Successful Bilateral Lung Transplantation After Previous Pneumonectomy Hans-Beat Ris, MD, Thorsten Krueger, MD, Michel Gonzalez, MD, Enrico Ferrari, MD, Madeleine Chollet-Rivier, MD, Carlos Marcucci, MD, John Prior, PhD-MD, Pierre-Yves Jayet, MD, and John-David Aubert, MD Departments of Thoracic and Vascular Surgery, Cardiovascular Surgery, Anesthesiology, Nuclear Medicine and Pneumology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
FEATURE ARTICLES
We report successful bilateral lung transplantation for end-stage suppurative lung disease after a previous right-sided pneumonectomy performed for a destroyed lung. Our results demonstrate the feasibility of the procedure even in the context of mechanical ventilation and extracorporeal artificial oxygenation. Posttransplan-
tation follow-up revealed excellent gas exchanges, no airway complications, and well-functioning grafts with right-sided ventilation and perfusion of 37% and 22%, respectively. (Ann Thorac Surg 2011;91:1302– 4) © 2011 by The Society of Thoracic Surgeons
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(partial arterial pressure of carbon dioxide, 99 mm Hg), which required femorofemoral extracorporeal artificial oxygenation (Novalung, Talheim, Germany). The patient was listed as super-emergency for LT and underwent bilateral LT 12 days later. The right chest was entered by a standard clamshell incision in the fourth intercostal space, and the intrathoracic latissimus dorsi flap was resected. The carina was dissected, and the remnant bronchus stump was resected. A right-sided hemipericardectomy was performed that allowed the intrapericardial exposure and dissection of the aorta, vena cava, and right pulmonary vessels. The pulmonary artery was dissected and clamped between the superior vena cava and the ascending aorta, which allowed the preservation of a 1-cm-long healthy pulmonary artery segment for anastomosis. Cardiopulmonary bypass (CBP) was installed after cannulation of the ascending aorta and the inferior vena cava. The donor lungs were of excellent quality, with a partial arterial pressure of oxygen of 350 mm Hg at the time of harvesting. After the donor lungs were separated, an upper right sleeve lobectomy was performed, with stapling of the upper lobar vein distally to the middle lobar vein. A tension-free end-to-end anastomosis between the intermediate donor bronchus and the recipient trachea was performed after a hilar release maneuver was completed (Fig 2). This was followed by a retrocaval end-to-end anastomosis between the donor and recipient pulmonary artery and a standard anastomosis between the 2 atrial cuffs. Because the transplant afforded convenient gas exchange without hemodynamic instability, we decided to remove CPB before implantation of the left lung. The ischemic times of the right and left lung were 200 and 320 minutes. Intraoperative bronchoscopy and transesophageal echocardiography revealed a patent airway and no stenosis of the vascular anastomoses.
nd-stage lung disease after previously performed pneumonectomy has been occasionally treated by single lung transplantation (LT) of the remaining lung [1–7]. However, this may result in significant postoperative morbidity and death due to mediastinal shift and airway complications related to the development of postpneumonectomy syndrome [7]. To circumvent these problems, we performed bilateral LT in a patient with end-stage lung disease after a right-sided pneumonectomy previously performed for a destroyed lung.
Technique A 32-year-old woman presented with recurrent respiratory infections due to a destroyed right lung (Fig 1A) and underwent right pneumonectomy and mediastinal reinforcement by a pedicled latissimus dorsi muscle flap. A progressive platypnea-orthodeoxia syndrome developed 6 months later. Pulmonary function testing revealed 38% predicted total lung capacity, forced expiratory volume in 1 second of 16% predicted, and diffusion capacity of carbon monoxide of 39% predicted. A computed tomography scan revealed a significant mediastinal shift (Fig 1B). Cardiac magnetic resonance imaging and right heart catheterization showed vascular postpneumonectomy syndrome with a twist of the inferior vena cava leading to postural decrease on venous return. Realignment of the mediastinum and correction of venous return was achieved by insertion of an intrathoracic expander by a repeat thoracotomy (Fig 1C). The patient’s postoperative course was complicated by respiratory insufficiency and development of acute respiratory distress syndrome, with refractory hypercarbia Accepted for publication Sept 3, 2010. Address correspondence to Dr Ris, Service de Chirurgie Thoracique et Vasculaire, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 21, 1011 Lausanne, Switzerland; e-mail:
[email protected].
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 doi:10.1016/j.athoracsur.2010.09.026
Ann Thorac Surg 2011;91:1302– 4
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Immunosuppression was achieved with intravenous administration of methylprednisolone (500 mg) at lung reperfusion, followed by a triple-drug regimen with tacrolimus, mycophenolate mofetil, and prednisone. Basiliximab (20 mg) was given for induction at day 0 and day 4 after transplantation. The surveillance transbronchial biopsy specimen at 1 month showed no rejection (A0/B0). The patient’s postoperative course was favorable, with progressive weaning from the ventilator, removal of
tracheotomy, and uneventful healing of airway anastomosis (Fig 3A). Ventilation and perfusion scintigraphy of the right lung 6 weeks after transplantation revealed an estimated ventilation of 37% and perfusion of 22% (Fig 3B, C). A computed tomography scan 2 months after transplantation estimated expiration/inspiration lung volume of 506 cm3/593 cm3 for the right and 786 cm3/1205 cm3 for the left (Fig 1D). The patient’s general condition and nutritional status improved gradually, and at 10 weeks after transplantation she did not require oxygen or ambulatory ventilator support.
Comment
Fig 2. Illustration shows right-sided lung transplantation with anastomosis of the intermediate donor bronchus to the recipient trachea and retrocaval anastomosis of the pulmonary artery.
Single LT after previously performed contralateral pneumonectomy has been occasionally reported and was associated with significant morbidity. Two patients with cystic fibrosis underwent single LT after contralateral pneumonectomy for a destroyed lung, and postpneumonectomy syndrome developed in one with fatal outcome [1, 2]. An additional 4 patients underwent single LT after previous contralateral pneumonectomy, with the development of postpneumonectomy syndrome in 2 [3– 6]. A recent publication of Le Pimpec and colleagues [7] reviewed 14 (9 left, 5 right) patients with single LT after previous contralateral pneumonectomy collected from different centers over 18 years. The in-hospital mortality was 29%, with 2 perioperative deaths due to technical difficulties related to mediastinal shift. All 14 patients revealed pulmonary edema after the operation. Airway complications developed in 4 patients; of these, postpneumonectomy syndrome developed in 2 that required endobronchial stenting and resulted in a fatal broncho-
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Fig 1. Estimation of configuration and size of the right chest cavity by transverse computed tomography images at comparable levels through the chest cavities (A) before pneumonectomy, (B) after pneumonectomy with important right-sided mediastinal shift, (C) after introduction of the chest expander, and (D) after transplantation.
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Fig 3. (A) Chest roentgenogram after transplantation, (B) ventilation scintigraphy, and (C) perfusion scintigraphy performed 6 weeks after transplantation.
FEATURE ARTICLES
vascular fistula in 1 patient. The authors concluded that single LT after previous contralateral pneumonectomy is associated with a high morbidity and mortality mainly related to mediastinal shift. To circumvent these problems, double instead of single LT was considered in our patient. We feared that single LT might bear an increased risk of infection of the contralateral postpneumonectomy cavity with the freshly implanted expander in place. Conversely, we feared recurrent postpneumonectomy syndrome if removal of the expander became necessary after the transplant. We speculated that if the implantation of the right lung would not be feasible for technical reasons, the left lung could be transplanted under CPB support. A new expander could then be implanted on the right side during the same procedure to avoid recurrent postpneumonectomy syndrome, as suggested by Le Pimpec and colleagues [7]. Because the implanted right lung, consisting of lower and middle lobe, was able to afford convenient gas exchange without hemodynamic instability, we transplanted the left lung without CPB to decrease the risk of hemorrhage associated with prolonged CBP and full anticoagulation. While judging the volume and configuration of the dissected postpneumonectomy cavity and of the right donor lung, we felt that the implantation of the lower and middle lobe allowed an optimum of functioning lung parenchyma on the right side and that this might alleviate the need of CPB for left-sided transplantation. With this article we report successful bilateral LT after previously performed pneumonectomy and reveal a per-
sistently perfused and ventilated graft within the postpneumonectomy cavity. In case of optimal donor lungs and young recipient age, the procedure is feasible even in the presence of mechanical respiratory support and extracorporeal artificial oxygenation.
References 1. Piotrowski JA, Splittgerber FH, Donoval TJ, Ratjen F, Zerkowski HR. Single-lung transplantation in a paient with cystic fibrosis and an asymmetric thorax. Ann Thorac Surg 1997;64:1456 – 8. 2. Souilamas R, Mostafa A, Guillemain R, Boussaud V, Amrein C, Chevalier P. Single-lung transplantation for cystic fibrosis and metachronous pneumonectomy: case reports. Transplant Proc 2008;40:3594 –5. 3. Sakiyalak P, Vigneswaran WT. Postpneumonectomy syndrome in single lung transplantation recipient following previous pneumonectomy. Ann Thorac Surg 2003;75:1023–5. 4. Vergnat M, Farhat F, Tronc F, Jegaden O. Metachronous single lung transplantation after contralateral pneumonectomy. A “big” challenge? Minerva Chir 2007;62:187–90. 5. Gomez de Antonio D, Gamez P, Cordoba M, Moradiellos J, Varela A. Graft pneumonectomy and delayed contralateral lung transplantation. Ann Thorac Surg 2007;83:1891–3. 6. Pawale A, McKean M, Dark J, Hasan A. Successful pediatric single-lung transplantation with previous contralateral pneumonectomy using controlled donation after cardiac death lung for congenital pulmonary vein stenosis. J Thorac Cardiovasc Surg 2010;139:e125– 6. 7. Le Pimpec-Barthes F, Thomas PA, Bonnette P, et al. Singlelung transplantation in patients with previous contralateral pneumonectomy: technical aspects and results. Eur J Cardiothorac Surg 2009;36:927–32.
