Ann Thorac Surg 1999;67:550-551
© 1999 The Society of Thoracic Surgeons
Case Reports
Bronchial-atrial fistula after lung transplant resulting in fatal air embolism
Riyad Karmy-Jones, MDa,
Eric Vallieres, MDa,
Bruce Culver, MDb,
Ganesh Raghu, MDb,
Douglas E. Wood, MDa
a Division of Thoracic Surgery, University of Washington, Seattle, Washington, USA
b Division of Pulmonary Medicine, University of Washington, Seattle, Washington, USA
Accepted for publication July 30, 1998.
Address reprint requests to Dr Wood, Division of Thoracic Surgery, AA-119D Health Sciences, University of Washington, 1959 NE Pacific St, Seattle, WA 98195
e-mail: woodd{at}ctd.surgery.washington.edu
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Abstract
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We describe a rare case of fatal air embolism in a patient in whom a left atrial-bronchial fistula developed 1 month after single lung transplant. The cause was a combination of mediastinal infection and bronchial necrosis.
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Introduction
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Lung transplant recipients are at risk for a variety of infectious and anastomotic complications [1, 2]. Hemoptysis and air embolism are rare and usually involve late necrotizing infections or problems with central line removal [3, 4]. We treated a patient in whom signs of sepsis developed, followed by intermittent hemoptysis after uneventful single lung transplant. Examination disclosed a cavitary process in the mediastinum and necrosis of the bronchus intermedius distal to the anastomosis. After bronchoscopy the patient had a cardiac arrest from what appears to have been a large systemic air embolism. Results of autopsy demonstrated a left atrial-bronchial fistula, separate from the anastomoses, that appeared to have developed as a consequence of mediastinal infection or bronchial necrosis.
A 57-year-old man underwent right orthotopic lung transplantation for interstitial pulmonary fibrosis (usual interstitial pneumonitis type, grade III/IV). He was discharged on the fifth postoperative day but was readmitted approximately 4 weeks after the original procedure because signs of sepsis had developed, with chills and malaise, brief episodes of bright red hemoptysis, and a platelet count that had decreased to 75. Results of blood cultures were positive for Streptococcus milleri. In the interim atrial fibrillation had developed and he had been started on Coumadin. Computed tomographic scan of the chest demonstrated a cavitary lesion in the mediastinum, involving the bronchus intermedius and extending up to the carina (Fig 1). Broad spectrum antibiotics were started, but over the next 4 days he had increasing hemoptysis and a transient ischemic attack that resulted in brief left hemiparesis. Results of computed tomographic scan of the head and transesophageal echocardiogram were normal. Bronchoscopy disclosed an intact bronchial anastomosis and necrosis of the medial aspect of the bronchus intermedius, through which an inflamed cavity was seen. Twenty minutes after bronchoscopy the patient had an abrupt cardiac arrest. The patient was intubated, resuscitated, and taken directly to the operating room for a presumed pulmonary artery-to-bronchial fistula. The endotracheal tube was full of bright blood but without ongoing hemorrhage. The endotracheal tube was advanced into the left mainstem bronchus, and a median sternotomy was performed with the goal of controlling the right pulmonary artery. The posterior pericardium between the superior vena cava and aorta was incised, allowing control of the right pulmonary artery and exposure of the carina and both mainstem bronchi. The anastomosis was again noted to be intact, and the heart and pulmonary artery were both full. The superior aspect of the necrotic cavity was exposed, and there was no bleeding from that site. Cardiac function was severely diminished, with little contraction, and asystole developed again. At this point resuscitation was terminated. Autopsy found a chronic abscess cavity, with cultures positive for S milleri. A 3.0 x 0.7-cm defect was noted in the medial aspect of the bronchus intermedius, just distal to the anastomosis, that communicated with the mediastinal abscess and with a 1.1-cm defect in the donor atrium, 0.4 cm distal to the atrial anastomosis midway between the inferior and superior pulmonary veins. In addition, cytomegalovirus was cultured from the transplanted lung and the mediastinal abscess cavity.
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Fig 1. Computed tomographic scan of the chest demonstrating air-filled cavity (3 x 2 cm) adjacent to inflamed medial wall of bronchus intermedius and right pulmonary artery.
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Comment
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Hemoptysis and air embolism as a consequence of fistula between the bronchi and cardiac chambers have been described in patients with central cavitating squamous cell lung cancer or after cardiac operations [5, 6]. Bronchial to left atrial fistula after lung transplantation has not been described previously. Bronchial-mediastinal fistula, with localized mediastinal cavitation after transplantation has been reported, with possible causes including ischemia of the donor bronchus, infection, or foreign bodies such as Teflon pledgets or staples [7]. In the absence of other factors, bronchial-mediastinal fistula can be treated successfully with antibiotics, physiotherapy, and repeat bronchoscopy [7]. Fatal pulmonary bacterial infections are more common in the first 30 days after lung transplantation than in the later period when viral infections predominate [2]. Hemoptysis resulting from necrotic infections with bronchial bleeding appears to occur later, after bronchial circulation has redeveloped [3].
The cause of the fistula in this patient is most likely ischemia of the donor bronchus intermedius resulting in necrosis with subsequent mediastinal abscess formation. We have seen evidence of bronchus intermedius ischemia with an intact and viable anastomosis in 2 other patients after right lung transplantation. Presumably, this ischemia is caused by relatively poor pulmonary arterial collateralization in this watershed zone, while the mainstem bronchus remains viable because of its proximity to the upper lobe collaterals. Preventive strategies include avoiding excessive dissection of both donor and recipient bronchi as well as the donor stump to within two cartilaginous rings of the upper lobe takeoff. Other methods that have been advocated to reduce anastomotic complications include the telescoping anastomosis, which protects the bronchi at the level of the anastomosis but not distally, and reinforcing the anastomosis with viable tissue, including omentum, pericardial fat pat, or intercostal pedicle flap [1]. The patient’s bright red hemoptysis, the transient ischemic attack, the development of atrial fibrillation, and the presence of a new abscess in the mediastinum might have suggested atrial involvement with a mediastinal infection. Although the diagnosis of air embolism could not be established absolutely, it appears to be the only unifying explanation in light of postmortem identification of the bronchoatrial fistula, an antemortem transient ischemic attack with no identifiable source, and cardiac arrest shortly after bronchoscopy. In lung transplant patients who develop bacteremia, evidence of mediastinal abscess, and hemoptysis, consideration of bronchioarterial or bronchio-left atrial fistula would allow early surgical intervention and avoidance of fatal hemoptysis or air embolism.
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References
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Kshettry V.R., Kroshus T.J., Hertz M.I., Hunter D.W., Shumway S.J., Bolman R.M., III Early and late airway complications after lung transplantation: incidence and management. Ann Thorac Surg 1997;63:1576-1583.[Abstract/Free Full Text]
-
Husain A.N., Siddique M.T., Reddy V.B., Yeldandi V., Montoya A., Garrity E.R. Postmortem findings in lung transplant recipients. Mod Pathol 1996;9:752-761.[Medline]
-
Schoenberger J.A., Darcy M.D. Bronchial artery embolization for hemoptysis in a lung transplant recipient. J Vasc Inter Radiol 1995;6:354-356.
-
McCarthy P.M., Wang N., Birchfield F., Mehta A.C. Air embolism in single-lung transplant patients after central venous catheter removal. Chest 1995;107:1178-1179.[Medline]
-
Costarangos C., Fletcher E.C. Bronchogenic carcinoma, massive hemoptysis, and systemic air embolus. Chest 1986;90:140-141.[Medline]
-
O’Donnell A., Tsou E., Katz N. Ventriculo-bronchial fistula: a rare cause of intermittent massive hemoptysis. J Cardiovasc Surg 1989;30:378-380.[Medline]
-
Borro J.M., Ramos F., Vicente R., Sanches F., Morales P., Caffarena J.M. Bronchial fistula to the mediastinum in a heart-lung transplant patient. Eur J Cardiothorac Surg 1992;6:674-676.[Abstract/Free Full Text]
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Abstract
Introduction
