Progression of Mitral Valve Regurgitation after Lung Transplantation

Purpose Development of early post-operative mitral valve regurgitation (MR) after lung transplantation is associated with substantial morbidity and may be an under-recognised phenomenon. Data is limited to single case reports only. We sought to review our centre's experience. Methods From 1990 to 2018, 1330 patients underwent lung transplantation at our centre (1032 bilateral, 298 single). We identified patients in whom significant MR developed post-operatively. Clinical and investigative data were evaluated. Results We identified 7 patients who developed severe MR post-lung transplantation. Five patients had undergone bilateral sequential lung transplantation while 2 underwent single right lung transplant Indications for transplantation were interstitial lung disease (ILD) in 4, chronic obstructive airways disease (COAD) in 2 and primary pulmonary arterial hypertension (PAH) in 1. Pre-operatively, 2 had trivial MR, 4 patients had mild, and 1 had moderate.. Three patients (2 ILD, 1 PAH) had pre-operative pulmonary hypertension with right ventricular dilatation and systolic dysfunction. Post-transplant MR was discovered intra-operatively in 2 patients, 4 were diagnosed within 6 months and one was diagnosed at 9 months post-transplant. Five patients underwent mitral valve surgery (2 repair, 3 replacement) between 1 day to 1.2 years post-transplant. One patient underwent transcatheter mitral valve repair at 3 months. Indications for mitral procedures were cardiogenic shock in 1, and progressive symptoms in the other 5. One patient had non-operative management of the mitral valve but required right pneumonectomy for graft necrosis. There were two mortalities at 5 and 13 years due to cancer and stroke respectively. Conclusion Development of significant mitral valve regurgitation is a rare but morbid complication after lung transplantation. We postulate that this phenomenon may be related to changes in left ventricular geometry due to RV unloading after lung transplantation coupled with unmasking of mild degenerative mitral valve disease. As an increasing number of patients with PAH and ILD with RV dysfunction undergo lung transplantation, post-transplant MR should be recognised as a rare but hemodynamically important complication that may require intervention.