Ann Thorac Surg 1995;59:1223-1226
© 1995 The Society of Thoracic Surgeons
Case Report
Right Lower Lobe Herniation After Domino Heart-Lung Transplantation
Nizar A. Yonan, FRCS,
Jim Egan, MRCP,
Abdul K. Deiraniya, FRCS,
Ali N. Rahman, FRCS
Department of Cardiac Surgery and North West Lung Centre, Wythenshawe Hospital, Manchester, England
Accepted for publication September 12, 1994.
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Abstract
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We report 2 cases of trapping and incarceration of the right lower lobe in the left hemithorax after heart-lung transplantation with bicaval anastamoses (domino donors). This occurred despite confirmation of the normal anatomy at the time of implantation, before lung inflation. In 1 case this complication resulted in a right lower lobectomy 7 days after transplantation due to infarction and infection of the right lower lobe. These cases illustrate the importance of reexamining the anatomy after lung inflation, before chest closure.
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Introduction
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Heart-lung transplantation (HLT) is an established treatment for end-stage lung disease [1]. A total of 26 HLT operations were performed at our institution between January 1990 and April 1993. In 2 of the long-term survivors a complication developed during operation wherein the right lower lobe herniated behind the heart and was partially inflated in the left hemithorax. In 1 case, the complication was recognized and corrected before chest closure. In the other case a lobectomy was performed on the seventh postoperative day. Both patients were domino donors.
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Case Reports
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Patient 1
A 23-year-old woman with cystic fibrosis underwent domino heart and lung transplantation in March 1991. Normal anatomy was observed at the time of implantation. There was no difficulty in weaning from bypass. However, before chest closure the surgeon noticed that the volume of the right lung was reduced and on further examination, three lobes were observed in the left hemithorax. The right lower lobe had herniated through a hiatus in the recipient pericardium posterior to the right phrenic nerve pedicle. The lobe had passed under the inferior vena cava and had become sandwiched between the recipient pericardium posteriorly and the donor heart anteriorly. The rest of the lobe was inflated in the lower left hemithorax (Figs 1A, 1C
). Normal anatomy was restored by deflating the herniated lobe and manipulating it back to its normal anatomic position. The lobe was reinflated when in the normal position with no further problems. This patient made an otherwise uneventful recovery. She is now alive and well 3
years after transplantation.
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Fig 1. . Anatomy of thoracic cavity after removal of recipient heart and lungs. (A) Total cardiectomy (domino). Note the increased potential space for lung herniation posterior to the right atrium and inferior vena cava. The dotted arrows indicate the lines of the enlargement of the hilum. (B) Standard cardiectomy with right and atrial cuffs left behind. Note the reduced space posterior to the right atrium and inferior vena cava. (C) Anatomy of right lower lobe herniation. The thin arrows illustrate placement of right and left lungs. The thick arrow indicates the path of the herniated right lower lobe.
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Patient 2
A 33-year-old woman with primary pulmonary hypertension underwent domino HLT in June 1992. The normal anatomy of each lung was observed at the time of placement of the heart-lung block. The patient weaned from bypass easily, with satisfactory gases and stable hemodynamics. In the intensive care unit the patient bled excessively (200 to 400 mL/h) despite correction of a coagulation abnormality and the administration of aprotinin (Trasylol; Bayer AG, Leverkusen, Germany). The patient was returned to the operating room 8 hours later because of excessive drainage and hemodynamic instability with signs of cardiac tamponade. Throughout this period in the intensive care unit, blood gases were satisfactory. Her first postoperative chest roentgenogram demonstrated a reduction in the volume of the right lung compared with the left lung (Fig 2).
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Fig 2. . Chest roentgenogram immediately after transplantation. Note reduced size of right lung compared with the left lung.
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Upon reexploration the hemodynamics stabilized quickly due to the release of the cardiac tamponade. No clots or retained blood was found in the pericardium or in the pleural spaces. While searching for the source of bleeding, we noted that the right lower lobe was inflated in the left hemithorax and had herniated, as in the first patient, through the gap in the recipient pericardium posterior to the right phrenic nerve. The proximal part of the herniated lobe was lying beneath the heart and the rest was fully inflated in the inferomedial part of the left hemithorax (see Fig 1C
).
The herniated lobe was relocated with difficulty. Additional sutures in the inferior vena caval anastamosis were required to control the bleeding resulting from the overstretching of that anastomosis.
After the reduction, the lobe was considered viable because it looked normal apart from a small part in the lateral and posterior basal segments which was bruised and hemorrhagic. There was general mediastinal oozing, but no active bleeding point was found. The chest was closed with subsequent minimal drainage.
The patient remained stable and was extubated on the third postoperative day. However, a persistent pyrexia (39°C) developed with hemoptysis and a positive sputum culture for alpha hemolytic streptococci and diphtheroids, and the patient had to be reventilated. Her white blood cell count was markedly raised (Table 1) and there was radiologic cavitation of the RLL (Fig 3). In view of this, fiberoptic bronchoscopy and transbronchial biopsy of the RLL was performed. This revealed severe erythema of the RLL bronchus with copious blood-stained secretions. Histologic examination showed necrosis of the alveolar wall with fibrinous exudate in the alveolar spaces and thrombi occluding the vessels; mixed gram-positive cocci and rods were also seen. This picture confirmed the diagnosis of infarction and infection of the lobe. Pulmonary angiography and perfusion scan would have been useful to assess the size and extent of the infarct and should have been performed earlier. At this stage, we believed that there was sufficient evidence to make the diagnosis and to decide on operative resection without the need for furthur tests.
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Fig 3. . Chest roentgenogram after relocation of right lower lobe in right chest cavity. Note the cavity in the right base.
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On the seventh postoperative day, the patient underwent right lower lobectomy through a lateral thoracotomy. The resected RLL was consolidated and dark in color in contrast to the anterior and apical segments, which were well-aerated and pink. Histologic examination of the specimen showed a large area of total hemorrhagic infarction with central cavitation, and the lung tissue surrounding it showed severe ischemic injury with alvaolar wall necrosis, fibrin thrombi in the vessels, and intraalveolar hemorrhage, edema, neutrophils, and macrophages. There was no evidence of rejection in the normal lung tissue. The divided bronchus bled freely and primary healing occurred without any further problems. The patient made a slow recovery and required assisted ventilation for 3 weeks. She was discharged from the hospital 9 weeks after transplantation with a satisfactory chest roentgenogram. She is now alive and well more than 2 years after HLT. Fiberoptic bronchoscopy a few months after lobectomy showed normal bronchial healing.
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Comment
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Lobe herniation after HLT is a rare and preventable complication. One recent report [2] described left lower lobe herniation to the right chest that required surgical correction without lung resection.
Early diagnosis and management of this complication is vital if irreversible damage and subsequent resection of lung tissue are to be avoided. Chest roentgenographic changes that suggest a discrepancy between right and left lung volumes are an important sign (see Fig 2). In the absence of collapse, effusion, or a raised hemidiaphragm, all of which can be seen early after HLT [3], a reduction of lung volume should lead one to consider seriously this complication.
Signs of cardiac tamponade also should lead one to suspect this complication. When these signs occurred in the second patient, they initially were considered to be due to either the 20% oversizing of the donor heart-lung block in this patient or to cardiac compression by retained blood and clots. At reexploration, hemodynamics normalized when the sternum was opened. The tamponade was due to compression of the heart between the retrocardiac herniated RLL and the sternum. Excessive bleeding was also a feature in our second case and was probably the result of congestion of the trapped lobe, but general oozing due to coagulopathy could not be ruled out. The bleeding settled after correction of the anatomy, with no major active bleeding points being found. The blood gases and ventilation pressures were satisfactory despite the herniation. Blood gases only deteriorated when cardiac function and hemodynamics became compromised.
The delay in diagnosing the extensive pulmonary infarct that occurred at the time of herniation was due to the operator's confidence of the right lower lobe viability at exploration based on the gross appearance. Retrospectively, we should have investigated the RLL with perfusion scan and pulmonary angiogram soon after reduction to establish the diagnosis and assess the size and the extent of any infarct. Despite our intention to avoid resection if at all possible, the diagnosis of a major lobar infarct would have swayed the decision toward resection at an earlier stage before infection had set in.
The internal chest anatomy after a HLT with recipient heart used as a domino is likely to be an important factor in the pathogenesis of this complication. Two factors can be identified: first, there is more freedom of movement of the heart with bicaval anastomosis compared with right atrial anastomosis (which tends to splint the heart). The freedom of movement allows the heart to slip toward the left pleural cavity during implantation, dragging with it the RLL, which is the nearest anatomic structure. The RLL herniates through the gap posterior to the right phrenic pedicle and the inferior vena cava/right atrium, then through the gap between the recipient and donor pericardium posterior to the left phrenic pedicle, ending in the left chest cavity (see Fig 1C). Second, in domino cardiectomy, the entire right and left atria are resected with adequate length of both cavae to preserve the sinus node and coronary sinus. The cavae are anastomosed during implantation, so there is a larger space behind the right atrium and the cavae (see Figs 1A, 1C) through which the RLL can herniate. This space is smaller when right atrial integrity is maintained in the standard HLT (Fig 1B). Suturing donor to recipient pericardium behind the heart and posterior to the left phrenic nerve pedicle will support the heart in its normal anatomic position and prevent it from slipping into the left hemithorax. Any attempt to obliterate the space between the right atrium and the underlying pericardium with sutures may help prevent this complication, but it carries the risk of bleeding from an inaccessible site (interatrial septum). Narrowing the hiatus around the right hilum with sutures after placing the graft will reduce the risk of RLL herniation, but it increases the risk of pulmonary vein strangulation.
There are 2 recent reports of pneumonectomies involving normal native bronchial stump healing after lung transplantation. The first is a case of left pneumonectomy after bilateral sequential lung transplantation for cystic fibrosis [4], and the second is a left pneumonectomy of the contralateral native lung after single-lung transplantation due to a persistent air leak [4]. Primary healing of these native bronchial stumps was satisfactory despite immunosuppression. Our case proved the adequacy of the blood supply to the major bronchi early after HLT, allowing primary healing of resected bronchus. The healing of the bronchial stump was excellent despite prolonged mechanical ventilation with positive end-expiratory pressure, associated severe bacterial infection, and the early use of steroids for immunosuppression.
The functional result in the second case was good despite loss of lung tissue and the lower than predicted forced expiratory volume in 1 second (1.4 L). This patient is alive and well over 2 years after operation and is in New York Heart Association class II.
In conclusion, herniation of a lobe in HLT is rare, but it is a potential complication. In our experience it is more common when the recipient heart is used as a domino. Prevention should be the aim, and it can be achieved by identifying normal pulmonary anatomy at implantation and particularly after lung inflation and before chest closure. Lobectomy can be performed safely early after HLT with primary bronchial healing.
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Footnotes
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Address reprint requests to Mr Yonan, The Transplant Centre, Wythenshawe Hospital, Southmoor Rd, Manchester M23 9 LT, England.
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References
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- Baldwin JC. Technique of combined heart-lung transplantation. J Cardiovasc Surg 1992;7:313–23.
- Gevenois PA, Antoine M, Yernault JC, Leclerc JC, Estenne M. Dextroposition of the left lower lobe after heart-lung transplantation. Chest 1993;103:1910–12.[Abstract/Free Full Text]
- Chiles C, Guthaner DF, Jamieson SW, Stinson EB, Oyer E, Silverman JF. Heart-lung transplantation: the postoperative chest radiograph. Radiology 1985;154:299–304.[Abstract/Free Full Text]
- Shennib H, Massard G, Gauthier R, et al. Single lung transplantation for cystic fibrosis: is it an option? J Heart Lung Transplant 1993;12:288–94.[Medline]
- Novick RJ, Menkis AH, Sandler D, et al. Contralateral pneumonectomy after single lung transplantation for emphysema. Ann Thorac Surg 1991;52:1317–9.[Abstract]
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Abstract
Introduction
