Mediastinal Lymphadenopathy in Patients Undergoing Cardiac Transplant Evaluation

doi:10.1378/chest.10-1386

Chest

Volume 139, Issue 6, June 2011, Pages 1451-1457

https://doi.org/10.1378/chest.10-1386 Get rights and content

Background

We evaluated the association between hemodynamic parameters of chronic congestive heart failure (CHF) and mediastinal lymphadenopathy (MLA) in heart transplantation (HT) candidates and the effect of HT on MLA. We also described the results of lymph node (LN) biopsies of MLA in the patients.

Methods

Patients who underwent HT evaluation over an 8-year period and had chest CT scans were evaluated retrospectively. Data collected included LN sizes pre-HT and post-HT, echocardiographic measurements, radionuclide-derived ejection fraction, and right-sided heart catheterization hemodynamics. MLA was defined as LNs > 1 cm in smallest dimension.

Results

Of 118 patients, 53 patients had MLA. MLA had weak statistically significant correlations with elevated mean pulmonary artery pressure (MPAP), mitral regurgitation (MR), tricuspid regurgitation (TR), right atrial pressure (RAP), and pulmonary capillary wedge pressure (PCWP). Thirty-six patients with MLA underwent HT, and nine of the 36 had post-HT chest CT scans. All nine patients showed a decrease in LN size post-HT (mean LN diameter pre-HT = 1.16 ± 0.137 cm, post-HT = 0.75 ± 0.32 cm). Seven of 53 patients with MLA underwent biopsies. Four had benign LNs, one had sarcoidosis, and two had lung cancer.

Conclusions

MPAP, MR, TR, RAP, and PCWP had weak statistically significant correlations with MLA. HT led to regression of MLA in patients who underwent CT scans post-HT, implying that MLA is related to CHF. However, we also identified clinically important causes of MLA; therefore, biopsy should be considered if enlarged LNs fail to regress after maximal medical management of CHF.

Section snippets

Study Design

The population was composed of patients with end-stage cardiomyopathy referred for cardiac transplantation at the Medical University of South Carolina from March 27, 1997, to November 15, 2005. Patients were excluded if they did not have a chest CT scan performed within 3 months of routine cardiac imaging and hemodynamic assessment as part of their transplant evaluation. Chest CT scans were ordered routinely in patients with a ≥ 20 pack-year smoking history and at the request of pulmonary

Results

Over the 8-year study period, we identified 118 cardiac transplant candidates who met our criteria for analysis. The mean age was 51.6 ± 9.5 years. Ninety-five patients (81%) were men, and 85 patients (72%) were white. The overwhelming majority of these patients had either an ischemic or idiopathic cardiomyopathy (Table 1). The mean time between chest CT scan and right-sided heart catheterization was 9 days (± 19 days).

Of the 118 patients studied, 53 (45%) patients had enlarged mediastinal LNs.

Discussion

The important findings of this study include the following: The frequency of MLA was 45% in this population of HT candidates. Of the hemodynamic parameters evaluated, an elevated MPAP, the presence of MR, the presence of TR, an elevated RAP, and an elevated PCWP had weak but significant correlations with mediastinal LN enlargement. In the group of nine patients transplanted with MLA, all nine had regression in the size of the lymphadenopathy after transplant. There were seven HT candidates (two

Acknowledgments

Author contributions: Dr Pastis: contributed to the writing of the study protocol, acquiring data, wrote first draft of manuscript and reviewed all drafts, and has seen and approved the final version.

Dr Van Bakel: contributed to writing of the study protocol, data acquisition, reviewing all drafts of the manuscript, and has seen and approved the final version.

Mr Brand: contributed to writing of the study protocol and manuscript and data acquisition.

Dr Ravenel: contributed to data acquisition,

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Cited by (9)

Sarcoidosis diagnosed on granulomas in the explanted heart after transplantation: Results of a French nationwide study
2020, International Journal of Cardiology
Citation Excerpt :
A large proportion of them did not have histological documentation of mediastinal lymph nodes. Non-caseating granuloma was found in only 1 out of 7 patients who had lymph nodes biopsy [26]. Interestingly, skin, nervous system, and renal involvements were not observed.
Cardiac sarcoidosis (CS) is a challenging diagnosis. Patients may progress to end-stage congestive heart failure and require cardiac transplantation without ever having been diagnosed. Characteristics and outcomes of patients with granulomas in the explanted hearts are unknown.
All French heart transplantation centers were contacted to participate in the study. Each center searched through local databases for the cases of non-caseating granuloma in the explanted hearts between 2000 and 2017. Data before and after transplantation were recorded from medical charts. Survival of CS and all- cause heart transplantation patients were compared.
Fifteen patients (10 men, 5 women) received a diagnosis of CS based on pathologic data of the explanted heart and were recruited for the study. All patients were diagnosed as non-ischemic dilated or hypertrophic cardiomyopathy and presented congestive heart failure. Eight patients (53%) had ventricular rhythm disturbances, and 3 (20%) a complete heart block. Ten out of 13 patients (77%) had extracardiac radiological signs compatible with sarcoidosis on chest computed tomography (CT) scans. One patient died 3 months after transplantation from infectious complications. The 14 remaining patients were still alive at the end of the study (median follow-up of 28.8 months). One patient had a second heart transplantation 5 years later because of chronic allograft vasculopathy. One patient presented a relapse of CS confirmed by myocardial biopsies 9 years after transplantation, requiring an escalation of immunosuppressive therapy.
CS may be undiagnosed before heart transplantation. In 77% of cases, sarcoidosis could have been detected before transplantation with non-invasive imaging techniques.
Frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension
2013, Chest
Citation Excerpt :
Mean LVEF for patients described in these reports ranged from 20% to 40%, with lymphadenopathy more commonly seen in patients with lower ejection fraction (<35%).1 Enlarged lymph nodes were also found to decrease in size with treatment of underlying heart failure or subsequent heart transplant.4,5,10 The underlying mechanism for MLAD in patients with CHF is believed to be elevated, left-sided filling pressures resulting in increased hydrostatic pressure at the alveolar capillary.
The objective of this study was to assess the frequency of mediastinal lymphadenopathy in patients with idiopathic pulmonary arterial hypertension (IPAH) and describe the correlative clinical features.
We conducted a retrospective review of patients with IPAH who underwent right-sided heart catheterization (RHC) and chest CT scan within 3 months of each other. Patients were from a single tertiary institution. CT scans were reviewed for the presence of mediastinal lymphadenopathy (MLAD) with correlating demographic and clinical data, including lymph node size and location, right atrial pressure (RAP), mean pulmonary arterial pressure (mPAP), and the presence of pleural and pericardial effusion.
The study population included 85 patients with a mean age of 48 ± 17.3 years; 70 (82%) were women. Fifteen patients (18%) had MLAD on chest CT scan. The mean short-axis diameter of the largest lymph node in these patients was 13.6 mm (range, 11-20 mm). The enlarged lymph nodes were located predominantly in the lower paratracheal and subcarinal stations. There was no association of MLAD with age, sex, RAP, or mPAP. MLAD was associated with presence of pleural effusion (P < .02) but not pericardial effusion. Mean left ventricular ejection fraction for those with lymphadenopathy was 63% (range, 45%-76%).
MLAD without other identifiable causes is seen in approximately one in five patients with IPAH and is associated with pleural effusion but not mPAP, RAP, or left ventricular function.
Multiscale classification of heart failure phenotypes by unsupervised clustering of unstructured electronic medical record data
2020, Scientific Reports
Mediastinal Lymphadenopathy, Class-Switched Auto-Antibodies and Myocardial Immune-Complexes During Heart Failure in Rodents and Humans
2020, Frontiers in Cell and Developmental Biology
Assessment of Mediastinal Lymph Node Size in Pneumococcal Pneumonia with Bacteremia
2018, Lung
Case report: Two men with dyspnea, enlarged lymph nodes · Dx
2016, Journal of Family Practice

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Original ResearchTransplantationMediastinal Lymphadenopathy in Patients Undergoing Cardiac Transplant Evaluation

Background

Methods

Results

Conclusions

Section snippets

Study Design

Results

Discussion

Acknowledgments

Am J Cardiol

Chest

Hematol Oncol Clin North Am

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Int J Cardiol

J Am Coll Cardiol

Chest

Mediastinal lymphadenopathy in congestive heart failure: a sequential CT evaluation with clinical and echocardiographic correlations

Eur Radiol

Mediastinal lymphadenopathy and hazy mediastinal fat: new CT findings of congestive heart failure

AJR Am J Roentgenol

Location, size, and distribution of mediastinal lymph node enlargement in chronic congestive heart failure

J Comput Assist Tomogr

Role of pulmonary lymphatics in chronic pulmonary edema

Circ Res

Original Research
Transplantation
Mediastinal Lymphadenopathy in Patients Undergoing Cardiac Transplant Evaluation