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J Thorac Cardiovasc Surg 2005;130:919-921
© 2005 The American Association for Thoracic Surgery
Brief Communication |
Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Mo.
Received for publication January 29, 2005; accepted for publication March 14, 2005. * Address for reprints: Charles B. Huddleston, MD, Professor of Surgery, No. 1 Children's Place, Suite 5S 50, Children's Hospital, St Louis, MO 63110 (Email: huddlestonc{at}msnotes.wustl.edu).
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Complete obstruction of one or more of the major pulmonary veins after lung transplantation is a devastating complication. It results in hemorrhagic infarction of the affected lung within 4 to 6 hours, leading to irreversible lung damage. Reported treatments have included resection of the affected lobe and retransplantation.
1,2
We present a case of pulmonary venous infarction after transplantation that was treated conservatively.
Clinical Summary
A 16-year-old girl with a history of cystic fibrosis, multiple pulmonary infections, insulin-dependent diabetes, malnutrition, and anemia underwent a bilateral living-donor lobar lung transplantation for the treatment of end-stage lung disease secondary to cystic fibrosis. Before the operation, she had a forced expiratory volume of 20% predicted and was severely limited by her poor respiratory function. She had to use a wheelchair and required continuous supplementary oxygen. The surgery was performed with cardiopulmonary bypass support and proceeded uneventfully. The donor right and left lower lobes were implanted into the recipient right and left hemithoraces, respectively. Her chest radiograph after the operation was unremarkable, apart from mild bilateral diffuse infiltrates. On postoperative day 1, her chest radiograph revealed a confluent opacity involving the apical segment of the right lower lobe (Figure 1, A). Examination with a flexible bronchoscope revealed bloody secretions in the right apical segmental airway. Pulmonary perfusion scintigraphy showed that the right lung received 56% of the total pulmonary perfusion, but there was a marked decreased perfusion in the upper portion of the right lung. Angiography revealed an obstruction involving the vein draining the apical segment of the right lower lobe (Figure 2, A). A diagnosis of segmental pulmonary venous infarction was made. The obstruction was probably related to technical issues at the time of donor harvest or implantation. The patient was treated conservatively because the infarction had involved only one segment of the donor lungs. Her postoperative course was also complicated by pulmonary edema, pulmonary infection, and renal failure, and she required postoperative mechanical ventilatory support for 7 days. She was discharged on day 28 without any requirement for supplementary oxygen. The right apical segmental opacity on the chest radiograph gradually resolved during a 6-week period (Figure 1, B). Pulmonary perfusion scintigraphy 3 months after the transplantation showed persistent, marked decreased perfusion in the upper portion of the right lung (Figure 2, B). She has remained well through a follow-up period of 2 years, with excellent functional health.
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Pulmonary venous infarction after lung transplantation is a rare but life-threatening condition. The causes in lung transplantation have been obstruction of the pulmonary vein by thrombosis formed secondary to a narrowing of the venous anastomosis in the setting of a lack of bronchial arterial blood supply.
1,2
The clinical and radiologic features may be mistaken for reperfusion injury, consolidation of the lung, or myocardial dysfunction. The diagnosis is often delayed, resulting in the onset of hemorrhagic infarction and irreversible lung damage. Early diagnosis and prompt treatment are therefore essential. This, however, seldom occurs, because it is difficult to diagnose pulmonary venous infarction by conventional roentgenologic means. The findings on chest radiography are nonspecific and variable and include pulmonary consolidation, atelectasis, increased pulmonary vascular markings, and increased hilar size.
3
Perfusion scan is useful in demonstrating a marked decreased perfusion in the affected area.
2,3
It does not, however, differentiate between arterial and venous obstruction. Pulmonary angiography is required to confirm pulmonary venous obstruction and is considered by some to be the investigation of choice when the diagnosis is suspected.
3
Others have found transesophageal echocardiography to be useful in diagnosing pulmonary venous obstruction, demonstrating minimal flow in the affected vein and visualization of a thrombus.
1,2
This investigation can be easily performed on the bedside and has the advantages of being quick and reliable, as well as not requiring any intravenous contrast.
The treatment options for pulmonary venous infarction after lung transplantation are often limited by the development of irreversible lung damage. Resection by lobectomy has been attempted after unilateral lung transplantation; however, the patient died 48 hours later.
1
Retransplantation has been performed with success for the treatment of pulmonary venous infarction that involved the entire donor lung in a patient who had undergone unilateral lung transplantation.
2
In our patient, the pulmonary venous infarction was treated conservatively because it involved only the apical segment of the right lower lobe, with the remainder of the donor lungs functioning adequately. The treatment of pulmonary venous infarction after lung transplantation needs to be tailored to the individual case and depends on the cause of the infarct, the extent of the infarct, and the remaining amount of unaffected donor lungs. If the cause of the infarct is correctable, such as a technical anastomotic problem, and the infarct involves the entire donor lung in a patient who has undergone unilateral lung transplantation, then the treatment should be surgical correction before irreversible damage, provided the diagnosis is made early, before established infarction has occurred. If irreversible damage has occurred, retransplantation is necessary. On the other hand, if the infarct has affected only a small part of the donor lung, such as in our case, with the remaining unilateral lung and the contralateral donor lung unaffected, then the treatment should be conservative, relying on sufficient amounts of unaffected lung and pulmonary reserve to get the patient through recovery from the lung transplantation. Thrombolytic therapy may be useful in treatment of a narrowing or occlusion of the anastomosis that has been caused by a thrombus in the absence of a surgically correctable problem.
In conclusion, we present a case of pulmonary segmentalvenous infarction after living-donor lung transplantation that was successfully treated with conservative means.
References
This article has been cited by other articles:
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  G. Massard, N. Santelmo, P.-E. Falcoz, and R. Kessler Noninfectious complications Lung Transplantation, June 7, 2010; 177 - 193. [Abstract] [Fulltext] [PDF]
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