Pulmonary embolism on postmortem examination: An under-recognized complication in lung-transplant recipients?

Introduction. Postmortem reports highlight the importance of factors that individually or collectively limit survival. The prevalence of pulmonary embolism (PE) at autopsy in lung-transplant recipients has not been characterized previously. Objective. We aimed to describe the prevalence of PE, infection, and acute and chronic rejection at autopsy and their respective contributions to death in lung-transplant recipients according to survival posttransplantation. Methods. We retrospectively reviewed 126 autopsy reports performed in lung and heart-lung-transplant recipients between June 1990 and September 2002. Results. PE was identified at autopsy in 34 (27.0%) of 126 lung- and heart-lung-transplant recipients. The prevalence of autopsy-established PE was highest, at 36.4%, in the early group (1-30 days) compared with 20.0% and 23.8% in the intermediate (31-365 days) and late (> 365 days) groups, respectively. Although fungal and viral pneumonia were noted most frequently in the early and intermediate groups, bacterial pneumonia was noted in 32% to 45% of autopsies over the posttransplant period. Acute cellular rejection and bronchiolitis obliterans were present in 29.5% and 2.3%, 40.0% and 17.5%, and 35.7% and 42.9% of patients in the early, intermediate, and late groups, respectively. The most frequent cause of death was bacterial infection. Conclusions. The prevalence of PE was highest in mechanically ventilated lung-transplant recipients in the early postoperative period. Heart-lung recipients were at lower risk for PE compared with double- and single-lung recipients. PE may be an under-appreciated complication contributing to respiratory failure in the early postoperative period.