Bilateral Lobar Lung Transplantation and a Single Lung Transplantation Using Lungs from a Single Organ Donor During Coronavirus Disease 2019 Pandemic
The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on healthcare systems worldwide, including organ transplantation programs. In China, the pandemic led to a drastic reduction in cadaveric organ donations, exacerbating the morbidity and mortality of patients on the lung transplant (LTx) waitlist. This article presents a case where the lungs from a single cadaveric donor were maximally utilized to perform a single left lung transplantation for one recipient and a bilateral lobar transplantation for another recipient. This innovative approach highlights the feasibility of donor lung bipartitioning as a strategy to address organ shortages during the pandemic.
The case involved two recipients and one donor. Recipient 1 was a 67-year-old female with Sjogren syndrome-related interstitial fibrosis complicated by bilateral pneumonia. Recipient 2 was a 67-year-old male with pulmonary fibrosis. Both patients experienced rapid deterioration in February 2020, necessitating urgent transplantation. The organ donor was a 48-year-old male who suffered a cerebral hemorrhage during the COVID-19 pandemic. To ensure safety, three consecutive nucleic acid tests on bronchoalveolar lavage and rectal swabs from the donor were performed, all of which were negative for COVID-19.
The predicted total lung capacities (pTLC) were as follows: donor, 7.14 L; recipient 1, 4.37 L; recipient 2, 6.74 L. Given the significant reduction in organ donation activity during the pandemic and the pTLC values, the decision was made to bipartition the donor’s right lung for bilateral lobar transplantation for recipient 1 and to use the donor’s left lung for a single left lung transplantation for recipient 2.
The donor’s right upper lobe was partitioned from the right middle and lower lobes. The left atrial cuff of the right lung was inspected, revealing three separate openings for the venous drainage corresponding to each of the three lobes. The atrial cuff was divided such that one part contained the right upper lobe pulmonary vein, while the other part contained the right middle and lower lobe pulmonary veins. The right pulmonary artery was divided distal to the posterior ascending artery, and the right bronchial tree was divided at the level of the bronchus intermedius.
For recipient 1, a bilateral anterolateral thoracotomy was performed, and veno-venous extracorporeal membrane oxygenation (ECMO) was established. After a right pneumonectomy, the donor’s right middle and lower lobes were implanted. The recipient’s right main bronchus was anastomosed to the donor’s bronchus intermedius with continuous 4/0 polydioxanone (PDS). The recipient’s right main pulmonary artery was anastomosed to the donor’s interlobar pulmonary artery with continuous 5/0 prolene, ensuring neither undue tension nor excessive length. The recipient’s left atrium was anastomosed to the donor’s atrial cuff (containing the veins draining the right middle and lower lobes) using continuous 4/0 prolene.
Next, a left pneumonectomy was performed, preserving a long length of the recipient’s left main pulmonary artery and bronchus. A “right-to-left inverted” lobar transplantation using the right upper lobe graft was performed by placing it inside the left chest after rotating it 180° along the vertical axis. The recipient’s left main bronchus and the donor’s right upper lobe bronchus were trimmed and anastomosed with 4/0 PDS. The recipient’s left main pulmonary artery was anastomosed to the donor’s right upper lobe pulmonary artery with 5/0 prolene, and the recipient’s left superior pulmonary vein was anastomosed directly to the donor’s right superior pulmonary vein with 4/0 prolene. After inflation, both grafts appeared to fit well within the recipient’s chest cavity.
ECMO was weaned on postoperative day (POD) 2, and the patient was extubated on POD 3. The patient was discharged on POD 33. Postoperative imaging confirmed patent airway and vascular anastomoses. Follow-up evaluation eight months after the operation revealed the patient was well with no significant complications. Functional assessments included a forced expiratory volume in 1 second (FEV1) of 1.22 L (75% predicted), forced vital capacity (FVC) of 1.32 L (66% predicted), total lung capacity (TLC) of 2.43 L (59% predicted), residual volume (RV) of 1.28 L (70% predicted), and RV/TLC ratio of 52.5% (124% predicted). The patient achieved 380 meters on her 6-minute walk test with no desaturation. A transthoracic echocardiogram showed an ejection fraction of 63%, mild to moderate regurgitation, and a pulmonary artery systolic pressure of 54 mmHg. The bronchial anastomoses appeared satisfactory.
For recipient 2, a single left lung transplantation was performed with intraoperative veno-arterial ECMO support. Good size match between the graft and the recipient was observed. ECMO was weaned on POD 3, and the patient was extubated on POD 4. The patient was discharged on POD 29. There were no complications at the 8-month follow-up.
Pulmonary fibrosis patients often deteriorate rapidly and constitute the commonest group for cadaveric lobar transplantation. Donor size-matching can be challenging due to the small chest cavities of these patients. Recipient 1 had bilateral pneumonia, making single lung transplantation unsuitable and necessitating bilateral lung transplantation. Recipient 2, however, was suitable for single lung transplantation. By splitting the donor lungs as described, the utilization of the available organ was maximized during a time of severe donor scarcity, allowing transplantation for both recipients who were rapidly deteriorating.
During the COVID-19 pandemic, Chinese national guidelines were followed to reduce the risk of infection transmission from organ donors. Assessments included severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid tests on at least two occasions, influenza A and B antigens, H7N9 nucleic acid testing, next-generation sequencing of lower respiratory tract samples, lower respiratory tract microbiologic culture, and computed tomography of the chest. For suspected SARS-CoV-2 patients, additional tests were performed for nasal, sputum, lower respiratory tract, blood, and fecal samples.
While graft downsizing by wedge resection is an option, when the donor/recipient pTLC mismatch exceeds 1 L, downsizing by lobectomy is recommended. Couetil et al. first reported bipartitioning of a cadaveric donor left lung for bilateral lobar lung transplantation. The use of inverted lobar lung transplantation has been described in living lobar lung transplantation, usually implanting a donor right lower lobe or middle lobe to the left side. Recently, the Okayama group reported a case of lobar lung transplantation with transplantation of a cadaveric right upper lobe to the left side.
The satisfactory early and mid-term post-transplant outcomes of our recipients demonstrate the feasibility of donor lung bipartitioning for lobar transplantation as a strategy to maximize donor lung utilization. This approach is particularly valuable during times of organ scarcity, such as the COVID-19 pandemic, and can be considered for patients with rapid deterioration and challenging donor size-matching requirements.
doi.org/10.1097/CM9.0000000000001630
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