Two cases of bilateral lung transplantation combined with intracardiac repair and pulmonary artery replacement: perioperative managements based on the left ventricular function

Abstract

We report on two patients who underwent bilateral lung transplantation (BLTx) combined with cardiac surgery. Patient 1 was a female whose pulmonary hypertension resulted from a congenital atrial septal defect (ASD) and idiopathic pulmonary arterial hypertension. She had a very small left ventricle (LV). We initiated venoarterial extracorporeal membrane oxygenation (ECMO) before induction of general anesthesia. She underwent ASD patch closure, pulmonary artery replacement, and BLTx under cardiopulmonary bypass (CPB). At the weaning from CPB, primary graft dysfunction and pulmonary edema induced by LV diastolic dysfunction was apparent. We gradually decreased the ECMO support and eventually weaned off the ECMO on the 4th postoperative day (POD) and the ventilator on the 29th POD. Patient 2 was a male with Eisenmenger syndrome, which resulted from ASD and ventricular septal defect (VSD). He had a normal LV. General anesthesia was induced smoothly without ECMO. He underwent ASD and VSD patch closure, pulmonary artery replacement, and BLTx under CPB. Weaning from CPB proceeded smoothly. These patients needed different management because of their different LV function. Especially, perioperative management of the BLTx patient with LV diastolic dysfunction was difficult. Assessment of perioperative cardiac function is very important in BLTx combined with cardiac surgery.

Transplantation for pulmonary arterial hypertension with congenital heart disease: Impact on outcomes of the current therapeutic approach including a high-priority allocation program

“…However, median waitlist durations before DLTx and HLTx were similar in our cohort. The shift towards DLTx is in line with suggestions that PAH‐CHD may be treatable by DLTx and cardiac repair provided the cardiac abnormalities are relatively simple and the function of both ventricles is preserved 15,20,32,33,34,35 . In our cohort, DLTx accounted for 11.1% of transplantations before HPAP implementation compared to 31.0% afterward.…”

“…preserved. 15,20,32,33,34,35 In our cohort, DLTx accounted for 11.1% of transplantations before HPAP implementation compared to 31.0% afterward. The indications of DLTx were extended to patients with an absent or closed shunt and to those with atrial septal defects eligible for percutaneous closure.…”

Heart Failure in Adult Congenital Heart Disease: From Advanced Therapies to End-of-Life Care

“…Some Eisenmenger's patients with good ventricular function, such as those with an atrial or ventricular septal defect, can be listed for lung transplant and intracardiac repair, instead of a heart-lung transplant to increase the likelihood transplant and longterm survival. 83 The assessment of patients with ACHD referred for heart-lung transplant should begin with an ACHD-HF team, who can first consider nontransplant strategies. For patients with no other options, who wish to proceed with listing for heart-lung transplant, counselling during the long wait is essential.…”

Ask the Expert: Transplantation in Eisenmenger Syndrome: Getting to the Heart of the Matter

“…The reasons for this are not entirely clear, as data concerning the specific anatomy of the VSDs or their repairs are not available; however, 5 deaths in the LT arm were due to ventricular failure, while no such deaths were reported in the HLT arm, suggesting that perhaps the recipient heart was not as healthy as expected in these cases. Toyama and colleagues reported 2 cases of ES treated with an LT-and-repair strategy 6 ; in the first, the underlying cardiac lesion was an ASD and the postoperative course was complicated by significant left ventricular diastolic failure, manifested by elevated pulmonary capillary wedge pressure and severe pulmonary edema requiring prolonged extracorporeal membrane oxygenation (ECMO) and ventilator support. The second case involved both a VSD and an ASD, where no such difficulty was experienced.…”