Commentary: Paving the way with visualization of the invisible craftsmanship.

Toyofumi F. Chen-Yoshikawa, MD, PhD (left), and Shota Nakamura, MD (right)

Lung transplantation can be performed successfully in selected patients with CF with severe asymmetric chest cavities, and bilateral transplantation can provide good long-term outcomes.

See Article page 652.

Cystic fibrosis (CF) affects a large proportion of patients undergoing lung transplantation; however, patients sometimes develop severe asymmetric chest cavities in the course of their disease. Although asymmetric chest cavities, in general, should not be considered a contraindication for lung transplantation, many transplant centers are reluctant to accept these patients because of a high perioperative risk in addition to surgical difficulty. Many patients with a long-standing chest asymmetry have limited compliance and mucus clearance can be impaired in the early postoperative period, which can lead to prolonged respiratory weaning and recurrent infections. Another main concern is the confusion regarding the surgical modality to be applied from among the 4 types described by Sinn and colleagues.

In the decision regarding surgical options, size matching with the assessment of the correct dimensions is essential. Sinn and colleagues tried to perform 3-dimensional computed tomography (3D-CT) volumetry of recipient CT scans retrospectively to better quantify the volume of both chest cavities; however, it was unfortunate that only less than half of CT scans were electronically available. Because 3D-CT volumetry might be a useful tool for living-donor lobar lung transplantation,, for patients with asymmetric chest cavities, preoperative evaluation using 3D-CT volumetry is recommended in addition to the consideration of the shape and configuration of the chest by an experienced surgeon.

In this issue of the Journal, Sinn and colleagues provided persuasive data on short- and long-term outcomes in 13 patients with CF with severe asymmetric chest cavities undergoing lung transplantation. Several reports of successful lung transplantations for patients with CF and asymmetric chest cavities were sporadically performed, but none of them provided long-term follow-up and survival data. Although the number of patients was small, this is the first report with the largest number of patients of this kind. Sinn and colleagues also showed that bilateral lung transplantation was superior to single lung transplantation in terms of short- and long-term outcomes.

One of the challenging topics is pneumonectomy, especially in cases with a shrunken and consolidated lung. Single lung transplantation is usually contraindicated in patients with CF because the remaining bronchiectatic lung inevitably endangers the graft especially in patients who are colonized with multidrug-resistant pathogens. The concept of single lung transplantation combined with a contralateral pneumonectomy was developed, and delayed pneumonectomy after single lung transplantation might be preferred because of a shorter operating time and a reduced risk of complications such as bleeding. Furthermore, a distinct subgroup of the cohort of this study was patients who had undergone pneumonectomy. Few reports on these challenging cases were found in the literature, and therefore this report would provide novel skill for single lung transplantation after a previous pneumonectomy to the lung transplant surgeons in the world.

Again, Sinn and colleagues are congratulated on their challenging spirit regarding difficult lung transplantation for patients with CF with asymmetric chest cavities. They presented excellent long-term outcomes with the superiority of bilateral lung transplantation to single lung transplantation.