PEDIATRIC LUNG TRANSPLANTATION - ARE THERE SURGICAL CONTRAINDICATIONS

Lung transplantation has evolved as a successful treatment for end-sta ge cardiopulmonary disease in children; however, clear guidelines rega rding surgical exclusion criteria for pediatric lung transplant candid ates have not been well-established. Since December 1994, we have perf ormed 10 bilateral lung transplants and 1 heart-lung transplant in 10 recipients (mean age, 7 years; range, 3 months to 19 years). Indicatio ns for transplantation included pulmonary vascular disease (n=6), bron chiolitis obliterans (n=2), bronchopulmonary dysplasia (n=1), graft fa ilure due to viral pneumonitis (n=1), and cystic fibrosis (n=1). Among the 10 patients, 4 were evaluated elsewhere for lung transplantation; of these, 3 were rejected by 1 or more programs because of ''high-ris k'' characteristics. We considered 8 of the 10 patients to have 1 or m ore ''high-risk'' characteristics, as follows: previous chest operatio ns other than open lung biopsy (n=6 patients having 1-4 previous opera tions), ventilator-dependence with tracheostomy and high-dose corticos teroids (n=4), redo lung transplant (n=2), concomitant intracardiac re pair (n=6), portal hypertension (n=1), and the use of extracorporeal m embrane oxygenation (ECMO) at the time of transplant (n=1). Our standa rd operative approach was a bilateral thoracosternotomy. Cardiopulmona ry bypass was used for explant of the recipient lungs and implant of t he donor lungs, and during repair of coexisting congenital heart defec ts. Aprotinin and fresh whole blood were administered during the proce dure to aid in hemostasis. Concomitant procedures were frequently perf ormed and included repair of an intra-atrial baffle leak (prior Mustar d procedure), closure of an atrial septal defect, repair of partial an omalous pulmonary venous return, reconstruction of the pulmonary venou s confluence, ECMO decannulation, and splenectomy. There were no opera tive deaths, and no patient required re-exploration for bleeding. One patient had primary graft failure due to adenovirus infection of the d onor lungs, and required prolonged mechanical ventilation and eventual ly ECMO support until retransplantation was performed. The mean hospit al stay after transplant was 25+/-13 days (range, 10-56 days). All pat ients were discharged with a natural airway. Airway complications cons isted of one bronchial anastomotic stricture which required dilation, for a complication rate of 5% per anastomoses at risk, One patient req uired reoperation for stenosis of the superior vena cava. There have b een no late deaths, with a mean follow-up of 7+/-4 months (range, 1-13 months). We attribute this 100% operative and short-term survival in these ''high-risk'' pediatric lung transplant recipients to our operat ive methods, a multidisciplinary approach to postoperative management, and the enormous physiologic reserve of pediatric patients. Therefore , the standard exclusion criteria used for adult lung transplantation may not be applicable to the pediatric age group. We hope to use these data to expand the use of lung transplantation in pediatric patients.