This cohort of LT patients undergoing concomitant cardiac surgery had longer ICU stay and ventilator support (as reported by Castleberry et al.). However, the authors noted no significant prolongation of hospital LOS. Moreover, there was no statistically significant difference in long-term survival between LT patients with and without concomitant cardiac surgery. Johnson et al. demonstrated similar results with 13 patients, but grouped preoperative intervention [three PCI, two CABG, one mitral valve replacement (MVR)] and concomitant surgery (five PFO closure, one CABG, one VSD closure) together (18). Median LOS was longer in the groups with preoperative or concurrent cardiac intervention vs. isolated LT, but both duration of ventilator support and mortality were not statistically different between the two groups.

These early studies demonstrated promising results, but had limited cohorts and limited follow-up, with few cases in which valvular disease was addressed. More recent studies address some of these limitations. Biniwale et al. in 2016 provide data on 120 LT patients undergoing concomitant cardiac surgery and demonstrate no difference in 5-year survival, ICU LOS, ventilation, or hospital LOS between this cohort and those undergoing isolated LT (19). Again, however, there was minimal cardiac intervention on mitral or aortic valvular disease, with 1.7% undergoing aortic valve repair and 1.7% undergoing mitral valve repair. Koprivanac et al. reported that 61 well-matched pairs of LT patients undergoing CAD intervention vs. no CAD intervention had similar ICU LOS, overall LOS, and mortality (20). This study also did not differentiate between timing or type of intervention.

More recent studies have begun to address the question of timing and subsequent outcomes. In 2020, Kanaparthi and colleagues analyzed four groups over the span of 6 years: those who underwent pre-LT PCI, those who underwent pre-LT CABG, those who underwent concomitant CABG, and those who underwent isolated LT (21). Their analysis found that there was no difference in LOS, survival, and postoperative adverse events, indicating that both types of CAD intervention and timing of intervention did not have a significant impact on outcomes.

Most recently, a systematic meta-analysis in 2022 confirmed that there was no difference in 1-, 3-, and 5-year mortality, nor in LOS, between isolated LT patients and those undergoing concurrent cardiac surgery (6). Again, however, this study primarily included papers that evaluated CABG and did not include any aortic or mitral valve interventions.

In summary, over time, a growing body of evidence strongly suggests that outcomes in LT patients with treatable CAD who undergo revascularization are non-inferior to outcomes in LT patients without CAD. However, it remains unclear whether CABG or PCI is more advantageous in the long term; further studies are needed to determine late outcomes, and if timing or type of intervention impacts LT outcomes.

Aortic and mitral valvular disease in LT patients

Although data on aortic and mitral valvular disease in LT patients are limited, clinical decision-making points parallel those described above for CAD. Specifically, if cardiac intervention is indicated and feasible, two determinations should be made: whether valvular intervention should be via transcatheter vs. surgical means, and whether intervention timing should be pre-LT, intraoperative, or post-LT. Given the recency of transcatheter treatment options for aortic and mitral valvular disease, the existing literature concerning aortic and mitral intervention in LT patients remains limited to case reports, case series, and a few small, retrospective cohort studies (Table 2).

Aortic valve intervention

TAVR bridge to LT

Although LT with concomitant aortic surgical replacement has proven feasible and successful in selected cases, it makes intuitive sense in modern times that pre-LT TAVR could greatly benefit patients with end-stage lung disease and concomitant severe AS. This is especially true since treatment of severe AS before LT with TAVR could improve a patient’s candidacy for LT and eliminate the need for surgical aortic valve replacement (SAVR) at the time of LT. Patients with end-stage lung disease and severe AS can therefore be bridged to LT with TAVR. This has only recently been reported within the field. Wallen et al. reported two patients who underwent successful TAVR as a bridge to eventual LT (8). The first patient, a 66-year-old male, had a history of idiopathic pulmonary fibrosis and severe AS. His treatment team deemed the patient would be a candidate for LT if his severe AS was corrected, and he subsequently underwent uncomplicated TAVR, followed by successful double LT 56 days later. He remained free of symptoms from AS and good TAVR valve function at 1-year follow-up. The second patient was a 70-year-old male with hypersensitivity pneumonitis and bioprosthetic AS in a previous surgical placed aortic tissue valve. Since he was deemed an appropriate LT candidate aside from his cardiac valvular pathology, he underwent valve-in-valve TAVR without postoperative complications. He then underwent successful single LT 103 days later and also had no TAVR valve-related issues at 1-year follow-up.

More recent case series also corroborate the clinical effectiveness of TAVR in treating AS as a bridge to LT. Braat et al. reported three patients who underwent TAVR before successful LT (22). The first case was a 69-year-old male with combined pulmonary fibrosis and emphysema with concurrent AS and single-vessel disease. He first successfully underwent TAVR while in-patient waiting for LT, then 2 days later, underwent concomitant double LT and off-pump CABG with good clinical outcome at 30 days post-LT. The second patient, a 64-year-old female with interstitial pneumonia and severe AS underwent TAVR, followed by successful double LT 3 weeks later with good lung and TAVR valve function 1 year later. The third and final patient, a 73-year-old man with pulmonary fibrosis and emphysema, was found to have severe AS requiring intervention. He successfully underwent TAVR and while in-patient, 4 days later, underwent double LT with good lung and TAVR valve function at 6 years postoperatively.

Another report describes outcomes in the general solid organ transplant population. An earlier report from our institution reporting TAVR outcomes in solid organ and bone marrow transplant recipients provided some insight into possible longer-term issues in this patient population. Chahine et al. reported 35 patients who underwent TAVR (both pre- and post-transplant) among patients undergoing any solid organ or bone marrow transplant (23). Not surprisingly, transplant patients in this study were more likely to develop prosthetic valve endocarditis and had a statistically significant higher 3-year mortality rate when compared to non-transplant patients. However, survival at 30 days and 1 year was similar. Of note, only eight of 35 patients in this study were LT recipients (three pre-LT TAVR and five post-LT TAVR) and the authors provide no sub-group analyses by transplant type. The authors concluded that TAVR was a viable treatment option for patients with organ transplantation and severe AS.

We have reviewed our own center’s initial experience with TAVR as bridge to LT as well as outcomes of TAVR performed after LT. Mubashir et al. evaluated all patients who underwent TAVR pre- or post-LT from 2000 to 2020, identifying five patients with TAVR bridge to LT and 5 who received TAVR after LT (24). For the five patients who underwent TAVR for AS as a “bridge to LT”, median time from TAVR to LT was 7.4 months. In LT patients who had TAVR for severe AS after LT, the median time from LT to TAVR was 5 years. In both groups, the only complications of TAVR were a requirement for permanent pacemaker placement in 1 out of 5 patients in each group. All deaths in both groups were related to post-LT pulmonary or infectious etiologies and were not related to TAVR.

Taken together, these studies suggest that TAVR can be performed in LT patients either as a bridge to transplant or in the post-transplant period with good short-term outcomes. However, these reports are limited in size, and follow-up and further studies reviewing outcomes are needed. In our institution, LT candidates with severe AS and LT recipients who develop severe AS undergo a multidisciplinary heart team evaluation including both structural cardiologists and cardiac surgeons to determine the best treatment for an individual patient.

LT with concomitant SAVR

Despite the increasing prevalence of TAVR in both transplant and non-transplant patients, it is important to recall that SAVR was feasible and safe in selected LT patients before TAVR became widely available. In previous reports of LT and cardiac surgery, data regarding concomitant aortic valve surgery with LT are limited. Chan et al. reported a 66-year-old male patient with interstitial pulmonary fibrosis, listed for LT, with coexistent moderate AS and severe aortic insufficiency, necessitating aortic valve intervention (25). He ultimately underwent bioprosthetic SAVR concomitantly with bilateral LT, during which SAVR was performed first on cardiopulmonary bypass (CPB), followed by weaning from CPB to confirm appropriate valvular function. Next, CPB was reinstituted for the double LT implantation, with good valvular and transplant outcomes at 2-month follow-up.

There are no large or randomized, controlled studies comparing TAVR pre-LT vs. SAVR pre-LT or concomitant with LT, and it is unlikely that there will be, since TAVR is less invasive and can be performed with conscious sedation. It is reasonable to presume that in LT recipients or in patients with end-stage lung disease awaiting transplant, SAVR will be used in cases in which contraindications for TAVR exist, such as low coronary clearance, unfavorable annular or left ventricular outflow tract anatomy for TAVR, and bicuspid AS with heavily calcified raphes deemed unfavorable for TAVR. In addition, treatment of severe symptomatic aortic regurgitation may not be feasible with TAVR valves, and concomitant aortic valve surgery may be an important consideration. Given the limited evidence to date, further studies are required to better define the role of SAVR in this patient population and interrogate the success of this intervention.

TAVR or SAVR post-LT

Additionally, many LT recipients may subsequently develop valvular disease. This was reported by Sayeed and colleagues, who describe a 32-year-old woman who underwent heart-LT and subsequently developed infective endocarditis of her aortic valve (26). She originally underwent transplantation for end-stage pulmonary disease secondary to cystic fibrosis, and 9 months post-LT was admitted with bacteremia and echocardiographic findings of endocarditis of her aortic valve. She underwent redo sternotomy and SAVR with a bioprostheses, and the authors report a successful clinical outcome at 1 year, with the patient remaining asymptomatic and active. A similar report has demonstrated that SAVR is feasible with a bioprosthetic SAVR 4 years after bilateral LT through a redo sternotomy (27).

Additional single case studies report similar degrees of success. Morsolini et al. describe a 22-year-old who underwent double lung LT with concomitant VSD repair in 1994 (28). Fifteen years later, he was found to have severe AS, requiring SAVR with a mechanical valve. His postoperative course was complicated by complete atrioventricular block requiring a permanent pacemaker. Next, the patient was readmitted with aortic-mitral junction abscess 5 months later and underwent successful reoperation for aortic-mitral curtain abscess and repeat SAVR. The authors report that he did well with 24 months follow-up. Mohite et al. reported a 64-year-old man who presented 10 years following double LT with severe AS, necessitating SAVR (29). He similarly had an uneventful postoperative course with no adverse events up to 30 days postoperatively.

To date, there are very few reports concerning TAVR following LT. One of the first reports is that of a 64-year-old male who underwent double LT for chronic obstructive pulmonary disease in 2004 (30). Four years following transplantation, moderate AS was diagnosed with severe left ventricular ejection fraction reduction, and SAVR was indicated. However, the patient was deemed a poor candidate for SAVR due to numerous comorbidities, including his previous LT. Six years later, and 9 years post-LT, the patient was readmitted with severe progression of symptoms, and a TAVR was considered given the high predicted operative risk of SAVR. TAVR was successfully performed, although complicated by right femoral access site bleeding post-procedurally. He was discharged 13 days later with improvement of symptoms and a properly functioning bioprosthetic valve, and the authors report he was doing well 10 months later. Notably, TAVR in this patient was performed in an early era of TAVR in which delivery sheaths were significantly larger than the current era, which likely accounts for the vascular complication associated with TAVR in this case.

As previously noted, our center has reported on the successful intervention on aortic valves both pre- and post-LT (24). Our report, along with others, demonstrates that selected patients can undergo either SAVR or TAVR in a safe and effective manner. The overall clinical experience is limited by short follow-up with less than 5 years in all and often less than 1 year, as well as selection bias. Further ongoing review of outcomes will be needed to better understand the true clinical effectiveness of SAVR and TAVR in the LT population.

Surgical and transcatheter mitral valve intervention

Mitral TEER as a bridge to transplant

Prior to mitral valve TEER, the presence of severe MR in an LT candidate (I) mandated mitral valve intervention (valve repair or replacement) at the time of transplant or (II) precluded transplant candidacy altogether. Successful case reports of LT with concomitant surgical mitral valve repair suggest anecdotal success with surgical management of MR, and our LT program is among others which has had success with mitral valve repair at the time of LT. Recently, percutaneous mitral intervention with TEER has emerged as a viable management option for clinically significant MR as a bridge to LT. Wallen et al. described a 61-year-old female with chronic obstructive pulmonary disease necessitating LT but who had severe MR and thus a contraindication to transplantation (31). She successfully underwent MitraClip, reducing her MR to residual, then underwent a successful single LT 16 months later, and was doing well at follow-up 4 years later with no increase in MR.

Although the above case demonstrates a successful instance of pre-LT mitral intervention with TEER, care must be taken in this population. In LT candidates with end-stage lung disease and clinically significant MR, the need for sedation for transesophageal echocardiogram (TEE) to (I) determine the mechanism of severe MR, (II) define anatomic candidacy for TEER, and (III) provide appropriate imaging during the performance of TEER, may limit the applicability of TEER in the patients with end-stage lung disease or those that are post-LT in whom intubation would present a physiologic setback or possibly necessitate tracheostomy. Additional clinical experience is needed to determine the role of TEER as a bridge to LT, including the possible use of alternative cardiac imaging modalities other than TEE (such as intracardiac echo) to facilitate performance of TEER in this patient population.

LT and concomitant mitral valve surgery

There are even fewer reports on the outcomes of concomitant surgical mitral valve intervention during LT. Biniwale and colleagues in their report on concomitant cardiac surgery included two patients who underwent concomitant mitral valve repair, but do not separately report their outcomes (19). Anecdotally, our center has also performed mitral valve repair or replacement concomitant with LT with good surgical outcomes. Despite the paucity of strong evidence, prior experience to date suggests that concomitant surgical mitral valve intervention (repair or replacement) is safe and warranted in patients with appropriate anatomy undergoing LT at experienced centers. In a pre-TEER era survey [2014], surgeons not surprisingly expressed a preference for concomitant mitral valve over pre-LT mitral treatment—9.7% preferred replacement preceding transplantation while 41.9% preferred concomitant LT and MVR (10). Thus, although simultaneous surgical treatment of mitral valve pathology may be considered during LT, appropriate surgical expertise and multidisciplinary heart team review in the current era are required for proper decision making and optimal clinical outcomes.

Mitral intervention post-LT

Similar to decision making for TAVR post-LT, mitral valve intervention after LT, whether surgical or transcatheter in approach, may be required in those who develop clinically important MR following LT. Case reports have outlined unique mechanisms for MR as a direct result of the LT. Bermudez et al. describe a case of non-infectious, new functional MR following LT (32). The authors hypothesized that reduction of systolic pulmonary pressure following successful LT would unload the right ventricle (RV) with a subsequent reduction in size and improvement in function and ejection. This would ultimately lead to a higher left ventricle (LV) preload, a subsequent increase in LV size, and a parallel dilation of the mitral annulus. Their hypothesis was correct, with a post-LT 0.9cm increase in mitral annular dimension, resulting in secondary MR. Ultimately, surgical mitral valve repair with an annuloplasty ring 44 days after LT corrected the regurgitation. Previously, other authors also have reported a similar clinical picture of new-onset MR following successful LT (33,34).

Others have suggested that LT may uncover, or even augment, existing MR. McCartney and colleagues reported a 63-year-old male with end-stage pulmonary fibrosis who had existing mild-to-moderate MR, who underwent successful left single LT without mitral intervention (35). Four weeks later, he presented in respiratory distress and was found to have progressive right-sided fibrosis and severe MR. Eight weeks following original LT, he underwent concomitant mitral valve repair and right LT. He was doing well 2 years later, with no pulmonary or cardiac complications. This case suggests that MR progression following initial LT is possible, and that its correction with mitral valve repair can, in part, successfully address the MR.

Until recently, the rare complication of MR following LT and its subsequent treatment were only demonstrated in single case reports. In 2022, Shi et al. evaluated over 1,000 patients undergoing LT and found 8 who developed severe MR following LT (36). The authors noted that surgical mitral valve repair, surgical MVR, and MitraClip were used to correct the MR, with no procedure-related comorbidity or mortality. Two of the 8 patients had expired at the most recent follow-up, both due to non-surgical and non-mitral related causes (cancer and stroke, at 5 and 12.9 years, respectively). The authors conclude that MR remains a rare but dangerous complication following LT that providers must be ready to diagnose and treat, and that both traditional surgical as well as modern TEER methods were effective.

In addition, others have reported MR from infectious sources post LT and have similarly demonstrated successful treatment. Scherer et al. report on a 28-year-old who underwent bilateral LT for cystic fibrosis and was readmitted to the hospital 1 month later for signs of stroke (37). During her hospital stay, she was found to have mitral valve endocarditis which required MVR. The excised valve subsequently demonstrated colonies of Aspergillus. Although the surgery was successful, she suffered from brain fungal dissemination during her hospital stay and expired. Similarly, Saxena and co-authors describe a 57-year-old who underwent bilateral LT and was found to have Aspergillus infection in the explanted lungs (38). After appropriate medical treatment postoperatively, he was discharged. However, he returned 4 months later in cardiogenic shock and was found to have Aspergillus endocarditis of the mitral valve. He successfully underwent MVR with a mechanical valve.

There is also at least one report of LT in a patient with existing MR, who first underwent LT with subsequent mitral intervention post-LT. Hamad et al. describe a female who had 3+ to 4 MR who required bilateral LT due to advanced disease secondary to systemic lupus erythematous (39). Although the transplant was successful, the patient remained intubated for 5 weeks with failure to wean due to pulmonary edema secondary to MR. Ultimately, mitral valve intervention was surgical MVR with a mechanical valve. The patient was successfully extubated 3 days later and had an uneventful course. Taken together, these cases illustrate that clinically significant MR can be successfully treated by surgery in a LT recipient. As the clinical practice of TEER continues to evolve, multidisciplinary heart team evaluation will be important in determining the role(s) of surgical mitral valve intervention, TEER, and ultimately transcatheter mitral valve replacement in the LT population.

Tricuspid valve intervention

Tricuspid valve TEER as a bridge to transplant

Functional tricuspid regurgitation (TR) secondary to pulmonary hypertension is a common finding in patients with end-stage lung disease and secondary pulmonary hypertension related to lung disease and is frequently associated with right ventricular dilation and dysfunction. However, if LT is technically successful and there is no significant graft dysfunction in the early post-LT period, TR is typically improved without need for surgical intervention. A review of 553 patients with TR and no correction undergoing LT by Jacob et al. demonstrated significant reduction in regurgitation following transplantation (40). In their study, the authors conclude that, given the improvement or lack of change in TR following transplant, tricuspid surgery is unnecessary in this patient population. To date, there are no known reports of preoperative mitigation of functional TR in LT candidates by transcatheter methods.

LT and concomitant tricuspid valve surgery

Successful concomitant repair of the tricuspid valve in those with severe regurgitation, pulmonary hypertension, and RV dysfunction has also been reported. Shigemura and colleagues reported 20 such patients from 2004 to 2011 who underwent concomitant tricuspid repair and LT (41). When compared to LT patients who also had severe pulmonary hypertension but no TR and thus, did not receive concomitant tricuspid repair, outcomes were similar or better in those who underwent tricuspid repair. All early outcomes were not significantly different except for patients with tricuspid valve repair requiring less inotropic support, and a smaller portion needing prolonged mechanical ventilation. The repair group also had lower rates of primary graft dysfunction. In terms of pulmonary function, those with tricuspid repair also had greater improvement in forced vital capacity, postoperative forced expiratory volume, and 6-minute walk test. Despite a similar postoperative LV ejection fraction at 1-month follow-up, fewer patients had RV dysfunction, and none had residual TR.

However, as noted above, the need for concomitant tricuspid surgery for functional TR during LT remains controversial. The editorial response of Sanders and coauthors to Shigemura’s paper included a review of postoperative outcomes in patients with moderate or severe TR undergoing LT (n=16) (42). The authors demonstrated that, at a median of 14.5 days, there was a significant improvement in TR following LT. Right ventricular dysfunction and mean pulmonary arterial pressure also improved. Thus, despite some evidence that concomitant tricuspid valve repair may be beneficial to patients, LT alone may be adequate.

Tricuspid intervention post-LT

Reports of patients requiring surgical tricuspid intervention following LT are very limited. Clinical experience with tricuspid valve TEER in LT patients is sparse but may increase as newer tricuspid valve TEER devices and systems gain greater clinical acceptance.

Limitations

To the authors’ knowledge, this review provides the first robust accounting of valvular interventions in LT candidates and patients. However, there are some limitations to our review. First, it is a summary and review of existing data in the field and not a presentation of new clinical data per se. Additionally, the limitations of reporting within previous studies limited the ability for a meta-analysis. Thus, no comparisons between intervention types or timing were conducted. Lastly, although expansive, this review is not all-inclusive. There may be additional studies that were not included within this review.

Conclusions

In the modern era of LT, especially with older LT candidates, we anticipate a higher incidence of concomitant cardiac and cardiac valve disease. As survival post-LT improves, and LT recipients live longer, we also expect a higher incidence of post-LT cardiac and valvular disease that requires intervention. Given the rapid past evolution of TAVR, and the current evolution of TEER for percutaneous mitral and tricuspid valvular interventions, novel approaches to the treatment of valvular disease in the LT population will continue to expand (Table 2). While all therapeutic approaches must be considered, the synergistic expertise of heart teams including cardiologists and cardiac surgeons should be leveraged to determine if surgical vs. percutaneous therapies should be favored in individual LT patients, whether before, during, or after LT. A nuanced knowledge and review of the clinical results of both surgical and percutaneous cardiac therapies in LT patients will be critical to enable heart teams to identify and provide the best therapy for each patient.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Haytham Elgharably) for the series “Lung Transplantation: New Frontiers” published in Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-17/rc

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-17/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-17/coif). The series “Lung Transplantation: New Frontiers” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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