.jpg "Sadia Shah, MBA, MD photo")
Sadia Shah, MBA, MD
Lung Transplant Pulmonologist
Mayo Clinic Hospital
Phoenix, Arizona
Disclosure information not submitted.
Mathew Thomas, MBBS, MD
Associate Professor of Surgery
Mayo Clinic, United States
Disclosure information not submitted.
Si Pham, MD
Professor of Surgery
Mayo Clinic Florida, Florida, United States
Disclosure information not submitted.
Tarik Haddad, MD
Assistant Professor of Medicine
Mayo Clinic Florida, United States
Disclosure information not submitted.
Kevin Landolfo, MD
Professor of Surgery
Mayo Clinic Florida, United States
Disclosure information not submitted.
Title: Lobar Torsion after Bilateral Lung Transplantation, Rare Complication Requiring Urgent Intervention
Case Report Body:
Introduction: Lobar torsion is rare complication seen early post lung transplantation. There are only a few case reports published in literature so far. Early recognition and surgical intervention are the keys to improve outcome in these cases.
Description: 60-year-old male with history of idiopathic pulmonary fibrosis underwent bilateral lung transplant. Donor lungs had to be trimmed down as they were slightly bigger for the chest cavity of the recipient. Post lung transplantation, patient was found to be hypoxic with low minute ventilation intra-operatively. He required higher amounts of positive pressure on mechanical ventilation to be able to oxygenate. Chest X-ray did not show any evidence of primary graft dysfunction, infiltrates or edema to explain the hypoxia and need for higher positive pressures. When the positive pressure was decreased the tidal volumes on ventilator would decrease significantly leading to a low minute ventilation. Bronchoscopy showed the right sided airways were twisted leading to complete obstruction of right upper and middle lobes. Significant amount of thin secretions was seen pooling in the right airways. Once the positive pressure was decreased and a CT chest with contrast was performed, it revealed complete collapse of right upper and middle lobes. Pulmonary arterial supply was patent, but the venous phase showed decreased flow. Patient was diagnosed with lobar torsion and patient was taken back to OR for Video assisted thoracoscopy. Visualization of the lungs revealed no evidence of necrosis. Torsion was corrected with expansion of both right upper and middle lobes. Patient was able to be weaned off the mechanical ventilator within a few days and was discharged from the hospital on room air in 3 weeks post-transplant.
Discussion: Lobar torsion is a rare complication early post-lung transplant. Bronchoscopy for evaluation of airways when lobar collapse is observed and early CT chest with contrast to evaluate the vascular patency is crucial in these cases. In severe cases, in which arterial compromise occurs, potential necrosis of the lobe can happen. Early recognition and urgent surgical evaluation to save the lobe can dramatically change outcomes in these cases.