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Anesth Analg 2000;91:558-560
© 2000 International Anesthesia Research Society

CARDIOVASCULAR ANESTHESIA

Graft Failure Caused by Pulmonary Venous Obstruction Diagnosed by Intraoperative Transesophageal Echocardiography During Lung Transplantation

Yu-Chen Huang, Ya-Jung Cheng, Yu-Hua Lin, Ming-Jiuh Wang, and Shen-Kou Tsai

Department of Anesthesiology, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan

Address correspondence and reprint requests to Shen-Kou Tsai, MD, PhD, Department of Anesthesiology, National Taiwan University Hospital, 7, Chung-Shan Rd., Taipei, Taiwan.


   Abstract
Top
 Abstract
Introduction
 Case Report
 Discussion
 References
 

Implications: Intraoperative transesophageal echocardiography can be useful to diagnose pulmonary venous anastomotic stenoses during lung transplantation.


   Introduction
Top
 Abstract
 Introduction
Case Report
 Discussion
 References
 
Lung transplantation is used increasingly as a treatment modality for end-stage lung disease in patients refractory to medical therapy. After lung transplantation, graft failure is commonly attributed to infection, rejection, or airway complication (1). However, complications may also arise from dysfunction of pulmonary artery or vein anastomoses (2–4). Pulmonary venous obstruction as a cause of graft failure is rare but fatal, especially in the single-lung transplant recipients.

Recently, transesophageal echocardiography (TEE) has been considered the diagnostic technique to evaluate pulmonary arterial and venous anastomoses. We report a case of single-lung transplantation for bronchiolitis obliterans. The patient developed acute graft dysfunction as a result of technical difficulties with the anastomosis of one of the pulmonary veins. We used TEE to successfully detect the pulmonary venous abnormality during surgery. In our experience, we confirm that stenosis of a pulmonary venous graft with less than a 0.25-cm diameter can result in graft failure.


   Case Report
Top
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 52-yr-old woman was admitted to our hospital with the complaint of shortness of breath. She had taken Sauropus androgynus, an herb used for weight reduction in Taiwan, for 2 mo. She had lost 10 kg but developed difficulty in breathing, chest tightness, and a chronic cough. Although she stopped taking the herb, the dyspnea continued to progressively worsen.

Physical examination showed a thin woman in obvious respiratory distress with a blood pressure of 120/80 mm Hg, heart rate of 86 bpm, respiratory rate of 27/min, and temperature of 37.5°C. Chest auscultation revealed bibasilar rales and wheezing over the right lower lung field. Electrocardiogram and two-dimensional echocardiogram were normal. The arterial blood gas values at room air were pH 7.39, PaO2 71.2 mm Hg, PaCO2 43.3 mm Hg, and HCO3 25.7 mmol/L. Chest radiograph showed increased lung markings over the perihilar areas bilaterally. A pulmonary function test showed severe obstructive ventilatory defects. S. androgynus-induced bronchiolitis obliterans was diagnosed.

As a result of poor response to medical therapy and progressive dyspnea, the patient underwent right single-lung transplantation. Standard monitors, including electrocardiogram, pulse oximeter, and arterial catheter, were established before the induction of anesthesia. Anesthesia was induced with IV 0.3 mg/kg etomidate and 250 µg of fentanyl. Endotracheal intubation with a 35F double-lumen endotracheal tube was facilitated with IV 1.5 mg/kg succinylcholine. After anesthetic induction, a pulmonary artery catheter was placed. Anesthesia was maintained with isoflurane-oxygen, and rocuronium was used for muscle relaxation. Multiplane TEE was also used intraoperatively.

During surgery, persistent arterial hypoxemia was noted, and the pulmonary artery pressure suddenly increased after clamping the pulmonary artery. Therefore, partial cardiopulmonary bypass was established. After the right lung transplant was completed, color Doppler echocardiography showed a mosaic pattern of right lower pulmonary vein inflow with 1.6-m/s peak systolic flow velocity indicating severe stenosis of the right lower pulmonary vein where it entered the left atrium (Fig. 1). An attempt to repair the right lower pulmonary venous obstruction failed as a result of inadequate donor graft. Because the donor graft was simultaneously separated into heart transplant and lung transplant, the atrial cuff of the right pulmonary veins were inadvertently torn.



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  		Figure 1. Color Doppler echocardiography showing a mosaic pattern of right lower pulmonary vein inflow (arrows) where it enters left atrium (LA) and revealing severe obstruction of its anastomoses.

 
After surgery, extracorporeal membranous oxygenation was performed because of persistent hypoxemia. The patient also became hypotensive and responded poorly to maximal inotropic support. Chest radiograph showed progressive consolidation and volume loss of the right lower lobe (Fig. 2). Retransplantation was considered, but a fresh donor organ was not available. The patient died on the 10th day after surgery because of profound hemodynamic and progressive multisystemic failure.



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  		Figure 2. Chest radiograph of the first day after surgery showing increased infiltration of right lower lobe.

 

   Discussion
Top
 Abstract
 Introduction
 Case Report
 Discussion
References
 
Graft failure after lung transplantation is a devastating postoperative complication. It is associated with a high mortality rate, lengthy hospitalization, and protracted, as well as often compromised, recovery among survivors (5). Pulmonary venous complications after lung transplantation may be more common than previously suspected. In a series reported by Leibowitz et al (3), 29% of the patients had abnormalities of the pulmonary veins. Nonetheless, pulmonary venous obstruction is a rare cause of graft failure.

Pulmonary venous obstruction can be suspected by postoperative chest roentgenogram, which shows unilateral pulmonary edema. Evaluation of the perfusion to the newly transplanted lung by scintigraphic scan confirms the diagnosis, if less than 50% perfusion uptake is demonstrated (6). Pulmonary angiography with careful pressure measurement provides greater sensitivity to detect pulmonary venous obstruction, but it is not available intraoperatively. However, TEE can be easily performed intraoperatively to offer real-time information and rapidly detect the obstruction of pulmonary arterial and venous anastomoses (7). It has been reported that TEE is capable of visualizing 100% of right pulmonary artery anastomoses and pulmonary venous connections because the ultrasound transducer is in close proximity to the left atrium, allowing precise analysis of the region and accurate measurement of the transstenotic gradient (8).

Although using TEE to evaluate pulmonary arterial and venous anastomoses has been described and is widely used, evaluation of vascular anastomoses in lung transplantation has been reported in the postoperative period only. Reports of intraoperative TEE assessment for fatal pulmonary obstruction are rare. In the report by Michel-Cherqui et al. (4), a diameter less than 0.5 cm without early graft dysfunction could result in increased peak systolic flow velocity, but it did not compromise the outcome. A diameter of 0.25 cm was insufficient to ensure normal perfusion of the graft, and immediate reoperation was indicated (4). Our case illustrates a rare mechanical cause of posttransplant lung failure diagnosed by TEE. The diameter of stenotic pulmonary vein was less than 0.25 cm. The stenosis was approximately 1 cm long. This indicates that graft failure was inevitable without further treatment. We pointed out the problem and offered the timely information that altered the surgeon’s decisions regarding management. Although the lesion ultimately could not be surgically corrected for technical reasons and the patient eventually died, the usefulness of intraoperative TEE is clearly demonstrated by this case.

Until now, the threshold values for artery or vein stenoses requiring immediate reoperation have not been established. In our case, a diameter of pulmonary vein less than 0.25 cm was definitely insufficient to ensure perfusion of the graft lung, and this may represent the critical threshold for graft failure. Moreover, the clinical implication is that any delayed correction of pulmonary venous obstruction during single-lung transplantation may result in hemodynamic impairment and ventilatory failure. Timely intraoperative diagnosis by TEE can guide early decision making and management during lung transplantation.


   References
Top
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Arcasoy SM, Kotloff RM. Lung transplantation. N Engl J Med 1999; 340: 1081–91.[Free Full Text]
  2. Haydock DA, Trulock EP, Kaiser LR, et al. Management of dysfunction in the transplanted lung: experience with 7 clinical cases. Ann Thorac Surg 1992; 53: 635–41.[Abstract]
  3. Leibowitz DW, Smith CR, Michler RE, et al. Incidence of pulmonary vein complications after lung transplantation: a prospective transesophageal echocardiographic study. J Am Coll Cardiol 1994; 24: 671–5.[Abstract]
  4. Michel-Cherqui M, Brusset A, Liu N, et al. Intraoperative transesophageal echocardiographic assessment of vascular anastomoses in lung transplantation. Chest 1997; 111: 1229–35.[Abstract/Free Full Text]
  5. Christie JD, Bavaria JE, Palevsky HI, et al. Primary graft failure following lung transplantation. Chest 1998; 114: 51–60.[Abstract/Free Full Text]
  6. Malden ES, Kaiser LR, Gutierrez FR. Pulmonary vein obstruction following single lung transplantation. Chest 1992; 102: 645–7.[Abstract/Free Full Text]
  7. Suriani RJ. Transesophageal echocardiography during organ transplantation. J Cardiothorac Vasc Anesth 1998; 12: 686–94.[Web of Science][Medline]
  8. Canivet JL, Defraigne JO, Demoulin JC, Limet R. Mechanical flow obstruction after heart transplantation diagnosed by TEE. Ann Thorac Surg 1994; 58: 890–1.[Abstract]
Accepted for publication May 9, 2000.




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This Article
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press