Lung Transplantation:

Indications Donor ,

and Recipient Selec-

tion, and Imaging of

Kai’itci Gaig, MD
1Icirtii R. Zainora, MD
Rub/n Ti,de,; MD
Jobi J).Arinstrong II, MD
Dark! A. 4yiich, MB

Lung transplantation has become a well-established treatment for end-

stage pulmonary parenchymal and vascular disease. Careful selection of
recipients and donors is important to decrease early graft failure, which
is primarily due to rejection and bronchial dehiscence. Common compli-
cations include the reimplantation response, acute rejection, pleural ef-
fusion, lyniphoprohiferative disorders, bronchiolitis obliterans, infection,
and airway stenosis or dehiscence. The reimplantation response is a
form of noncardiogenic pulmonary edema that begins SOOfl after surgery
and resolves in days to weeks. Acute rejection occurs in most recipients;
a dramatic response to steroid therapy is the most diagnostic clinical fea-
ture. Lymphoproliferative disorders are posttransplantation neoplasms
that may disappear when imnninosuppressive therapy is stopped and of-
ten manifest as a discrete lung mass. In bronchiolitis obliterans-a major
long-term complication probably due to chronic rejection-computed
tomography (CT) often shows bronchial dilatation and air trapping. Air-
was’ stenosis and dehiscence are easily diagnosed with bronchoscopy
and (;T. Infections remain the major cause of morbidity and mortality.

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. RS\.. 0996

355
 . INTRODUCTION
Table 1
Lting transplantation has hccoiuie au accepted
Indications for Single Lung Transplantation
thucrap) for hitticnt5 with end-stage litilnuoluars’
Indicatioim Fneqtieimcs- (%)
Ii1renchi)’nial or vascular disease (‘I’ables 1 , 2).
Early graft failure-due primarily to acute rejee- Enmphmvseumma 33.5
tioii , amr’sva) isehicnmia, and bronchial aiuasto- Idiopathic puinmoimar) fibrosis 24 .2
niotic disrtiptioiu - has hcciu overconue withi urn- tX1-aultitrvl)siti deficieimc- 15.8
pno’ed niethods of ininutinostippression and Pninmars- puinmonars- lm-perteumsion 8. 1
the tise of either vasetilarized oniental tissue Other I)Liifliohlan thiscasc 6.5

wraliped arouiud the hroiueiuial aluastoiuiosis or Retransplantation 5.5

Sarcoitlosis 2.7
the “telescoped” aluastonmotic teciuniqtie (2,3).
Coumgeimital heart tlisease 2.6
Single lting trauusplaiutation, first perfoniuicd
Cystic fibrosis 0.
for fibrotic Iting diseases, is also perfornued for
Pncunmoeoimiosis 0.2
chronic obstructive iulnuonary disease aiud pa- Mahigumaimev 0.2
ncnehu)’nual disorders. l)otihlc luuug transplanta-
tioui iS hierforiiicd hininu-aril)’ for the ‘ septic” lung Source-Reference I.
diseases stiehu as cystic fibrosis and bronehiec-
tasis. Hcart-ltiiug transplantation, oniginaihy lien-
formed for hituinloluar)’ hu)’pcrteIision, is iiow rc-
Table 2
served for hiiticuit5 witiu tincorrectable cardiac Indications for Double Lung Transpian-
defects associated withi pulnuoiuar arterial ii)- tation
Pcrtensiohi.
Indicatioum Fretitleimey (%)
Single lung transplantatioii is performed
thmrotighu a lateral timoracotoni)’ incision. double Cystic fibrosis 37.9
htiiug transplantation thirotighi a suhmaiuinuarv Pninmar’s- lithhnlIian hliienteuisioti - I
,, elanushucil “ iiieisioiu , aiud hicart-luiug transplaiuta- (;Oilgeumital heart disease 4.2
tioli thunoughu a niedian sternotoni)’ incision. Air- Other ptilnioiman disease 46.6
wL)’ anastoIuiosis is hierforluictl citiier with end- Idiopathic pulnmoimar fibrosis 6.2
Eimmphmvscnma 30.6
to-cud anastonuosis or with die telescoped tech-
Retransplatmtatioim 4.2
nique, in ‘svhuicii the donor hroiuchutis is overlap-
ped by iic cartilaginous niiug iii the recipient Sotirce.-Rcfereimee 1.
hroiuehmus.
Time efficacy of ltiiig transplantation is still ne-
strictcd by flue sniahl ntinuhcr of available do-
iuors, the difficult)’ of adequately preserving cx- U INDICATIONS
cised lungs, ptulnionary infectious, aiud chronic The indications for king traiusplantation are
rejection (nuanifcstcd as bronehuiohitis ohlite- listed iii Tables 1 and 2. Single lung transplanta-
rans) (3). Owing to the rapid expansion of elini- tion is tue Procedure of choice for tue fibrotic
cal experience and advancements in this field, lung diseases because both blood flow and ‘en-
recipient and doiuor selection, choice of opera- tikition teuud to favor the graft, whiiciu huas lower
the tcehiiuiqtic, iiuiniuuuostippression . diagnosis vascular resistaluce and conuphianee. Single hung
and niaiuagement of infection auud rejection, and transplantation has also heeuu extended to treat-
long-ternu follow-tip continue to tindengo devei- ment of chronic obstructive ptilnionary disease,
opiuueiut. ct-antitrypsmn deficienc)’ (Fig 1), sarcoidosis,
Iii this article, we present the current iiudiea- and iymphaiugiolciomyomatosis. There is eon-
tiohis for lung transplantation. the criteria for se- troversy over whether patients withu ptilmonar’
iceting recipients aiud donors, aiud an overview hypertension shuotild receive single or double
of patient follow-tip. We then descrilic and ii- lting transplauuts. In general, double iting trans-
lustrate the coniphications of thus proecdtire on plantation is hierfornued in hiatuents with “ sep-
the basis of otir experience with 53 patients. tic” luiig diseases such as e)’stuc fibrosis and
bronchiectasis or in patients tinder the age of
40-45 years withu ct-antitrypsin deficiency.

356 U Scientific Exhibit Volume 16 Number 2

a.
Figure 1. Severe enmplm-senma set’oumtlar’s- to ct-antitrs-psin defieieimcv iim a -.I-ycar-o)ltl woman. (a) Prt’-
oper-iti’s’c histero)tnterir chest rathiogra)h shiosvs bi lateral imy)eri nflat ion ‘svithm imitiltipic l)tlhlae iii t he
lower lobes. Miltily thilatetl cetmtral ptiltml1mar) arteries are also) imo)tcd. (b) Preolierative hmigh-resolution
comptitetl toimmographmic..’ ( ( ;‘F) scum through time right lung base silO))\5 paimaci imar t’iii 1)h1)5tt1iL ‘svithi a
central h)Lihha. There is also tlifftisc cvhintlric bronehmiectasis with imiticous plugging. Paimaciumar eilll)hi\’
senma aimd broneimiectasis were also Prcselmt iii time left lower lobe. Because of time bilateral broimclmiec-
tasis aimd Ptiflhleiit sptittiiii. the patient ‘s’s-as schmetltileth for bilateral rather than unilateral lung trLilsl)lail-
tation. Bro)lmcimiectasis occurs iii 1 5 of patients -ovitim ct1-aimtitr’spsiim tleflcieimcv. Scalt- is iii o.’eimtiummeters.

Heart-iting transplantation is indicated f’cn pa- svstciliic thiseasc ‘svitli significant noimptulnmoimar’s-
tients withi uiueorrcctahlc cardiac defects (large organ iuuvolvcnmcuut; significaiit coronary artcr)
atnial septal defects or ventricular scptah de- disease or left vciitnictilar dvsftinetioim: irrcvers-
fcets) or severe veiutnieular tl’s’sfunctiom assoem- ihihe d’ssftiiuctioii o)f the liver, kidneys, or central
ated ‘svitii hithlnuonar) arterial hiypcrtchisiohi. uiervous svstenm; tinctired nmaiignanc)’ (cxeltid-
hug basal cell car.iiuoiiua of die skiuu): sigiiifieant
U CRITERIA FOR RECIPIENT SELEC- ps)’ciuosocial problenis: thrug o)r aleo)hlo)l ahiusc;
TION auud a huistors’ O)f immcdical imonconuphiance. I sc of
In gciueral, luuug rceipiciuts have ehiiuiealh- and corticosteroids in a dosage above 20 immgJd is
physiologically severe hithlnlIiary parehichi)’iimal also t contraindication. (urrcuit cigarette sniok-
or vasetular disease that is tinrcsponsivc to nmcdi- ens are imcvcr considered flin tnansplantatio)n ( 1 ).
cal thucrap)’. ‘limese hiatichuts have significant hinmi-
tations in time activities of daily life antI a limited . CRITERIA FOR DONOR SELECTION
life cxpcctaiucy of I 2-24 nmoiuthus. i’hc Iitciltiti Strict donor selection criteria arc essential to)
recipient should have adcqtiatc cardiac ftiiue- ciusure earl)’ hi5to)hienati\c graft ftuiictioui auth
tioii ‘svithoi..it signifIcant coronary artery disease, lo)uig-tenilm sunm’ival after Iting tralushildumtatioil.
should he anihitilatorv with rehmahihitatioim, and ‘I’hmc ideal lung doimor has iio evideim..e of pcim-
should have an adequate iiutnitional stattis aiud a etrating or severe hltiimt chest tratuumla, clear
satisfactorv cnmotionah suppo)rt svstcnm ( I ).

Contraiiudications to) traiusplantatioim iiueltide

active ptulnmonarv or cxtraiitilnmonar’s- infection:

March 1996 Garg et a! #{149}

RadioGraphics U 357
 a. b.
Figure 2. Slosv resoltition of pulnmotmau-- cdenma after left lung traimsplaimtttio)ii iii a 5-i-year-oltl umian.
(a) Chest radiograph obtaineth 8 hmotirs after transplaimtatioim simon’s-s iimcreasetl vascular dianmeter aimd a
nmild interstitial pattern with penivasetular and hienii)roimcilial thmicketmiimg. consisteimt with time reiimiplan-
tation response. Ptuinmonarv edcnma due to) fluid o)venload caimimot he differentiateth rttiio)graphmieailv from
thitt dtic to) the reiimmplantation response. (b) Chest rathiographi obtainetl 3 weeks later shows immild re-
sidtial hicrihmilar increased opacity iii the left luumg. Aim enmphlvscmLto)tis native right luimg is iio)tetl.

lungs on chest radiographs without evidence of discharge from due hospital, several studies are
significant pttlnuonary edema or contusion, performed- ineltiding weekly chest radiogra-
nonptirulent sptitunu, normal cardiac function, phi)-, spirouimctr’s-. and exercise oxiuuietry-tintil
and adequate lung compliance and gas cx- the hiatieumt imas sturvivcth for 3 niontius. After this
change. Tue partial prcsstire of oxygen in the period, time tiimdengoes nmouithil)’ ehiest ra-
blood shiotild be greater than 300 nini Hg whuen diograpiuy aimd spironmetny. Several centers have
the patient is receiving 100% oxygen with 5 enu fotind that daily huonme spironmctrs- is effleaciotis
of positive end-expiratory pressure. All donors iii nionitoring for rejcetioiu. Ittients niotuitor
undergo bronchoscopy to check for aspiration their vital siguis and tcnmperattircs dail)’ to check
0I foreign bodies. I)onors are then matchued to for possible iiufeetion. ‘Fiie use of routiluc sun-
recipients by means of ABO blood type, cv- vcihlaiuce hironchuoscopv is coiutroversial aiid is
tomegalovinis serologic stattis, and appropriate hot eurrcuitlv practiced iii otur center. CT scans
size matching based on height, chest cireumfen- arc obtained when chinicahis indicated and are
enee, and the vertical dimensions of tue lungs niost eonmimmouul’s- ohtiiuictl for evaluatiouu of non-
(4). specific radiographic alinormalitics.

. PATIENT FOLLOW-UP . COMPLICATIONS

In the immediate postoperative period, patients
tindergo daily chest radiography and eontinti- . Reimplantation Response
Otis oximetrs’ to check for complications. After Patiiopiivsiologicahlv, time rciiiiplauitatioii re-
5Pii5e is a forum of noncardiogciuie ptilniouuary
cdenma. Iii practice, it is a diagnosis of cxciusioiu

358 #{149}
Scientific Exhibit Volume 16 Number 2
a. b.
Figt.ire 3. Severe ptilnlo)imar) edeimia due to overperfusion after right hung transplantation in a 50-year-
oltl wonman with pnmnmar)’ Iitlhilloliafl imyperteimsion. (a) Chest ratiio)graphl obtained 8 hours after sun-
gery shows widespread o)paeifieationm of time tratmsplaiited lung. Coniplete opacification nmust lie differ-
entiated fronm vasetilar anastonmotic oil)structioil. In fact, time chest was re-explored to confimni the in-
tegrity of time vascular anastonmosis. Ixtracorporeal tmienmbrane oxygenation and a double-lumen endo-
tracheal ttibe were used to prduee tlifferential ventilation of each lung. (b) Follow-tip radiograph oh-
tamed 8 days later, after vigorotis ditiretie thmerap’s. shows a clear lung.

and includes all radiographic eiiaiuges begin- tube nuav he used to produce differential venti-
ning SOOhi after stirgery that are hot due to left latioii of each lung in cases of severe reimplan-
ventricular failure, rejection, fluid overload, iii- tation response.
fection, or atelectasis (3,5,6). Fiuudings on chest
radiographs vary froni a subtle perihilar haze to . Acute Rejection
consolidation with air bronchuograms (Figs 2, Tue first episode of rejection commonly occurs
3). The process alniost always begins mmmcdi- at 5 days btit may ocetir as early as 48 hours af-
ateiv after transplantation and is always present ten transplantation. Most recipients experience
by day 3. The tinue to conupicte rcsoiutiouu of ra- two r three significant rejection episodes in
diographuic findings is variable, ranging fronu time first 3 months. After 6 months, acute rejec-
days to weeks (Fig 2). In double hung trans- tion becomes less common. The clinical diagno-
plants, the distribution of hiulnuonar’ ahnormahi- sis of rejection is imprecise, being based Ofl a
ties can he asvnumetnie. combination of suggestive signs and symptoms,
In tir experience and in timat reported by iuicituding deterioration in arterial oxygenation,
O’I)onovan (7), radiographuicahl” severe rciuiu- Iiyrexia, decreased exercise tolerance, and in-
plantation response is nuore coninion iii pa- creased fittigtie (3,6). The diagnosis is eon-
tieuuts who undergo single lung t ranspiaimtation fimnied h’, finding a lvmphocytic perivascular in-
for primary ptuimonary hyperteuusion thiaiu in fIltrate at traiushronchuial biopsy.
those who undergo ltiuug transplantation for
other conditions. A douhle-ltiniciu endotrachucal

March 1996 Garg et al #{149}

RadioGraphics U 359
 C. d.
Figure ‘4. MiltI rejection of a traumsplaimtetl right bug in a 5 1-vc-ar-ol(l imuim ‘svith eimiphvsenma. (a) Base-
hue chmesi rtthio)grapim obtaiiieti 8 days after surgers shoovs a clear trLiisl)ltiltctl luiig. (b) ( lit-st rLtlio)-
grd)il o)i)tLiimeti 32 tlavs after surgen’s shows hazy iimcreaseth ol)acitv the right lo’sver lung ‘svithm iimtlis-
tiilct notluies. (c) Iligh-po’sver phlo)to)nlicro)graph (onigiimal nmagimilicatioum. x-iOO: ho..-iiittoxvhin-o..’osiim
stain) 0)f a hroiichioscoh)ic hiops)- specinmeim shows a lvnmpimonmoimonuclear ..t-ll infIltrate (arrow) exitiimg
t sniahl ptilnitiary vessel (z’). ‘so-hmichmis l)rohthly a venuic. Time iumflammatorv l)ro)dess exteiitis to atija-
cent alveolar septa. The alveolar l)Iieunloume’tes (p) siio’s’s nmarketl reactivity as tienmo)imstrttetl h)v time
increasc..-tl size. hmvperchmn)nmaticitv of nuclei, aimd iurescumce of destltiLnmLtetl eleiiio..-umts in t he alveolar
spLce. (d) 10110W-UI) radiograph obtained I i weeks after stirgerv shows .Llmo)st coimmplett’
- reso)ltitioim
of time areas 0)f iumcrcasetl opacity in the right lo)wcr lo)be after treatiilt-imt with methvlprednisoioume.

‘l’hc radiographic ahnonuuuaiitics seen iuu rejec- ground-glass iiicreascd opacit’s. and to )nsohida-
tiouu include reticular areas of increased opacity, tioui (5,6). lIo)wever, time chest ratiiographu nma
iuudistiuuet 2-3-rnnm-diauumctcr nodules (Fig 4), he nornial. In hiatieiuts with hueart-htuuig traius-
hilauits, the colmmliinatio)im of septal hues auth iucsv
o)r increasing hilctirth efftisioums ‘svithmotit a coil-

360 #{149}
Scientific Exhibit Volume 16 Number 2
 Figures 5-7. (5) Empyenma after right lung transplanta-
tio)il in i 53-year-old nmaum. Chest radiograph shows a right
Pleural effusion , which slmowcd growth of Lactobcicillis at
culture. ‘Fime donor bronchus also) showed growth of Lacto-
bacillus, stiggesting transnmission of the organisnm fronm do-
umor to recipient (9). (6) Bilateral pnetinmo)tho)rax after hilat-
cral lung transplantatio)n ill L 34-year-old man. Chest radio-
graph shows nlarketI bilateral pnetimothorax (arrows).
Placenment of a left-sitled chest tube resulted in resolution
of time pncunmotlmorax on both sides. (7) Paralysis 0)f time ip-
siiateral hmenlithiapimragnm after left lung transplantation in a
48--ear-oltl wonan with cnmphysema. Postcroaumterior
chest rathiographi shows aim elevated left henmidiaphlragnm.
Paradoxical nlotio)n of the imeimmidiaphmragnm was imoteth at
fluo)ro)scopv. Whereas interruption of lynmphmaties, time ‘sa-
gus imcr’se. anti bronchial arteries tiocs umo)t cause signifltaimt
physiologic tlerangeimieumt, phreimic imcrve injur’s- tail result
ill conmproilmise of bug fuimt-tioim (3).
5.

6. 7.

(.0hllitLIit iumcrcasc iii cardiac size or ‘s’aseular (Fig 6), and piurcuuic nerve iuijur)’ (Fig 7). Bc-
‘svidthm on evidcimce of vascular nethistnilitution is eatuse time pleural spaces eo)nlnitinicatc after
reported to iumthi&.ate actite itung rejcetio)n ‘svithm a dotible luuug or heart-lung transplantation , a uni-
scuusitivit) O)f 68, specificity of 9f)) and over- lateral air leak niav eatise bilateral pncunuo-
ihh acc-turac- of 83 (8). ‘Fime single nlo)st tiseful thiorax (Fig 6) ( 10) or siuifting pncumothorax
thiagnostic feattire of rejection is thranmatic chiuii- (11).
cal aimd rathio)grapimie iniprovciilcuit (Fig 4) in re-
5PIl5e to) iiltravcimo)tisl)- tdiuiiiiistened steroids. . Large-Airway Complications
Luiug transplantatiouu is tiniquc conupared withu
. Pleural Space and Diaphragmatic transplantation of oilier solid orgaius in thu-at a
Abnormalities s)’steniie arterial supply is not restored at the
Pletiral efftisioims are coninion after traulshilaflta- tinic of transplantation. Time prevalciuce of air-
tiouu, hinoiiiiil) l)tidtlse fluid clcar;ince through way stenosis and dehuiscenec iuas been draiuiati-
the l’snmphmatics O)f time visceral hilctira is him- call)’ decreased by avoiding a steroid dosage
paired. ( )thmer ..oiimphicatiouus incltide enipvcnma
( Fig 5 ). tiumilateral or iiiiateral piittiiiitiiortx

March 1996 Garg et a! U RadioGraphics U 361

 . I
-1
Figure 8. Focal thefect due to a telescopeth hImasto)-
fliOsis after right luimg transplaimtatioim iii a 56-vear-oitl Figure 10. Bronchial tlelmiseence after left ltuumg
wonman. (;1’ seaum shows mild irregtularitv of time right traimsplaimtatio)im iii J pttieumt ‘svithm eniphmvscnia. CT
nmain bronchitis due to a telescoped aimasto)nR)sis (ar- scaim obtajimeti after time patieimt experienced left up-
ro)wheads). Iimcideimtall- umoted is
right I)ilCtifll0
i )- icr loh)e cO)llapse (L( L(.’) shows left bronchial dehis-
thorax. It is inmportaimt imofl to nhisiimtcrpret a tek’- Ceilct’ (I)). .-1.-I = asceimtiiimg aorta. I).-1 desecimthing
seoped aumastonmosis (overlapping of time donor l)ron- dOI”ti, I..IISB = left maiim-steimm hroimchmus, MPz1 nmain
ehmtis witim time recipient hroimchtis) as hroimchmiai h)tulnioimar\ artery. (Courtesy o)fjaimice Senmenkovich,
stehiosis. MI). .“olailiimckrotlt Institute of Radiology, St Lotus,
Mo).)
greater than 20 mg/d in the pcnipcrttive pe-
nod and h) “telescoping” (overlapping) time
bronchial anastonuosis (Fig 8) or wrapping ‘sas- Bronehonialacia ‘svithiotit stciuosis nuay lie fotind
cularized tissue such as onuentunl aro)uumd it ill liatiehits with chronic rcjectioIu. Iii a recent
(12, 13). Airway stenosis and deimisecuice are sttidy of 23 selected patients suspected or
best assessed withu bronehuoseopy , altimotighu CF known to have bronchial dehuiseciuce (16), CT
ma)’ be useful for assessing the leuugthi of the was 100 sensitive aiud 9-4 specific for detec-
stenosis (14,l5)(Fig 9) and dctcetiiig extraluummi- tiohl of dchmisccimee.
nal air, which indicates a bronchmial defect (Fig
10). In a recent stud)’ ( 1 5), helical CT withu . Lymphoproliferative Disorders
mtultiplanar reconstruction was 94 aectirate iii Posttraiusplaiutatioim hvnupimoproiifcrative dison-
depicting bronchial stenosis conipared withi a tIers are au iuucrcasiuigh)’ well-characterized stub-
91% accuracy for axial CT aloime. set of Po5ttraIusPlLntatioIl neoplasia. The slice-
trulum of expression ‘sanies froni a nmild beuuign
IiolYelouutl prhifcnatioui of i)ililiiioid tissue with
few if au)’ signs tiid syiumptoimis to noiu-Hodgkin

362 #{149}
Scientific Exhibit Volume 16 Number 2
a. c.
Figure 9. ili( )iiCi1i0l di1ISit )iiit )l it.. sit-nusis ihit’i’ It’ll
bug ti’diIsI)i.Iuiiatiouliii I 59 t.’ui’-oid oman. (a) istop-
erativt’ clmc-st i’atiiogripli .Lm,)t’Li’s lu)rnLli. (b) Slur-al
( :1 sh( )‘sVS niu’rt )‘s’s lUg of I lit’ it’ll i’fllii-i i’)i’( )li-

cimus. I )iltust’ fIbrosis is st’t’n iii hit’ i1LliVt’ right lung.

(c) h)ll0 )‘sV-Lllmcht.’st radio )gr.lmh slu )v:’, slt’nts iii I lit’
left nualim hmronchnis.

tulle h)ct’s’sc’t’lmtraulsl)illmtltioim auth oust-I of this-

cISt’ raumgcs h’Ouii 1 nmoimthm to) st’t’ral vt’.urs timd
sceumms to he rt’latetI to thit’ iimiimiuimosupprcssi’sc
rcgiiimen used ( 1 ‘). A tuumiqtit’ lt’ittint’ of this en-
tity is tim-at lViiii)hmoitl iiil55t’S immay regress or this-
1l)I)cdr ‘s’shmt’ii iuimuiitiiiosupprtssi’s’c thmt’rih)v iS

b. Stop)et.I 01’ rt’thuct’th.

hiiti’tthoi’.it’ii’ lvimmuhmopi’oiitt’rLtivc thisordt’r is
immo)st c’onmnmo)imly l’iLti’tctt.’i’i/t’ti by time irtst’imi’t
l)’uimpiB)umil ( I 7). ‘l’imt- reportt-tl i)rt-’sLituit’t- of 0)1 thiscretc imothules, t’itimc’i’ S0litli’S (ii’ imitultipic
h)oSttnuuisPlauitLtiui iviiiphioprohift..’ritivt thisor- ( 1 ‘). Less lnt’qtieiitlv, ummt’thiusLiiial or hilar lvnmphm
dens is -I’u. ‘lime coimdit Io)il o)cc.urs imi( )st ( )lttli iii node euilangt’ummt’imt caim 1)1’ i uiaumifestttioum of
lung traumspiaimt rec’ih)icimts auth is huiiost iumvLn-
ably tSS0tLuht.’t.h ‘svithi ll)stCiui-hLLil’ virus. ‘lime

March 1996 Garg et at N RadioGraph/es U 363

 Figure 1 1. Ixnmphmoprohiferative thisou’-
der 8 nmonthms after left lung traumsplaumta-
tion in a 5l-ear-chd ‘sVOfllfl withm eni-
ph)-scma. (a) Posteroaumterior chest ra-
thiograpim shio)\V5 J umew left hiilar immass.
(b) CT seaii obtaineti 1 ciii interior to)
time division of time left main broumeimus
tienmonstrates a noncalcifjc, no)nc’umimanc-
ing nia.ss hctwceim die left lower lobe
bronchtus aumti time left PtllnmimaI’Y arter’s.
Transthoraeie fine-needle aspiratio)n hi-
opsy denmonstrated lvnmphmo)prohiferative
disease. (c) Chest rathiographm shows ra-
pid progression of disease in 2 nmontlls
with posto)hstructive ill tile

hingula. Suhscqtient radiogruphms shmowetl

partial reso)ltitio)n of time mass after cvclo-
sporine thicripy was tiecreasetl iimtl in-
terfcro)n alfa thmerap was stai’teth.

lymphoproiiferativc disease (Fig I I ). ‘Fhiymie, tltic to) chinoumit’ rejection. ‘l’hmis conmphicatn)uu tic-
pericardial, and pletural involvemciut has also vclo)ps iii aiproxiniatch o)uic-thiird of httients
been reported (5). Lynipiioprohifcnativc disease ‘sVhl() 5tii%’i’s,c lo)ngen timaum 6 ummonthis. ‘lime cliuiicai
is often detected incidentally Ofl routine chest ummauiifestationms of hnoumthmiolitis obhiterans in-
radiographs. The diagnosis eaiu he verified by elude cotigim aimd progressive thvshinea. ( ;hmcst ra-
demonstrating Epstein-Barr virus and l)’nuplio- thiographs are often umo)rmal or ummav show a uumild
cvtes at percutaneous transtiuoracic uuccdle hi- decrease iii PeriPheral vasetulanit’,, areas of
opsy(Fig 11). stuhsegumicumtal atcle.tasis, aimd ahno)rnmal hues
( I 8). ‘Ehie luuig ‘soluimies are tistiallv uiornmal or
. Bronchiolitis Obliterans uililthl) iuucrcascd. Cl’ co)ummumloull dcummouustratcs
The major long-term conuplicatiouu of hung aiud hrouuchiial dilatation ( 1 8) auth a difftisc decrease
heart-lung transplantation is the devciopnuent iii ituuug attcuitiatioui ‘svitim umarrotviiug of’ vessels,
of hronchuiohitis obhiterans, which is hirohably wimichu is asstinmcd to lie tltic to air trapping and
ohigenmia ( 19,20) (Fig 1 2). Aithuotighm clinical di-
agnosis of bronchiolitis obhiterauts tlcpciitls un-

364 #{149}
Scientific Exhibit Volume 16 Number 2
 --

a. b.

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#{149}#{149}#
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c. d.
Figure 12. llronehmiolitis oh)literans after right bug traumsplaimtation in a 38-year-old nman with idiopathic pulmo-
nary fibrosis. (a) Po)stoperative (:1 sciim shows a relatively umormal trauisplauitctl bug. (b) CT sean ohtaiimed at
time same level ilio)umths later shows umitiltiple thiiateti, umoumtapening broneimi iimtl a hmypoattentuating right hung.
Puhnmoumarv vessels are umarrowed co)umsitherahly eoimmi)aretl ‘svithm those in a, irestuimiahly because of hi)’poxie ‘s’aso-
constnictio)n. (Figs I Lu tnti I 2b repniultetl. ‘svitlm fronm reference ii).) (c) High-power pimotonmiero-
graph (original ummagniflcatioim. x--i00) of aim open luumg biopsy specimeum shows a terummiuial bronchiole (t) that is
partly obliterated h)v fragimmentition of the nmtist’le Liver auth replacenmeumt in coumnective tisstie. Time destructive
liree55 eveumtualiv results iii aim irregtular hiroimehiolar outline, witlm polvpoid projections (arrow) extending to-
warti time hronciiioiar Itunicum. (d) Iligh-po-over )iiotoimiic’rogriphm (origiumal immagniflcation, x400; Verhoeff-van
(;iesoim staium) sho)W5 iumgro’svthm of sul)epithmehial eo)umumet’tive tisstie. The hrouiehmiohar elastic tisstie (black-stained
areas) appears lraguiicumteth. Note time accuimmtuiation of coumumective tisstue -eilo’s’s’-stainetl areas) and nmucopolysae-
charities (greeum-staiumetl art-as) with disal)h)caraumec of tIme nmtiscle iaer (arrow’s).

nuarul) Oil Ptuh1mm0uiifl ftunctioum tests, CT lila) lie . Infections

tuseful in earl)’ diagnosis of this coumthitiouu. Iii a The major catuse of nmorhidity and nuortality af-
recent sttith)’ (2 1 ), hiroumeimial dilatation ouu CT ten lung auud hicart-itung transplantation is infec-
scauus hireectictl chiuuical niauuifestations of tioIl. The conihination of expostire to bacterial
broncimiohitis ohilitcrauis iii t’v() of I 4 cases.

March 1996 Garg et al U RadioGraphics #{149}

365
 contamination froiui time ttniosphuerc, ischucniia
of the donor air’svav titue to interruption of die
hrouuehial eiretilatio)n, auth tue tuse of inuimmtuno-
stiliprcssauits has lctl-uiot surprisingly-to sig-
uiiflcauut Prohileulls whim hitilflluiLr) sepsis.
Iii general, earl) iimfeetions (tip to 1 nionthu)
are chimer bacterial on fuumgal (Fig I 3). Iuufcctiouus
occurring after 1 iiioumthi arc eonunioiulv titue to a
virus, ustiahl) evtoniegalovirus (Fig 14), aiud less
frcqtienthv to P!zeIll?loe)’stis, bacteria, or fungi.
(;trcftil attention to time recipient’s serologic
stattis for evtomegaio’s’irus (ic, cnsuriuug that es’-
tomegalovirtis-uuegative recipients receive onl)’
cytonuegalovirus-negative organs) auud tue use of
gauueiclovir have hceuu hmelpftil in rcdtieiiug the
hire’s’alcuuce of cvtoniegalovirtis pncuniouuitis.
Prophvlaxis with trinmethmopniuim and sulfaniethi-
oxazoic appears to lie effective iii decreasing Figure 13. .-ls/)e)#{231}’iIII1s infection
of time umative Iting
the hire’s’Llciiec of P,ieii,noej’stis air!??!! iuufcc- iii a -i(’i-vear-old ( ;liest radiograph
‘s’souiman. shows aim
tioIi (22). ill-thefiimed h)ireu1t’ii\u11al area o)f increaseth OI)acit) iii

the right lower lobe. llroumchmo)aiveo)lar lavage of this

U SUMMARY regio)um showetl .-1spt’tilIiis. Infectioim of time native
luumg occtirs k’ss freqtieimtlv timium iumfectioum of the do-
The early coniplications of htuuug tnauusplauuta-
umor luimg.
tioui-iuueltithiuig the reiummplantatiouu response,
actute rejection, and cytonmegalovirtus infec-
tioiu-huavc uiouispccific radiographic features.
‘Fhic rciniplaiitatioiu C5hi0Ii5 occurs ‘svithiiii the 5. Iiernmaum Sj. Rappaport I)C. \Xeishrod (L. Ols-
I st week of transplauutation auid is tistiahly trauu- caummp (;(;. Patterso)n (A. Cooper,JI). Single-
sicnt. Acute rejcctioiu ocetirs toward time cuud of ltuumg traumsplaumtLtio)n : iumlagiumg features. Radiol-
time 1 st week or later auth nespouuds dranuatieally ogy l)89; h):89-93.
6. Elerummaum Sj, \X’eishrotl (L, \X7eishn)th L. Patter-
tO steroids. Bronchial Jchuisccnec is easily diag-
sOii (;A, MaurerjR. Clmest ratiiograplmic find-
uuosed broneimoseopicahly arid with CT because
iumgs after bilateral Iting traumsplaumtatioim . 1jR
of the iiresence of cxtraltuuumiuial air. Chronic
1989: 153:i181-.1185.
conipiicatiouus like lvnmphmoproliferative disor- . ODoimovan PB. ImLgiulg of co)ummplicatio)lms of
dens, airway stenosis. auth hironuehuiohitis oblite- luumg transplaumtatioim. RatlioCraphmics I 993: 13:
raius have distinctive iumiaging features.
8. llergiim (J. (astehhiumo R1. Blaumk N. Bern (j.
. REFERENCES Sibley RK. Starnes \A. Actite ituumg rejection
I. Truloek EP. Recipieumt selectio)n. Chest Sturg after lmeart-iuimg traumspiaultatio)um : correlatioum of
(:hium N Aimm l)93:l-l8. chest ratliograpims withm luimg bio)psv results. AJR
2. (;alhmoon JH . ( ro)vt’r Fl.. ( ;ihboums \‘j. et al. l)90: 155:23-2.
Siumgle lting transplaumtatioum: altenimative iumdica- 9. joumes SI), Ftillertoim I), Zaummora MR. et al.
tiouis aumd techmumiqtue. ,J ‘l’hmorac Cardio’sasc Stirg lraumsnmissio)um 0)f Laetobacilliis puietuimmo)uiia by a
1991: 101:816-825. traumsplumted ltuumg. Aumn Thmorac Sting 1994; 58:
3. Cooper .11). I.uimg trLuisl)laumtatioIi. Ill: Sahistoum 88-889.
& Spencer. etis. Surger’s of the chest. 5th ed. 1 0. lLralmj)t’ I)V. \Xittichm (R. ilaimmith I.\V, Bergin
‘sol 2. 1 990: 1 950- 196-i. CJ. Fretluencv antI nmaimageimieimt of Iiimeunmo-
-I. (;alhoon jIl. Iniimkle K. l)oimor selection and thmoraces in lieurt-ltiimg traumsplaumt recipieumts. Ra-
ummaimagenmeumt. Chest Surg Cliii N Anm 1993:19- tlio)lo)gv I t)9.4: I 90:255-256.
28. 1 1. Iimgeler (I. ()lsoum PN. Engeler CM. et al.
Shmiftiimg l)umetuumlotho)rax after heart-bug traums-
l)laumtatii). Ritiiologv I 992: i 85:’ I 5-7 1
I 2. Ranmirez ,J. Patterson (\. Airway coummphca-
tions after iuumg transplantatioim. Senmiim ‘Fhmorac
(:arthio)v.Lsc Sung i)92: 4:122-125.

366 U Scientific Exhibit Volume 16 Number 2

a. b.
Figure 14. Cvtoummegaiovirus iumfcction of time left ltuumg after bilateral lung trails-
Pl1umtLti0)im iii a 35-vear-oitl cystic
wo)immaum with fibrosis. (a) ( lit-st ratiiographm slmovs
tin) indistiumct no)tiules aimtl mild broimchiial wail timickeuming iuivolviumg the left lower
iol)e. (;hiimieal auth ratliologic consitleratioims ‘s’sere rejection anti iumlectio)um. (b) (;hmest
rathiograplm ohtaiumeth I tlav later after hroimchoaiveolar lavtge o)f thmt’ left lo’sver blue
shows uimildly iumcreaseth opacity. Evaluatioum of the hro)nchoalvt’olar lavige Lsl)irlte
‘svithm time shell vial assay showeti cvtonmegalovirus. The patient ‘s’sas treateth ‘s’sithm iii-
travenousls- atlnmiumistcretl gumciciovir umtl recovered. ( ;k’aruimce of hroumchoaiveolar
bavage fluid is often tlelaved iii traimsplaimtetl ltuumgs.

I 3. Colquhotin 1W, Ahistair I)C, Au J, Corns PA, 18. Leumtz I). Bergium (J, Bern’s (J, et al. I)iagnosis
Hilton (,J, l)ark ,JlI. Aiu’wav coummphications al of hroulchn)bitis obhiteraums iii hmeart-lting trans-
ter pulnmoimarv traumsplaImtatio)um . Ann limorac pllumtLtiim PLtieumt5: inmportaumee of bronchial di-
Sturg 199-i: 5: b-u 1-145. latation Oil (‘l,. 1JR 1992: 159:463-46”.
1 i. Medina I.S. Siegel M,J. Cl’ o)f complications in I 9. (arg K. 1.yumcim Newell JI). King ‘FE. Pro-
pediatric bug trLumsplantatio)im . Ratlio)( ripimics iifcrative umti constrictive bronehmiohitis: classifi-
1994; l4:l341-i349. catio)n iumtl ridio)grapilic features. AJR 199-i:
1 5. (tuiult I.E. \X”hmste RI, Kazerooiii LA, et al. Ste- 162:803-808.
uiO)sis of thmt’central airways: evaituatioum l) tus- 20. Hartnmiim ‘IL. Priumiuck SI., I.ee SK, Swensen SJ,
ing helical ( ‘1’ with ummtultiplaumar reco)nstrtuc- \liiller NI.. ( ‘i of broumehmiab antI bronchiolar
tio)ns. Radiology I 995: 1 )-i:8 I -8. tiiseases. Rltiio)(;raplmics 1 99i: I 4:99 1 - 1003.
16. Senmenkowit’hm ,J\V, (bazer 115. Anderson I)C. et 2 1. Loubeyre P. Revel I). I)elignette A. et al.
al. Broimelmial dehmisceulce iii lung trauisplaumta- Bronclmiectasis thetectetl witim thin-section CT as
tion: C’I’ evaluation. Rathio)logv I 995: 19-i:205- a prt’tlictr of chroimic ii.uuig allograft rejcetioum.
208. Radiology 1995: 19-i:213-2i6.
17. Bragg I)C. (;hr P,J. .\1urriv Kjeltishcrg CR. 22. Timeotbore J , l.c’wiston N . I.uimg transplantation
l.-niphmoproliterative tlisortiers of tIme luumg: imis- co)ummt-s of age (editorial). N Eumgl j Med 1990;
to)xttimobogv. cbiumicib niaumitcstatioums. tumtI inmLg- 322:2-”#{149}i
iumg feattires. JR 199-u: l63:23-2Hl -

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