What's New in Thoracic Transplant?
Activity: 103rd Annual Meeting
Vanderbilt University Medical Center
Nashville, TN
United States - Contact Me
Konrad Hoetzenecker, MD PhD is a member of the surgical faculty of the Department of Thoracic Surgery, Vanderbilt University Medical Center, and the Surgical Director of the Vanderbilt Lung Transplant Program. Besides lung transplantation he is specialized in airway surgery and extended thoracic procedures. Dr Hoetzenecker has authored numerous peer-reviewed articles and is an editorial board member of the Journal of Thoracic and Cardiovascular Surgery and the Journal of Heart and Lung Transplantation. Dr Hoetzenecker has been awarded several prizes and grants including the Graham Memorial Traveling Fellowship from the American Association of Thoracic Surgery.
University of Maryland Medical Center
Baltimore, MD
United States - Contact Me
Dr. Christine L. Lau, MBA is the Dr. Robert W. Buxton Chair of the Department of Surgery at the University of Maryland School of Medicine and the Chief of Surgery at the University of Maryland Medical Center. She specializes in all aspects of general thoracic surgery including lung cancer, mediastinal diseases, benign lung and esophageal disease, esophageal cancer and lung transplantation. Dr. Lau is board certified in general and thoracic surgery. Dr. Lau received her medical degree from Dartmouth Medical Center in Hanover, NH. She received numerous awards while she was there, including being elected to Junior AOA and receiving the Janet M. Glasgow Memorial Award for graduating 1st in her medical school class. She subsequently did her internship and residency in general surgery at Duke University Medical Center in Durham, NC. After completing her general surgery training, she went to Washington University in St. Louis, one of the premier lung transplant programs in the world and spent a year doing a lung transplant fellowship, as well as her fellowship in cardiothoracic surgery which she subsequently finished in 2005. Dr. Lau had an academic appointment at the University of Michigan Medical Center in Ann Arbor, MI as an Assistant Professor of Surgery prior to joining the University of Virginia. She has consistently been voted a Top Doctor in Thoracic Surgery and Cancer. In 2006, she was awarded the John Kirklin Fellowship given by the AATS. In 2008, she was awarded a K08 from the NIH to study mechanisms of chronic rejection in lung transplants. In 2015 she received a R01 from the NHLBI to continue her research in lung transplantation. Dr. Lau serves on numerous national committees and boards, including being a Director of the ABTS, a Director for the AATS, and a member of the Leapfrog Expert Panel. She is also is a member of the Surgery, Anesthesia, and Trauma Study Section at the NHLBI.
Saturday, May 6, 2023: 9:45 AM - 11:30 AM
Los Angeles Convention Center
Posted Room Name: 408A
Track
Thoracic
103rd Annual Meeting
Presentations
62. Limited Cumulative Center Experience with Ex-vivo Lung Perfusion is Associated with Inferior Outcomes After Lung Transplantation
Total Time: 15 Minutes
Objective: Ex-vivo lung perfusion (EVLP) allows for prolonged preservation and evaluation/resuscitation of donor lungs. Data from specialized centers have demonstrated comparable outcomes between transplanting EVLP lungs and conventionally selected lungs. We evaluated the influence of center experience with EVLP on lung transplant outcomes.
Methods: From the United Network for Organ Sharing database, 9708 isolated adult lung transplants were identified (3/1/2018-3/1/2022), including 553 (5.7%) patients who received donor lungs after EVLP. Using the inflection point from the restricted cubic spline analysis, the total center volume of EVLP lung transplants during the study period was dichotomized into high (>15 cases) and low (1-15 cases). Adjusted comparisons of 1-year mortality were performed using multivariable Cox regression.
Results: Forty-one centers performed EVLP lung transplants (Figure 1A), including 26 low-volume and 15 high-volume EVLP centers (median volume 3, IQR 1-5 vs. 23, IQR 18-29 cases, p<0.001). Recipients at low-volume EVLP centers (n=109) had similar lung allocation scores (LAS) (39.8, IQR 34.9-48.6 vs. 38.9, IQR 34.7-53.2) and baseline comorbidities compared to those at high-volume centers (n=444) (all p>0.10). Low-volume centers had numerically more donation after circulatory death (DCD) donors (37.6% vs. 28.4%, p=0.06) with a lower P/F ratio (P/F ratio<300: 24.8% vs. 9.7%, p<0.001), and numerically they used more EVLP lungs perfused by external perfusion centers (30.3% vs. 27.5%, p=0.06). After EVLP lung transplants, low-volume centers had higher rates of extracorporeal membrane oxygenation requirement at 72 hours (24.8% vs. 15.5%, p=0.02) and inferior 1-year survival (77.6%, 95% CI 68.0-84.7 vs. 87.3%, 95% CI 83.5-90.2, Figure 1B, p=0.008), with a hazard ratio (HR) of 1.61 (95% CI 1.02-2.59) after adjusting for recipient age, race, LAS, pre-transplant dialysis, DCD donor, and annual lung transplant volume per center. When compared to non-EVLP lung transplants, outcomes of EVLP lung transplants were significantly worse at low-volume centers (adjusted HR 2.17, 95% CI 1.49-3.17) but similar at high-volume centers (adjusted HR 0.99, 95% CI 0.70-1.41).
Conclusion: Increasing center EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts. Organized transfer of knowledge to low-volume centers may help improve outcomes and broaden the adoption of EVLP.
Methods: From the United Network for Organ Sharing database, 9708 isolated adult lung transplants were identified (3/1/2018-3/1/2022), including 553 (5.7%) patients who received donor lungs after EVLP. Using the inflection point from the restricted cubic spline analysis, the total center volume of EVLP lung transplants during the study period was dichotomized into high (>15 cases) and low (1-15 cases). Adjusted comparisons of 1-year mortality were performed using multivariable Cox regression.
Results: Forty-one centers performed EVLP lung transplants (Figure 1A), including 26 low-volume and 15 high-volume EVLP centers (median volume 3, IQR 1-5 vs. 23, IQR 18-29 cases, p<0.001). Recipients at low-volume EVLP centers (n=109) had similar lung allocation scores (LAS) (39.8, IQR 34.9-48.6 vs. 38.9, IQR 34.7-53.2) and baseline comorbidities compared to those at high-volume centers (n=444) (all p>0.10). Low-volume centers had numerically more donation after circulatory death (DCD) donors (37.6% vs. 28.4%, p=0.06) with a lower P/F ratio (P/F ratio<300: 24.8% vs. 9.7%, p<0.001), and numerically they used more EVLP lungs perfused by external perfusion centers (30.3% vs. 27.5%, p=0.06). After EVLP lung transplants, low-volume centers had higher rates of extracorporeal membrane oxygenation requirement at 72 hours (24.8% vs. 15.5%, p=0.02) and inferior 1-year survival (77.6%, 95% CI 68.0-84.7 vs. 87.3%, 95% CI 83.5-90.2, Figure 1B, p=0.008), with a hazard ratio (HR) of 1.61 (95% CI 1.02-2.59) after adjusting for recipient age, race, LAS, pre-transplant dialysis, DCD donor, and annual lung transplant volume per center. When compared to non-EVLP lung transplants, outcomes of EVLP lung transplants were significantly worse at low-volume centers (adjusted HR 2.17, 95% CI 1.49-3.17) but similar at high-volume centers (adjusted HR 0.99, 95% CI 0.70-1.41).
Conclusion: Increasing center EVLP experience is associated with improved outcomes of lung transplantation using EVLP-perfused allografts. Organized transfer of knowledge to low-volume centers may help improve outcomes and broaden the adoption of EVLP.
View Submission
Invited Discussant
*Matthew Hartwig, Duke Hospital - Contact Me Durham, NCUnited States
Abstract Presenter
*Michael Bowdish, Cedars-Sinai Medical Center - Contact Me Los Angeles, CAUnited States
63. The Early Outcome of Lung Transplantation with the Lung Allografts from the Donors Tested Positive for COVID-19
Total Time: 15 Minutes
Objective:
COVID-19 can be detected for extended periods of time with nucleic acid test (NAT) even after the virulence and transmissibility become negligible. The lung allograft from the donor who tested positive for COVID-19 has been used for transplantation in highly selected cases. This study aimed to clarify the early outcomes of lung transplantation with COVID-19-positive donors.
Methods: The Organ Procurement and Transplantation Network/United Network for Organ Sharing data between April 2020 and June 2022 was retrospectively analyzed. Multiorgan transplantation was excluded from the analysis.
Results: In the study periods, 29,944 donors were identified, including 1,297 COVID-19-positive donors (4.3%). The lungs were transplanted from 47 donors (3.6%), whereas 296 hearts (22.8%), 733 livers (56.5%), and 1772 kidneys (68.3%) were transplanted. Of these 47 lung donors, COVID-19 was diagnosed with NAT in 22 cases (46.8%). Among the transplanted cases, compared to the lung donors without COVID-19 infection (n=5,433), the COVID-19-positive lung donors are younger (28.4±11.6 years vs. 35.4±13.6 years, p<0.001). On the other hand, the recipients who received the lungs from COVID-19-positive lung allografts (COVID-positive group, n=47) had higher LAS (57.1±23.0 vs. 50.9±20.0, p=0.033) comparing to the recipients who received COVID-19-negative lung allografts (COVID-negative group, n=5,501). The rate of ECMO bridge to lung transplantation (14.9% [7/47] vs. 8.9% [490/5,501], p=0.19) and the waiting time on the waitlist (median 29 days vs. 31 days, p=0.70) were comparable between the two groups. The COVID-positive group are more frequently underwent double lung transplantation (91.5% [43/47] vs 79.5% [4,371/5,501], p=0.044). The post-transplant length of hospital stay (median 16 days vs 19 days, p=0.52), needs of ECMO at 72 hours after transplantation (2.6% [1/38] vs 10.4% [541/5,184], p=0.18), survival outcomes (n = 5,226; logrank test p = 0.48) were comparable between the two group.
Conclusions:
Carefully selected lung allografts from COVID-19-positive donors had comparable early post-transplant outcomes to the lung allografts from COVID-19-negative donors.
COVID-19 can be detected for extended periods of time with nucleic acid test (NAT) even after the virulence and transmissibility become negligible. The lung allograft from the donor who tested positive for COVID-19 has been used for transplantation in highly selected cases. This study aimed to clarify the early outcomes of lung transplantation with COVID-19-positive donors.
Methods: The Organ Procurement and Transplantation Network/United Network for Organ Sharing data between April 2020 and June 2022 was retrospectively analyzed. Multiorgan transplantation was excluded from the analysis.
Results: In the study periods, 29,944 donors were identified, including 1,297 COVID-19-positive donors (4.3%). The lungs were transplanted from 47 donors (3.6%), whereas 296 hearts (22.8%), 733 livers (56.5%), and 1772 kidneys (68.3%) were transplanted. Of these 47 lung donors, COVID-19 was diagnosed with NAT in 22 cases (46.8%). Among the transplanted cases, compared to the lung donors without COVID-19 infection (n=5,433), the COVID-19-positive lung donors are younger (28.4±11.6 years vs. 35.4±13.6 years, p<0.001). On the other hand, the recipients who received the lungs from COVID-19-positive lung allografts (COVID-positive group, n=47) had higher LAS (57.1±23.0 vs. 50.9±20.0, p=0.033) comparing to the recipients who received COVID-19-negative lung allografts (COVID-negative group, n=5,501). The rate of ECMO bridge to lung transplantation (14.9% [7/47] vs. 8.9% [490/5,501], p=0.19) and the waiting time on the waitlist (median 29 days vs. 31 days, p=0.70) were comparable between the two groups. The COVID-positive group are more frequently underwent double lung transplantation (91.5% [43/47] vs 79.5% [4,371/5,501], p=0.044). The post-transplant length of hospital stay (median 16 days vs 19 days, p=0.52), needs of ECMO at 72 hours after transplantation (2.6% [1/38] vs 10.4% [541/5,184], p=0.18), survival outcomes (n = 5,226; logrank test p = 0.48) were comparable between the two group.
Conclusions:
Carefully selected lung allografts from COVID-19-positive donors had comparable early post-transplant outcomes to the lung allografts from COVID-19-negative donors.
View Submission
Invited Discussant
*Jules Lin, University of Michigan Hospital - Contact Me Ann Arbor, MIUnited States
Abstract Presenter
Takashi Harano, University of Southern California Keck Medical Center - Contact Me Los Angeles, CAUnited States
64. Lung Transplantation Outcomes for Patients with Acute Respiratory Distress Syndrome (ARDS) Requiring Preoperative ECMO: A Comparison of COVID ARDS and Non-COVID ARDS
Total Time: 15 Minutes
Objective: Lung transplantation (LTx) has rarely been performed in patients with ARDS supported on ECMO. An important change in this practice was observed as a result of the COVID-19 pandemic. This study aims to compare the outcomes of patients who underwent LTx for ARDS due to COVID and non-COVID etiologies, and to assess the impact of type and duration of ECMO support on survival. Methods: Using the UNOS database, we performed a retrospective study of patients who underwent LTx for ARDS in the United States between February 2007 and June 2022. A total of 311 patients with ARDS were identified using primary diagnosis at the time of listing; 244/311 were diagnosed with COVID-19 ARDS (CARDS) and 67/311 with non-COVID ARDS (N-CARDS). Of these patients, we analyzed 236 who underwent LTx after preoperative ECMO support. The primary outcome was one-year survival. Secondary outcomes included the effect of type and duration of ECMO support on survival. Survival analyses were conducted using the Kaplan-Meier survival function and Cox proportional hazards models. Results: A total of 236 patients underwent LTx for ARDS with preoperative ECMO support. Of these, 181 (77%) had a listing diagnosis of CARDS and 55 (23%) of N-CARDS. ECMO device information was available for 168 patients. Patients with CARDS were older (46 vs 32 years, p <0.001), more likely to be female (46% vs 27%, p=0.0014), and had higher BMI (27.3 vs 25.3, p=0.019) than the N-CARDS cohort. Overall, patients with CARDS had longer waitlist times (11 vs 6 days, p=0.0068) and were less likely to require pre-transplant dialysis (7.2% vs 9.1%, p <0.0001) than N-CARDS patients. The two groups had similar 1-year survival rates (85.8% vs 81.1% for CARDS and N-CARDS patients, respectively, p=0.2) (Figure 1). There were no differences in postoperative complications including renal failure, stroke, or acute rejection (all p >0.28). N-CARDS patients were significantly more likely to require pre-LTx support with VA ECMO (21.4% vs 7.1%; p=0.03) and CARDS patients required longer times on ECMO pre-transplant (72.5 vs 56 days, p=0.017). Despite this, duration of ECMO support was not a univariate predictor of one-year post-transplant survival (p=0.2). Conclusions: Our data suggests that, despite prolonged periods of pre-transplant ECMO support, selected CARDS and N-CARDS patients can be transplanted safely with acceptable short-term outcomes. Appropriate selection and long-term implications require further analysis.
View Submission
Invited Discussant
*Yoshiya Toyoda, Temple University Hospital - Contact Me Philadelphia, PAUnited States
Abstract Presenter
Mallory Hunt, Hospital of the University of Pennsylvania (Penn Medicine) - Contact MeUnited States
Circulatory Support for Lung Transplant: Always or Almost Never?
Total Time: 15 Minutes
65. Storage with a Novel Donor Lung Preservation System versus Traditional Ice Storage: Comparing Outcomes and Costs
Objective:
A novel hypothermic preservation system (LG) was developed in response to concerns around organ temperature with static ice storage (SIS) for donor lungs in lung transplant (LTx). However, LG is more expensive than SIS and its short-term outcomes in a larger cohort are unclear. Here, we compare short-term outcomes and costs of index hospitalization at a single, high-volume institution between LG recipients and a matched SIS control group.
Methods:
Patients who received lungs stored with LG at our institution were matched 1:1 to a contemporary cohort of patients receiving SIS lungs, based on age at LTx, lung allocation score, disease group, ischemic time, previous LTx, and pre-operative extracorporeal membrane oxygenation (ECMO). Descriptive statistics compared perioperative outcomes and index hospitalization costs between LG and SIS groups.
Results:
In total, 67 LG and 67 matched SIS recipients were included. Cohorts did not differ in age (SIS vs LG: 63.0 vs 62.0 years, p = 0.66), lung allocation score (42.7 vs 41.2, p = 0.61), or proportion of restrictive lung disease (N=50, 74.6% vs N=49, 73.1%). We did not observe differences between groups in donor age, (35.0 vs 34.0 years, p = 0.77), donation after circulatory death (N=11, 16.4% vs N=14, 20.9%, p = 0.66), or ischemic time (7.6 vs 8.0 hours, p = 0.81). The median of average allograft temperatures using the LG device was 5.6°C. Following LTx, LG and SIS recipients had similar rates of grade 3 primary graft dysfunction (PGD) at 72 hours (N=4, 6.0% vs N=9, 13.4%, p = 0.31), acute rejection prior to discharge (N=1, 1.5% vs N=4, 6.0%, p = 0.37), and hospital length of stay (21.0 vs 23.0 days, p = 0.23). LG and SIS recipients had comparable postoperative survival (Figure, p = 0.18). LG and SIS recipients also had similar total direct costs (97300 vs 91900, p = 0.66) and total direct variable costs (85771 vs 80644, p = 0.83) during index hospitalization, with significantly different direct variable costs for respiratory care (7010 vs 2650, p <0.001).
Conclusions:
The LG storage system appears to be an effective alternative for lung preservation compared to SIS, with similar total direct and direct variable costs after LTx as well as similar postoperative survival and perioperative outcomes in the short-term.
Figure. Kaplan-Meier survival analysis of postoperative patient survival among LG and ICE lung transplant recipients.
A novel hypothermic preservation system (LG) was developed in response to concerns around organ temperature with static ice storage (SIS) for donor lungs in lung transplant (LTx). However, LG is more expensive than SIS and its short-term outcomes in a larger cohort are unclear. Here, we compare short-term outcomes and costs of index hospitalization at a single, high-volume institution between LG recipients and a matched SIS control group.
Methods:
Patients who received lungs stored with LG at our institution were matched 1:1 to a contemporary cohort of patients receiving SIS lungs, based on age at LTx, lung allocation score, disease group, ischemic time, previous LTx, and pre-operative extracorporeal membrane oxygenation (ECMO). Descriptive statistics compared perioperative outcomes and index hospitalization costs between LG and SIS groups.
Results:
In total, 67 LG and 67 matched SIS recipients were included. Cohorts did not differ in age (SIS vs LG: 63.0 vs 62.0 years, p = 0.66), lung allocation score (42.7 vs 41.2, p = 0.61), or proportion of restrictive lung disease (N=50, 74.6% vs N=49, 73.1%). We did not observe differences between groups in donor age, (35.0 vs 34.0 years, p = 0.77), donation after circulatory death (N=11, 16.4% vs N=14, 20.9%, p = 0.66), or ischemic time (7.6 vs 8.0 hours, p = 0.81). The median of average allograft temperatures using the LG device was 5.6°C. Following LTx, LG and SIS recipients had similar rates of grade 3 primary graft dysfunction (PGD) at 72 hours (N=4, 6.0% vs N=9, 13.4%, p = 0.31), acute rejection prior to discharge (N=1, 1.5% vs N=4, 6.0%, p = 0.37), and hospital length of stay (21.0 vs 23.0 days, p = 0.23). LG and SIS recipients had comparable postoperative survival (Figure, p = 0.18). LG and SIS recipients also had similar total direct costs (97300 vs 91900, p = 0.66) and total direct variable costs (85771 vs 80644, p = 0.83) during index hospitalization, with significantly different direct variable costs for respiratory care (7010 vs 2650, p <0.001).
Conclusions:
The LG storage system appears to be an effective alternative for lung preservation compared to SIS, with similar total direct and direct variable costs after LTx as well as similar postoperative survival and perioperative outcomes in the short-term.
Figure. Kaplan-Meier survival analysis of postoperative patient survival among LG and ICE lung transplant recipients.
View Submission
Invited Discussant
*Konrad Hoetzenecker, Vanderbilt University Medical Center - Contact Me Nashville, TNUnited States
Abstract Presenter
Arya Pontula, University of Manchester - Contact Me Durham, NCUnited States
66. Safety and Efficacy of Delaying Nighttime Lung Transplantation to a Morning Start
Total Time: 15 Minutes
Objective: Lung transplantation is still routinely performed at night due the unpredictability of donor organ procurement. However, late start-times for complex operations such as lung transplantation have been associated with adverse outcomes. We hypothesized that for donors with cross clamp times occurring after 1:30 AM, the recipient operation may be delayed until morning with acceptable outcomes.
Methods: All consented adult lung transplant recipients from March 2018 to May 2022 with donor cross-clamp times between 1:30 AM and 5 AM were prospectively enrolled in this study. Skin incision for enrolled recipients was delayed until 6:30 AM (Night cohort). The control group was identified using a 1:2 logistic propensity score method and included recipients of donors with cross clamp times occurring at any other time of day (Day cohort). Short- and medium-term outcomes, including early mortality (30-day and in-hospital), a composite of post-operative complications, lengths of stay (ICU and total), survival (1- and 3-year) and chronic lung allograft dysfunction at 3-years, were examined between groups. Kaplan-Meier survival estimates were used to assess for differences in survival.
Results: Thirty-four patients were enrolled in the Night group, with 68 matched patients in the Day cohort. The two groups had similar preoperative recipient and donor characteristics. As expected, the Night donors had longer cold ischemia times (344 minutes vs 285 minutes, P<0.01) compared to the Day group. Early mortality (Figure) and incidence of grade 3 Primary Graft Dysfunction at 24 (12% vs 10%, P=0.82), 48 (15% vs 4%, P=0.11), and 72 (8% vs 4%, P=0.40) hours were similar. A composite of post-operative complications (26% vs 38%, P=0.28), ICU (7 vs 6 days, P=0.51), and total post-transplant length of stay (15 vs 14 days, P=0.91) were also similar between groups. No significant differences were noted between groups for 1- and 3-year survival (Figure), or freedom from chronic lung allograft dysfunction at 3 years (91% vs 95%, P=0.12).
Conclusions: Lung transplant recipients with donor cross clamp times scheduled after 1:30 AM may safely have their operations delayed until 6:30 AM with acceptable outcomes. In experienced lung transplant centers, adoption of such policy may lead to alternative workflow and improved team well-being.
Methods: All consented adult lung transplant recipients from March 2018 to May 2022 with donor cross-clamp times between 1:30 AM and 5 AM were prospectively enrolled in this study. Skin incision for enrolled recipients was delayed until 6:30 AM (Night cohort). The control group was identified using a 1:2 logistic propensity score method and included recipients of donors with cross clamp times occurring at any other time of day (Day cohort). Short- and medium-term outcomes, including early mortality (30-day and in-hospital), a composite of post-operative complications, lengths of stay (ICU and total), survival (1- and 3-year) and chronic lung allograft dysfunction at 3-years, were examined between groups. Kaplan-Meier survival estimates were used to assess for differences in survival.
Results: Thirty-four patients were enrolled in the Night group, with 68 matched patients in the Day cohort. The two groups had similar preoperative recipient and donor characteristics. As expected, the Night donors had longer cold ischemia times (344 minutes vs 285 minutes, P<0.01) compared to the Day group. Early mortality (Figure) and incidence of grade 3 Primary Graft Dysfunction at 24 (12% vs 10%, P=0.82), 48 (15% vs 4%, P=0.11), and 72 (8% vs 4%, P=0.40) hours were similar. A composite of post-operative complications (26% vs 38%, P=0.28), ICU (7 vs 6 days, P=0.51), and total post-transplant length of stay (15 vs 14 days, P=0.91) were also similar between groups. No significant differences were noted between groups for 1- and 3-year survival (Figure), or freedom from chronic lung allograft dysfunction at 3 years (91% vs 95%, P=0.12).
Conclusions: Lung transplant recipients with donor cross clamp times scheduled after 1:30 AM may safely have their operations delayed until 6:30 AM with acceptable outcomes. In experienced lung transplant centers, adoption of such policy may lead to alternative workflow and improved team well-being.
View Submission
Invited Discussant
*Daniel Kreisel, Barnes Jewish Hospital - Contact Me St. Louis, MOUnited States
Abstract Presenter
Samuel Kim, UCLA - Contact MeUnited States
67. A Case of Living-Donor Segmental Lung Transplantation and Concomitant Nuss Procedure in a Pediatric Patient with Pectus Excavatum
Total Time: 15 Minutes
Objective: Severe chest wall deformities are considered a contraindication for lung transplantation. We herein report a pediatric patient who underwent living-donor segmental lung transplantation and simultaneous correction of a severe pectus excavatum.
Case Video Summary: A ten-year old boy with severe pectus excavatum was referred to us due to drug-induced interstitial pneumonia after chemotherapy for neuroblastoma. While on a wait-list of deceased-donor lung transplantation, he developed intractable pneumothorax and became bedridden. It was unlikely for the patient to survive until deceased-donor was allocated, thus we planned living-donor lung transplantation. His chest cavities were very small due to the progression of restrictive lung disease and pectus excavatum. The donors were his old sisters in their twenties. It was obvious that donors' lower lobes were two large for the boy. We planned to use bilateral basal segmental grafts, however, anatomical size-matching based on CT volumetry was estimated to be 255%. Expanding boy's chest cavities appeared to be mandatory to implant oversized segmental grafts. Therefore, we planned to perform concomitant Nuss procedure. In donor basal segmentectomy, intersegmental plane was developed in vivo by a cautery based on indocyanine green orientation and S6 segment was preserved. The divided intersegmental planes were then covered with fibrin glue and absorbable pieces of polyglycolic acid sheet in order to prevent air leakage. Bilateral basal segmental graft implantation was performed though the clamshell incision under cardiopulmonary bypass (CPB). The implant technique of the basal segment was similar to that of the lower lobe graft. The basal segments were vertically rotated 90° after implantation. Right pulmonary venous anastomosis required an auto-pericardial conduit. After discontinuation of CPB, 2 pectus bars were placed to expend chest cavities. Delayed chest closure was required and the chest was closed on postoperative day (POD) 7. The patient discharged home without oxygen therapy 2 months after the transplantation. Six months after the operation, the boy is able to carry out daily activities. As for the two donors, postoperative course was uneventful and preserved S6 segments expanded well.
Conclusion: Living-donor segmental lung transplantation with concomitant Nuss procedure is feasible for a selected patient with pectus excavatum.
Case Video Summary: A ten-year old boy with severe pectus excavatum was referred to us due to drug-induced interstitial pneumonia after chemotherapy for neuroblastoma. While on a wait-list of deceased-donor lung transplantation, he developed intractable pneumothorax and became bedridden. It was unlikely for the patient to survive until deceased-donor was allocated, thus we planned living-donor lung transplantation. His chest cavities were very small due to the progression of restrictive lung disease and pectus excavatum. The donors were his old sisters in their twenties. It was obvious that donors' lower lobes were two large for the boy. We planned to use bilateral basal segmental grafts, however, anatomical size-matching based on CT volumetry was estimated to be 255%. Expanding boy's chest cavities appeared to be mandatory to implant oversized segmental grafts. Therefore, we planned to perform concomitant Nuss procedure. In donor basal segmentectomy, intersegmental plane was developed in vivo by a cautery based on indocyanine green orientation and S6 segment was preserved. The divided intersegmental planes were then covered with fibrin glue and absorbable pieces of polyglycolic acid sheet in order to prevent air leakage. Bilateral basal segmental graft implantation was performed though the clamshell incision under cardiopulmonary bypass (CPB). The implant technique of the basal segment was similar to that of the lower lobe graft. The basal segments were vertically rotated 90° after implantation. Right pulmonary venous anastomosis required an auto-pericardial conduit. After discontinuation of CPB, 2 pectus bars were placed to expend chest cavities. Delayed chest closure was required and the chest was closed on postoperative day (POD) 7. The patient discharged home without oxygen therapy 2 months after the transplantation. Six months after the operation, the boy is able to carry out daily activities. As for the two donors, postoperative course was uneventful and preserved S6 segments expanded well.
Conclusion: Living-donor segmental lung transplantation with concomitant Nuss procedure is feasible for a selected patient with pectus excavatum.
View Submission
Invited Discussant
*Daniel Raymond, Cleveland Clinic - Contact Me Cleveland, OHUnited States
Case Video Presenter
*Hiroshi Date, Duke University Medical Center - Contact Me Durham, NCUnited States