Sequential Redo Bilateral Lung Transplantation in a Patient with a Prior Heart-Lung Transplantation with Tracheal Anastomosis

Abstract

<h3>Introduction</h3> Redo lung transplantation (LT) for chronic lung allograft dysfunction (CLAD) is technically complex. We present a redo bilateral LT after previous heart-lung transplantation (HLT) with salvage of tracheal anastomosis and donor-to-donor main bronchi anastomoses. <h3>Case Report</h3> Patient is a 22-year-old male with previous HLT 17 years prior for pulmonary arterial hypertension now with preserved cardiac function, CLAD (FEV1 36%) with chronic hypercapnic respiratory failure, and pulmonary fungal infection with multidrug resistant <i>Lomentospora prolificans</i>. Prior to listing sputum culture was negative for fungal growth. His LAS was 45.8, and he spent 36 days on the wait list prior to a suitable donor being identified. Surgical approach involved redo clamshell thoracotomy. To control for possible fungal dissemination both lungs were explanted simultaneously under cardiopulmonary bypass, and extensive irrigation of chest cavities and trachea was completed with amphotericin B and caspofungin. The prior tracheal anastomosis was left intact. Pump suction and cell salvage was avoided. Standard sequential implantation with donor-to-donor main bronchi anastomoses was completed. Lung explant pathology demonstrated active subtotal and total bronchiolitis obliterans (C1) associated and necrotizing and non-necrotizing granulomas. Primary graft dysfunction was grade 1 at time 0, 24, 48, and 72 hrs. Postoperative antifungal regimen was Olorofim, caspofungin, and inhaled amphotericin B. No short-term airway complications were encountered. First transbronchial biopsy (TBBx) demonstrated moderate acute cellular rejection (ACR; A3B2), and <i>Lomentospora prolificans</i> growth. Due to persistent fungal growth, but no evidence of fungal pneumonia on chest imaging, systemic antifungal regimen was adjusted to fosmanogepix, miltefosine, posaconazole, and caspofungin. After 5 days of new antifungal regimen, 500 mg methylprednisone x 3 days was administered for ACR. Patient was discharged home on POD32. Second TBBx demonstrated no ACR but fungal elements persisted. <h3>Summary</h3> Redo bilateral LT after HLT with salvage of tracheal anastomosis and donor-to-donor main bronchial anastomosis is feasible without airway complications. Antifungal regimen will continue with re-evaluation at 6 months postoperatively.