Lung transplant feasibility after lobar resection in a case of pectus excavatum and severe unilateral space loss

An optimized approach to donor-recipient size matching is essential to expand transplant opportunities and improve post-operative outcomes. A commonly used and pragmatic metric is the donor-to-recipient predicted total lung capacity ratio. However, thoracic deformities or unilateral lung parenchymal disease may significantly distort true intrathoracic volume, leading to misleading predicted total lung capacity estimates and inappropriate donor lung selection. Clinical experience has shown increased morbidity and mortality in cases of severe size mismatch. To address such discrepancies, several strategies have been described in the literature, including split-lung transplantation, lobar transplantation, and peripheral segmental resections. When these options are not feasible, temporary measures such as diaphragmatic plication, open-chest management or chest wall stenting may be used to accommodate oversized grafts until post-operative oedema resolves. We present the case of a young female with pectus excavatum and severe unilateral loss of intrathoracic space on the lung transplant waiting list. She successfully underwent lung transplant, which was made possible by ex-vivo donor lobar resection, permitting optimal size adjustment and preventing post-operative compression within the severely reduced left thoracic cavity.