Use of over-sized mature pulmonary lower lobe grafts results in superior pulmonary function

Background. Mature lobar transplantation will increase the pediatric donor organ pool; however, issues regarding size discrepancy between donor grafts and recipient lungs remain unresolved. We hypothesized that an oversized mature pulmonary lobar allograft implanted into an immature recipient would provide adequate longterm pulmonary function versus a size-matched mature lobar graft or an immature whole lung. Methods. We investigated our hypothesis in a porcine orthotopic left lung transplant model in which 19 immature animals made up one control and three recipient groups. Group I underwent sham left thoracotomy (control, n = 4). Group II received age- and size-matched immature whole left lung transplant (n = 6). Group III received mature size-matched left upper lobe transplants (n = 4). Group IV received mature over-sized left lower lobe transplants (n = 5). Twelve weeks after implantation, data were collected after the native right lung was excluded. Results. Graft weight was significantly elevated in group IV as compared with the explanted lung (72.4 ± 6.8 versus 38.3 ± 4.5 g; p = 0.003). Pulmonary artery pressure and pulmonary vascular resistance were significantly elevated in group III as compared with the over-sized mature lower lobe transplants (51.8 ± 2.2 versus 40.4 ±2.5 mm Hg [p < 0.0001] and 1,605.9 ± 117.5 versus 857.6 ± 133.6 dynes · s · cm−5 [p < 0.0005], respectively). A trend toward decreased oxygenation was identified in group II. Conclusions. Over-sized mature lobar grafts provide improved hemodynamics as compared with sizematched grafts. Mature left lower lobe grafts are superior to size-matched upper lobe grafts in this model, probably as a result of an augmented vascular bed.