Abstract A 67-year-old woman with hypersensitivity pneumonitis-related interstitial lung disease, coronary artery disease with prior stenting, former tobacco use, and type II diabetes mellitus was admitted for bilateral lung transplantation. She required 2-3 L/min supplemental oxygen at home.On hospital day (HD) 0, she underwent bilateral orthotopic lung transplantation supported with cardiopulmonary bypass using a modified ECMO strategy. Intraoperatively, previously reported donor pulmonary vein injury required repair, and both pulmonary veins required complex reconstruction, adding substantial operative time. A significant size mismatch of the left main bronchus necessitated partial telescoping. Right and left inferior pulmonary vein angioplasties were performed, and intraoperative transesophageal echocardiography guided surgical decision-making.On HD 1, she demonstrated elevated pulmonary artery pressures and right ventricular hypokinesis on echocardiography, along with reduced flow in pulmonary veins. She required vasopressin, norepinephrine, inhaled nitric oxide, and milrinone for right ventricular support. Hemorrhage through the endotracheal tube prompted multiple bronchoscopies. Computed tomography angiography revealed pulmonary vein stenosis. An Arndt blocker was placed to protect the contralateral lung.Due to clinical deterioration and suspicion of compromised graft perfusion, she was taken emergently for left pneumonectomy on HD 2. During the procedure, venovenous ECMO was initiated, and a pericardial flap was used to reinforce the bronchial stump. Concurrent mediastinal re-exploration was completed. Persistent respiratory failure led to tracheostomy on HD 3.Following pneumonectomy, the patient developed progressive hemodynamic instability with worsening renal and hepatic function, disseminated intravascular coagulation, and gastrointestinal bleeding. She required transfusion support with platelets and packed red blood cells. Multisystem organ failure continued despite maximal intervention. After multidisciplinary discussions, the patient was made do-not-resuscitate on HD 4, and continuous renal replacement therapy was declined by the family.On HD 5, she was transitioned to comfort-focused measures and subsequently died peacefully.This case highlights rare, catastrophic early postoperative complications following bilateral lung transplantation, including complex pulmonary vein reconstruction, post-implant pulmonary vein stenosis, graft failure requiring pneumonectomy, and refractory right ventricular dysfunction. Early recognition of compromised vein flow is critical, as progressive hemodynamic collapse may necessitate aggressive salvage interventions. Despite maximal cardiopulmonary support, outcomes may remain poor when complicated by multiorgan failure. This abstract is funded by: none
Uysal et al. (Fri,) studied this question.