PURPOSE: Study frequency and risk factors for symptomatic narrowing oratresia of bronchus intermedius(BI) following right lung transplantation (rLTx).
METHODS: From a retrospective chart review of patients receiving at least a rLTx between 1990 –2005, 7 of 344 eligible patients (2%) were identified with VBIS (symptomatic narrowing or atresia of the bronchus intermedius). This included all patients with at least 50-80% bronchial stenosis. Data collected on this subset of patients included: demography, ischemic time, cardiopulmonary-bypass time, duration of mechanical ventilation, radiological findings, pre- and post-transplant infections, rejection episodes, therapeutic interventions, and survival.
RESULTS: VBIS was documented as early as 6.5 months (range 2-13) post transplant. Symptoms were cough (n=6 patients), shortness of breath (n=4), and wheezing (n=4). Chest radiograph revealed RLL collapse (n=4 patients), RML collapse (n=1), and RML and RLL collapse (n=1). Pulmonary infections were MRSA(n=1), Pseudomonas aeruginosa(n=3), Aspergillus spp(n=2) and Ebstein-barr virus (n=1) being the most common and five patients had one or more episodes of rejection. Mean ICU stay was 12.7±11.4 days. Therapeutic interventions included: bronchoscopic bronchoplasty (n=5), bronchoplasty with metallic stent placement (n=5), brachytherapy (n=3), electrocautery (n=3), and mitomycin application (n=2). Complete bronchial atresia ultimately developed in 6 patients with 5 dying of respiratory failure. Mean survival after diagnosis of VBIS was 25.3 (range 1-76months). Overall survival was 31.1±25.9 months.
CONCLUSION: LTx related airway complications occur mainly at the anastomotic site in 15%. VBIS, although unusual, is associated with significant morbidity, respiratory failure and eventually mortality. Etiology includes ischemia, rejection, or both, and once identified, limited therapeutic options exist. More frequent surveillance bronchoscopes in less symptomatic rLTX recipients may allow early diagnosis,intervention and possibly improve long-term outcomes.
CLINICAL IMPLICATIONS: Symptomatic narrowing or complete atresia of the bronchus intermedius is an unusual consequence following LTx, as it is not associated with the anastomotic site. From our small experience we are unable to identify risk factors for these complications. Physicians should keep this in mind when they experience recurrent persistent fever, pneumonia, atelectasis and septic shock following LTx.
DISCLOSURE: Sonia Shah, None.