Ann Thorac Surg 2001;72:935-937
© 2001 The Society of Thoracic Surgeons
Case report
Management of congenital abnormalities of the donor lung
Frank Schmidt, MDa,
David C. McGiffin, MDa,
George Zorn, MDa,
K. Randall Young, MDb,
David Weill, MDb,
James K. Kirklin, MDa
a Lung Transplant Program, Division of Cardiothoracic Surgery, Birmingham, Alabama, USA
b Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
Accepted for publication September 14, 2000.
Address reprint requests to Dr McGiffin, University of Alabama at Birmingham, 1530 3rd Ave South, LHRB 780, Birmingham, AL 35294-0007
e-mail: david.mcgiffin{at}ccc.uab.edu
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Abstract
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Congenital abnormalities were encountered in three donor lungs. A donor tracheal bronchus was incorporated into the right bronchial anastomosis. Anomalous pulmonary venous return of the right upper lobe to the superior vena cava and the left upper lobe to the innominate vein were managed by bridging the anomalous veins to the left atrial cuff with autologous pericardium and donor iliac vein, respectively.
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Introduction
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The increasing disparity between the number of donor lungs available and the number of patients requiring lung transplantation obligates surgeons to consider all potential donor lungs for transplantation, including those with congenital abnormalities. This report describes the intraoperative management of a donor lung with anomalous origin of the apical segmental bronchus of the right upper lobe from the trachea as well as 2 patients with partial anomalous pulmonary venous drainage.
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Case reports
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Case 1
A 49-year-old woman underwent bilateral sequential lung transplantation for smoking-related emphysema. The apical segmental bronchus of the right upper lobe of the donor lung arose anomalously from the trachea. After division of the right main stem bronchus, the origin of the anomalous bronchus was excised with a cuff of donor trachea. After transection of the recipient right main bronchus, a small wedge of recipient right main bronchus was excised from the upper border to accommodate the cuff of donor trachea. The bronchial suture line was performed with continuous 4-0 polydioxanone suture to the membranous floor and interrupted sutures of 4-0 prolene to the cartilaginous arch incorporating the anomalous apical segmental bronchus into the cartilaginous portion of the anastomosis (Fig 1). A wrap of peribronchial adventitial tissue was sutured over the bronchial anastomosis. The patient’s recovery was uneventful and routine surveillance bronchoscopy has continued to demonstrate a patent apical segmental bronchus, now 3 years after transplantation.
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Fig 1. Excision of the anomalous segmental bronchus with a cuff of donor trachea and incorporation of the cuff into the bronchial suture line.
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Case 2
A 24-year-old man who had previously undergone repair of a fossa ovalis type atrial septal defect at 4 years old subsequently developed Eisenmenger’s syndrome. He underwent bilateral sequential lung transplantation requiring the use of cardiopulmonary bypass. The donor right upper lobe pulmonary vein drained anomalously to the superior vena cava. The pulmonary venous anastomosis was performed by anastomosing the donor lower pulmonary vein to the recipient left atrial cuff with a conduit of autologous pericardium. Postoperatively, graft function was initially good without radiologic or clinical evidence of right upper lobe venous thrombosis. The patient subsequently succumbed from multiorgan system failure precipitated by cyclosporine-induced acute renal failure. No autopsy was performed.
Case 3
A 56-year-old man with smoking-related emphysema underwent a left single lung transplant. The donor left upper lobe pulmonary vein was found to drain anomalously to the innominate vein. The donor inferior pulmonary vein was anastomosed directly to the recipient inferior pulmonary vein and the anomalous superior pulmonary vein was bridged to the recipient superior pulmonary vein with a segment of donor iliac vein (Fig 2). Graft function was good and the patient made an uneventful recovery. A magnetic resonance angiogram with gadolinium was performed 1 year after transplantation, which demonstrated a patent iliac vein graft (Fig 3).
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Fig 2. Bridging the donor anomalous left upper lobe pulmonary vein to the recipient upper lobe pulmonary vein with a segment of donor iliac vein.
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Comment
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These congenital abnormalities of the lung should not exclude organs for transplantation since their management is straightforward. The use of donor iliac vein to bridge an anomalous pulmonary vein to the recipient left atrial cuff simplifies the reconstruction. Partial anomalous pulmonary venous drainage of the left or right upper lobe [1–3] and anomalous origin of the apical segmental bronchus from the trachea [4, 5] are uncommon anomalies that may be encountered at the time of donor lung procurement. These technical modifications to the lung transplant procedure will allow transplantation of donor lungs with these congenital abnormalities.
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References
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Frye R.L., Krebs M., Rahimtool S.H., Ongley P.A., Hallermann F.J., Wallace R.B. Partial anomalous pulmonary venous connection without atrial septal defect. Am J Cardiol 1968;22:242.[Medline]
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Alpert J.S., Dexter L., Vieweg W.V.R., Haynes F.W., Dalen J.E. Anomalous pulmonary venous return with intact atrial septum: diagnosis and pathophysiology. Circulation 1977;56:870.[Abstract/Free Full Text]
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Babb J.D., McClynn T.J., Pierce W.S., Kirkman P.M. Isolated partial anomalous venous connection: a congenital defect with late and serious complications. Ann Thorac Surg 1981;31:540.[Abstract/Free Full Text]
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Barat M., Konrad H.R. Tracheal bronchus. Am J Otolaryngol 1987;8:118.[Medline]
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Le Roux B.T. Anatomical abnormalities of the right upper lobe bronchus. J Thorac Cardiovasc Surg 1962;44:225.
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Abstract
Introduction
