Ann Thorac Surg 2007;84:642-644
© 2007 The Society of Thoracic Surgeons
Case Reports
Third-Time Lung Transplant Using Extended Criteria Lungs
Takahiro Oto, MD,
Michael Rowland, FRACS,
Anne P. Griffiths, FRCNA,
Bronwyn J. Levvey, RN,
Donald S. Esmore, FRACS,
Trevor J. Williams, FRACP,
Gregory I. Snell, FRACP*
Lung Transplant Service, The Alfred Hospital, Monash University, Melbourne, Victoria, Australia
Accepted for publication March 9, 2007.
* Address correspondence to Dr Snell, Department of Allergy, Immunology, and Respiratory Medicine, The Alfred Hospital, Commercial Road, Melbourne, Victoria, 3004, Australia (Email: g.snell{at}alfred.org.au).
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Abstract
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There is an increasing requirement for lung re-transplants (re-LTx) related to the bronchiolitis obliterans syndrome. Nevertheless, re-LTx, especially second-time re-LTx, poses the dilemma of appropriate allocation of a scarce donor lung resource versus the desire to optimize outcomes for an individual patient. Extended donors have been used to partially alleviate a scarce donor lung supply with satisfactory outcomes for primary lung transplant. However, the usefulness of the extended donors remains unknown, including donation-after-cardiac-death donors for re-LTx. This report describes a second-time re-LTx using significantly extended donor criteria lungs from a Maastricht category IV donation-after-cardiac-death donor with resultant good clinical outcomes.
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Introduction
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With lung transplantation (LTx) as an established therapy for end-stage pulmonary disease, the number of patients potentially requiring a lung re-transplant (re-LTx) is increasing related to late graft dysfunction secondary to the bronchiolitis obliterans syndrome (BOS) [1–3]. Nevertheless, lung re-LTx remains a controversial procedure limited by a shortage of donor lungs and potentially inferior outcomes compared with primary LTx [1, 2]. Re-LTx, especially second-time Re-LTx, poses a dilemma of appropriate allocation of a scarce donor lung resource and the desire to optimize outcomes for an individual patient.
Extended donors have been used to partially alleviate a scarce donor lung supply with satisfactory outcomes for primary LTx [4, 5]. However, the usefulness of extended donors for re-LTx remains unknown, including donation-after-cardiac-death donors. This report describes a second-time re-LTx using marginal lungs from a Maastricht category IV donation-after-cardiac-death donor.
A second-time re-LTx was performed on an otherwise excellent 46-year-old candidate with recurrent BOS using extended donation-after-cardiac-death (Maastricht category IV) donor lungs 4.5 years after the first-time re-LTx. The donor was a larger 27-year-old anoxic brain-dead male who was a marijuana and tobacco smoker with a very abnormal chest roentgenogram, moderate bloody secretions, and deteriorating blood gases (lowest measured PaO
2 on 100% oxygen = 67 mm Hg). The donor left lower lobe had extensive pneumonic change (Fig 1). These organs had been rejected for transplantation by all other Australian centers and were not suitable for any other local recipient. Prospective lymphocytotoxic cross-matching was used to avoid pre-sensitization related to previous donors and blood products. During organ procurement, hypoxemia contributed to cardiac arrest (ie, technically a Maastricht category IV donation-after-cardiac-death organ), and the lungs were rapidly procured with minimum warm ischemic time. Prior to implantation, a left lower lobectomy was performed to remove the frankly consolidated left lower lobe and to downsize the graft to allow a bilateral re-LTx. Significant adhesions were observed around the hilar structures bilaterally, and during pneumonectomy specific care was taken not to injure the phrenic nerves. The main bronchus was transected along the previous suture line, and the donor remnant bronchial tissue was resected to avoid posttransplant bronchial strictures. For vascular anastomoses, 5 mm of previous donor vascular cuff (attached to the recipient’s native vascular structures) was preserved to provide sufficient length to place a vascular clamp. Bilateral re-LTx was performed without cardiopulmonary bypass. Lung grafts were implanted with a total ischemic time of 410 minutes on the right side and 525 minutes on the left. The recipient experienced grade 3 primary graft dysfunction in the first 6 hours after transplant (PaO
2/PIO
2 = 146 at 0 hour and 179 at 6 hours). However, graft function recovered within the first 72 hours (PaO
2/PIO
2 = 205 at 12 hours, 272 at 24 hours, 263 at 48 hours, and 226 at 72 hours). The recipient was able to be extubated at 74 hours posttransplant and was subsequently discharged from the hospital on day 30. Currently she remains very well with pulmonary function at 6 months posttransplant again approaching 85% of predicted values (Fig 2).
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Fig 1. An extended donor lung from Maastricht category IV donation after cardiac death donor: (A) dark-red, solid, edematous left lower lobe compared to white, soft left upper lobe, and (B) severely damaged left lower lobe was unsuitable for transplant, and lobectomy was performed. Remnant left upper lobe and contralateral lung was successfully used for bilateral re-transplantation.
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Fig 2. Recipient forced expiratory volume in 1 second before and after lung re-transplant. Recipient’s predicted forced expiratory volume in 1 second was 3.1 L.
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Comment
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Re-LTx remains a challenging surgical and medical procedure. We believe that this is the first report to describe a second-time re-LTx (a third-time LTx). At the Alfred Hospital, 595 LTx (315 bilateral, 221 single, and 59 heart-lung) operations were performed before November 2006, and 11 (1.8%) of these were re-LTx for 10 recipients (n = 1, second re-LTx). Our policy for re-LTx has evolved with emerging medical literature that suggests carefully selected, ambulatory, nonventilated patients with BOS surviving beyond 2 years post-primary transplants are the best re-LTx candidates [1]. Intrinsically we undertook this transplant with these donor organs because of the belief that the recipient ultimately represented good protoplasm and that the young donor organs could recover, particularly by taking the unusual step of excising the pneumonic lobe. Theoretically an ideal donor is desirable for any high-risk procedure; however with a general donor shortage this is not practical. The donor lungs described in this case report were certainly extended criteria lungs due to the falling oxygenation in the setting of a solid current smoking history, secretions, and pneumonia, on top of cardiac arrest and the surgical challenge of a donor-recipient size mismatch.
Evolving clinical practice has seen a tendency to perform bilateral LTx with these extended donors, using an interleukin-2 blocking agent with lower corticosteroid doses and calcineurin-inhibitor levels. Mycophenolate mofetil and rapamycin-related medications provide potent alternative immunosuppressive choices to hopefully decrease the prospect of BOS returning rapidly in the re-LTx allograft. An aggressive stance is taken with antibiotic, antifungal, and antiviral prophylaxis and early treatment of infection. In the current case, the seesaw lung function after the second transplant (Fig 2) represented serious Aspergillus bronchitis and was avoided after the third transplant by using aggressive voriconazole prophylaxis.
Second-time re-LTx is feasible and could be an option to treat recurrent BOS. We believe that this challenging case resets the definitions of donor and recipient lung transplantation acceptability, proving that we still have yet to understand where the true boundaries of lung transplantation lie. Although further research is needed on long-term survival and BOS, ideal donors are not exclusively required for re-LTx, and using extended criteria donors, including donation-after-cardiac-death donors, may provide greater LTx opportunities for re-LTx candidates.
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References
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- Novick RJ, Stitt LW, Al-Kattan K, et al. Pulmoary retransplantation: predictors of graft function and survival in 230 patients Ann Thorac Surg 1998;65:227-234.[Abstract/Free Full Text]
- Brugiere O, Thabut G, Castier Y, et al. Lung retransplantation for bronchiolitis obliterans syndrome Chest 2003;123:1832-1837.[Medline]
- Struber M, Fischer S, Gottlieb J, et al. Long-term outcome after pulmonary retransplantation J Thorac Cardiovasc Surg 2006;132:407-412.[Abstract/Free Full Text]
- Orens JB, Boehler A, de Perrot M, et al. A review of lung transplant donor acceptability criteria J Heart Lung Transplant 2003;22:1183-1200.[Medline]
- Oto T, Levvey BJ, Whitford H, et al. Feasibility and utility of a lung donor score: correlation with early post-transplant outcomes Ann Thorac Surg 2007;83:257-263.[Abstract/Free Full Text]
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Abstract
Introduction
