Lung Retransplantation after Heart-lung Transplantation: A Case Report

Lung retransplantation after prior heart-lung transplantation is uncommon and presents significant surgical and immunologic challenges. We report the case of a 24-year-old male with a history of congenital heart disease and Eisenmenger syndrome who underwent heart-lung transplantation in January 2018. While his cardiac function remained stable postoperatively, his pulmonary function declined 2 years later due to chronic lung allograft dysfunction (CLAD), confirmed by a 17% drop in forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio, recurrent infections, and positive class II donor-specific antibodies (DSAs). Between June and September 2020, he was admitted 4 times with suspected antibody-mediated rejection and managed with oxygen therapy, bilevel positive airway pressure, and supportive care. In January 2023, he underwent bilateral lung retransplantation with no major intraoperative complications. Postoperative recovery included management of a right-sided pulmonary embolism with heparin infusion. Over the next year, he developed recurrent class II DSAs (anti-DQ8 and anti-DR5), which were treated with i.v. immunoglobulin, rituximab, plasmapheresis, and antithymocyte globulin. His most recent evaluation showed stable graft function: FEV1, 1.83 L; FVC, 2.10 L; FEV1/FVC ratio, 87%; oxygen saturation, 98%. Bronchoalveolar lavage and biopsy revealed no signs of acute rejection. This case highlights the feasibility and potential success of lung retransplantation following heart-lung transplantation in selected patients. With close monitoring, individualized immunosuppressive therapy, and multidisciplinary care, favorable long-term outcomes are achievable-even in complex post-transplantation scenarios.