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Pleural complications in lung transplantation

Lorriana Leard, MD
Section Editor
Elbert P Trulock, MD
Deputy Editor
Helen Hollingsworth, MD


Pleural disease is an important consideration in patients undergoing lung transplantation. For some patients being considered as candidates for lung transplant, pre-existing pleural disease may increase their risk of postoperative pleural complications. Even in the absence of pre-existing pleural disease, pleural complications following lung transplantation are common due to disruption of the pleural space at the time of transplant surgery, complications related to rejection of the allograft, and the immunosuppression regimen post-transplant.

The risk factors for pleural complications and the postoperative pleural complications that develop in patients undergoing lung transplantation will be reviewed here. Issues regarding the selection of candidates for lung transplantation and the physiologic changes that occur following lung transplantation are discussed separately. (See "Lung transplantation: General guidelines for recipient selection" and "Physiologic changes following lung transplantation".)


Lung transplant recipients with pre-existing pleural space abnormalities and donor-recipient size mismatch are at increased risk of pleural complications at the time of lung transplant surgery.  

Pre-existing pleural space abnormalities — Pre-existing pleural disease may increase the risk of intraoperative and postoperative complications following lung transplantation, but is not necessarily considered a contraindication to lung transplantation [1]. At the time of lung transplantation, a recipient's native lung must be completely removed from that thoracic cavity. Pleural adhesions may make it much more difficult to remove the native lung, increasing operative time and placing the patient at increased risk for intraoperative bleeding.

Pre-existing pleural space abnormalities may be secondary to many different etiologies, such as prior pneumothorax, hemothorax, chylothorax, empyema, or pleural adhesions. Underlying suppurative lung disease and prior surgical lung biopsy can lead to pleural adhesions. In addition, treatment of these pleural space diseases by the placement of chest tubes, pleurodesis, or pleurectomy may further contribute to pleural space abnormalities that may complicate lung transplantation.

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Literature review current through: Oct 2017. | This topic last updated: May 26, 2016.
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  1. Weill D, Benden C, Corris PA, et al. A consensus document for the selection of lung transplant candidates: 2014--an update from the Pulmonary Transplantation Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant 2015; 34:1.
  2. Herridge MS, de Hoyos AL, Chaparro C, et al. Pleural complications in lung transplant recipients. J Thorac Cardiovasc Surg 1995; 110:22.
  3. Benden C, Rea F, Behr J, et al. Lung transplantation for lymphangioleiomyomatosis: the European experience. J Heart Lung Transplant 2009; 28:1.
  4. Reynaud-Gaubert M, Mornex JF, Mal H, et al. Lung transplantation for lymphangioleiomyomatosis: the French experience. Transplantation 2008; 86:515.
  5. Flume PA, Strange C, Ye X, et al. Pneumothorax in cystic fibrosis. Chest 2005; 128:720.
  6. Dusmet M, Winton TL, Kesten S, Maurer J. Previous intrapleural procedures do not adversely affect lung transplantation. J Heart Lung Transplant 1996; 15:249.
  7. Curtis HJ, Bourke SJ, Dark JH, Corris PA. Lung transplantation outcome in cystic fibrosis patients with previous pneumothorax. J Heart Lung Transplant 2005; 24:865.
  8. Madden BP, Hodson ME, Yacoub MH, et al. Heart-lung transplantation for cystic fibrosis. BMJ 1992; 304:835.
  9. Shitrit D, Fink G, Sahar G, et al. Successful lung transplantation following lung volume reduction surgery. Thorac Cardiovasc Surg 2003; 51:274.
  10. Keshava HB, Mason DP, Murthy SC, et al. Pediatric donor lungs for adult transplant recipients: feasibility and outcomes. Thorac Cardiovasc Surg 2012; 60:275.
  11. Backhus LM, Sievers EM, Schenkel FA, et al. Pleural space problems after living lobar transplantation. J Heart Lung Transplant 2005; 24:2086.
  12. Siegleman SS, Sinha SB, Veith FJ. Pulmonary reimplantation response. Ann Surg 1973; 177:30.
  13. Ferrer J, Roldan J, Roman A, et al. Acute and chronic pleural complications in lung transplantation. J Heart Lung Transplant 2003; 22:1217.
  14. Arndt A, Boffa DJ. Pleural space complications associated with lung transplantation. Thorac Surg Clin 2015; 25:87.
  15. Raju S, Heath BJ, Warren ET, Hardy JD. Single- and double-lung transplantation. Problems and possible solutions. Ann Surg 1990; 211:681.
  16. Judson MA, Sahn SA, Hahn AB. Origin of pleural cells after lung transplantation: from donor or recipient? Chest 1997; 112:426.
  17. Judson MA, Handy JR, Sahn SA. Pleural effusions following lung transplantation. Time course, characteristics, and clinical implications. Chest 1996; 109:1190.
  18. Judson MA, Handy JR, Sahn SA. Pleural effusion from acute lung rejection. Chest 1997; 111:1128.
  19. Gotway MB, Dawn SK, Sellami D, et al. Acute rejection following lung transplantation: limitations in accuracy of thin-section CT for diagnosis. Radiology 2001; 221:207.
  20. Vakil N, Su JW, Mason DP, et al. Allograft entrapment after lung transplantation: a simple solution using a pleurocutaneous catheter. Thorac Cardiovasc Surg 2010; 58:299.
  21. Chhajed PN, Bubendorf L, Hirsch H, et al. Mesothelioma after lung transplantation. Thorax 2006; 61:916.
  22. Diez Martinez P, Pakkal M, Prenovault J, et al. Postoperative imaging after lung transplantation. Clin Imaging 2013; 37:617.
  23. Siegel MJ, Lee EY, Sweet SC, Hildebolt C. CT of posttransplantation lymphoproliferative disorder in pediatric recipients of lung allograft. AJR Am J Roentgenol 2003; 181:1125.
  24. Liguori C, Schulman LL, Weslow RG, et al. Late pulmonary venous complications after lung transplantation. J Am Soc Echocardiogr 1997; 10:763.
  25. Griffith BP, Zenati M. The pulmonary donor. Clin Chest Med 1990; 11:217.
  26. Eberlein M, Arnaoutakis GJ, Yarmus L, et al. The effect of lung size mismatch on complications and resource utilization after bilateral lung transplantation. J Heart Lung Transplant 2012; 31:492.
  27. Kozower BD, Meyers BF, Ciccone AM, et al. Potential for detrimental hyperinflation after lung transplantation with application of negative pleural pressure to undersized lung grafts. J Thorac Cardiovasc Surg 2003; 125:430.
  28. Trulock EP. Management of lung transplant rejection. Chest 1993; 103:1566.
  29. Trulock EP, Ettinger NA, Brunt EM, et al. The role of transbronchial lung biopsy in the treatment of lung transplant recipients. An analysis of 200 consecutive procedures. Chest 1992; 102:1049.
  30. Greene CL, Reemtsen B, Polimenakos A, et al. Role of clinically indicated transbronchial lung biopsies in the management of pediatric post-lung transplant patients. Ann Thorac Surg 2008; 86:198.
  31. McWilliams TJ, Williams TJ, Whitford HM, Snell GI. Surveillance bronchoscopy in lung transplant recipients: risk versus benefit. J Heart Lung Transplant 2008; 27:1203.
  32. Spaggiari L, Rusca M, Carbognani P, et al. Contralateral spontaneous pneumothorax after single lung transplantation for fibrosis. Acta Biomed Ateneo Parmense 1993; 64:29.
  33. Venuta F, Rendina EA, de Giacomo T, et al. Thoracoscopic treatment of recurrent contralateral pneumothorax after single lung transplantation. J Heart Lung Transplant 1994; 13:555.
  34. Waller DA, Conacher ID, Dark JH. Videothoracoscopic pleurectomy after contralateral single-lung transplantation. Ann Thorac Surg 1994; 57:1021.
  35. Wahidi MM, Willner DA, Snyder LD, et al. Diagnosis and outcome of early pleural space infection following lung transplantation. Chest 2009; 135:484.
  36. Shields RK, Clancy CJ, Minces LR, et al. Epidemiology and outcomes of deep surgical site infections following lung transplantation. Am J Transplant 2013; 13:2137.
  37. Mills NL, Boyd AD, Gheranpong C. The significance of bronchial circulation in lung transplantation. J Thorac Cardiovasc Surg 1970; 60:866.
  38. Shaver CM, Castilho JL, Cohen DN, et al. Fatal Scopulariopsis infection in a lung transplant recipient: lessons of organ procurement. Am J Transplant 2014; 14:2893.
  39. Hayes D Jr, Diaz-Guzman E, Hoopes CW. Rhodococcus equi infection after lung transplantation. Respir Care 2011; 56:1605.
  40. Boehler A, Speich R, Russi EW, Weder W. Lung transplantation for lymphangioleiomyomatosis. N Engl J Med 1996; 335:1275.
  41. Penketh AR, Higenbottam TW, Hutter J, et al. Clinical experience in the management of pulmonary opportunist infection and rejection in recipients of heart-lung transplants. Thorax 1988; 43:762.
  42. Ryu JH, Doerr CH, Fisher SD, et al. Chylothorax in lymphangioleiomyomatosis. Chest 2003; 123:623.
  43. Fremont RD, Milstone AP, Light RW, Ninan M. Chylothoraces after lung transplantation for lymphangioleiomyomatosis: review of the literature and utilization of a pleurovenous shunt. J Heart Lung Transplant 2007; 26:953.
  44. Ohara T, Oto T, Miyoshi K, et al. Sirolimus ameliorated post lung transplant chylothorax in lymphangioleiomyomatosis. Ann Thorac Surg 2008; 86:e7.
  45. Sugimoto R, Nakao A, Yamane M, et al. Sirolimus amelioration of clinical symptoms of recurrent lymphangioleiomyomatosis after living-donor lobar lung transplantation. J Heart Lung Transplant 2008; 27:921.
  46. Kanou T, Nakagiri T, Minami M, et al. Peritoneovenous shunt for chylous ascites after lung transplantation for lymphangioleiomyomatosis. Transplant Proc 2012; 44:1390.
  47. Yousem SA, Burke CM, Billingham ME. Pathologic pulmonary alterations in long-term human heart-lung transplantation. Hum Pathol 1985; 16:911.
  48. Haverich A, Dawkins KD, Baldwin JC, et al. Long-term cardiac and pulmonary histology in primates following combined heart and lung transplantation. Transplantation 1985; 39:356.
  49. Verleden SE, Ruttens D, Vandermeulen E, et al. Restrictive chronic lung allograft dysfunction: Where are we now? J Heart Lung Transplant 2015; 34:625.
  50. Ofek E, Sato M, Saito T, et al. Restrictive allograft syndrome post lung transplantation is characterized by pleuroparenchymal fibroelastosis. Mod Pathol 2013; 26:350.
  51. Engeler CE, Olson PN, Engeler CM, et al. Shifting pneumothorax after heart-lung transplantation. Radiology 1992; 185:715.
  52. Wittich GR, Kusnick CA, Starnes VA, Lucas DE. Communication between the two pleural cavities after major cardiothoracic surgery: relevance to percutaneous intervention. Radiology 1992; 184:461.
  53. Paranjpe DV, Wittich GR, Hamid LW, Bergin CJ. Frequency and management of pneumothoraces in heart-lung transplant recipients. Radiology 1994; 190:255.
  54. Sacks EM, Unger EC. Heart-lung transplantation: postoperative pleural effusion. AJR Am J Roentgenol 1990; 154:1344.
  55. Ng YL, Paul N, Patsios D, et al. Imaging of lung transplantation: review. AJR Am J Roentgenol 2009; 192:S1.