Single-lung transplantation in patients with previous contralateral pneumonectomy: technical aspects and results.

OBJECTIVE

Single-lung transplantation (SLTX) in patients with previous contralateral pneumonectomy (PN) is a rarely observed situation. Intrathoracic anatomical changes caused by mediastinal shift may complicate the surgical procedure. We collected observations from different transplantation centres to analyse the technical aspects and results.

PATIENTS AND METHODS

Between July 1990 and September 2008, 14 patients (seven women and seven men) with previous PN underwent SLTX for end-stage pulmonary failure. Patients were categorised in three groups according to lung disease: cystic fibrosis bronchiectasis (group 1; n=4), non-cystic fibrosis bronchiectasis (group 2; n=6) and bronchioloalveolar carcinoma (group 3; n=4). We reviewed patients' characteristics according to mediastinal shift, thoracic approach, bypass cannula procedure, perioperative difficulties and immediate and long-term results.

RESULTS

Median age was 19.5, 33.5 and 52.5 years in groups 1, 2 and 3, respectively; there were nine left and five right cases of SLTX. Surgery was performed by sternotomy (n=4), anterolateral thoracotomy (n=4), clamshell (n=4) or posterolateral thoracotomy (n=2). Cannulas for bypass were inserted into femoral (n=7) or central vessels (n=5) or both (n=2). Mediastinal shift did not complicate surgical procedure but rendered cannulation more difficult with ensuing cardiopulmonary bypass dysfunction (n=3) and early bronchial complications (n=2). In-hospital mortality rate was 29% (4 out of 14 patients), including two deaths due to perioperative difficulties linked to mediastinal shift. Median global survival was 108 months. Median survival was higher in group 2 (108 months vs 1 month in the other groups) and in case of PN during childhood (n=6, median survival 108 months corresponding to one death).

CONCLUSIONS

SLTX after PN is associated with high perioperative morbidity and mortality due to mediastinal shift. Best results are observed in patients undergoing PN for non-cystic fibrosis bronchiectasis and during childhood. Anatomical changes induced by PN must be anticipated to adapt the thoracic approach and cardiopulmonary bypass access.