The Effect of Prior Pneumonectomy or Lobectomy on Subsequent Lung Transplantation

Lung transplantation in patients with a history of anatomical native lung resection

OBJECTIVES

History of anatomical lung resection complicates lung transplantation (LTx). Our aim was to identify indications, intraoperative approach, and outcome in these challenging cases in a retrospective multicentre cohort analysis.

METHODS

Members of the ESTS Lung Transplantation Working Group were invited to submit data on patients undergoing LTx after a previous anatomical native lung resection between 01/2005 and 07/2020. The primary end-point was overall survival (Kaplan-Meier estimation).

RESULTS

Out of 2690 patients at 7 European centers, 26 (1%) patients (14 male; median age 33 years) underwent LTx after a previous anatomical lung resection. Median time from previous lung resection to LTx was 12 years. The most common indications for lung resection were infections (n = 17), emphysema (n = 5), lung tumour (n = 2), and others (n = 2). Bronchiectasis (cystic fibrosis (CF) or non-CF related) was the main indication for LTx (n = 21), followed by COPD (n = 5). Two patients with a previous pneumonectomy underwent contralateral single LTx and 1 patient with a previous lobectomy had ipsilateral single LTx. The remaining 23 patients underwent bilateral LTx. Clamshell incision was performed in 12 (46%) patients. Moreover, LTx was possible without extracorporeal life support in 13 (50%) patients. 90-day mortality was 8% (n = 2) and the median survival was 8.7 years.

CONCLUSIONS

History of anatomical lung resection is rare in LTx candidates. The majority of patients are young and diagnosed with bronchiectasis. Although the numbers were limited, survival after LTx in patients with previous anatomical lung resection, including pneumonectomy is comparable to reported conventional LTx for bronchiectasis.

Lung Transplantation Long-term Survival is Worse in Patients Who Have Undergone Previous Cardiac Surgery

OBJECTIVE

Approximately 10% of lung transplant recipients have had previous cardiothoracic surgery. We sought to determine if previous surgery affects outcomes after lung transplant at a national level.

METHODS

The United Network for Organ Sharing database was analyzed from 2005-2019 to include adult patients who underwent lung transplant who had previous cardiac surgery, and previous thoracic surgery. T-test and chi-squared analysis was used to compare perioperative outcomes. Long-term survival comparison was performed using the Kaplan-Meier method in an unadjusted and propensity matched analysis.

RESULTS

Out of 24,784 lung transplants, 691 (2.7%) had previous cardiac surgery and 1,321 (6.5%) had previous thoracic surgery. Operative mortality was worse in previous cardiac surgery 42(6.1%) versus no previous cardiac surgery 740(3.1%), p < 0.001, and in previous thoracic surgery 65(4.9%) versus no previous thoracic surgery 717(3.1%), p < 0.001. The previous thoracic surgery group had more primary graft failure and treated rejection during the first-year post-transplant. There was no difference in stroke, dialysis, intubation and extracorporeal membrane oxygenation at 72 hours. Long-term survival was significantly worse for lung transplant patients who had undergone previous cardiac surgery (median 3.8 vs 6.3 years, p < 0.001) due to an increase in cardiovascular deaths (p = 0.008) and malignancy (p = 0.043). However, there was no difference in previous thoracic surgery (median 6.6 vs 6.1 years, p = 0.337).

CONCLUSIONS

Previous cardiac surgery prior to lung transplant results in worse survival related to cardiovascular death and malignancies. Previous thoracic surgery worsens perioperative outcomes but does not affect long term survival.

Bilateral sequential lung transplantation: technical aspects

The surgical technique for lung transplantation has evolved dramatically over the last three decades. Significant improvements in short term outcomes in the early years of lung transplantation were due, in large part, to techniques developed to reduce airway anastomotic complications in single lung transplantation. Following development of the technique of en bloc double lung transplantation, evolution to the bilateral sequential technique further reduced airway complications for double lung transplantation. More recently, some programs have utilized the en bloc double lung transplant technique with bronchial artery revascularization to aid airway healing and potentially improve short- and long-term outcomes. The experience with bronchial artery revascularization remains limited to a few series, with the technique having not been widely adopted by most lung transplant programs. With the implementation of priority allocations schemes in many countries, patients with higher risk profiles are being prioritized for transplantation which results in more complex procedures in fragile recipients with multiple comorbidities. This includes the increased need for concomitant cardiac procedures as well as performing lung transplantation after prior cardiothoracic surgery. Different surgical approaches have been described for bilateral sequential lung transplantation with or without intra-operative mechanical circulatory support (MCS), such as sternotomy, clamshell (bilateral anterior thoracotomies with transverse sternotomy), and bilateral thoracotomy incisions. Herein, we aim, not only to describe the various surgical approaches for double lung transplantation, but to provide a comprehensive review of other aspects related to the recipient pathology and different anatomical variants as well as handling technical challenges that might be encountered during the procedure.

A Case Report of Cystic Fibrosis Plus Tuberous Sclerosis: A Cautionary Tale Regarding Lung Transplantation

BACKGROUND

Cystic fibrosis (CF) and tuberous sclerosis complex (TSC) are 2 rare genetic diseases that often affect the lungs. Pulmonary compromise in TSC or CF can be severe enough to require lung transplantation. In rare instances patients with CF undergo pneumonectomy to control recurrent lung infections and lung necrosis affecting one lung more than the other. Lung transplantation in these patients is exceedingly rare because preexistent pneumonectomy increases the risk of lung transplant-associated morbidity and mortality.

CASE PRESENTATION

We present the case of a young woman with co-occurrence of TSC and CF, who underwent left-sided pneumonectomy and, approximately 2 years later, right-sided single lung transplant. The posttransplant clinical course was complicated by phrenic nerve injury, ventilator dependency, Aspergillus endocarditis with embolic shower, and death. Pretransplant pneumonectomy, Aspergillus colonization, and posttransplant phrenic nerve injury contributed to the complex postoperative course, ventilatory dependence, and poor outcome.

CONCLUSION

This cautionary case should alert physicians on the challenges associated with single lung transplant in patients with preexistent pneumonectomy.

Redo Heart Double-Lung Transplant in a Previous Double-Lung Transplant Recipient With Pneumonectomy: A Case Report

Placing a new donor lung into a postpneumonectomy pleural space has many potential surgical challenges. We report the technical challenges we faced in a case of a 42-year-old man who had initially undergone a double-lung transplant for idiopathic pulmonary arterial hypertension. Unfortunately, his left transplanted lung failed, which required a left pneumonectomy. Eight years later, his remaining right lung failed. He was evaluated and deemed suitable for retransplant. Our report presents the first successful redo heart double-lung transplant surgery preceded by pneumonectomy. There were significant technical intraoperative challenges; however, the procedure was performed successfully with an uneventful postoperative course and follow-up.

Successful Lung Transplantation in a Patient With History of Lobectomy for Small Cell Lung Cancer: A Case Report

A recent history of malignancy is an absolute contraindication for lung transplantation according to the International Society of Heart and Lung Transplantation; however, a 5-year disease-free interval should be demonstrated in most cases of malignancies to consider the patient a suitable recipient. Currently, no specific guidelines are reported for addressing previous lung cancer in the selection of recipients. We report a case of a patient who underwent right upper lobectomy for small cell lung cancer in 2013 followed by adjuvant chemotherapy and prophylactic encephalic radiotherapy. In 2019 she underwent lung transplantation for emphysema. Currently she is alive with no recurrence of neoplastic disease.

Combined Single Lung and Liver Transplantation in a Cystic Fibrosis Patient With Previous Contralateral Pneumonectomy: A Case Report

Combined lung-liver transplantation is a rare life-saving procedure to treat concomitant end-stage lung and liver failure. In this report, we describe the first published case of single lung and liver transplantation in a cystic fibrosis patient who had previously undergone a pneumonectomy for the treatment of an infected and destroyed right lung. We detail the lung first, sequential transplant procedure and surgical difficulties due to mediastinal shift. Emergent intraoperative renal replacement therapy was carried out before liver transplantation to overcome pulmonary edema in the transplanted lung. After fluid balance equilibration, liver transplantation was performed in good conditions. The patient is currently alive with no signs of rejection 8 years after the procedure.