RIGHT LUNG HERNIATION TO LEFT CHEST AFTER HEART-LUNG TRANSPLANT

Abstract

SESSION TITLE: Complications You Don't Want to Miss SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/10/2018 10:45 AM - 11:45 AM INTRODUCTION: Lung herniation to contralateral pleural space is a rare complication after heart-lung transplant (HLT). CASE PRESENTATION: A 51-year-old Hispanic female with a history of congestive heart failure, pulmonary hypertension, Sjogren’s syndrome, and pulmonary fibrosis underwent HLT. Post-operative course was initially uneventful and she was extubated on post-operative day (POD) 3. Bilateral chest tubes were removed POD 5. Patient was transferred to the telemetry floor on low dose dobutamine on POD 6. Chest radiography showed right greater than left pleural effusion which progressed over the next few days. On POD 8 she underwent ultrasound-guided right thoracentesis with removal of 800 mL of fluid serosanguinous fluid and bronchoscopy revealed features concerning for right middle lobe torsion and right lower lobe (RLL) atelectasis. This prompted a computed tomography (CT) scan of the chest on POD 9 that showed herniation of the RLL into the left pleural space behind the heart with complete atelectasis of the RLL. On POD 10 she was taken to the operating room for mediastinal exploration and reduction of RLL herniation. RLL appeared viable. The airway and vessels appeared patent. Pneumopexy of right upper, middle, and lower lobes was completed. RLL was also pexied to the chest wall and diaphragm to prevent recurrence. Patient did well. She was extubated, and eventually discharged home without negative sequela related to herniation. DISCUSSION: This patient was doing well clinically despite lung herniation. Chest X ray findings suggestive of lung herniation were obscured by bilateral pleural effusions in our case. Lung herniation behind the heart into the contralateral thoracic cavity can increase infection risk, cause vascular compromise, or infarction. CONCLUSIONS: Lung herniation after HLT is a rare complication. CT scan is the diagnostic imaging of choice. Early diagnosis and surgical correction can prevent lung compromise. If diagnosis is delayed, irreversible damage may occur that may potentially require resection of the nonviable lung lobe. Reference #1: Yonan NA, Egan J, Deiraniya AK, et al. Right Lower Lobe Herniation After Domino Heart-Lung Transplantation. Ann Thoracic Surg 1995; 59:1223-1226. DISCLOSURES: No relevant relationships by Mudassar Ahmad, source=Web Response No relevant relationships by Thomas Kaleekal, source=Web Response