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Remembering en bloc double-lung transplantation
Comments and Opinions the transplanted and explanted hearts did not show T cruzi forms. Despite starting benznidazole on Day 46), her clinical condition worsened, skin lesions became bullous and necrotic (Fig 1, center), and hemophagocytic syndrome developed. She died on Day 53 of multiple organ failure associated with refractory shock and Serratia marcescens bacteriemia. Autopsy did not show graft rejection. T cruzi reactivation affects 27% to 90% of Chagasic heart recipients, usually within 1 to 24 months postoperatively, and most recipients suffer 2 or more episodes.2,3 Benznidazole prophylaxis before or after transplant does not prevent reactivation.2,5 This patient’s fatally delayed diagnosis has several causes. Chagas disease is still rare in Europe, and clinicians are not familiar with its presentation. Most patients present as asymptomatic or with mild cardiomyopathy. In Europe, Latino American immigrants may consult under a second nationality (Spain, Portugal), thus blinding clinicians to epidemiologic clues on the risk of Chagas disease. Recent guidelines recommend that screening in organ donors should be considered in regions harboring significant populations of immigrants at risk.5 Considering this emerging problem, we recommend measures to be taken in Europe: 1. improving and disseminating information on Chagas disease to health professionals concerned with organ transplantation, highlighting the risk of reactivation in Latino recipients and of transmission by donors with risk factors; 2. ensuring that diagnostic tools are available in centers performing organ transplantation or in national reference laboratories; and 3. screening for T cruzi infection in all candidates for heart transplant with cardiomyopathy of unknown origin, ventricular aneurysm, and normal coronary artery angiogram.
Disclosure statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose. The authors acknowledge the help of A. Moore (Centers for Disease Control and Prevention), J. Jannin (World Health Organization), S. Rotman, S. De Vallière, I. Letovanec, G. Greub, C. Seydoux, E. Laffitte, J. Bille, P. Tozzi, J-P Revelly (Lausanne), and F. Chappuis (Geneva) in collecting data and supervising the redaction of this article.
References 1. World Health Organization. Chagas disease in Europe. Neglected tropical diseases; 2010. http://www.who.int/neglected_diseases/integrated_ media_chagas_statement/en/index.html. Accessed: July 22, 2010. 2. Bestetti RB, Theodoropoulos TA. A systematic review of studies on heart transplantation for patients with end-stage Chagas’ heart disease. J Card Fail 2009;15:249-55. 3. Bocchi EA, Fiorelli A. The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology. Ann Thorac Surg 2001;71:1833-8.
485 4. Campos SV, Strabelli TM, Amato Neto V, et al. Risk factors for Chagas’ disease reactivation after heart transplantation. J Heart Lung Transplant 2008;27:597-602. 5. Kotton CN, Lattes R. Parasitic infections in solid organ transplant recipients. Am J Transplant 2009;9(suppl 4):S234-51.
Remembering en bloc double-lung transplantation Masaki Anraku, MD, Cheryl Volling, BSc, Andrew Pierre, MD Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Onario, Canada
To the Editor: The technique of en bloc double-lung transplantation was developed using a canine model,1,2 and was first used for clinical lung transplantation by the Toronto Group in 1986.3 At the time, the en bloc technique allowed double-lung transplanation with much shorter ischemic times than what a sequential bilateral technique would be expected to produce. Bronchial anastomotic problems were a major issue in 1986 and ischemic time was considered to be a significant contributing factor. However, the en bloc technique requires cardiopulmonary bypass and cardioplegia in every case, and it was believed that donor bronchial collateral blood supply to the anastomosis would be better in the sequential bilateral technique. Improved lung preservation would also allow longer ischemic times and, by 1990, the en bloc operation was forgotten and replaced by the sequential bilateral technique. Despite being replaced, the en bloc double-lung transplant technique is worth remembering. It can still be used today in select cases to deal with central airway and pulmonary artery problems. Unexpected carinal or left mainstem airway problems, or central pulmonary artery anomalies, may make sequential bilateral lung transplantation technically complex and/or with increasingly high risk for complications. En bloc double-lung transplantation may overcome these technical complexities and reduce the risks in these particular cases. Recently, we performed 2 en bloc double-lung transplantation procedures for: (1) a patient with an endotracheal intubation–related tear of the carina and left mainstem bronchus; and (2) a patient with complex congenital heart disease with hemitruncus arteriosus to the right lung and a large patent ductus arteriosus to the left lung. En bloc lung transplantation handled all the technical problems in both patients, resulting in good outcomes. Figure 1A shows the preparation of the donor lung block, which was flushed and procured in standard fashion. The trachea is opened just above the carina, the main pulmonary artery is trimmed as needed, and the entire left atrial cuff is left intact for the atrial anastomosis. Figure 1B shows the position of the heart lifted upward, and how the donor right lung is passed underneath the right atrium/ right phrenic nerve into the empty hemithorax, and the left donor lung is passed under the left phrenic nerve/pericardial window into the left hemithorax. The tracheal anastomosis is performed first, followed by the left atrium and then the main pulmonary artery.
486
The Journal of Heart and Lung Transplantation, Vol 30, No 4, April 2011 cross-clamp time can also be minimized by mobilizing the entire left atrium intact and keeping it closed while tracheal anastomosis is performed. In conclusion, it is worth remembering the en bloc double-lung transplant technique to deal with select central airway problems or central pulmonary artery anomalies. The 2 patients in this report had no acute or delayed tracheal anastomotic complications and are presently alive and well.
Disclosure statement Figure 1 En bloc double-lung transplantation. Arrows labeled As and Bs in (A) and (B) correspond to the way in which to place the donor lungs into each pleural space. (A) The donor lungs prepared in en bloc fashion. (B) The recipient heart is lifted upward to allow the pair of donor lungs to be placed through pericardial windows created on both the right and left sides.
Lung preservation methods have improved significantly since 1986 and we found no tracheal anastomotic problems using the en bloc technique. Only 3 anastomoses are required and cardiopulmonary bypass times are shorter than the average times for sequential lung transplants. Aortic
The authors have no conflicts of interest to disclose.
References 1. Vanderhoeft P, Dubois A, Lauvau N, et al. Block allotransplantation of both lungs with pulmonary trunk and left atrium in dogs. Thorax 1972;27:415-9. 2. Dark JH, Patterson GA, Al-Jilaihawi AN, et al. Experimental en bloc double-lung transplantation. Ann Thorac Surg 1986;42:394-8. 3. Cooper JD, Patterson GA, Grossman R, et al. Double-lung transplant for advanced chronic obstructive lung disease. Am Rev Respir Dis 1989;139: 303-7.
Disclosure statement None of the authors has a financial relationship with a commercial entity that has an interest in the subject of the presented manuscript or other conflicts of interest to disclose. The authors acknowledge the help of A. Moore (Centers for Disease Control and Prevention), J. Jannin (World Health Organization), S. Rotman, S. De Vallière, I. Letovanec, G. Greub, C. Seydoux, E. Laffitte, J. Bille, P. Tozzi, J-P Revelly (Lausanne), and F. Chappuis (Geneva) in collecting data and supervising the redaction of this article.
References 1. World Health Organization. Chagas disease in Europe. Neglected tropical diseases; 2010. http://www.who.int/neglected_diseases/integrated_ media_chagas_statement/en/index.html. Accessed: July 22, 2010. 2. Bestetti RB, Theodoropoulos TA. A systematic review of studies on heart transplantation for patients with end-stage Chagas’ heart disease. J Card Fail 2009;15:249-55. 3. Bocchi EA, Fiorelli A. The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology. Ann Thorac Surg 2001;71:1833-8.
485 4. Campos SV, Strabelli TM, Amato Neto V, et al. Risk factors for Chagas’ disease reactivation after heart transplantation. J Heart Lung Transplant 2008;27:597-602. 5. Kotton CN, Lattes R. Parasitic infections in solid organ transplant recipients. Am J Transplant 2009;9(suppl 4):S234-51.
Remembering en bloc double-lung transplantation Masaki Anraku, MD, Cheryl Volling, BSc, Andrew Pierre, MD Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Onario, Canada
To the Editor: The technique of en bloc double-lung transplantation was developed using a canine model,1,2 and was first used for clinical lung transplantation by the Toronto Group in 1986.3 At the time, the en bloc technique allowed double-lung transplanation with much shorter ischemic times than what a sequential bilateral technique would be expected to produce. Bronchial anastomotic problems were a major issue in 1986 and ischemic time was considered to be a significant contributing factor. However, the en bloc technique requires cardiopulmonary bypass and cardioplegia in every case, and it was believed that donor bronchial collateral blood supply to the anastomosis would be better in the sequential bilateral technique. Improved lung preservation would also allow longer ischemic times and, by 1990, the en bloc operation was forgotten and replaced by the sequential bilateral technique. Despite being replaced, the en bloc double-lung transplant technique is worth remembering. It can still be used today in select cases to deal with central airway and pulmonary artery problems. Unexpected carinal or left mainstem airway problems, or central pulmonary artery anomalies, may make sequential bilateral lung transplantation technically complex and/or with increasingly high risk for complications. En bloc double-lung transplantation may overcome these technical complexities and reduce the risks in these particular cases. Recently, we performed 2 en bloc double-lung transplantation procedures for: (1) a patient with an endotracheal intubation–related tear of the carina and left mainstem bronchus; and (2) a patient with complex congenital heart disease with hemitruncus arteriosus to the right lung and a large patent ductus arteriosus to the left lung. En bloc lung transplantation handled all the technical problems in both patients, resulting in good outcomes. Figure 1A shows the preparation of the donor lung block, which was flushed and procured in standard fashion. The trachea is opened just above the carina, the main pulmonary artery is trimmed as needed, and the entire left atrial cuff is left intact for the atrial anastomosis. Figure 1B shows the position of the heart lifted upward, and how the donor right lung is passed underneath the right atrium/ right phrenic nerve into the empty hemithorax, and the left donor lung is passed under the left phrenic nerve/pericardial window into the left hemithorax. The tracheal anastomosis is performed first, followed by the left atrium and then the main pulmonary artery.
486
The Journal of Heart and Lung Transplantation, Vol 30, No 4, April 2011 cross-clamp time can also be minimized by mobilizing the entire left atrium intact and keeping it closed while tracheal anastomosis is performed. In conclusion, it is worth remembering the en bloc double-lung transplant technique to deal with select central airway problems or central pulmonary artery anomalies. The 2 patients in this report had no acute or delayed tracheal anastomotic complications and are presently alive and well.
Disclosure statement Figure 1 En bloc double-lung transplantation. Arrows labeled As and Bs in (A) and (B) correspond to the way in which to place the donor lungs into each pleural space. (A) The donor lungs prepared in en bloc fashion. (B) The recipient heart is lifted upward to allow the pair of donor lungs to be placed through pericardial windows created on both the right and left sides.
Lung preservation methods have improved significantly since 1986 and we found no tracheal anastomotic problems using the en bloc technique. Only 3 anastomoses are required and cardiopulmonary bypass times are shorter than the average times for sequential lung transplants. Aortic
The authors have no conflicts of interest to disclose.
References 1. Vanderhoeft P, Dubois A, Lauvau N, et al. Block allotransplantation of both lungs with pulmonary trunk and left atrium in dogs. Thorax 1972;27:415-9. 2. Dark JH, Patterson GA, Al-Jilaihawi AN, et al. Experimental en bloc double-lung transplantation. Ann Thorac Surg 1986;42:394-8. 3. Cooper JD, Patterson GA, Grossman R, et al. Double-lung transplant for advanced chronic obstructive lung disease. Am Rev Respir Dis 1989;139: 303-7.