Lung Herniation and Torsion Contributing to Persistent RV Dysfunction after Heart-Lung Transplant

Purpose Lung herniation and torsion are rare and life-threatening complications post-lung transplant, resulting in vascular compromise, airway obstruction and eventual necrosis. Timely diagnosis is imperative as delays can potentiate ischemia of the lung tissue, increasing morbidity and mortality. Few case reports of lung herniation post-dual heart-lung transplant (HLTx) have been published. We present a unique case of a HLTx complicated by retrocardiac lung herniation and torsion. Methods 50 y.o. M with bronchiectasis, cor pulmonale, and severe pulmonary HTN underwent HLTx. He was extubated to nasal canula within 24 hours, however remained vasoplegic requiring inotropic and pressor support, with TTE showing RV dysfunction. On POD 5, pressors were weaned off, however, inotropic support was still required despite normal oxygenation and chest radiograph without acute infiltrates. Further evaluation with bronchoscopy showed extrinsic, pulsating compression of right lower lobe (RLL) “fish-mouth” inlet with inability to pass bronchoscope (Figure 1A). Emergent CT chest revealing RLL torsion and retrocardiac herniation into contralateral hemithorax (Figure 1B). Results Patient taken to OR for de-torsion and herniation reduction, with intraoperative bronchoscopy confirming correct anatomical position (Figure 1C). Conclusion Acute RV failure accounts for 50% of post-operative complications and 20% of early mortality post-HLTx. Although airway complications are generally confined to the anastomosis, the heart may be compressed by adjacent structures, including a malpositioned lung lobe, and may present as cardiac dysfunction. Early recognition of unique complications, as seen in this case, is critical as vascular and airway compromise may result in irreversible lung damage. De-torsion and reduction of the herniation may allow for full recovery; however, if it fails or is unable to be performed, patients may require a lobectomy to protect the remaining viable lung tissue.