DK2985_C000 1..28 - AlSharqia Echo Club

Lung Transplantation 485(A)PVF-RUPV(B)PVF-LUPVS D S D(C)HVFS D ARARFigure 21.6 Suggested sequence for transesophageal echocardiographic systematic examination following bilateral lungtransplantation in a 45-year-old man. The pulsed-wave Doppler profile of the right upper pulmonary vein (RUPV) (A) shows a systolicvelocity of 60.7 cm/sec compared with 43.3 cm/sec in the left upper pulmonary vein (LUPV) (B). (C) Doppler examination of thehepatic vein shows abnormal diastolic flow predominance (S/D , 1) consistent with right ventricular diastolic dysfunction (AR,atrial reversal; HVF, hepatic venous flow; PVF, pulmonary venous flow).transplant recipients diagnosed with a pulmonary veinthrombosis postoperatively. In 12 of the 13 cases, thethrombosis was localized in the upper lobe veins of thetransplanted lung. The thrombi had a mean width of0.9 + 0.4 cm, with a mean pulmonary venous flow velocityof 127 + 23 cm/sec. The mortality in the presenceof this complication was significant, with five of the 13patients (38.5%) dying postoperatively. The incidence ofthe complication was similar regardless of the side of thetransplant or the use of CPB. Transesophageal echocardiographywas thought to be helpful by obviating the need forangiography.Complications involving the PA anastomosis occurfar less frequently. Indeed, from a surgical technicalstandpoint, this anastomosis is less difficult to accomplishwhile abnormalities are usually easily detected earlyintraoperatively. Clark et al. (22) reported five cases ofstenosis (two RPAs, three LPAs) from a series of 109transplantations. Despite three surgical revisions of thePA anastomosis, all five patients ultimately died in theearly postoperative period. Griffith et al. (15) alsodescribed fives cases of PA anastomotic complications,for a rate of 3.7%, in his review of 134 transplant recipients.Three of the five patients underwent reoperationand revision of the PA anastomosis. The author notedthat excessive length of the donor PA and/or the recipientPA can create distortion or kinking of the anastomosisleading to reduced blood flow and thrombosis. This situationmay arise particularly when an oversized lung isplaced in a small chest during single lung transplantation.In the immediate postoperative period, both TEE and thePAC are useful to quantitate the severity of the pulmonaryanastomosis (Fig. 21.7).In our own experience with 158 lung transplantationsover a seven year period (1997–2004), we have notencountered any vascular anastomotic complications