Contralateral Pneumonectomy 27 Years After Right Single-Lung Transplantation for Emphysema: A Case Report

Abstract

BACKGROUND Following single-lung transplantation, native lung inflation can progressively develop in patients with emphysema. CASE REPORT A 74-year-old female patient presented with worsening dyspnea during daily activities. She underwent a right single-lung transplantation for emphysema 27 years ago. Despite recurrent episodes of acute rejection of the grafted lung, the patient had satisfactory recovery of physical fitness during that period and did not report any serious complications or respiratory symptoms. Her recent dyspnea was due to hyperinflation of the native emphysematous lung with mediastinal shift, reduction of venous blood return, and compression of the grafted lung. Although surgical lung volume reduction had resulted in temporary functional improvement 2 years ago, a completion contralateral pneumonectomy was deemed necessary to allow re-expansion of the grafted lung. After anesthesia induction and placement of a double-lumen tube, selective ventilation of the left emphysematous native lung confirmed the absence of gas exchange based on near-zero end-expiratory carbon dioxide fraction. During selective ventilation of the grafted lung, satisfactory gas exchange was achieved and pneumonectomy proceeded uneventfully under minimally-invasive thoracotomy. Immediately after anesthesia emergence and tracheal extubation, the patient experienced respiratory improvement. Continuous thoracic epidural blockade allowed pain-free mobilization and respiratory therapy to facilitate re-expansion of the grafted lung. CONCLUSIONS After single-lung transplantation in COPD patients, native lung hyperinflation is a well-described rare complication. Lung volume reduction including pneumonectomy can be considered a valuable treatment option.

Figure 1.

(A) Preoperative axial chest computed tomography scan. (B) Preoperative coronal chest computed tomography scan. (C) Preoperative plain chest radiography illustrating rightward mediastinal deviation and compression of the grafted lung; arrows pointing at the border of the trachea showing right deviation.

Figure 2.

Antero-posterior chest radiographs: (A) Before surgery. (B) 2 hours after extubating the patient. (C) Ten hours postoperatively showing fluid accumulation in the left pleural cavity; red arrow pointing at the upper limit of the fluid level.