Abstract A 71-year-old male with a history of progressive pulmonary fibrosis underwent bilateral lung transplantation via clamshell incision seven months prior to presenting with dyspnea and recurrent bilateral pleural effusions. His post-transplant course was complicated by lymphocytic myocarditis, leading to acute hypoxic respiratory failure and heart failure. Outpatient management with torsemide improved fluid status but was discontinued due to worsening renal function, resulting in effusion recurrence. Upon readmission, a right-sided 12 Fr pigtail thoracostomy tube was placed and left thoracentesis was done. Pleural fluid analysis revealed a serosanguineous, lymphocytic, exudative effusion on the right and a neutrophilic, transudative effusion on the left. Both had negative cytology and infectious studies. The left effusion initially seemed to be controlled. Persistent right-sided drainage prompted placement of a right indwelling tunneled pleural catheter (IPC). Pre-procedure imaging showed bilateral effusions, and ultrasound revealed a diminishing right effusion during setup, supporting interpleural communication. To aid IPC placement, one liter of lactated Ringer’s (LR) solution was infused into the right pleural space. Post-procedure imaging showed a large left-sided effusion and a small right effusion (Figure 1.), confirming buffalo chest physiology—fluid migration between pleural cavities due to the clamshell incision. Despite suction drainage and positional maneuvers, the left effusion persisted. Intrapleural administration of lytics via the right IPC failed to evacuate the left effusion. A subsequent left thoracentesis removed one liter of fluid, but recurrence necessitated placement of a left IPC one week later. Three weeks post-placement, the right IPC was removed, and continued drainage from the left IPC prevented recurrence of the right effusion. This case highlights the anatomical alterations following bilateral lung transplantation via clamshell incision, which can lead to atypical pleural fluid dynamics, including interpleural communication and buffalo chest physiology. Awareness of these changes is critical for effective management of pleural effusions in post-transplant patients. This abstract is funded by: None
Kornafeld et al. (Fri,) studied this question.