- Email: [email protected]
Bilateral lobar transplants using one donor for two small size recipients
Journal Pre-proof Bilateral lobar transplants using one donor for two small size recipients Pedro Reck dos Santos, MD, Jonathan Yeung, MD, Bruno Andrade, MD, Jeremie Reeb, MD, Hironobu Wada, MD, Shaf Keshavjee, MD, Marcelo Cypel, MD PII:
S0003-4975(19)31469-9
DOI:
https://doi.org/10.1016/j.athoracsur.2019.08.078
Reference:
ATS 33101
To appear in:
The Annals of Thoracic Surgery
Received Date: 11 August 2019 Accepted Date: 17 August 2019
Please cite this article as: dos Santos PR, Yeung J, Andrade B, Reeb J, Wada H, Keshavjee S, Cypel M, Bilateral lobar transplants using one donor for two small size recipients, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.08.078. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
Bilateral lobar transplants using one donor for two small size recipients. Running Head: cadaveric lobar lung transplantation
Pedro Reck dos Santos MD, Jonathan Yeung MD, Bruno Andrade MD, Jeremie Reeb MD, Hironobu Wada MD, Shaf Keshavjee MD, Marcelo Cypel MD.
Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
Word count: 1500
Corresponding author: Pedro Reck dos Santos MD. Division of Cardiothoracic Surgery, University of Pittsburgh. 200 Lothrop St, C922, Pittsburgh, PA, 15213. Email: [email protected]
1
Abstract Cadaveric lobar lung transplantation (LTx) is an alternative for patients whose chest cavities have small dimensions. We present here a case where one donor was used for bilateral lobar transplantations in two high-risk patients. Coordination between the graft preparation at the back table and the two concomitant LTx teams were necessary to minimize the ischemic injury of the grafts as well as to plan for adequate vascular and bronchial cuffs for both implantations.
2
Lung Transplantation (LTx) is a definitive treatment for patients with end stage lung disease, but unfortunately the number of donors does not meet recipient demand. Consequently, strategies have been developed to increase the pool of donors available. It remains particularly challenging to find suitable donors for patients whose chest cavity is small such as children and small adults. In order to increase the number of donors for these patients, techniques for the resection of peripheral segments and for lobar transplantation from cadaveric or living donors have been described(1). In conventional cadaveric lobar transplantation, a lobe or bi-lobe from each donor lung is chosen for each side of the recipient, isolated at the back table (BT), and the remaining lobe(s) discarded (2). The use of a single donor for two recipients who need bilateral transplants is consequently more complex due to the technical challenges in preparing of the lobes at the BT and assuring adequate vascular cuffs for both lobes. We herein describe a case where lungs from a single donor were split and used for two high-risk recipients who received bilateral lobar transplants. Case Reports Donor Our program was notified about a 39 year-old brain dead donor with a total lung capacity (TLC) of 8.75 liters. Due to size of the lungs and the urgency of the recipients, two small recipients (predicted TLC of 4.3 and 4.14 liters) eligible for bilateral LTx were chosen. Lungs were procured as per our usual protocol. Starting with the BT preparation of the right lung, we first focused on the dissection and isolation of the pulmonary artery (PA) within the major fissure. Special attention was made in dividing the interlobar PA a few millimeters before the origin of the branches to the right lower lobe (RLL) as shown in Figure 1A. The atrial cuff (AC) was divided between the upper and lower pulmonary veins (Figure 1B). The bronchial division was performed at the moment when the right pneumonectomies were concluded on both recipients in order to keep the
3
donor lung inflated as long as possible. The division of the bronchus for the RLL was done at the level of the origin of the middle lobe (RML) and we decided not to use the RML. The right upper lobe (RUL) bronchus was divided at its junction with the bronchus intermedius (Figure 1C). Implantation of the RUL in one recipient and the RLL in the other were performed in a standard fashion. After both right-sided implants were concluded, we then proceeded to the left pneumonectomies of the recipients. Again, in preparation of the left lung, we started by dissecting the PA in the fissure and identified the area above the origin of the branches for the left lower lobe (LLL)(Figure 2A). It is particularly important to divide the PA between the lingular branches and the superior segmental artery to the LLL. The distal PA stump of the left upper lobe (LUL) was closed with a running suture (Figure 2B). The AC was divided between the LUL and LLL pulmonary veins (Figure 2C). Here, considering the length of the left main bronchus, we decided to carefully identify the interlobar carina, without excessive dissection of the upper and lower peribronchial tissue (Figure 2D). The bronchus was opened exactly at the interlobar carina (Figure 2E), generating two bronchial cuffs ready to be anastomosed (Figure 2F). Recipient Recipient 1 was a 55-year old female, listed under Canadian status 3 (rapidly deteriorating), with pulmonary veno-occlusive disease and pulmonary hypertension. TLC of 4.3 liters, PA pressures of 100/60 mmHg, PRA negative. During induction of anesthesia, patient had severe hemodynamic decompensation with supra systemic levels of PA pressures, requiring emergency chest opening and installation of central Veno-Arterial Extra Corporeal Life Support (VA ECLS). The transplant (RLL and LUL) was performed without other problems and weaning of VA ECLS was possible without difficulties using 20 ppm of inhaled nitric oxide (iNO). Immunosuppression was maintained with Cyclosporine, Azathioprine and steroids. The postoperative period was complicated by cardiac decompensation due to a
4
hyper dynamic right ventricle and diastolic dysfunction of the left ventricle, requiring emergency installation of femoral VA ECLS at day 3. Following weaning of VA ECLS 4 days later, she recovered and continues to do well 3 years after LTx. Recipient 2 was 63 years old, female, listed under Canadian status 2 with pulmonary fibrosis. TLC of 4.14 liters, PA pressures of 35/14 mmHg, PRA class I 11%,class II negative. Transplant (RUL and LLL) was performed on central VA ECLS, which was weaned at the end of the case with the aid of iNO. Immunosuppression was Cyclosporine, MMF and Steroids. Post-operative period was uneventful, and patient is doing well at home 3 years after LTx. Figure 3 shows Chest X-Rays at ICU admission and at 1-year follow up of both recipients. Comment Recipients with small TLC are a challenging population due to the scarcity of donors available and lobar LTx can help overcome this problem. The living lobar LTx can achieve very good results, but there is risk to healthy living donors (3). Cadaveric lobar LTx have been performed worldwide with satisfactory results (4). However, use of a single donor for double lung lobar transplants in two recipients is a technique rarely employed due to the technical complexity and invariably transplantable lung tissue is wasted(5). In the case described here, many challenging steps were identified. First, the implantation of the lobes is complex due to the restricted length of vascular and bronchial cuffs available. Second, the BT procedure requires a meticulous dissection for the proper preparation of the grafts. Additionally, a perfect synchronization between the BT and the two transplant teams is essential in order to minimize the cold ischemic injury. In our cases, there was additional complexity due to the high-risk nature of our recipients, especially the patient with pulmonary hypertension. We believe that intraoperative VA ECLS is critically important, protecting the grafts during the implantation of the second lobe, where the first graft (with its restricted vascular bed) is
5
subjected to the entire cardiac output (6). We currently perform all our lobar transplants on central VA ECLS. In summary, size reduction of lungs is important to increase the chances of patients with small chest cavities who are waiting for a transplant. The use of a single donor for two bilateral lobar transplants is a very complex and demanding procedure, which should be performed in experienced centers but should carefully be considered to maximize lung utilization.
6
References: 1.
De Perrot M, Weder W, Patterson GA, Keshavjee S. Strategies to increase limited
donor resources. Eur Respir J. 2004 Mar 1;23(3):477–82. 2.
Mitilian D, Sage E, Puyo P, et al. Techniques and results of lobar lung
transplantations. Eur J Cardiothorac Surg. 2014 Jan 13;45(2):365–70. 3.
Date H. Update on living-donor lobar lung transplantation. Current Opinion in Organ
Transplantation. 2011 Oct;16(5):453–7. 4.
Mahesh B, Bhama JK, Odell DD, et al. Surgical Strategy for Lung Transplantation in
Adults With Small Chests: Lobar Transplant Versus a Pediatric Donor. Transplantation. 2016 Jan 12. 5.
Inci I, Benden C, Kestenholz P, et al. Simultaneous Bilateral Lobar Lung
Transplantation: One Donor Serves Two Recipients. Ann Thorac Surg. 2013 Sep 1;96(3):e69–e71. 6.
Machuca TN, Collaud S, Mercier O, et al. Outcomes of intraoperative extracorporeal
membrane oxygenation versus cardiopulmonary bypass for lung transplantation. J Thorac Cardiovasc Surg. 2014 Nov 21.
7
Figure Legends: Figure 1. Preparation of the right lung with isolation of the PA within the major fissure (A), division of the AC between the lower (green arrow) and upper (blue arrow) veins (B) and section of the RUL bronchus at its junction with the bronchus intermedius (C). Figure 2. Preparation of the left lung with dissection of the PA within the fissure, where length is important(A), enabling a LLL arterial cuff(B). The AC is divided between upper (blue arrow) and lower (green arrow) veins(C). Dissection of the interlobar carina(D). After opening of the bronchus(E), bronchial cuffs are ready for anastomosis(F). Figure 3. Chest X-Rays at ICU arrival of Patient 1(A) and Patient 2(B) and at 1-year follow-up of each respective patient (C,D).
8
S0003-4975(19)31469-9
DOI:
https://doi.org/10.1016/j.athoracsur.2019.08.078
Reference:
ATS 33101
To appear in:
The Annals of Thoracic Surgery
Received Date: 11 August 2019 Accepted Date: 17 August 2019
Please cite this article as: dos Santos PR, Yeung J, Andrade B, Reeb J, Wada H, Keshavjee S, Cypel M, Bilateral lobar transplants using one donor for two small size recipients, The Annals of Thoracic Surgery (2019), doi: https://doi.org/10.1016/j.athoracsur.2019.08.078. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 by The Society of Thoracic Surgeons
Bilateral lobar transplants using one donor for two small size recipients. Running Head: cadaveric lobar lung transplantation
Pedro Reck dos Santos MD, Jonathan Yeung MD, Bruno Andrade MD, Jeremie Reeb MD, Hironobu Wada MD, Shaf Keshavjee MD, Marcelo Cypel MD.
Toronto Lung Transplant Program, University Health Network, Toronto, ON, Canada
Word count: 1500
Corresponding author: Pedro Reck dos Santos MD. Division of Cardiothoracic Surgery, University of Pittsburgh. 200 Lothrop St, C922, Pittsburgh, PA, 15213. Email: [email protected]
1
Abstract Cadaveric lobar lung transplantation (LTx) is an alternative for patients whose chest cavities have small dimensions. We present here a case where one donor was used for bilateral lobar transplantations in two high-risk patients. Coordination between the graft preparation at the back table and the two concomitant LTx teams were necessary to minimize the ischemic injury of the grafts as well as to plan for adequate vascular and bronchial cuffs for both implantations.
2
Lung Transplantation (LTx) is a definitive treatment for patients with end stage lung disease, but unfortunately the number of donors does not meet recipient demand. Consequently, strategies have been developed to increase the pool of donors available. It remains particularly challenging to find suitable donors for patients whose chest cavity is small such as children and small adults. In order to increase the number of donors for these patients, techniques for the resection of peripheral segments and for lobar transplantation from cadaveric or living donors have been described(1). In conventional cadaveric lobar transplantation, a lobe or bi-lobe from each donor lung is chosen for each side of the recipient, isolated at the back table (BT), and the remaining lobe(s) discarded (2). The use of a single donor for two recipients who need bilateral transplants is consequently more complex due to the technical challenges in preparing of the lobes at the BT and assuring adequate vascular cuffs for both lobes. We herein describe a case where lungs from a single donor were split and used for two high-risk recipients who received bilateral lobar transplants. Case Reports Donor Our program was notified about a 39 year-old brain dead donor with a total lung capacity (TLC) of 8.75 liters. Due to size of the lungs and the urgency of the recipients, two small recipients (predicted TLC of 4.3 and 4.14 liters) eligible for bilateral LTx were chosen. Lungs were procured as per our usual protocol. Starting with the BT preparation of the right lung, we first focused on the dissection and isolation of the pulmonary artery (PA) within the major fissure. Special attention was made in dividing the interlobar PA a few millimeters before the origin of the branches to the right lower lobe (RLL) as shown in Figure 1A. The atrial cuff (AC) was divided between the upper and lower pulmonary veins (Figure 1B). The bronchial division was performed at the moment when the right pneumonectomies were concluded on both recipients in order to keep the
3
donor lung inflated as long as possible. The division of the bronchus for the RLL was done at the level of the origin of the middle lobe (RML) and we decided not to use the RML. The right upper lobe (RUL) bronchus was divided at its junction with the bronchus intermedius (Figure 1C). Implantation of the RUL in one recipient and the RLL in the other were performed in a standard fashion. After both right-sided implants were concluded, we then proceeded to the left pneumonectomies of the recipients. Again, in preparation of the left lung, we started by dissecting the PA in the fissure and identified the area above the origin of the branches for the left lower lobe (LLL)(Figure 2A). It is particularly important to divide the PA between the lingular branches and the superior segmental artery to the LLL. The distal PA stump of the left upper lobe (LUL) was closed with a running suture (Figure 2B). The AC was divided between the LUL and LLL pulmonary veins (Figure 2C). Here, considering the length of the left main bronchus, we decided to carefully identify the interlobar carina, without excessive dissection of the upper and lower peribronchial tissue (Figure 2D). The bronchus was opened exactly at the interlobar carina (Figure 2E), generating two bronchial cuffs ready to be anastomosed (Figure 2F). Recipient Recipient 1 was a 55-year old female, listed under Canadian status 3 (rapidly deteriorating), with pulmonary veno-occlusive disease and pulmonary hypertension. TLC of 4.3 liters, PA pressures of 100/60 mmHg, PRA negative. During induction of anesthesia, patient had severe hemodynamic decompensation with supra systemic levels of PA pressures, requiring emergency chest opening and installation of central Veno-Arterial Extra Corporeal Life Support (VA ECLS). The transplant (RLL and LUL) was performed without other problems and weaning of VA ECLS was possible without difficulties using 20 ppm of inhaled nitric oxide (iNO). Immunosuppression was maintained with Cyclosporine, Azathioprine and steroids. The postoperative period was complicated by cardiac decompensation due to a
4
hyper dynamic right ventricle and diastolic dysfunction of the left ventricle, requiring emergency installation of femoral VA ECLS at day 3. Following weaning of VA ECLS 4 days later, she recovered and continues to do well 3 years after LTx. Recipient 2 was 63 years old, female, listed under Canadian status 2 with pulmonary fibrosis. TLC of 4.14 liters, PA pressures of 35/14 mmHg, PRA class I 11%,class II negative. Transplant (RUL and LLL) was performed on central VA ECLS, which was weaned at the end of the case with the aid of iNO. Immunosuppression was Cyclosporine, MMF and Steroids. Post-operative period was uneventful, and patient is doing well at home 3 years after LTx. Figure 3 shows Chest X-Rays at ICU admission and at 1-year follow up of both recipients. Comment Recipients with small TLC are a challenging population due to the scarcity of donors available and lobar LTx can help overcome this problem. The living lobar LTx can achieve very good results, but there is risk to healthy living donors (3). Cadaveric lobar LTx have been performed worldwide with satisfactory results (4). However, use of a single donor for double lung lobar transplants in two recipients is a technique rarely employed due to the technical complexity and invariably transplantable lung tissue is wasted(5). In the case described here, many challenging steps were identified. First, the implantation of the lobes is complex due to the restricted length of vascular and bronchial cuffs available. Second, the BT procedure requires a meticulous dissection for the proper preparation of the grafts. Additionally, a perfect synchronization between the BT and the two transplant teams is essential in order to minimize the cold ischemic injury. In our cases, there was additional complexity due to the high-risk nature of our recipients, especially the patient with pulmonary hypertension. We believe that intraoperative VA ECLS is critically important, protecting the grafts during the implantation of the second lobe, where the first graft (with its restricted vascular bed) is
5
subjected to the entire cardiac output (6). We currently perform all our lobar transplants on central VA ECLS. In summary, size reduction of lungs is important to increase the chances of patients with small chest cavities who are waiting for a transplant. The use of a single donor for two bilateral lobar transplants is a very complex and demanding procedure, which should be performed in experienced centers but should carefully be considered to maximize lung utilization.
6
References: 1.
De Perrot M, Weder W, Patterson GA, Keshavjee S. Strategies to increase limited
donor resources. Eur Respir J. 2004 Mar 1;23(3):477–82. 2.
Mitilian D, Sage E, Puyo P, et al. Techniques and results of lobar lung
transplantations. Eur J Cardiothorac Surg. 2014 Jan 13;45(2):365–70. 3.
Date H. Update on living-donor lobar lung transplantation. Current Opinion in Organ
Transplantation. 2011 Oct;16(5):453–7. 4.
Mahesh B, Bhama JK, Odell DD, et al. Surgical Strategy for Lung Transplantation in
Adults With Small Chests: Lobar Transplant Versus a Pediatric Donor. Transplantation. 2016 Jan 12. 5.
Inci I, Benden C, Kestenholz P, et al. Simultaneous Bilateral Lobar Lung
Transplantation: One Donor Serves Two Recipients. Ann Thorac Surg. 2013 Sep 1;96(3):e69–e71. 6.
Machuca TN, Collaud S, Mercier O, et al. Outcomes of intraoperative extracorporeal
membrane oxygenation versus cardiopulmonary bypass for lung transplantation. J Thorac Cardiovasc Surg. 2014 Nov 21.
7
Figure Legends: Figure 1. Preparation of the right lung with isolation of the PA within the major fissure (A), division of the AC between the lower (green arrow) and upper (blue arrow) veins (B) and section of the RUL bronchus at its junction with the bronchus intermedius (C). Figure 2. Preparation of the left lung with dissection of the PA within the fissure, where length is important(A), enabling a LLL arterial cuff(B). The AC is divided between upper (blue arrow) and lower (green arrow) veins(C). Dissection of the interlobar carina(D). After opening of the bronchus(E), bronchial cuffs are ready for anastomosis(F). Figure 3. Chest X-Rays at ICU arrival of Patient 1(A) and Patient 2(B) and at 1-year follow-up of each respective patient (C,D).
8