Thoracic Christopher E. Engeler, Becky L. M. Carpenter, Marshall I. Hertz, MD
MD #{149}Paul N. Olson, MD MD #{149}James E. Crowe, MD #{149} R. Morton Bolman III, MD
Claudia Deborah
Heart-lung transplantation involves the total replacement of two of the most complex organs of the thoracic cavity. This procedure is usually reserved for patients with failure of both systems, such as in primary pulmonary hypertension or chronic Eisenmenger physiology. The en bloc replacement of the heart and lungs leaves an open communication between the two sides of the thorax that may allow air or fluid to shift from one side to the other. To evaluate this possibility,
the
authors
reviewed
the
chest radiographs of 25 heart-lung transplant recipients for signs of rapidly changing pneumothoraces that could not be explained by the conventional dynamics of pleural physiology. A series of postoperative radiographs showed unusual shifting or apparently rapid disappearance of pneumothoraces in eight patients. Decompression of a pneumothorax with a contralateral chest tube was a phenomenon observed in six of these patients. Index
terms:
Lung, 60.73
transplantation,
Radiology
Heart,
1992;
transplantation, 51.459 60.459 #{149} Pneumothorax,
185:715-717
M. Engeler, MD L Day, MD
#{149}
#{149}
Shifting Pneumothorax Transplantation’
after
H
EART-LUNG
procedure for patients with hypertension
Heart-Lung
transplantation is a principally reserved primary pulmonary
or pulmonary
hyper-
tension
secondary to congenital heart disease (1,2). The en bloc replacement of both the heart and lungs through a median sternotomy radically alters intrathoracic anatomy. Anastomoses of the trachea, great vessels, and right atrium are created, while the native esophagus and portions of the pencardium are left in place to provide support for the transplanted organs and preserve the vagus and recurrent laryngeal nerves (3). By leaving the esophagus
and
most
of the
trachea
with the adjacent adventitial tissue in place, there continues to be a partial division of the pleural cavities by the posterior and middle mediastinum. Anteriorly,
however,
open
communi-
cation between the two sides is established. We reviewed the radiographs of 25 heart-lung transplant recipients with particular attention to the dynamics of pneumothoraces and found patterns unique to this population that can be explained only by the open communication between the pleural spaces. MATERIALS The
chest
AND radiographs
METHODS of 25 consecutive
heart-lung transplant recipients years (mean, 32 years; standard
aged 6-54 deviation,
14 years) were reviewed to identify pneumothoraces. The vast majority of these postoperative images were bedside an-
teroposterior radiographs obtained at 80 kVp and a target-film distance of 40 inches (100 cm). The patients were imaged in either a supine No cross-table I
From the Departments
of Radiology
(C.E.E.,
P.N.O., C.M.E., B.L.M.C.,J.E.C., D.L.D.), Pulmonary and Critical Care Medicine (M.I.H.), and Surgery (R.M.B.), University of Minnesota Hospital, Box 292, 420 Delaware St SE, Minneapolis, MN 55455. Received May 27, 1992; revision requested June 26; revision received July 20; accepted July 27. Address reprint requests to
C.E.E. C RSNA,
1992
or semirecumbent lateral radiographs
position. were
obtained. Only moderate ces were included
to large pneumothorain this study. Image
sequences considered to demonstrate evidence for side-to-side pleural communication were found in the following two situations: (a) unusually unilateral pneumothorax
eral chest
tube(s)
and
Radiology
rapid
resolution of a with contralat(b) rapid side-to-side
shifting
of pneumothoraces
ing chest
tubes.
the presence were excluded
strating
tubes usually
rapid
without
All radiographs
exist-
demon-
of bilateral chest from this study. Un-
disappearance
of a pneumo-
thorax was determined qualitatively when the amount of pleural air that had apparently been resorbed was much greater than
expected
interval shifting
in less
than
between images or resolution of
12 hours.
The
demonstrating
pleural
air was
recorded.
RESULTS A sequence of images-all of which were bedside radiographs-documenting shifting or rapidly resolving pneumothoraces was found in eight of the 25 patients. Chest tubes were absent in two cases. Unilateral chest tubes (two right-sided, four left-sided) were in place in six patients. The position of the single chest tubes was anterosuperior in all patients. Two unilateral chest tubes were present in three patients. In these three patients, the second tube had been placed anteriorly at the right lung base in the first
patient
and
anteromedially
in the
second; in the third patient, the additional tube paralleled the first and coursed toward the apex (Table). The pneumothoraces that qualified for this study were of moderate to large size so that detection on supine chest radiographs was possible and unusually large displacements of air could be documented. The pneumothorax was large enough in seven of the eight patients to fulfill the criteria for diagnosis in two regions (Table). The distribution of the pneumothoraces was typical for the supine position (4,5),
with
anteromedial
air
collections
being more prevalent than subpulmonary, apicolateral, and posteromedial collections (Table). Marked, radiographically documented, rapid shifts of air in the pleural space occurred in both directions. This phenomenon was most common in the immediate postoperative pe715
b.
a.
Figure
1.
Radiographs
colateral
obtained
in 37-year-old
(arrows)
are seen.
pneumothorax
nod, with tion being
man
5 days
(b) Complete
after
heart-lung
reexpansion
transplantation.
of the right
lung
(a) Left
occurred
chest
within
5/2
was
found
on
the
15th
The interval for of pneumothoraces in one patient and
other. The most
stances
dramatic
in which
who
originally
pneumothoraces. plete
radiographic
hours,
bilateral
time
ranging
from
tube
and the anterior adhesions have
5
4 to 61/2 hours
of several
of
suction.
seemingly
heart-lung
surprising
disappearances,
trans-
appearances,
and after
shifting
This
the
transplantation,
no surgical attempt is made to recreate the normal anterior barriers between the right and left hemithoraces, recognized radiographically as the anterior junction line and the inferior and superior recesses (3). These pleural reflections are formed by four lay-
heart-lung
trans-
study
true
ing,
incidence
since
mothoraces lateral chest side-to-side exists
probably
we
does
not
of pleural
excluded
reflect
air shift-
smaller
pneu-
and all patients with bitubes. It is likely that pleural communication
in all postoperative
heart-lung
hemithoraces remains (Fig 3), at least until postoperative scar tissue bridges
transplant recipients. Since the mcidence of pneumothoraces after the immediate postoperative period is low, we could not determine at what point in time, if ever, anterior scar tissue and adhesions completely divide the thorax into two separate
the
gap
spaces.
716
#{149}
ers
of pleura
Open pleural
and
mediastinal
communication spaces of the
between
Radiology
5#{189}
AL,AM
5Y2
AL,PM AM,SP
6/2
4 4
AM,SP AM,SP
4
...
...
6/4
AM,SP
...
14
posteromedial,
=
the
fat
(6).
between the left and right
anterior
medias-
has
A case been
of shifting reported
in the left lateral while undergoing graphic
(CT)
R
=
right an-
pleural effusion in a patient placed
decubitus position a computed tomo-
examination
phenomenon
is also
postoperative
of pneu-
plantation.
DISCUSSION heart-lung
thoracic wall. been reported
plant recipients (7,8). Our results demonstrate that the continuity of the pleural spaces accounts for the
of the
about
tinum Pleural
mothoraces
During
AL
PM
at autopsy
to com-
resolution
averaged
contralateral
(h)
in-
effectively be chest tube in six pa-
had
The
pneumothorax
Time for Complete Shift (h)
a pneumothorax
found on one side could treated with a contralateral (Figs 1, 2). This occurred tients
rapid was 1/ 6#{188} hours in
were
Complete Resolution
AL,AM
this
cases
to
Time
of
postoperative day. The latest observed pneumothorax was seen on the 42nd postoperative day. A substantial decrease in the size of a pneumothorax associated with the appearance of a new or marked increase in size of an existing contralateral pneumothorax was seen in two
the
and moderately large right apiwithout a second chest tube.
the mean time after opera9 days. The latest observed
occurrence
patients. shifting hours
tube hours
(9).
unique
heart-lung
This
to the transplant
recipient. of fluid
The only possible passage from one side to the other is
also
the
via
anterior
route.
In the
postoperative supine or semirecumbent patient, this shifting of pleural effusions is a rare occurrence that can be produced only by extensive ma-
neuvenng of the patient. Although we observed instances of shifting pleural fluid in our review, radiographic quantification of pleural effusions on supine radiographs may be less reliable than the detection of shifting pneumothoraces. Substantial
changes effusions ted (10).
In the
in the may
distribution therefore
treatment
of pleural go undetec-
of heart-lung December
1992
b.
a. Figure 2. Radiographs with a moderately large hours
without
additional
obtained in 6-year-old boy 6 days after heart-lung transplantation. right apicolateral pneumothorax (arrows) are seen. (b) Complete chest
tubes.
The
patient
underwent
extubation
at this
(a) Left chest reexpansion
tube of the
and right
left anteromedial lung
chest
occurred
within
time.
I
Figure
3.
CT scan
obtained
at cardiac
man.
Bilateral
pneumothora-
in 46-year-old
ces are present. Free communication tween the pleural spaces is evident
(a) Mediastinal windows
4.
5.
6.
a.
b. 7.
the
open
ral spaces
recipients,
knowledge
communication
of the
is important.
The
of pleu-
surgeon
needs to be aware, for example, that a new asymptomatic pneumothorax on the side opposite an indwelling chest tube does not automatically warrant placement of new chest tubes if the existing
device
is properly
and functioning. tions may require tubes. For the communication spaces of both
Volume
185
Loculated additional
radiologist, between hemithoraces
Number
#{149}
3
being shifting
not necessarily new pleural
the open the pleural requires
signify air leak.
for
bidirectional which do
evidence
8.
of a
#{149}
References 1.
positioned
air collecchest
constantly alert pneumothoraces,
2.
3.
Reitz BA, Wallwork
JL, Hunt
SA, et al.
Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease. N EnglJ Med 1982; 306:557561. Bolman RM III, Shumway SJ, Estrin JA, Hertz MI. Lung and heart-lung transplantation: evolution and new applications. Ann Surg 1991; 214:456-470. Baumgartner WA, Reitz BA, Achuff SC. Heart and heart-lung transplantation. Philadelphia: Saunders, 1990.
9.
10.
window
display,
level be-
(arrows). (b) lung
display.
Tocino IM. Pneumothorax in the supine patient: radiographic anatomy. RadioGraphics 1985; 5:557-586. Tocino IM, Miller MH, Fairfax WR. Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR 1985; 144:901-905.
Proto tenor
AV, Simmons JD, Zylak CJ. The anjunction anatomy. Crit Rev Diagn
Imaging 1983; 20:111-120. Scott JP, Higenbottam TW,
al.
transplant
tube 5/2
Risk factors
Sharples
for obliterative
L, et
bronchioli-
tis in heart-lung transplant recipients. Transplantation 1991; 51:813-817. Couraud L, Baudet E, Velly JF, Roques X, Martigne C, Gallon P. Lung and heartlung transplantation for end-stage lung disease: The Bordeaux Lung and HeartLung Transplant Group. Eur J Cardiothorac Surg 1990; 4:318-322. Sacks EM, Unger EC. Heart-lung transplantation: postoperative pleural effusion (letter). AJR 1990; 154:1344-1345. WoodringJH. Recognition of pleural effusion on supine radiographs: how much fluid is required? AJR 1984; 142:59-64.
Radiology
#{149} 717
MD #{149}Paul N. Olson, MD MD #{149}James E. Crowe, MD #{149} R. Morton Bolman III, MD
Claudia Deborah
Heart-lung transplantation involves the total replacement of two of the most complex organs of the thoracic cavity. This procedure is usually reserved for patients with failure of both systems, such as in primary pulmonary hypertension or chronic Eisenmenger physiology. The en bloc replacement of the heart and lungs leaves an open communication between the two sides of the thorax that may allow air or fluid to shift from one side to the other. To evaluate this possibility,
the
authors
reviewed
the
chest radiographs of 25 heart-lung transplant recipients for signs of rapidly changing pneumothoraces that could not be explained by the conventional dynamics of pleural physiology. A series of postoperative radiographs showed unusual shifting or apparently rapid disappearance of pneumothoraces in eight patients. Decompression of a pneumothorax with a contralateral chest tube was a phenomenon observed in six of these patients. Index
terms:
Lung, 60.73
transplantation,
Radiology
Heart,
1992;
transplantation, 51.459 60.459 #{149} Pneumothorax,
185:715-717
M. Engeler, MD L Day, MD
#{149}
#{149}
Shifting Pneumothorax Transplantation’
after
H
EART-LUNG
procedure for patients with hypertension
Heart-Lung
transplantation is a principally reserved primary pulmonary
or pulmonary
hyper-
tension
secondary to congenital heart disease (1,2). The en bloc replacement of both the heart and lungs through a median sternotomy radically alters intrathoracic anatomy. Anastomoses of the trachea, great vessels, and right atrium are created, while the native esophagus and portions of the pencardium are left in place to provide support for the transplanted organs and preserve the vagus and recurrent laryngeal nerves (3). By leaving the esophagus
and
most
of the
trachea
with the adjacent adventitial tissue in place, there continues to be a partial division of the pleural cavities by the posterior and middle mediastinum. Anteriorly,
however,
open
communi-
cation between the two sides is established. We reviewed the radiographs of 25 heart-lung transplant recipients with particular attention to the dynamics of pneumothoraces and found patterns unique to this population that can be explained only by the open communication between the pleural spaces. MATERIALS The
chest
AND radiographs
METHODS of 25 consecutive
heart-lung transplant recipients years (mean, 32 years; standard
aged 6-54 deviation,
14 years) were reviewed to identify pneumothoraces. The vast majority of these postoperative images were bedside an-
teroposterior radiographs obtained at 80 kVp and a target-film distance of 40 inches (100 cm). The patients were imaged in either a supine No cross-table I
From the Departments
of Radiology
(C.E.E.,
P.N.O., C.M.E., B.L.M.C.,J.E.C., D.L.D.), Pulmonary and Critical Care Medicine (M.I.H.), and Surgery (R.M.B.), University of Minnesota Hospital, Box 292, 420 Delaware St SE, Minneapolis, MN 55455. Received May 27, 1992; revision requested June 26; revision received July 20; accepted July 27. Address reprint requests to
C.E.E. C RSNA,
1992
or semirecumbent lateral radiographs
position. were
obtained. Only moderate ces were included
to large pneumothorain this study. Image
sequences considered to demonstrate evidence for side-to-side pleural communication were found in the following two situations: (a) unusually unilateral pneumothorax
eral chest
tube(s)
and
Radiology
rapid
resolution of a with contralat(b) rapid side-to-side
shifting
of pneumothoraces
ing chest
tubes.
the presence were excluded
strating
tubes usually
rapid
without
All radiographs
exist-
demon-
of bilateral chest from this study. Un-
disappearance
of a pneumo-
thorax was determined qualitatively when the amount of pleural air that had apparently been resorbed was much greater than
expected
interval shifting
in less
than
between images or resolution of
12 hours.
The
demonstrating
pleural
air was
recorded.
RESULTS A sequence of images-all of which were bedside radiographs-documenting shifting or rapidly resolving pneumothoraces was found in eight of the 25 patients. Chest tubes were absent in two cases. Unilateral chest tubes (two right-sided, four left-sided) were in place in six patients. The position of the single chest tubes was anterosuperior in all patients. Two unilateral chest tubes were present in three patients. In these three patients, the second tube had been placed anteriorly at the right lung base in the first
patient
and
anteromedially
in the
second; in the third patient, the additional tube paralleled the first and coursed toward the apex (Table). The pneumothoraces that qualified for this study were of moderate to large size so that detection on supine chest radiographs was possible and unusually large displacements of air could be documented. The pneumothorax was large enough in seven of the eight patients to fulfill the criteria for diagnosis in two regions (Table). The distribution of the pneumothoraces was typical for the supine position (4,5),
with
anteromedial
air
collections
being more prevalent than subpulmonary, apicolateral, and posteromedial collections (Table). Marked, radiographically documented, rapid shifts of air in the pleural space occurred in both directions. This phenomenon was most common in the immediate postoperative pe715
b.
a.
Figure
1.
Radiographs
colateral
obtained
in 37-year-old
(arrows)
are seen.
pneumothorax
nod, with tion being
man
5 days
(b) Complete
after
heart-lung
reexpansion
transplantation.
of the right
lung
(a) Left
occurred
chest
within
5/2
was
found
on
the
15th
The interval for of pneumothoraces in one patient and
other. The most
stances
dramatic
in which
who
originally
pneumothoraces. plete
radiographic
hours,
bilateral
time
ranging
from
tube
and the anterior adhesions have
5
4 to 61/2 hours
of several
of
suction.
seemingly
heart-lung
surprising
disappearances,
trans-
appearances,
and after
shifting
This
the
transplantation,
no surgical attempt is made to recreate the normal anterior barriers between the right and left hemithoraces, recognized radiographically as the anterior junction line and the inferior and superior recesses (3). These pleural reflections are formed by four lay-
heart-lung
trans-
study
true
ing,
incidence
since
mothoraces lateral chest side-to-side exists
probably
we
does
not
of pleural
excluded
reflect
air shift-
smaller
pneu-
and all patients with bitubes. It is likely that pleural communication
in all postoperative
heart-lung
hemithoraces remains (Fig 3), at least until postoperative scar tissue bridges
transplant recipients. Since the mcidence of pneumothoraces after the immediate postoperative period is low, we could not determine at what point in time, if ever, anterior scar tissue and adhesions completely divide the thorax into two separate
the
gap
spaces.
716
#{149}
ers
of pleura
Open pleural
and
mediastinal
communication spaces of the
between
Radiology
5#{189}
AL,AM
5Y2
AL,PM AM,SP
6/2
4 4
AM,SP AM,SP
4
...
...
6/4
AM,SP
...
14
posteromedial,
=
the
fat
(6).
between the left and right
anterior
medias-
has
A case been
of shifting reported
in the left lateral while undergoing graphic
(CT)
R
=
right an-
pleural effusion in a patient placed
decubitus position a computed tomo-
examination
phenomenon
is also
postoperative
of pneu-
plantation.
DISCUSSION heart-lung
thoracic wall. been reported
plant recipients (7,8). Our results demonstrate that the continuity of the pleural spaces accounts for the
of the
about
tinum Pleural
mothoraces
During
AL
PM
at autopsy
to com-
resolution
averaged
contralateral
(h)
in-
effectively be chest tube in six pa-
had
The
pneumothorax
Time for Complete Shift (h)
a pneumothorax
found on one side could treated with a contralateral (Figs 1, 2). This occurred tients
rapid was 1/ 6#{188} hours in
were
Complete Resolution
AL,AM
this
cases
to
Time
of
postoperative day. The latest observed pneumothorax was seen on the 42nd postoperative day. A substantial decrease in the size of a pneumothorax associated with the appearance of a new or marked increase in size of an existing contralateral pneumothorax was seen in two
the
and moderately large right apiwithout a second chest tube.
the mean time after opera9 days. The latest observed
occurrence
patients. shifting hours
tube hours
(9).
unique
heart-lung
This
to the transplant
recipient. of fluid
The only possible passage from one side to the other is
also
the
via
anterior
route.
In the
postoperative supine or semirecumbent patient, this shifting of pleural effusions is a rare occurrence that can be produced only by extensive ma-
neuvenng of the patient. Although we observed instances of shifting pleural fluid in our review, radiographic quantification of pleural effusions on supine radiographs may be less reliable than the detection of shifting pneumothoraces. Substantial
changes effusions ted (10).
In the
in the may
distribution therefore
treatment
of pleural go undetec-
of heart-lung December
1992
b.
a. Figure 2. Radiographs with a moderately large hours
without
additional
obtained in 6-year-old boy 6 days after heart-lung transplantation. right apicolateral pneumothorax (arrows) are seen. (b) Complete chest
tubes.
The
patient
underwent
extubation
at this
(a) Left chest reexpansion
tube of the
and right
left anteromedial lung
chest
occurred
within
time.
I
Figure
3.
CT scan
obtained
at cardiac
man.
Bilateral
pneumothora-
in 46-year-old
ces are present. Free communication tween the pleural spaces is evident
(a) Mediastinal windows
4.
5.
6.
a.
b. 7.
the
open
ral spaces
recipients,
knowledge
communication
of the
is important.
The
of pleu-
surgeon
needs to be aware, for example, that a new asymptomatic pneumothorax on the side opposite an indwelling chest tube does not automatically warrant placement of new chest tubes if the existing
device
is properly
and functioning. tions may require tubes. For the communication spaces of both
Volume
185
Loculated additional
radiologist, between hemithoraces
Number
#{149}
3
being shifting
not necessarily new pleural
the open the pleural requires
signify air leak.
for
bidirectional which do
evidence
8.
of a
#{149}
References 1.
positioned
air collecchest
constantly alert pneumothoraces,
2.
3.
Reitz BA, Wallwork
JL, Hunt
SA, et al.
Heart-lung transplantation: successful therapy for patients with pulmonary vascular disease. N EnglJ Med 1982; 306:557561. Bolman RM III, Shumway SJ, Estrin JA, Hertz MI. Lung and heart-lung transplantation: evolution and new applications. Ann Surg 1991; 214:456-470. Baumgartner WA, Reitz BA, Achuff SC. Heart and heart-lung transplantation. Philadelphia: Saunders, 1990.
9.
10.
window
display,
level be-
(arrows). (b) lung
display.
Tocino IM. Pneumothorax in the supine patient: radiographic anatomy. RadioGraphics 1985; 5:557-586. Tocino IM, Miller MH, Fairfax WR. Distribution of pneumothorax in the supine and semirecumbent critically ill adult. AJR 1985; 144:901-905.
Proto tenor
AV, Simmons JD, Zylak CJ. The anjunction anatomy. Crit Rev Diagn
Imaging 1983; 20:111-120. Scott JP, Higenbottam TW,
al.
transplant
tube 5/2
Risk factors
Sharples
for obliterative
L, et
bronchioli-
tis in heart-lung transplant recipients. Transplantation 1991; 51:813-817. Couraud L, Baudet E, Velly JF, Roques X, Martigne C, Gallon P. Lung and heartlung transplantation for end-stage lung disease: The Bordeaux Lung and HeartLung Transplant Group. Eur J Cardiothorac Surg 1990; 4:318-322. Sacks EM, Unger EC. Heart-lung transplantation: postoperative pleural effusion (letter). AJR 1990; 154:1344-1345. WoodringJH. Recognition of pleural effusion on supine radiographs: how much fluid is required? AJR 1984; 142:59-64.
Radiology
#{149} 717
