Bilateral sequential lung transplantation: The procedure of choice for double-lung replacement

We recently described a technique for bilateral sequential lung transplantation that replaces the en bloc doublelung operation, a procedure that was accompanied by frequent problems with airway healing. Twenty-seven patients have undergone 28 bilateral sequential lung transplantations over the past 14 months. Eighteen patients had transplantation because of end-stage emphysema; 6, cystic fibrosis; and 1 each, obliterative bronchiolitis, usual interstitial pneumonitis with pulmonary fibrosis, and bronchiectasis. Cardiopulmonary bypass was used electively in the first 5 patients until it was recognized that the procedure could be done safely without it, and in only 3 additional recipients has it been employed. Mean ischemic time for the first lung was 276 ± 43 minutes and for the second lung, 410 ± 64 minutes. There have been five deaths, three in the postoperative period (11% operative mortality) and two late. The other patients are alive and well and do not require oxygen 2 to 15 months after transplantation. Mean forced expiratory volume in 1 second rose from 16% ± 8% of predicted to 84% ± 17% at 12 weeks. Six-minute walk values increased from a mean of 251 ± 91 m to 666 ± 42 m at 24 weeks. The excellent exposure afforded to both hemithoraces by the thoracosternotomy incision and the rare need of cardiopulmonary bypass have allowed us to offer the option of transplantation to patients who formerly would have been turned down because of previous pulmonary resection or pleurectomy. On four occasions, ventilator-dependent patients underwent successful transplantation. The applicability of the procedure seemingly will be limited only by donor considerations and questions regarding how much better one lung is than two in patients other than those with chronic infection. Bilateral sequential lung transplantation can be performed with a minimum of early mortality and morbidity, which is comparable with single-lung transplantation.