Technique and Controversies of Pediatric Lung Transplantation

Lung transplantation in pediatric patients, from infants to adolescents, involves unique clinical and management issues. All the portions of this delicate process are a challenge. The major limitation to pediatric lung transplantation is the rarity of size-matched cadaveric donor lungs of acceptable quality. The optimization of allocation policies, downsizing and bipartinioning of cadaveric donor lungs, and living donation have improved the access to lung transplantation for pediatric candidates. Extended criteria donors, donation after circulatory death, and ex-vivo lung perfusion can contribute to safely expand the organ pool. Bilateral sequential transplantation is the most common technique for pediatric lung transplantation. The more complex en bloc lung transplantation, especially in the smallest recipients, and the likewise demanding bronchial artery revascularization technique, have recently gained interest in order to reduce airway complications. Pediatric lung re-transplantation, although technically demanding, has shown remarkably good results in selected patients. The use of extracorporeal membrane oxygenation (ECMO) as a bridge-to-transplant in pediatric patients is still a controversial matter. Venoarterial ECMO or cardiopulmonary bypass have both been used successfully for intraoperative extracorporeal support. The clinical outcomes have improved over time and currently, in experienced hands, lung transplantation in pediatric patients of all age groups appears to provide similar results compared to adult lung transplantation.