Surgical Considerations in Infant Lung Transplantation

Challenges and Opportunities

John P. Costello; Horacio G. Carvajal; Aaron M. Abarbanell; Pirooz Eghtesady; Dilip S. Nath


American Journal of Transplantation. 2021;21(1):15-20. 

In This Article

Abstract and Introduction


Lung transplantation is a crucial component in the treatment of end-stage lung disease in infants. Traditionally, most lung transplants have been performed in older children and adults, resulting in a scarcity of data for infant patients. To address the challenges unique to this age group, novel strategies to provide the best preoperative, intraoperative, and postoperative care for these youngest patients are paramount. We review recent advances in bridge-to-transplantation therapy, including the use of a paracorporeal lung assist device, and differences in surgical technique, including bronchial artery revascularization, for incorporation into the overarching treatment strategy for infants undergoing lung transplantation.


Lung transplantation continues to be a valuable tool for the management of end-stage lung disease, including in infants and children. Although the utility of this therapy is well established, its use is not uniform across the full spectrum of pediatric patients. This variability is particularly noticeable when looking at utilization differences among the separate pediatric and infant patient populations.[1] In addition to variability in rates of use, the technique employed when performing these transplants has differed considerably between centers and eras. Pediatric lung transplantation and infant lung transplantation, in particular, are limited by very small numbers annually in the current era. In 2016, only six infant lung transplants and eight lung procurements from donors younger than 1 year of age were performed worldwide.[2] In addition, the underlying causes of lung failure in infants differ from those in older pediatric patients. Unlike older children, who primarily undergo transplant due to cystic fibrosis,[3] the major indications for lung transplantation in infants are surfactant protein deficiencies, congenital heart disease, and idiopathic pulmonary arterial hypertension.[3,4] Overall, survival for infants undergoing lung transplant is similar to that for older children,[1] although few data are available regarding outcomes for less common diagnoses. For instance, in the case of transplantation for pulmonary hypoplasia due to congenital diaphragmatic hernia, a single case series consisting of three patients has been published, in which only one infant survived to discharge.[5] Consequently, infants undergoing lung transplantation present unique challenges in their preoperative management and surgical approach. We sought to review the current approaches for bridging infants to lung transplantation, surgical techniques utilized, and postoperative outcomes, as well as to highlight areas for further research.