Case Report
A 50-year-old-male with cystic fibrosis and multidrug resistant pseudomonas, Achromobacter, methicillin resistant Staph aureus, and recurrent sinusitis was referred for a double lung transplant and concomitant liver transplant. He was declined for a liver transplant due to congenital absence of the IVC. We decided to proceed with double lung transplant only since the synthetic function of the liver was preserved. Other comorbidities included diabetes, compensated cirrhosis, and HIV. He required 4L of O2 at rest and 5L with exertion, had a mean PA pressure of 21 mmHg, an ejection fraction of 65%, and no significant coronary artery disease. MRI and CT showed an absence of normal infrahepatic IVC with enlarged lumbar retro peritoneal collaterals continuing into the azygous. There was normal portal venous flow and hepatic venous flow into the suprahepatic IVC (figure 1). A suitable donor became available. We thought that it would not have been prudent to initiate emergent CPB or ECMO intraoperatively given his anatomy; therefore, the decision was made to insert the Protek duo prior to the transplantation. For right ventricular and oxygenation support, a 31-Fr Protek Duo cannula was inserted percutaneously into the right internal jugular vein using fluoroscopy and transesophageal echocardiography. The cannula was connected to a modified cardiopulmonary bypass (CPB) machine, in an Oxy-RVAD configuration. The right ventricle (RV) remained decompressed and the patient was well oxygenated throughout the operation. Bilateral sequential lung transplantation required extensive adhesiolysis. The patient had previously undergone several chest tube placements bilaterally and doxycycline pleurodesis due to pneumothoraces. The lungs were adherent to the chest well, diaphragm, and pericardium. Right and left lung total ischemic times were 387 and 488 minutes. The Protek duo was left in place for perioperative oxygenation support. The patient remained on Oxy-RAVD support after completion of the case due to a hypokinetic RV and large amount of blood product transfusions. Postoperatively, the CPB machine was converted to a CentriMag System with an inline Quadrox oxygenator. Due to the extensive adhesiolysis the chest was left open and packed. After 48 hrs the patient returned to the OR for chest washout, closure and tracheostomy (figure 2). The patient was decannulated bedside from support on postoperative day 11. Initially the patient was doing very well, however within 3 weeks post lung transplant he developed recurrent Achromobacter sepsis, renal failure requiring dialysis, and shock leading to multisystem organ failure. Due to multiple positive bacterial cultures during broad spectrum antibiotic coverage, the patient received phage therapy. However, after careful consideration with the patient, family, palliative care, and medical ethics, the patient was transitioned to comfort measures only at his request. He expired 7 weeks after transplantation.