Standard lung transplantation is not feasible for patients with pulmonary arterial hypertension (PAH) complicated with a giant pulmonary arterial aneurysm (PAA). We describe our experiences of lung transplantation with pulmonary artery reconstruction (PAR) using donor aorta in five patients from 2010 through 2020. All patients had a substantial PAA size (median pulmonary artery trunk diameter of 69.9mm) and were classified as NYHA III in terms of functional status.The operation times were long and intraoperative blood loss was profuse in all cases. Four patients required post-operative ECMO support. Despite these challenges, all patients survived throughout the follow-up period, with a median observation time of 94 months. Importantly, no complications associated with the donor aortic graft, such as dilatation, constriction, or infection of the aortic grafts were recorded. Based on these findings, we suggest that lung transplantation with PAR using a donor aorta can be considered as a viable surgical approach for PAH patients with a giant PAA. However, it is crucial to acknowledge the substantial perioperative risks associated with this procedure.

Right-to-left inverted lobar transplantation is a surgical technique to transplant a donor's right lower lobe to the recipient's left chest, usually in living donor lobar lung transplantation. This technique was developed in Kyoto University by Date and colleagues and is indicated mainly for the following conditions: 1) limited donor lungs' volume relative to the recipient's chest cavity; because the right lower lobe is generally slightly larger than the left lower lobe because of the medial segment (S7), the use of right lower lobe is advantageous. 2) A donor's left-lung anatomy is not suitable for donation, typically peripheral branching of lingular arteries (A4 and/or A5) necessitating vasculoplasty on the donor side, which potentially increases the risk of donor surgery. In addition to the successful case series in Kyoto, we have conducted 3 cases in Tokyo using the technique with a good outcome demonstrating reproducibility of the technique.

Single lung transplantation remains the procedure of choice for certain patients. When the candidates have uneven disease laterality, transplantation for the worst side is more suitable, even when the available organ is from an unsuitable side. We reported a case of right-to-left lung transplantation in 2020. This time, we present the detail of the procedures. Case. A 56-year-old male with idiopathic pulmonary fibrosis underwent a left lung transplantation using a right lung, due to uneven disease laterality. Initially, stay sutures were placed on both the recipient and donor bronchi, then pulled to create a space for pulmonary artery anastomosis behind the bronchi. The recipient pulmonary artery was cut in an oblique plane, from A1+2ab to A6, then sutured to that of the donor beyond the recipient bronchus. Then the donor bronchus was sutured to the recipient bronchus in front of the pulmonary artery. Finally, anastomosis of the left atrium was performed in the usual manner. The postoperative course was uneventful. The patient was without complications related to inverted lung transplantation until myelodysplasia syndrome and its subsequent leukemic conversion took his life.

In standard living-donor lung transplantation, the lower lobes are implanted in a single recipient. However, adult lower lobe grafts are frequently too big to be implanted in small pediatric patients. We successfully developed novel living-donor segmental lung transplant techniques, using basal and/or S6 segmental grafts. Segmental graft preparation in donor (Video 1): The intersegmental plane between the S6 and basal segments was identified by near-infrared thoracoscopy following the intravenous administration of indocyanine green and then completely divided in vivo using electrocautery. Segmental lung transplantation with grafts of the right basal segment and left S6 segment (Video 2): The implant technique of the basal segment was similar to that of the lower lobe in conventional living-donor lobar lung transplantation. The video shows implantation of the left S6 segmental lung graft. The graft bronchus was anastomosed to the recipient's left upper bronchus, the pulmonary vein (PV) to the recipient's lower PV, and the pulmonary artery (PA) to the recipient's main PA. The vascular anastomosis should be meticulously performed in order to prevent poor venous drainage.

BACKGROUND: Since donation after cardiac death is not approved for lung transplantation (LT) in Japan, maximizing the utilization of extended criteria donor lungs is essential to solve donor shortage. Among various techniques in LT, we describe our experience of downsizing cadaveric LT (DCLT).METHODS: We retrospectively reviewed 17 recipients who underwent DCLT among 218 recipients of LT at our institution.RESULTS: DCLT was performed for 10 female and 7 male patients ranging in age from 9 to 55 years. The diagnoses included interstitial pneumonia (n = 9), diffuse panbronchiolitis (n = 2), pulmonary hypertension (n = 2) and others (n = 4). The median waiting time was 467 (53-1029) days. Bilateral LT was performed after uni-lobectomy (n = 11) or multi-lobectomy (n = 6). The cause of lobectomy was pneumonia (n = 8), oversized graft (n = 5), and trauma (n = 4). Bronchial stenosis was observed in one of 4 bronchial stumps, whereas no complication developed in 13 lobar-to-lobar bronchial anastomoses. The 5- and 10-year overall survival rates were 78.7% and 78.7%, respectively.CONCLUSION: DCLT provided favorable long-term outcomes and appears to be a viable option for selected patients.

Aorta-pulmonary window (APW) is a rare congenital cardiac anomaly characterized by communication between the pulmonary artery and ascending aorta, which sometimes leads to Eisenmenger syndrome (ES). A 29-year-old female with an APW and Eisenmenger syndrome underwent brain-dead bilateral lung transplantation and APW repair procedures. The communication between the aorta and pulmonary artery was transected, then the pulmonary artery and aortic side were directly closed with felt strips. Thereafter, bilateral single lung transplantation (LTX) was performed in the usual manner. The patient was doing well without heart failure or graft rejection. Nine months following the LTX, the patient complained of chest pain, and chest CT scan findings revealed an ascending aortic pseudoaneurysm at the anastomotic site, thus emergency operation was performed. Under hypothermia to stop circulation, the aneurysm was resected, and ascending aortic artery replacement was performed. The postoperative course was uneventful. Presented here are details of the surgical techniques used as well as a discussion regarding this experience with an LTX procedure for APW.