SINGLE-LUNG TRANSPLANTATION FOR PULMONARY LYMPHANGIOMYOMATOSIS - UNEXPECTED NEED FOR EXTRACORPOREAL-CIRCULATION

The present case describes an acute respiratory-related hemodynamic fa ilure during a single left lung transplantation in a 32-year-old woman suffering from endstage pulmonary lymphangiomyomatosis. During the fi rst 5 min of single right lung ventilation, a progressive increase in airway pressure and decrease in tidal volume associated with a decreas e in arterial pressure and Spot occurred that were successfully counte red by reventilation of the left lung. Proper positioning of the doubl e-lumen tube was confirmed with a fiberoptic bronchoscope. Despite del iberate hypoventilation, within a few respiratory cycles, each further attempt at single lung ventilation was followed by abrupt hypotension , increase in pulmonary artery pressure, while airway pressure rose an d tidal volume collapsed. The surgical team saw no signs of right pneu mothorax, In these circumstances, cardiopulmonary bypass was required to perform pneumonectomy and grafting. Postoperatively a right anterio r pneumothorax remained undiscovered on standard radiograph but was la ter revealed on soft radiograph. This acute intraoperative respiratory failure could equally well have been related to air trapping, in whic h case, however, deliberate hypoventilation would have been effective. In addition, the striking difference between the progressive onset of the first episode of hemodynamic failure and the immediate onset of t he others argues in favor of a pneumothorax being at cause. Patients w ith pulmonary lymphangiomyomatosis are at high risk for intraoperative pneumothorax, but in our case, it could not be confirmed and treated during the surgical procedure without putting the patient at high risk for lung injury because of pleurodesis due to earlier pleural abrasio n. This case again clearly shows the need to have cardiopulmonary bypa ss whenever single lung transplantation is performed.