Abstract Since the inception of lung transplantation in 1982, it has been standard practice to implant donor lungs on the ipsilateral side in the recipient. The development of the techniques of lobar and bilateral lobar transplantation has shown that lung morphology may adapt to the shape of the thorax. Thus, variations in implantation have become possible. We describe a case of a 30-year-old man with severe bronchiectasis due to ciliary dyskinesis which required a left lower lobectomy at the age of 11 years and a left completion pneumonectomy 10 years later. His disease progressed and he was listed for a right lung transplantation. At the time of transplantation, the donor right lung was noted to be edematous and unfit for transplantation. This required grafting the donor left lung in the right thorax of the recipient. Follow-up at 7 years shows good exercise capacity and excellent functional tests without evidence of rejection.

1 De Hoyos A.L.

Patterson G.A.

Maurer R.

et al. Pulmonary transplantation. Early and late results. 2 Piotrowski J.A.

Splittgerber F.H.

Donovan T.J.

Ratjen F.

Zerkowski H.R. Single-lung transplantation in a patient with cystic fibrosis and an asymmetric thorax. 3 Couetil J.P.

Tolan M.J.

Loulmet D.F.

et al. Pulmonary bipartioning and lobar transplantation a new approach to donor organ shortage. Techniques in lung transplantation continue to evolve []. With the rising problem of an insufficient number of donors, each organ must be used to its maximum potential. Ever-decreasing problems with bronchial anastomotic techniques have enabled variations to become possible. The development of lobar lung transplantation [] has demonstrated two important concepts: firstly, that the lung may adapt morphologically with time to fill the thoracic cavity; and secondly, that the bronchial anastomoses may be performed without anatomic alignment of the bronchi. Having extensive experience in the techniques of bilateral lobar transplantation in our unit, both in experimental models, and clinically, we were able to adapt the technique of single lung transplantation and implant the left lung of a donor in the right thorax of a recipient.

A 30-year-old male patient presenting chronic respiratory failure, secondary to ciliary dyskinesis, was considered for a lung transplant. Past medical history revealed a left lower lobectomy for bronchiectasis at the age of 11 years, and a left completion pneumonectomy for progression of the disease 10 years later. The right lung continued to be diseased. H influenza was persistently isolated from his sputum, he was short of breath at rest, and he required continuous oxygen therapy. His oxygen saturation dropped to 84% on minimal exertion. Spirometry revealed a forced expiratory volume in 1 second of 17% and a forced vital capacity of 0.8 liters. He was 57 kg and 175 cm, and was cytomegalovirus (CMV) negative. Before placement on the transplant waiting list, cardiac catheterization revealed a pulmonary artery wedge pressure of 10 mm Hg, a mean pulmonary arterial pressure of 25 mm Hg, and a cardiac index of 2.5 lit/min/m2.

After 3 months on the transplant waiting list, a donor right lung became available and the left lung was offered to the other centers, but there was no requirement for it, which meant that the entire lung block was available to our center. The operation was performed through a right posterolateral thoracotomy with cannulation of the right femoral artery and the right atrium with a double-staged venous cannula. At its arrival, the donor block was examined and the right lung was edematous, secondary to unrecognized aspiration, and appeared most unsuitable for transplantation. The left lung, on the other hand, was of good texture and color. It was decided to transplant the left donor lung into the right thorax of the recipient. A maximal length of donor pulmonary artery and atrial cuff were retained. The donor bronchus was trimmed to two rings above the upper lobar origin. The recipient right pulmonary hilum was dissected free, the pericardium was open and tapes were passed around the vessels. The interatrial groove was dissected as much as possible to facilitate clamping the pulmonary veins as proximally as possible. The recipient main pulmonary artery and veins to the right lung were clamped, the main bronchus stapled at its emergence from the mediastinum, and the right lung was excised.

The donor left lung was placed in the recipient right thorax after a 180° rotation around its superior-inferior axis from its anatomic position. Consequently, the anatomic posterior aspect of the left lung became anterior in the right chest. When the bronchus of the donor was aligned with that of the recipient, the pulmonary arteries of the donor and the recipient were on opposite sides of the bronchus. The recipient pulmonary artery was located inferiorly and posteriorly relative to the bronchial axis, and the donor’s was located superiorly and anteriorly. To resolve this problem of arterial misalignment, it was necessary to extensively dissect the donor pulmonary artery and to translocate it in an anterior position relative to the bronchial axis. The donor pulmonary artery was also left long enough to prevent any tension on the anastomosis. No problem was encountered as far as the pulmonary veins were concerned. On the other hand, there was a substantial disparity between the size of the donor lung and thorax as considerable mediastinal shift had occurred postpneumonectomy. As in a standard left lung transplantation, the donor bronchial stump was trimmed to a length of two cartilaginous rings above the upper lobe bronchus to prevent ischemic complications. Because of the anteroposterior inversion of the left lung when placed in the right chest, the muscularis membranous portion of one bronchus was sutured to the cartilagenous portion of the other with no consequence on the healing process. The recipient right main bronchial staple line was excised and the bronchial anastomosis was constructed using an end-to-end suturing technique with 4.0 Prolene (Ethicon, Somerville, NJ). The venous anastomosis was fashioned with 5.0 Prolene suture, and the arterial anastomosis with 6.0 Prolene suture, in the end-to-end technique without kinking and tension. After lung reinflation, the upper part of the thoracic cavity was noted to be incompletely filled by the transplanted lung. The patient was weaned easily from bypass, drains inserted, and after standard closure was returned to the intensive care unit. Pathological examination of the donor right lung indeed showed it to be unsuitable for transplantation, as the alveoli were filled with blood and edema fluid. Aspiration was confirmed by pathological examination.

Fig 1 Postoperative chest roentgenogram at 7 years follow-up showing the transplanted lung in the right thorax. Fig 2 Postoperative pulmonary angiogram showing normal aspect of the pulmonary artery (arrow). The patient was weaned from ventilation on the 1st postoperative day and maintained on triple therapy, steroid therapy having been started after 3 weeks. The only problem encountered in the early postoperative period was a persistent pneumothorax which gradually healed after 7 days of pleural drainage. Follow-up chest roentgenogram ( Fig 1 ) and computed tomographic scans showed full resolution of the residual air spaces and expansion of the lung to fill the thoracic cavity. Bronchoscopy, both early and late, have revealed good healing of the bronchial anastomosis. Pulmonary angiography ( Fig 2 ) demonstrated no stricture, kinking, or narrowing of the pulmonary artery and veins. He suffered a pneumococcal pneumonia on the 4th postoperative month, which required in-hospital intravenous antibiotics, but he quickly recovered. He is at present 7 years posttransplantation and continues to do very well with good exercise capacity, excellent functional tests and full-time employment. Recent spirometry reveals forced expiratory volume in 1 second of 1.89 liters (50%) and forced vital capacity of 2.25 liters (45%).

Comment 4 Puskas J.D.

Winton T.L.

Miller J.D.

Scavuzzo M.

Patterson G.A. Unilateral donor lung dysfunction does not preclude successful contralateral single lung transplantation. 5 Calhoon J.H.

Grover F.L.

Gibbons W.J.

et al. Single lung transplantation. Alternative indications and technique. 6 Couetil J.P.

Tolan M.J.

Grousset A.

et al. Experimental bilateral lobar lung transplantation and its application in humans. 3 Couetil J.P.

Tolan M.J.

Loulmet D.F.

et al. Pulmonary bipartioning and lobar transplantation a new approach to donor organ shortage. Single lung transplantation is an evolving option for patients with end-stage lung disease but remains limited by a severe shortage of suitable donor lungs. Adequate single lung graft may be discarded as a result of pulmonary disease in the donor. Efforts have been made to select donors for single lung graft after contralateral pulmonary trauma or aspiration []. Bronchial healing has improved with better lung preservation, shortening of the donor bronchial stump, telescopic anastomotic technique, and low steroid regimens []. Techniques developed for bilateral lobar transplantation have shown that variations in bronchial and vascular suturing techniques are possible, and also that lung tissue eventually adapts to the shape and size of the cavity in which it lies as it expands to fill that cavity. In previous studies, we first showed the feasibility of bipartitioning and lobar transplantation experimentally [] and clinically []. With adult dogs used as donors, either right or left single lungs were divided into separate lobes which were subsequently implanted unilaterally and bilaterally into young dogs. Follow-up of the animals demonstrated satisfactory bronchial and vascular anastomoses and perfect adaptation of the transplanted lobes to the morphology of the recipient thorax. After the success of our animal experiments, we have shown that the technique of lobar separation of the left lung followed by bilateral transplantation is feasible and easily done in humans without an increase in mortality or morbidity. Carefully selected patients with a large size discrepancy with the donor demonstrate good functional results. In this reported case, we have shown this technique to be effective in bilobar transplantation when the upper-left lobe of a donor is sutured to the recipient right bronchus in our split lung technique. It is rarely necessary to transplant a lung on the contralateral side, and this technique should be used with caution. However, in case of donor shortage, all options should be considered in order to use the potential of available donors to its maximum.