Early rejection management in a heart-lung transplant adolescent under tubeless spontaneous ventilation anesthesia: a case report.

Abstract

Background: Heart-lung transplantation is a critical intervention for pediatric end-stage cardiopulmonary diseases, including severe pulmonary hypertension. Post-transplant rejection, predominantly pulmonary, poses significant challenges. Tubeless spontaneous ventilation is an emerging anesthetic modality that improves prognosis by minimizing the risk of mechanical ventilation.

Case description: This case report details a 15-year-old male patient who met the indications for combined heart-lung transplantation due to severe pulmonary hypertension in combination with right heart failure. The patient underwent combined heart-lung transplantation under tubeless spontaneous ventilation anesthesia. On postoperative day 6, the patient was observed to have early signs of pulmonary rejection, which was confirmed by testing for non-human leukocyte antigen antibodies. A tailored immunosuppressive regimen, including mycophenolate mofetil, methylprednisolone, and tacrolimus, was initiated. The patient also received antimicrobial treatment, along with nutritional support. On postoperative day 15, chylothorax was diagnosed, which was managed through fasting and modification of antifungal therapy due to hepatic dysfunction. Furthermore, exercise rehabilitation constitutes a significant component of the treatment regimen that patients receive. A phased rehabilitation program is a structured, multifaceted approach to recovery that encompasses all aspects of the patient's hospitalization. It incorporates active and passive physical activities, postural and endurance training, respiratory muscle training, and other exercises, all meticulously designed to address the patient's specific needs and facilitate their recovery. The patient exhibited a marked recovery in clinical symptoms by day 23 and was subsequently discharged from the hospital.

Conclusions: Tubeless anesthesia has been demonstrated to expedite postoperative recovery and mitigate pulmonary complications. Early rejection detection, tailored immunosuppression, and multidisciplinary coordination were instrumental in overcoming challenges. This case underscores the potential to reduce morbidity and highlights integrative strategies for optimizing transplant outcomes in children, emphasizing personalized care and vigilant monitoring.