Experimental bilateral lobar lung transplantation and its application in humans

Lobar lung transplantation--is it comparable with standard lung transplantation?

Lobar lung transplantation is used mainly for urgent small recipients who are less likely to obtain size matched lungs in due time. Only limited numbers have been published, and we herewith report the largest series of lobar-LuTX. We analyzed our LuTX database from 1/2001 to 12/2012 and compared the outcome of lobar-LuTX recipients with those receiving standard LuTX. Seven hundred and seventy-eighty LuTX (group 1) were performed either in standard technique by implanting the whole lungs (n = 539) or with downsizing by wedge resection of the right middle lobe and/or the left lingula (n = 239). One hundred and thirty-eight LuTX were performed in lobar technique (group 2) to overcome more pronounced size discrepancies. Patients in group 1 had a different spectrum of diagnoses and were less frequently bridged to LuTX (P < 0.001). Intubation time, ICU stay, and hospital stay were shorter in group 1 (P < 0.001). One-year survival was 84.8% vs. 65.1%, and 5-years survival 69.9% vs. 54.9% (P < 0.001). In multivariate analyzes, procedure, diagnosis, and pre-operative bridging were shown to be significant prognostic factors in survival. Early postoperative outcome in Lobar LuTX was significantly inferior to standard LuTX recipients. However, survival rates of successfully dismissed patients were comparable with standard LuTX (P = 0.168); thereby, Lobar-LuTX remains an important option in the management of urgent small recipients.

Case Report: A Left Donor Lung Implanted in the Recipient’s Right Thorax for the Therapy of Pulmonary Fibrosis

A 68-year patient suffering from pulmonary fibrosis underwent single lung transplantation on April 4, 2005. Because the ipsilateral donor lung was severely damaged, we had to implant the contralateral lung--the left lung--to the right thorax, and finally this patient recovered.

Split lung transplantation with intraoperative extracorporeal membrane oxygenation (ECMO) support

Pulmonary bipartitioning or split lung transplantation, which was first described in 1997, presently represents the most efficient use of donor lungs. With this technique, a left donor lung can be separated into an upper and lower lobe and used for bilateral transplantation in a smaller recipient. The right donor lung remains for use as a single lung graft in another patient. In 2001, a similar technique for splitting a right lung was described. The technique of harvesting and procurement of the donor organ for split lung transplantation is identical to the standard lung transplantation technique. The final separation of the donor lung is performed at the level of the interlobar fissure immediately prior to implantation. The lower lobe is implanted in the left recipient hemithorax, whereas the upper lobe, after closing of the central end of the left main pulmonary artery, and a 180° rotation along the vertical axis, is grafted into the right hilus. The use of extracorporeal membrane oxygenation (ECMO) provides intraoperative hemodynamic stability and protects the first implanted lobe from overflow and resulting reperfusion injury. This report discusses the technique developed at the department of cardiothoracic surgery of the Medical University of Vienna.

Contralateral lung transplantation: a left lung implanted in the right thorax

Since the inception of lung transplantation in 1982, it has been standard practice to implant donor lungs on the ipsilateral side in the recipient. The development of the techniques of lobar and bilateral lobar transplantation has shown that lung morphology may adapt to the shape of the thorax. Thus, variations in implantation have become possible. We describe a case of a 30-year-old man with severe bronchiectasis due to ciliary dyskinesis which required a left lower lobectomy at the age of 11 years and a left completion pneumonectomy 10 years later. His disease progressed and he was listed for a right lung transplantation. At the time of transplantation, the donor right lung was noted to be edematous and unfit for transplantation. This required grafting the donor left lung in the right thorax of the recipient. Follow-up at 7 years shows good exercise capacity and excellent functional tests without evidence of rejection.

Pulmonary bipartitioning and lobar transplantation: a new approach to donor organ shortage

The scarcity of small donors has significantly limited lung transplantation for pediatric and small adult patients. Use of single lobes procured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lung tissue. In an animal model we have shown that it is possible to divide one lung with careful partitioning of the vascular and bronchial structures and thus obtain two viable lobar grafts suitable for bilateral implantation in a smaller animal. We have now applied this procedure clinically in seven patients operated on between May 1993 and November 1994. The indications were cystic fibrosis in three children, primary pulmonary hypertension in two adults, bronchiectasis in one, and idiopathic pulmonary fibrosis in one. There were three children aged 13 to 17 years (median 14) and four adults aged 40 to 53 years (median 45). There was a 46% to 50% discrepancy for weight between recipient and donor and a 12% to 17% discrepancy for height. The surgical technique consisted of careful partitioning of the left donor lung, bilateral anterior thoracotomy in the recipient, and, with the use of cardiopulmonary bypass, implantation of the lower lobe in the left hemithorax and the upper lobe in the right hemithorax. Vascular and bronchial connections were facilitated by leaving a long pedicle on the recipient side. The pulmonary artery anastomosis for the donor left upper lobe was done with the "fissure" side of the artery to ensure an anastomosis without tension. An end-to-end bronchial anastomosis overcame the problem of size discrepancy. Six patients are alive and well 10 to 27 months (median 19) after operation. One patient with cystic fibrosis died of systemic aspergillosis infection. All were discharged from the hospital within the first or second postoperative month. No technical problems were identified: repeated bronchoscopy has demonstrated satisfactory healing without early stricture formation. All patients remain well subjectively with good exercise tolerance and all patients achieve greater than 70% of predicted values of forced expiratory volume in 1 second. Perfect adaptation of the transplanted lobes to the recipient pleural space has been demonstrated by postoperative computed tomographic scan. In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a large size discrepancy with the donor. This may help resolve the problem of donor availability in the pediatric population.