a 62-year - old man ( height , 158 cm ; weight , 63 kg ; blood type , a ) with a history of smoking ( 35 pack - years ) was registered for lung transplantation with a diagnosis of idiopathic pulmonary fibrosis .
the patient s status was new york heart association functional class iii , and the patient had lost 5 kg over a 6-month period .
room air arterial blood gas analysis showed an oxygen partial pressure of 59.1 mm hg , partial pressure of co2 was 39.2 mm hg , and oxygen saturation was 89.4% .
a pulmonary function test revealed a forced vital capacity of 1.60 l ( 47% of predicted ) and a forced expiratory volume in 1 second of 1.52 l ( 61% of predicted ) . computed tomography revealed subpleural and peribronchovascular reticulation with macrocystic honeycombing in both lungs ( fig .
1 ) . coronary angiography revealed total occlusion at the mid - right coronary artery , and left ventricular ejection fraction of 61% ( fig .
2 ) . therefore , we concluded that the patient needed bilateral lung transplantation and also required coronary artery bypass surgery .
two months after being listed for a lung transplant , a suitable donor lung was matched .
the donor was a 49-year - old man ( height , 170 cm ; weight , 52.1 kg ; blood type , a ) who had an intracranial hemorrhage .
the total lung capacity of the recipient was 4.755 l , while that of the donor was 6.078 l , which was a donor - to - recipient size match of 127.8% .
prior to the lung transplant , the patient s vital signs were stable ( heart rate of 98 beats per minute and arterial blood pressure of 115/75 mm hg ) .
after the induction of general anesthesia , a pulmonary arterial catheter was placed via the left internal jugular vein , and the pulmonary arterial pressures were initially 4050/2030 mm hg .
the operation was performed as follows : under general anesthesia , a clamshell incision was made and the hila were prepared for lung transplantation . at the same time , the left greater saphenous vein was harvested for coronary artery bypass . following a minimal dissection in both hila , the saphenous vein was anastomosed to the ascending aorta using a heartstring device ( heartstring proximal seal system , guidant , in , usa ) , and the right coronary artery was bypassed to the right posterior descending artery via the off - pump technique using a tissue stabilizer .
a venous cannula was placed in the right femoral vein and an arterial cannula was placed into the right femoral artery .
each side started with bronchial anastomosis , followed by pulmonary venous anastomosis with a side - biting clamp on the pulmonary veins , and ended with pulmonary artery anastomosis .
ecmo was discontinued and decannulated before the patient was transferred from the operating room to the intensive care unit .
the total ecmo time was 320 minutes , total operation time was 461 minutes , and total anesthesia time was 565 minutes .
on postoperative day ( pod ) 3 , heart rate ranged from 85 to 90 beats per minute , arterial blood pressure ranged from 110 to 120 mm hg/70 to 80 mm hg , and pulmonary arterial pressure ranged from 35 to 37 mm hg/15 to 17 mm hg .
the patient required a tracheostomy for recovery due to respiratory failure after tracheal extubation on pod 8 .
the patient was transferred to the general ward on pod 16 , the tracheostomy tube was removed on pod 30 , and discharged on pod 37 in good condition .
the presence of comorbidities in patients has previously been considered to be a relative contraindication for lung transplantation . in particular ,
the first lung transplantation was performed at severance hospital in july 1996 , and since then , the number of lung transplantations has increased . at the same time , the inclusion criteria for lung transplantation have been expanded to include patients with higher surgical risk . whether patients with significant coronary artery disease are suitable candidates for lung transplantation is unclear .
some reports have described the long - term survival outcomes following lung transplantation in cases with revascularized coronary arteries .
one report demonstrated that the long - term survival following lung transplantation in patients with significant coronary artery disease was influenced by whether they received coronary revascularization prior to lung transplantation .
however , some studies have reported successful results in the management of patients who simultaneously received coronary artery revascularization and lung transplantation .
patel et al .   reported successful simultaneous coronary artery bypass and lung transplantation in a small number of carefully selected patients .
however , patients with multivessel disease or left ventricular dysfunction were not considered suitable candidates for lung transplantation . in this case ,
combined bilateral lung transplantation and coronary artery bypass grafting was performed in a patient who had a single vessel disease with normal left ventricular function . in terms of surgical technique and devices ,
the off - pump technique was possible for the coronary bypass grafting through a clamshell incision . using a saphenous vein graft
might have enabled coronary artery grafting to be performed without much difficulty through the usual clamshell incision .
in korea at present , almost 50% of coronary graft bypass surgeries are performed via off - pump technique .
our previous study indicated that off - pump coronary artery bypass surgeries improved myocardial functioning and favored early and mid - term outcomes in the high - risk group . both single and bilateral lung transplantation
procedure selection should be carefully considering the following factors : recipient , donor , and transplant center .
although single lung transplantation reduced waitlist time and mortality , the long - term outcomes of bilateral lung transplantation were slightly superior .
the benefits of bilateral lung transplantation include better lung compliance , imp roved lung volume , and a voidance of native lung disorders . for these reasons , we performed a bilateral lung transplantation .
our center has used both ecmo and conventional cardiopulmonary bypass in the lung transplantation procedure . however , ecmo has been considered the method of choice since 2013 because of its advantages , such as less coagulopathy , less systemic inflammatory response , short postoperative recovery time , and less pulmonary and renal complications . with
off - pump coronary artery bypass graft surgery , we could use ecmo for cardiopulmonary support instead of conventional cardiopulmonary bypass . to the best of our knowledge ,
this case was the first successful bilateral lung transplantation combined with off - pump coronary artery bypass graft surgery in korea , and we reported a satisfactory outcome following surgery .
 coronary artery disease has historically been a contraindication to lung transplantation . 
 we report a successful combined bilateral lung transplantation and off - pump coronary artery bypass in a 62-year - old man . 
 the patient had a progressive decline in lung function due to idiopathic pulmonary fibrosis and a history of severe occlusive coronary artery disease . 