Transplantation of Lungs Procured From a Donor With an Atrioesophageal Fistula

Abstract

Lung transplantation continues to be limited by a shortage of donor organs. We report the case of procurement and transplantation of lungs from a young donor who died from an atrioesophageal fistula, complicating catheter ablation for atrial fibrillation. Our case illustrates that structural damage to the left atrium is not an absolute contraindication to lung donation. As atrioesophageal fistulas are being increasingly recognized as a rare but often lethal complication of catheter ablation, such donors can contribute to the expansion of the donor pool.

A shortage of donor organs continues to limit a wider utilization of lung transplantation. Given a waitlist mortality of approximately 20%, several avenues have been used in an attempt to expand the donor pool. These include extending traditional criteria for the use of donor lungs and reconditioning marginal pulmonary grafts ex vivo. Also, changes in lung allocation policy have been considered to address the chasm between availability of donor lungs and patients awaiting this often life-saving procedure. Nevertheless, the utilization of donor lungs remains low compared with other solid organs [1]. Here, we report the transplantation of lungs that were retrieved from a young donor, who died secondary to an atrioesophageal fistula resulting from catheter ablation for cardiac arrhythmia. This case illustrates a rare scenario, in which lungs can be used for transplantation despite structural damage to the left atrium.

A 24-year-old nonsmoking man with a history of atrial fibrillation since childhood underwent catheter ablation at another institution. At the time of ablation, the esophageal temperature was monitored and electrical isolation of the right and left pulmonary veins was power to achieve The ablation was performed using 30 W of power to achieve a target temperature of 45°C for 45 seconds at each trigger site. Atrial fibrillation persisted after ablation of the pulmonary vein orifices, necessitating an additional ablation of the mitral valve annulus and creation of a roof line. The patient was discharged in normal sinus rhythm. One month later, the patient presented to an emergency department complaining of fever, chills, and a headache. A chest computed tomography scan revealed a small focus of air in the pulmonary trunk and left atrium without evidence of a pneumomediastinum or pneumopericardium. There was no radiographic evidence of septic emboli in the chest or upper abdomen. Head computed tomography revealed low density air in the subarachnoid space overlying both cerebral hemispheres, and magnetic resonance imaging of the brain showed cerebral edema with effacement of the lateral ventricles and basal cisterns. While in the emergency department the patient developed seizures, and was subsequently sedated and intubated. The patient’s condition rapidly declined to the point of brain death.

The patient’s PaO₂/FiO₂ ratio was greater than 400, computed tomography revealed clear lung fields and his lungs were offered for transplantation. Because of concerns over potential damage to the pulmonary veins, the lungs were declined by many lung transplant centers. In light of the good pulmonary function and radiographic appearance of the lungs in this young nonsmoker, our center elected to evaluate the lungs with the understanding that the recipient operation would not start until the donor team assessed the pulmonary vein cuffs. The lung procurement was performed in a standardized fashion [2]. After the removal of the donor heart, which was not transplanted, the lungs were excised with all mediastinal tissue including the esophagus. The atrioesophageal fistula was approximately 1.5 cm in diameter and located in the left atrial posterior wall in close proximity to the right inferior vein (Fig 1). Both pulmonary veins were intact and had sufficient left atrial cuffs for the anastomoses.

Fig 1.

Left atrial cuff of donor lung during preparation on back table. Defect in left atrium (yellow arrow) caused by atrioesophageal fistula is in close proximity to the orifice of the right inferior pulmonary vein (black arrow). A forceps has been inserted into the atrial defect. The white arrow highlights the right superior pulmonary vein.

The recipient was a 74-year-old man with progressive idiopathic pulmonary fibrosis and moderate pulmonary hypertension. The preparation of the donor lungs was performed with caution on the back table during the recipient procedure. The descending aorta was dissected off the lung block in standard fashion. Rather than separating the esophagus from the lung block we opened it longitudinally. The esophagus was filled with blood clot. We excised the esophagus, leaving some esophageal tissue overlying the atrial defect. We carefully prepared right and left pulmonary veins retaining small but adequate cuffs. A bilateral lung transplant with cardiopulmonary bypass was performed without a requirement for pulmonary vein augmentation or reconstruction. Intraoperative transesophageal echocardiographic assessment of pulmonary venous flow at the completion of the transplantation did not demonstrate any stenosis. The ischemic time was 256 minutes for the left lung and 347 minutes for the right lung. The recipient developed primary graft dysfunction (grade 2 at 24 hours, grade 1 at 48 and 72 hours) and was discharged on postoperative day 42 with good graft function.

Comment

Lung transplantation represents the definitive treatment for many patients suffering from end-stage pulmonary disease. A shortage of donor organs continues to limit access to this procedure, however. Our case report provides evidence that lung donation in the presence of an atrioesophageal fistula can be technically feasible and represents a source of acceptable lungs for transplantation.

Catheter ablation is a common treatment modality for atrial fibrillation that is refractory to medical management. Atrioesophageal fistulas after catheter ablation is a rare but devastating complication with a high mortality rate [3]. Patients often present with chest pain, sepsis, meningitis, altered mental status, seizures, postprandial transient ischemic attacks, or stroke. The esophagus is capable of reaching pressures 10 times greater than that of the atrium, which allows air, food, or bacteria to enter the systemic circulation [4]; this pressure differential may explain why only approximately one third of patients present with hematemesis [5]. In this case, the patient presented 1 month after his catheter ablation with fever, headache, and seizures. Atrioesophageal fistulas typically occur 1 to 6 weeks after the catheter ablation procedure, though earlier and later onsets have been reported [6]. Patients exhibiting neurologic or nonneurologic symptoms after catheter ablation should be evaluated for atrioesophageal fistulas to facilitate prompt treatment, as the mortality rate is virtually 100% when left untreated [7]. Various surgical approaches for the repair of atrioesophageal fistulas have been proposed, such as primary repair with pledgeted sutures and repair using a pericardial patch [6].

In conclusion, to our knowledge this is the first case of lung procurement and successful transplantation from a brain-dead donor with an atrioesophageal fistula. Here we show that structural damage to the left atrium following catheter ablation is not an absolute contraindication for lung donation. As atrioesophageal fistulas are increasingly recognized as an often-fatal complication after catheter ablation for cardiac arrhythmias, it is likely that transplant centers will be offered lungs from these patients. Ablation lines typically do not include the orifices of the pulmonary veins, which should result in adequate atrial cuffs for anastomoses. Separate pulmonary venous anastomoses may be required, however, in the event that the tissue damage precludes the use of an atrial cuff.