Abstract
Prior cardiac surgery, particularly coronary artery bypass graft (CABG) with a left internal mammary artery (LIMA), poses a technical challenge to lung transplant (LT). LT candidates with a history of CABG most often undergo a single LTx, limiting candidacy for those who require bilateral LTx (BLTx). Three-dimensional (3D) modeling may afford an opportunity for improved surgical planning when performing BLTx in recipients with multiple operative challenges.
A 61-year-old man with a history of idiopathic pulmonary fibrosis, single vessel CABG (LIMA to left anterior descending artery), aortic valve replacement, and septal myomectomy was transferred to our center with hypoxemic respiratory failure requiring mechanical ventilation and veno-venous extracorporeal membrane oxygenation (VV-ECMO). Evaluation revealed a dilated right ventricle with reduced systolic function due to severe pulmonary hypertension (PH). The presence of PH and right ventricular dysfunction suggested a need for BLTx; however, we had concerns regarding the steric relationship of his patent LIMA to LAD graft. Traditionally, he would not be a candidate for BLTx based on these anatomic concerns and ongoing physiology. A 3D printed model of the patient's chest was developed as a novel means to plan the surgical approach. The donor's lungs were procured and placed on Organ Care SystemTM to decrease ischemic time. The patient underwent bilateral anterolateral thoracotomies with sternal preservation. A left-sided dissection plane was created and, using the cues of the 3D model, the area where the anterior aspect of the left lung adhered to the mediastinum was identified and the lung was divided distal to and on both sides of the predicted location of the LIMA. In a planned fashion, the patient was transitioned from VV-ECMO to central CPB with cannulation of the ascending aorta through the right chest and conversion of ECMO cannulas into bicaval venous drainage. At the conclusion of the BLTx, the patient was decannulated and transferred to the ICU for ongoing care. He left the hospital a month after transplant and is doing well without supplementary oxygen as an outpatient.
Patient-specific 3D modeling may be used to help guide a safe and individualized surgical approach in complex patients with a prior history of CABG requiring a BLTx.