Indications of thoracic transplantation
- Single lung transplant
- Pulmonary fibrosis
- Emphysema
- Primary pulmonary hypertension
- Double lung transplants
- Septic lung disease
- Cystic fibrosis
- Bronchiectasis
- Emphysema
- Primary pulmonary hypertension
- Heart / Lung transplant
- Irreversible disease of both heart and lung
Donor Selection
- Age <60 years
- No history of pulmonary disease
- Smoking history < 20 packs/ year
- Normal chest x-ray
- Adequate gas exchange
- Normal bronchoscopy
- Acceptable sputum gram stain
- Adequate size matching
Recipient selection
- Factors to consider include:
- Age <65
- Other disease processes
- Previous surgery
- Steroids
- Smoking
- Nutrition
- Ventilator dependence
- Psychosocial factors
Lung preservation
- Hypothermia
- Lung inflation
- Pulmonary artery vasodilatation- PGE1
- Pulmonary artery flush with
- Modified eurocollins solution
- Belzer's (Wisconsin) solution
- Low potassium Dextran
- Free radical scavengers
Surgery
Donor lung extraction
- Surgery is performed as follows
- Median sternotomy
- Isolate SVC and IVC
- Separate aorta and pulmonary artery
- Cannulate aorta and distal pulmonary artery
- Incise posterior pericardium and expose distal trachea
- Flush the graft, transect IVC and cross clamp aorta
- Administer cardioplegia
- Amputate tip of LA appendage and flush lungs
- Flood chest w/ iced saline and ventilate with 100% O2
- Extract heart by transecting SVC, IVC and aorta
- LA incision is last, leaving a cuff of atrium
- Extract lungs by dividing trachea
- Transect descending thoracic aorta
Lung transplantation procedure
- For single lung transplantation - posterolateral thoracotomy
- For bilateral lung transplantation - bilateral transverse
thoracosternotomy (“clamshell”)
- Divide pulmonary artery branch between ligatures and then staple the
PA trunk
- Mobilize both pulmonary veins intrapericardially
- Transect bronchus
- Topical cooling with iced gauze around graft
- Bronchial anastomosis
- Pulmonary artery and venous anastomosis
Complications
- Early complications include:
- Reperfusion pulmonary oedema
- Primary graft failure
- Haemorrhage
- Bronchial dehiscence
- Non-infectious pleural space problems
- Bronchiolitis obliterans
- Primary factor limiting long-term survival
- Exact etiology unknown (chronic rejection/infection)
- Most important cause of mortality and morbidity after lung
transplantation
- Affects 50% of long-term survivors
- 50% will respond to enhanced immunosuppression
- The remainder will have progressive deterioration of lung function
Outcome
- Outcome depends on:
- Indication for surgery
- Single or bilateral lung transplantation
- One year survival for:
- Single transplant is about 70%
- Bilateral transplant is about 40%
Bibliography
Al-Githmi I, Batawil N, Shigemura N et al.
Bronchiolitis obliterans following lung transplantation. Eur J
Cardiothorac Surg 2006; 30: 841-851.
Huddleston C B. Pediatric lung transplantation. Semin
Pediatr Surg 2006; 15: 199-207 |