Bilateral Sequential Lung Transplantation Research Articles

Thoracoscopic Decortication for Tubercular Empyema in a Lung Transplant Recipient

Tubercular empyema thoracis is a morbid postoperative complication in lung transplant recipients, which significantly impairs graft function and affects the survival rate. This report describes a case of tubercular empyema thoracis in a 42-year-old female, who underwent bilateral sequential lung transplantation for interstitial lung disease (non-specific interstitial pneumonia). She underwent video-assisted thoracoscopic surgery decortication, a preferred surgical approach due to its minimally invasive nature with excellent success rates. This report highlights the effectiveness of tailored surgical interventions and the importance of individualized post-transplant care to optimize patient recovery and graft functionality.

Quantifying the effects of training in lung transplantation: Lessons from NASA

IntroductionSequential lung transplantation is a complex procedure. The traditional training model continues to centre around operative experience with progressively increasing delegation of stages of the procedure. However, little evidence exists on the effects this has on surgical trainers. The NASA-TLX is a subjective, multi-dimensional assessment tool that rates perceived workload. We sought to employ this as a means of assessing the impact that training in lung transplantation has on trainers. MethodsWe prospectively collected the NASA-TLX data for 60 patients undergoing bilateral sequential lung transplantation. In 30 cases the operation was performed entirely by the senior surgeon (SS) who implanted both lungs. In 30 operations the senior surgeon implanted the right lung (SSR) and supervised a trainee implanting the left lung (TL). ResultsThe overall weighted rating was significantly lower for the surgeon undertaking the case themselves rather than training (p <0.001). Cases were comparable in terms of case type, donor ischaemic time and peri-operative characteristics. Mental and temporal demand were greater throughout training cases (p<0.001, p<0.05). There was less effect on frustration, physical demand and effort. Perceived performance showed no significant difference between the groups. ConclusionThe NASA task load index can be used to inform the effects of training lung transplantation on trainers. Training leads to greater mental and temporal demands with less effect on other factors. Crucially, there was no significant difference in perceived performance. As the specialty continues to be confronted with diverse challenges, this study should give confidence to those training the transplant surgeons of the future, as well as providing them with a mechanism to reflect on their own training performance. ACGME CompetenciesInterpersonal and communication skillsPractice-based learning and improvement

Abstract CT278: [DREAM] Double lung transplant registry aimed for lung-limited malignancies - a prospective registry study for medically refractory cancers

Abstract BackgroundAdenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) are listed as ‘special circumstances’ for lung transplantation according to a consensus document from the International Society for Heart and Lung Transplantation (ISHLT) (Weill D et al., 2015). Five studies have reported on lung transplantation in carefully selected subsets of patients with multifocal lung adenocarcinoma (Raemdonck DV et al., 2016; Glanville AR et al., 2018). The 5-year survival rate of bilateral sequential lung transplantation was estimated at over 50% in patients with multifocal BAC, invasive adenocarcinoma, and NSCLC (Ahmad U et al., 2012; Paloyan EB et al., 2000; Zorn GL et al., 2003; de Perrot M et al., 2004). Another a case series reported a post-transplant recurrence-free survival of 23 to 56 months in three patients (Garver RI et al., 1999). Moreover, there is an unmet need for patients who have lung-limited metastasis after successful treatment for primary tumors such as sarcomas or colorectal cancer (CRC). As with liver transplantation for CRC patients who have liver-confined metastases (Dueland S et at., 2020; Hernandez-Alejandro R et al., 2022), the applicability of lung transplantation in lung-limited metastatic patients should be explored. There is also an unmet need for patients with respiratory failure with a history of cancer in the last 5 years. MethodsThis is a prospective registration trial to evaluate outcomes of patients who undergo double lung transplantation for the treatment of the select groups of medically refractory cancers (primary lung cancers or metastatic cancers in lungs). Overall survival (OS), disease-free survival (DFS), allograft rejection (AR) and allograft survival (AS) as well as molecular and genetic biomarkers will be monitored to investigate the correlation with prognosis.The study duration will be 10 years including surveillance. Recruitment is to occur during the first 5 years of the study. The goal is to enroll 125 participants through the Northwestern Medicine Clinical Programs.Essential Criteria:1.The tumor should be without any extrapulmonary metastasis as determined by standard of care diagnostic and staging workup.2.All standard of care or experimental oncological treatments known to improve survival should have failed or deemed infeasible 3.Patients should meet the general criteria for lung transplant evaluation and listing Study cohorts:•Cohort A: Primary lung cancers - Examples include, but not limited to, invasive mucinous/non-mucinous non-small cell lung cancers and multifocal carcinomas.•Cohort B: Metastatic cancers to the lung only - Examples include, but not limited to, germ cell tumors, head &amp; neck tumors, colorectal tumors, renal cell tumors, testicular cancers.•Cohort C: Respiratory failure with a history of cancer in the last 5 years- Examples include, but not limited to interstitial lung disease (ILD), pulmonary fibrosis (idiopathic or secondary), advanced chronic obstructive pulmonary disease (COPD), bronchiectasis, emphysema, cystic fibrosis (CF), emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension (PAH) Clinical trial registry number : NCT05671887.Enrollment began November 16, 2022. Trial is open and continues to enroll participants as of Jan 8, 2024. Citation Format: Young Kwang Chae, Liam Il-Young Chung, Rade Tomic, Ankit Bharat. [DREAM] Double lung transplant registry aimed for lung-limited malignancies - a prospective registry study for medically refractory cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT278.

Unveiling the complexities of lung transplantation in situs inversus

BackgroundLung transplantation for situs inverse is considered technically challenging because of the reverse positioning of the organs. By providing a detailed description of the surgical procedure, perioperative care, and post-transplant follow-up, we aim to contribute valuable information to the existing knowledge base. We presented two cases of successful bilateral sequential lung transplantation in situs inverse patients.Case presentationOur first patient was a 28-year-old, non-smoking woman with Kartagener syndrome and advanced bronchiectasis that developed into pneumonia and required repeated hospital admissions. She underwent double lung transplantation. During the lung transplant procedure, venoarterial extracorporeal membrane oxygenation (VA ECMO) support was provided. The recipient’s morphologically right (anatomically left) lung was explanted. The right main bronchus was anastomosed, followed by the pulmonary artery and left atrial anastomoses. Afterward, we proceeded with the left side. Similar to the right side, left pneumonectomy and implantation were performed using the same methods. The duration of VA ECMO support was 147 min with a 328-min ischemic time. Because of the significant size mismatch, nonanatomic lung volume reduction over the right middle and left upper lobes was necessary. The patient had no complications postoperatively and was discharged on post-operative day (POD) 12. Our second patient was a 51-year- old man with scleroderma-associated interstitial lung disease with situs inversus. Bilateral sequential lung transplantation was performed. Similar to case 1, a clamshell incision was made at the fourth intercostal space entry. The patient then received VA ECMO support identical to that in case 1. The total VA ECMO support time was 155 min with 295 min of ischemic time. The patient recovered uneventfully and was discharged on POD 13.ConclusionsLung transplantation for situs inverse can be a viable treatment option without modifying established transplantation procedures.

Case Report of Complex Chest Wall Repair for Sternal Dehiscence After Bilateral Lung Transplantation

We report a case of a complex chest wall reconstruction because of sternal dehiscence, requiring different surgical procedures for its complete resolution. A 54-year-old man patient with Langerhans cell histiocytosis and chronic obstructive pulmonary disease underwent bilateral sequential lung transplantation through a clamshell incision, using nitinol thermo-reactive clips for sternal closure. One year later, he consulted because of chest pain, fever, and purulent secretions. Physical examination and chest X-ray revealed a right pulmonary hernia due to post-clamshell wound dehiscence. Chest wall repair was performed, placing an expanded-polytetrafluoroethylene synthetic mesh, and the sternum was realigned and fixated with titanium plates and screws. However, in the immediate postoperative period, there was a large amount of serous drainage through the surgical wound, needing negative pressure therapy. Unfortunately, the wound became necrotic with exposure to the osteosynthesis material. In addition, a chest computed tomography scan showed fluid accumulation in the anterior chest wall. Therefore, two-stage revision surgery was indicated: first, the removal of the previous prosthesis and, the definite one, the use of a pedicled latissimus dorsi myocutaneous flap to provide effective coverage of the wound. Sternal dehiscence is not an uncommon complication after clamshell incision in patients undergoing bilateral sequential lung transplantation, and it is associated with significant morbidity. In the presence of chest wall instability, surgical repair is mandatory.

Postmortem Identification of Vascular Ehlers-Danlos Syndrome in a Lung Transplant Recipient.

Postmortem Identification of Vascular Ehlers-Danlos Syndrome in a Lung Transplant Recipient.

Abstract CT051: Double lung transplant registry aimed for lung-limited malignancies (DREAM) - a prospective registry study of bilateral lung transplantation for medically refractory cancers confined to the lungs

Abstract Background: According to a consensus document from the International Society for Heart and Lung Transplantation (ISHLT), adenocarcinoma in situ (AIS) and minimally invasive adenocarcinoma (MIA) are listed as ‘special circumstances’ for lung transplantation (Weill D et al., 2015). There have been five reported studies of lung transplantation in carefully selected subsets of patients with multifocal lung adenocarcinoma (Raemdonck DV et al., 2016; Glanville AR et al., 2018). The 5-year survival rate of bilateral sequential lung transplantation was estimated at over 50% in patients with multifocal BAC, invasive adenocarcinoma, and NSCLC (Ahmad U et al., 2012; Paloyan EB et al., 2000; Zorn GL et al., 2003; de Perrot M et al., 2004). In 1999, a case series reported a post-transplant recurrence-free survival of 23 to 56 months in three patients (Garver RI et al., 1999). There is also an unmet need for patients who have lung-limited metastasis after successful treatment for primary tumors such as sarcomas or colorectal cancer (CRC). As with liver transplantation for CRC patients who have liver-confined metastases (Dueland S et at., 2020; Hernandez-Alejandro R et al., 2022), the applicability of lung transplantation in lung-limited metastasis patients should be explored. Methods: This is a prospective registration trial to evaluate outcomes of patients who undergo lung transplantation for the treatment of the select groups of medically refractory cancers (primary lung cancers or metastatic cancers in lungs). Overall survival (OS), disease-free survival (DFS), allograft rejection (AR) and allograft survival (AS) will be monitored as well as molecular and genetic biomarkers to investigate the correlation with prognosis. The study duration will be 10 years including surveillance. Recruitment to occur during the first 5 years of the study. The goal is to enroll 175 participants through the Lurie Comprehensive Cancer Center of Northwestern University. Essential Criteria: The tumor should be without any involvement of mediastinal lymph nodes involvement confirmed by endobronchial ultrasound (EBUS) or mediastinoscopy. The patient who are resistant or refractory to or without available standard of care treatment options or experimental treatment options that are known to increase survival outcome. Study cohorts: • Cohort A: Primary lung cancers - Examples include, but not limited to, invasive mucinous/non-mucinous non-small cell lung cancers and multifocal carcinomas. • Cohort B: Metastatic cancers to the lung only - Examples include, but not limited to, germ cell tumors, head &amp; neck tumors, colorectal tumors, renal cell tumors, testicular cancers. Clinical trial registry number: NCT05671887. Enrollment began November 16, 2022. Trial is open and recruiting as of January 12, 2023. Citation Format: Young Chae, Liam Il-Young Chung, Rade Tomic, Ankit Bharat. Double lung transplant registry aimed for lung-limited malignancies (DREAM) - a prospective registry study of bilateral lung transplantation for medically refractory cancers confined to the lungs [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 2 (Clinical Trials and Late-Breaking Research); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(8_Suppl):Abstract nr CT051.

The Use of Intraoperative Extracorporeal Membrane Oxygenation in Lung Transplantation: Initial Institutional Experience.

Lung transplantation is the final treatment option for end-stage lung disease, and extracorporeal membrane oxygenation (ECMO) is increasingly being used during lung transplantation. The present study aimed to review our initial experience with patients who underwent lung transplantation with or without ECMO since the implementation of the lung transplantation program at our center. Data were prospectively collected on all patients between December 2016 and December 2018. Patients undergoing ECMO as a bridge to lung transplantation were excluded. A total of 48 lung transplants were performed, and ECMO was used in 29 (60.4%) cases. Twenty (83%) patients were female. The median age was 48.5 (range, 14-64) years. The most common indications were idiopathic interstitial pneumonia in 9 (31%) patients, chronic obstructive pulmonary disease in 7 (24.1%) patients, and bronchiectasis in 6 (20.7%) patients. Sequential bilateral lung transplantation was performed in all patients. The 30-day mortality was 20.6% (6/29) for patients with ECMO, however, it was 10.5 (2/19) for patients without ECMO (P=0.433). The median length of stay in the intensive care unit (ICU) was 5 (range, 2-25) days. The ECMO weaning rate was 82.8% (24/29). One-year survival was 62.1% with ECMO versus 78.9% without ECMO, and the 3-year survival was 54.1% versus 65.8%, respectively (P=0.317). ECMO is indicated for more severe patients who underwent lung transplantation. The use of ECMO provides adjuvant support during surgery and the mortality rate is acceptable. Survival is also as similar as non-ECMO patients. ECMO is appropriate for critically ill patients.

Comprehensive Review of Pulmonary Hypertension and Treatment Options in the Paediatric Population

Pulmonary hypertension (PH) is a complex condition that can occur as a result of a wide range of disorders, including left heart disease, lung disease, and chronic pulmonary thromboembolism. Multiple improvements have been made in the diagnosis and treatment of pulmonary arterial hypertension (PAH)including a greater understanding of the involvement of extrapulmonary vascular organ systems, validated point of care, clinical assessment tools, and a focus on the initial exposure of numerous pharmacotherapeutics in the appropriate level of care. To achieve a minimal symptom burden, improve the patient's biochemical, hemodynamic, and functional profile, and reduce adverse impact, early diagnosis of PAH is a key objective today. The preferred method of management for thromboembolic PH, which is chronic, is pulmonary endarterectomysince the majority of affected patients are operable. The timing of pulmonary endarterectomy should never be delayed for medical reasons, and risk stratification can enable us to select patients who have a high chance of success. Patients who are not qualified for endarterectomy should be referred for drug trials. Even though there are more effective ways to guarantee a sufficient, long-lasting septostomy, atrial septostomy is promising but undervalued. The procedure's indications remain the sameand needto be taken into account more frequently. Class III or IV patients who are not improving need to be consulted at a transplant centre as soon as possible as they may be candidates for potential recipients of bilateral sequential lung or heart-lung transplants, which is a significant choice for some people. PH is rarely linked to other conditions like connective tissue or thromboembolic disease. It is either idiopathic or linked to congenital heart disease. Infants and children with PH are more frequently recognised in conjunction with a congenital diaphragmatic hernia and developmental lung diseases like bronchopulmonary dysplasia. Although the underlying disease has not yet been treated and advanced structural changes have not yet been reversed, the value of natural life and survival have suggestively increased. Children's haemodynamic and functional outcomes have improved as a result of endothelin receptor antagonists, prostacyclin analogues, and phosphodiesterase type 5 inhibitors, which are examples of targeted pulmonary vasodilator therapies. The health maintenance of paediatric PH is still difficult because treatment decisions are largely based on the findings of adult studies that have been supported by evidence and the clinical expertise of paediatric specialists.

Donor neo-atrial cuff construction after accidental lower lobe vein transection

BackgroundAn inadequate donor left atrial cuff is a rare technical issue after graft procurement for lung transplantation. With regard to the shortage of suitable donor organs for lung transplantation, these organs should be surgically reconstructed to avoid the loss of an organ and a futile intervention in the critically ill recipient.Case presentationWe report a case of a 62-year old patient who underwent bilateral sequential lung transplantation for chronic obstructive pulmonary disease. During isolated lung procurement, the right inferior pulmonary vein was circumferentially transsected and separated from the right superior pulmonary and middle lobe veins. Subsequently, a reconstruction of the left atrial cuff with an acellular biological patch was performed to complete the atrium anastomosis. The patient experienced an uneventful postoperative recovery and a follow-up ventilation/perfusion scan showed normal perfusion of the right lower lobe.ConclusionsThis case demonstrates that reconstruction of an inadequate left atrial cuff with a biological patch is feasible and allows for an adequate venous drainage and therefore normal transplant organ function.

Technical Aspects of Lung Transplantation: General Considerations

Surgical approaches to lung transplantation in adults vary substantially among surgeons and institutions, but the underlying principles are consistent. This article provides a surgical overview of bilateral sequential lung transplantation.

Human immunodeficiency virus and solid organ transplantation: a 15-year retrospective audit at a tertiary Australian transplant centre.

The incidence of end-stage organ disease in people living with human immunodeficiency virus (HIV) (PLWH) is increasing, as people live longer due to potent, tolerable antiretroviral therapy (ART). Consequently, the number of PLWH who would benefit from solid organ transplant (SOT) is rising. The SOT experience in PLWH in Australia remains limited. Aim To retrospectively review the outcomes for SOT in PLWH at our service, in Victoria, Australia. A retrospective cohort study of PLWH undergoing SOT over a 15-year period was performed. Adult PLWH age >18 years were eligible and identified from the Victorian HIV Service database. Descriptive statistics were used to summarise baseline demographics and clinical data, and outcomes following SOT. Nine virologically suppressed PLWH underwent SOT from HIV-negative donors (five kidneys, two livers and two bilateral sequential lung transplants). All patients were male, with a median age of 57.3 years (interquartile range (IQR)=54.3-60.1) and CD4 count of 485 (IQR=342-835) at transplantation, and comorbidities were common at baseline. After a median follow up of 3.9 years (IQR=2.7-7.6), 8 (89%) patents were alive, 7 (78%) had functioning grafts, although 5 (56%) experienced organ rejection. Infections were common. Two patients required modification to their ART due to significant drug-drug interactions prior to transplant, while 5 (56%) had modifications post-SOT. No patients experienced HIV virologic failure. PLWH with end-stage organ disease experience good clinical and functional outcomes and should be considered for SOT where indicated. However, multidisciplinary planning and care is essential to optimise care in this patient group.

Experience using a flexible reinforced fiber suture for sternal closure in bilateral lung transplantation recipients undergoing bilateral transverse thoracosternotomy.

Experience using a flexible reinforced fiber suture for sternal closure in bilateral lung transplantation recipients undergoing bilateral transverse thoracosternotomy.

Long Term Outcomes of Minimally Invasive Lung Transplantation Compared to Clamshell Approach

<h3>Purpose</h3> Bilateral lung transplantation is traditionally performed via a clamshell incision (CS). Minimally invasive lung transplantation (MILT) is increasingly propagated via bilateral thoracotomies. However, the clinical benefits of (MILT) have not been conclusively established. This study compares a decade of experience with MILT with CS in the same institution. <h3>Methods</h3> The retrospective observational study between January 2010 and January 2020 evaluated short and long term outcome bilateral sequential lung transplants (296 patients with CS = 204 and MILT = 92). <h3>Results</h3> Skin-to-skin surgical time tended to be less in the MILT group [394 ± 122 vs 447 ± 287 min, p=0.15). Ischaemic time for both lungs was longer in the MILT group (right lung: 423.07 ± 157.3 vs 369.4± 152.8 min, p=0.3; left lung 535.5 ± 174.3.9 vs 480.8± 163.9 min, p=0.06). There was no significant difference between the two groups regarding administration of blood product (p=0.78) or blood drainage (p=0.22). Patients requiring renal replacement therapy were significantly less in the MILT group [25%vs 35.3%, P = 0.05] . There were no between-group differences in ventilation time (1.6 vs 1.8 days, P < 0.4) or hospital stay (34 vs 41 days, p=0.11). No significant difference between the two groups regarding 30 days mortality (p=0.55) Fraction of expired volume in 1 s (FEV₁) at 3 months was significantly higher in the MILT group compared with CS (2.5 vs 2.2 l, p=0.01), although the difference was no longer significant at 6 months (2.6 vs 2.4L, p=0.08). 5-year survival tended to be higher (66.8%) in MILT compared to CS group (59.7%, p=0.5.) Multivariate regression analysis found surgical approach (MILT) to be the main predictor of improved FEV1 at 3 months (coef 0.266, 95% CI 0.165 - 0.742, p=0.002). <h3>Conclusion</h3> MILT is a safe alternative to conventional approaches for lung transplantation and offers an earlier improvement in patient respiratory function. This may have important implications for enhanced recovery in transplant recipients.

Current status of lung transplantation in Hong Kong

: The only lung transplant program in Hong Kong, which is jointly led by respiratory physicians in Tuberculosis and Chest Unit of Grantham Hospital (GH) and surgeons in Cardiothoracic Surgical Department of Queen Mary Hospital (QMH), has been running for 25 years. The programme was running initially at low profile and with a low case volume in the first decade. The case load has increased significantly in the last decade. Among 187 potential recipients that had been put on waiting list so far, 77 had received lung transplants and 70 died while on waiting list. Majority of the lung transplant surgeries were bilateral sequential lung transplant. Common underlying diagnoses for lung transplant in Hong Kong included chronic obstructive pulmonary disease (COPD), suppurative lung diseases, pulmonary vascular disease, post haemopoietic stem cell transplant bronchiolitis obliterans syndrome (BOS), interstitial lung diseases (ILDs), and lymphangioleiomyomatosis (LAM). The mean age of recipients at transplant was 47.26 years. The 1-, 3-, 5- and 10-year survival were 84.4%, 74.9%, 64.1% and 50.3% respectively. The rate of acute rejection and chronic lung allograft dysfunction (CLAD) were low compared to international data. With a very low organ donation rate (about 6 per-million-population yearly) in the territory, shortage of donor organs remains the biggest unmet need for lung transplantation in Hong Kong.

Chronic Type A Aortic Dissection Repair in a Double Lung Transplant Recipient.

A 69-year-old man presented with a chronic Stanford Type A aortic dissection (CTAAD). The patient had undergone bilateral sequential lung transplantation 15 years prior for α-1-antitrypsin deficiency. We describe the management of CTAAD in the context of lung transplantation from the surgical and anesthetic perspectives.

Bilateral sequential lung transplantation: technical aspects.

The surgical technique for lung transplantation has evolved dramatically over the last three decades. Significant improvements in short term outcomes in the early years of lung transplantation were due, in large part, to techniques developed to reduce airway anastomotic complications in single lung transplantation. Following development of the technique of en bloc double lung transplantation, evolution to the bilateral sequential technique further reduced airway complications for double lung transplantation. More recently, some programs have utilized the en bloc double lung transplant technique with bronchial artery revascularization to aid airway healing and potentially improve short- and long-term outcomes. The experience with bronchial artery revascularization remains limited to a few series, with the technique having not been widely adopted by most lung transplant programs. With the implementation of priority allocations schemes in many countries, patients with higher risk profiles are being prioritized for transplantation which results in more complex procedures in fragile recipients with multiple comorbidities. This includes the increased need for concomitant cardiac procedures as well as performing lung transplantation after prior cardiothoracic surgery. Different surgical approaches have been described for bilateral sequential lung transplantation with or without intra-operative mechanical circulatory support (MCS), such as sternotomy, clamshell (bilateral anterior thoracotomies with transverse sternotomy), and bilateral thoracotomy incisions. Herein, we aim, not only to describe the various surgical approaches for double lung transplantation, but to provide a comprehensive review of other aspects related to the recipient pathology and different anatomical variants as well as handling technical challenges that might be encountered during the procedure.

PSEUDOANEURYSM OF THE ASCENDING THORACIC AORTA AS A COMPLICATION OF BILATERAL LUNG TRANSPLANT AND THE RISK OF UNDERGOING A NEW CARDIOTHORACIC SURGERY

TOPIC: Transplantation TYPE: Fellow Case Reports INTRODUCTION: Lung transplantation is an effective option for those with advanced lung disease. Acute or chronic graft failure may lead to significant morbidity and mortality. Lung retransplantation is an alternative for patients that develop allograft dysfunction. Preoperative investigation must consider complications from previous cardiothoracic procedures that may impose additional risk. We herein reported on a previously undiagnosed pseudoaneurysm of the thoracic ascending aorta (PTA) successfully treated during a bilateral lung retransplantation. CASE PRESENTATION: Patient is a 24-year-old female with history of bilateral lung transplant due to cystic fibrosis with pulmonary manifestation. She was admitted for bilateral retransplantation after progressive decline in lung function. Initial decompensation consisted of acute respiratory failure with hypoxemia secondary to Pseudomonas pneumonia, consistent with A4 pulmonary allograft rejection. She rapidly progressed to other episodes of respiratory failure, infection, dyspnea on minimal exertion, rest tachycardia, and significant decline in spirometry consistent with Bronchiolitis Obliterans Syndrome. After general anesthesia, upon intraoperative Transesophageal echocardiography, the anesthesiologist detected a previously undiagnosed PTA on the anterior surface. A redo bilateral sequential lung transplantation with PTA repair was performed under cardiopulmonary bypass (CPB) with transverse sternotomy and cannulation of right common femoral artery and vein. With the heart decompressed, the PTA, which was 2x1.5x2cm and located at the previous cannulation site, was dissected from the surrounding adhesions. The PTA was resected and repaired by partial clamping of the aorta, followed by an uneventful bilateral lung transplant. Pathology reports of the resected PTA showed fibroadipose and benign thymic tissues. Cultures were negative. The patient had an uncomplicated post-operative course and was discharged after 19 days. DISCUSSION: This is the first report of PTA as a complication of lung transplant. Postoperative PTA is rare and has been described only in cardiac procedures. It usually occurs in previous suture lines and in immunocompromised patients such as transplant recipients it is commonly related to infection in these endothelial damaged sites. It is crucial to be aware that they can be asymptomatic or misdiagnosed due to the primary clinical conditions such as lung rejection or multiple infections in the present case. In hindsight, the PTA was present in the patient's previous chest CTs and would have been easily identified if the arterial phase was performed. CONCLUSIONS: It is imperative that the multidisciplinary team involved in the care of patients undergoing lung retransplantation is vigilant about the possibility of PTA. Preoperative diagnosis can be lifesaving by avoiding rupture and exsanguination in a new cardiothoracic procedure REFERENCE #1: Glanville AR, Verleden GM, Todd JL, Benden C, Calabrese F, Gottlieb J, Hachem RR, Levine D, Meloni F, Palmer SM, Roman A, Sato M, Singer LG, Tokman S, Verleden SE, von der Thüsen J, Vos R, Snell G. Chronic lung allograft dysfunction: Definition and update of restrictive allograft syndrome-A consensus report from the Pulmonary Council of the ISHLT. J Heart Lung Transplant. 2019 May;38(5):483-492. REFERENCE #2: Behzadnia N, Ahmadi ZH, Mandegar MH, Salehi F, Sharif-Kashani B, Pourabdollah M, Ansari-Aval Z, Kianfar AA, Mirhosseini SM, Eiji M. Asymptomatic mycotic aneurysm of ascending aorta after heart transplantation: a case report. Transplant Proc. 2015 Jan-Feb;47(1):213-6. REFERENCE #3: Sullivan KL, Steiner RM, Smullens SN, Griska L, Meister SG. Pseudoaneurysm of the ascending aorta following cardiac surgery. Chest. 1988 Jan;93(1):138-43. DISCLOSURES: No relevant relationships by Thais Peclat, source=Web Response No relevant relationships by Si Pham, source=Web Response No relevant relationships by Eduardo Rodrigues, source=Web Response

653 LAPAROSCOPIC TOUPET FUNDOPLICATION RARELY INFLUENCES THE DECLINE IN FEV1 SEEN AFTER LUNG TRANSPLANT

Abstract Lung allografts have the shortest survival of any solid organ transplant. The leading cause of chronic lung allograft dysfunction (CLAD) is bronchiolitis obliterans syndrome (BOS). The aetiology of BOS remains poorly understood, with infections, immunosuppression and gastro-oesophageal reflux disease (GORD) amongst the proposed co-factors. A recent systematic review of GORD and BOS examined six retrospective case series with relatively small numbers and conflicting results. Our dataset is the largest cohort reported to date. Methods Retrospective review of a prospectively maintained database containing 149 consecutive lung transplant recipients undergoing laparoscopic Toupet fundoplication. A single expert surgeon (&amp;gt;5000 procedures) with published high-quality long-term outcomes in the non-transplant population did the operations. All were referred with symptoms of GORD and/or positive 24-hour ambulatory pH study. FEV1 was measured at three time points before (6, 3 and 1 month) and after (3, 6 and 12 months) surgery. Data were analysed using random intercept generalised linear (mixed) models to examine changes in FEV1 across time, as well as graphical methods (least squares method for FEV1 trendlines and two-tailed t-test). Results Median age was 56 (IQR 44–66) years; 84/149 were male. 132 had bilateral sequential single lung transplantation. The underlying pathologies were representative—emphysema, cystic fibrosis, interstitial lung disease. 8 patients died within 6 months of fundoplication. Using a linear mixed model there was no significant change in FEV1 across time after surgery compared with the last pre-operative measurement (p = 0.48). A significant reduction in FEV1 was seen in those undergoing fundoplication after CLAD was diagnosed (1.47 L, 95% CI 1.21–1.72, p &amp;lt; 0.001). There was no change in trajectory of FEV1 when trendlines for each patient were analysed (p = 0.777). Conclusion As with any solid organ transplant, lung allografts unfortunately suffer failure with time. Laparoscopic Toupet fundoplication performed in a high-volume centre by an experienced surgeon did not appear to alter this. In particular, once CLAD is diagnosed it seems that the decline in function (FEV1) is accelerated and cannot be salvaged by fundoplication. A minority of patients had their declining FEV1 stabilised or improved by surgery, but it is not yet possible to predict response.

Diffuse Panbronchiolitis After Lung Transplantation: First Case in the Literature

Diffuse panbronchiolitis is a chronic airway disease characterized by diffuse inflammation of respiratory bronchioles and peribronchial tissue. We present a case of diffuse panbronchiolitis developed after lung transplantation, which to our knowledge has not been previously described in the literature. A 52-year-old white woman was admitted with reports of weakness, shortness of breath, and productive cough 6 months after bilateral sequential lung transplantation. Thorax computed tomography revealed the appearance of a budding branch pattern in the lower lobes of both lungs. Repeated transbronchial lung biopsies were not diagnostic. A lower lobe wedge biopsy with thoracotomy was performed in the patient, whose respiratory function gradually deteriorated. Dense lymphocyte infiltration in the respiratory bronchiole wall and foamy macrophage groups in the adjacent interstitial area were detected in the histopathologic sections. The dramatic response was achieved with pulse steroid therapy in a short time. Rapidly worsening clinical course and response to the pulse steroid therapy suggested acute cellular rejection. Acute cellular rejection is expected within the first year in lung transplant recipients. Diffuse panbronchiolitis may be a kind of clinical presentation in lung recipients and should be considered in patients who develop severe graft function loss in a short time.