Bilateral lung transplantation

Butler, J.E., A. Anand, M.R. Crawford, et al. 2001. Changes in respiratory sensations induced by lobeUne after human bilateral lung transplantation. /. Physiol. 534(Pt. 2) 583-593. 

Lung or heart-lung transplantation has been performed for refractory PAP, but data are limited to case reports (105,106) and a small series in infants (n = 3) (107). Recurrent (and ultimately fatal) PAP developed in a child with lysinuric protein intolerance and PAP within 18 months of heart-lung transplantation (105). In an adult who underwent bilateral lung transplant for refractory PAP, the... 

ScHULMAN et al. (1997) published two cases of pulmonary tuberculosis, both 3 months after bilateral lung transplantation, and found radiographically a narrowing of the middle lobe bronchus of the right lung caused by an endobronchial granulomatous mass (n=l) and a focal cluster of small nodules in the upper lobe of the left lung and small bilateral pleural effusions (n=l). 

The most common airway problems are anastomotic dehiscence and bronchial stenosis due to strictures. The reason is mostly a lack of perfusion of the bronchial tree, as the donor airways depend on a retrograde pulmonary-to-bronchial arterial circulation until revascularization of the bronchus wall occurs. Ischaemia is greater on the right main bronchus than on the left, therefore anastomotic healing is better on the left and early stenotic problems or dehiscence occur on the right anastomosis more frequently than on the left side. In the early years of transplantation the en bloc technique was mainly performed with a high incidence of tracheal dehiscence, which prompted the development of bilateral lung transplantation. 

A 51-year-old man underwent double lung transplantation for pulmonary fibrosis, accidentally received an infusion of ciclosporin 30 mg/hour instead of 3 mg/hour, and 3 hours later had bilateral reactive mydriasis and absence of tendon reflexes. A CT brain scan showed diffuse cerebral edema, and massive intracranial hjrpertension rapidly developed. He died 5 hours later from brainstem compression, and pathological examination showed diffuse cerebral edema with neuronal necrosis. 

LT (either single or bilateral) is a viable option for patients with end-stage pulmonary sarcoidosis refractory to medical therapy (113,198-200). From January 1995 to June 2006, 438 adults worldwide had received lung transplants for sarcoidosis (201). Long-term survival rates following LT for sarcoidosis are generally similar to other indications (198). However, in a retrospective review of U.S. data from 1995 to 2000, 30-day survival post-LT was 83% among 133 patients with sarcoidosis compared to 91% with other conditions... 

LT is the best therapeutic option for patients with IPF with life-threatening disease (208-210). Since no medical therapies have been proven to influence survival in IPF, IPF patients should be referred to LT centers at the time of diagnosis (provided no contraindications exist). The decision to list for LT is best made by the local transplant team members, who are familiar with local waiting times. Either single (SLT) or bilateral sequential lung transplantation (BSLT) can be performed (208,209,211). Data from the International Society for Heart and Lung Transplantation (ISHLT) Registry reported that 19% of >17,000 LTs... 

In 1983 the Toronto Lung Transplant Group (1986) performed the first single-lung transplantations for patients with end-stage chronic obstructive pulmonary disease and advanced pulmonary fibrosis. Their technique was later expanded to bilateral sequential single-lung transplantation for patients with bronchiectasis and cystic fibrosis. 

Sheridan et al. (1995) evaluated 27 lung transplant recipients and found 8 with phrenic nerve injury, an incidence of 30%. An increased hospital stay was noted in these patients. In most cases, the event occurred in patients with bilateral LuTX and had little impact on lung function. 

The incidence of pulmonary tuberculosis after lung transplantation is estimated to be between 2% and 3.8% (Kesten and Chaparro 1999 Schulman et al. 1997). The transmission of pulmonary tuberculosis after lung transplantation is probably via the donor allograft (Collins 2002). The infection typically occurs 1.5-9 months after surgery. CT finding are nonspecific and include subtle bronchial narrowing, pleural effusions and bilateral small nodules, multiple bilateral upper and lower lobe cavitary lesions... 

Artemiou O, Birsan T, Taghavi S, Eichler I, Wisser W, Wolner E, Klepetko W (1999) Bilateral lobar transplantation with the split lung technique. JThorac Cardiovasc Surg 118 369-370... 

Calabrese F, Giacometti C, Rea F, Loy M, Sartori F, Di Vittorio G, Abudureheman A, Thiene G, Valente M (2002) Recurrence of idiopathic pulmonary hemosiderosis in a young adult patient after bilateral single-lung transplantation. Transplantation 74 1643-1645... 

A 44-year-old woman received interferon alfa 6 MU/ day for relapse of chronic myeloid leukemia 7 years after successful bone marrow transplantation. About 2 years later, interferon alfa was withdrawn because of diffuse erythematous skin lesions with discoid lupus erythematosus on skin biopsy and severe dysphagia with esophagitis and pseudomembranes at endoscopy. Fever, bilateral pulmonary infiltrates, and respiratory distress syndrome subsequently developed, and she required mechanical ventilation. An open lung biopsy showed features of chronic pulmonary graft-versus-host disease. All her symptoms completely resolved with ciclosporin and corticosteroids. An infectious cause was ruled out. 

Fig. 6.2.5. Parainfluenza 3 infection in a 60-year-old man who had severe neutropenia secondary to chemotherapy and HSC transplant for myelodysplastic syndrome. Transverse thin-section (1-mm collimation, lung window) CT scan at the level of the aortic arch shows bilateral areas of ground-glass opacity in the upper lobes...

Fig. 6.2.18a,b. Organizing pneumonia after allogeneic HSC transplantation, a HRCT scan at the level of lower lung zones shows bilateral patchy areas of consolidation in a predominantly peribronchial distribution, b Photomicrograph shows the presence of fibroblastic tissue in the lumens of peribronchial alveoli (arrows). (H and E, xlOO) (with permission from Franquet et al. 2005a)... 

---