19. Thoracic Organ Procurement- Clinical Scenarios

Rebecca Phillip, MD, Rajasekhar Malyala, MD, and Suresh Keshavamurthy, MD

Concept

Heart procurement procedure
Lung procurement procedure
Donor criteria for heart procurement and lung procurement
Management of complications during procurement

PART ONE – Heart procurement

Chief complaint

“Patient recipient is a 65-year-old gentleman with end-stage ischemic dilated cardiomyopathy, who had undergone three-vessel coronary artery bypass grafting ten years prior, suffered a myocardial infarction earlier this year, and since that event has had chronic decompensated heart failure. He has been sustained on 0.25 mcg/kg/min of milrinone infusion and was readmitted for volume overload.”

Criteria for viable donor graft

Donor 50-60 years of age, or younger (donors younger than 16 years of age are not generally used for adult recipients)
Absence of the following:

Prolonged cardiac arrest
Prolonged severe hypotension
Hemodynamic stability without high dose inotropic support (<20 ug/kg/min of dopamine at the time of procurement)
Severe chest trauma with evidence or concern for cardiac injury
Pre-existing cardiac disease or vascular disease (coronary artery disease, hypertension, diabetes mellitus, cardiomyopathy, history of sudden cardiac death in first degree relative, cardiac channelopathies, mitochondrial diseases, peripheral arterial disease)
Extracerebral malignancy and glioblastoma
Septicemia
Positive serology for HIV, Hepatitis B, Hepatitis C (although Hepatitis C positive serology may be accepted in higher acuity situations)
Intracardiac drug injection or extensive history of smoking, alcohol use, and illicit drug use (cocaine or intravenous administration)

Donor history and physical

“The donor is a 38-year-old woman who was found at home by a friend, unresponsive, after a suspected drug overdose. EMS arrived and found the patient to be in PEA arrest. CPR was initiated and continued for 48 minutes, with subsequent return of spontaneous circulation. Norepinephrine and epinephrine were given to maintain blood pressure. Patient was areflexive on arrival to hospital, subarachnoid hemorrhage was suspected, and the patient was placed on hypothermia protocol and cooled to 36 degrees for 24 hours. The patient remained areflexive and was declared brain dead via clinical exam, transcranial doppler, and cerebral blood flow nuclear study. The patient was confirmed as an organ donor and the family was in support.

The donor had a medical history significant for depression, hypertension, drug-related seizures, migraines, and had a fifteen-year smoking history. She had previously had two cesarean sections, an appendectomy, and cholecystectomy. She had traveled once outside of the country to Mexico.

She was 172cm tall and weighed 104kg, giving her a BMI of 35 and her blood type was A.”

Tests

Electrocardiogram
Chest radiograph
Arterial blood gases
Labs (ABO, HIV, HBV, HCV)
Pulmonary artery catheter evaluation/CVP
Echocardiogram imaging (transthoracic and transesophageal, if available)
Cardiac catheterization results(if performed)

Index scenario (additional information)

“Upon arrival to the donor medical facility you introduce yourself and your team to the operating room staff as well as the other procurement teams present, which include a lung procurement team. You request to review the electrocardiogram, echocardiography, and catheterization imaging of the donor patient. Evaluate the morphology of the aortic, mitral and tricuspid valves and any valvular abnormalities; the dimensions of the left ventricle and interventricular septum (septal width larger than 1.5cm would be concerning and may warrant declining the heart). You confirm no obstructive coronary artery lesions. You confirm with the anesthesiologist the donor hemodynamics, inotropic and pressor infusion rates, and the most recent arterial blood gas. You request to see the donor history and physical documents, with results from any recent labs or cultures, including the certification of brain death documents from two sources. You confirm the donor and recipient blood typing and compatibility from two sources. You verify and sign that you have reviewed all the above items and that you are there to procure the heart. You report to your home recipient team that there are no discrepancies or abnormalities with the donor organ thus far. You confirm all of the correct equipment is available by reviewing items with the host OR staff as well as the organ procurement organization staff. Make sure to request and keep available internal defibrillator paddles in case these are needed during manipulation of the heart while procurement is underway.

Operative steps

Evaluation of Donor Heart

Access is gained through a median sternotomy, performed in the standard fashion.
A pericardial well is created with three silk stay sutures on the surgeon’s side and three on the assistant’s side. These can be clamped all three together on each side with a single hemostat, allowing for easy access to the pleura by simply transferring the hemostat across the field, and tenting the pericardium away from the pleura.
The heart and great vessels are examined for any anatomic abnormalities or traumatic injuries. The heart is evaluated for any signs of atherosclerotic coronary artery disease. It is important to palpate the left main coronary to the left of the main pulmonary artery, the left anterior descending artery, and the right coronary artery. This is done gently by using the pulp of the finger.
Palpable thrills are assessed, and ventricular contractile function is visually examined. It should be noted if the right atrium is turgid, pink, or dark blue.
The anatomy of systemic and pulmonary venous drainage is confirmed to rule out any abnormal variants.
Next, the pleura is entered bluntly on each side, without cautery, to avoid any risk of burn injury to the lung parenchyma. This can be done by the lung team.
The lung team will then perform visual inspection and palpation of both lungs and recruitment of any atelectatic segments.
The results of the initial donor organ exam, including donor hemodynamics and inotropic/pressor requirements, as well as the anticipated cross clamp time is then communicated to the recipient team.

Donor Heart Dissection

The aorta is separated from the main pulmonary artery and from the right pulmonary artery. This is to facilitate adequate cross clamp application. A wet umbilical tape is passed around the aorta and secured with a hemostat.
The superior vena cava is separated from the right pulmonary artery. The superior vena cava is dissected free to the level of the innominate vein.
A heavy silk ligature is passed on a right-angle clamp around the superior vena cava cephalad to the azygos vein and fixed with a Rummel and hemostat.
A second heavy silk ligature is passed around the azygos vein. Care must be taken not to damage the upper lobe branch of the right pulmonary artery that lies near the azygos vein.
The azygos vein can then be ligated but it does not need to be divided, as this may risk injury to this vessel and subsequent hemorrhage.
The inferior vena cava is looped with a heavy silk tie, fixed to a hemostat. If a liver procurement team is present, the level of division should be agreed upon at this time.
The posterior pericardium between the superior vena cava and the aorta, and cephalad to the right pulmonary artery, can be incised in order to allow palpation and gentle dissection of the trachea above the carina. This will facilitate tracheal access during subsequent lung resection. Care must be taken not to dislodge the endotracheal tube. In a heart that is irritable or tenuous, this step should be omitted to avoid causing arrhythmias.
A 4-0 polypropylene horizontal mattress suture is placed in the anterior middle portion of the ascending aorta, leaving enough room distally for cross clamp placement, and fixed with a Rummel and hemostat for future cannula placement.
A second 4-0 polypropylene purse-string suture is placed at the distal main pulmonary artery, near or at the bifurcation of the main pulmonary artery (this should be 1-2 cm from the pulmonary valve to allow for enough pulmonary artery cuff during cardiac implantation).

Donor Heart Preservation

At this time the heart procurement team will ensure that all donor organ dissection is complete with the accompanying procurement teams.
Heparin (30,000 units) is administered via a central venous line. Several minutes should elapse prior to placement of cannulas.
The plegia lines are flushed and de-aired.
The cardioplegia (standard cannula) and pulmoplegia (6.5mm metal tip high flow) cannulas are placed, each rummel is tightened, and infusion tubing is connected to the respective cannulas.
The lung team will administer a bolus of prostaglandin E1 into the main pulmonary artery adjacent to the pulmoplegia cannula.
A partial occluding clamp is placed on the left atrial appendage, well away from the base, to avoid tearing the tissue or injuring the circumflex coronary artery. A one-centimeter incision is made in the tip of the appendage above the level of the clamp.
The left atrial appendage clamp can remain in place until just prior to aortic cross clamp application.
The superior vena cava is ligated by tying the silk ligature or cinching the rummel tightly.
The inferior vena cava is then vented by hemitransection.
The left atrium is vented via the tip of the left atrial appendage by removing the clamp that was previously placed.
The left atrial appendage is the preferred left atrial venting incision when there is a lung procurement team working simultaneously; however, there are several other methods of venting the left atrium which may be better options if only the heart is being procured, such as venting the left atrium via the interatrial groove. A sucker can be placed through this incision into the left heart to facilitate emptying if needed.
Confirm ligation of the superior vena cava, partial transection of the inferior vena cava, and removal of the clamp from the left atrial appendage.
Confirm adequate decompression of the left ventricle.
Apply the aortic cross-clamp. This should be placed cephalad to the cardioplegia catheter, fully around the aorta, but not encompassing the pulmonary artery which lies beneath.
Start the infusion of cardioplegia solution such that the root pressure is 60-80mmHg; some surgeons prefer to run it by gravity whereas others recommend transducing the root pressure to accurately measure this. The key is to have a firm aorta below the clamp and a soft and decompressed LV.
Ice saline slush is applied to the heart for topical cooling.
A volume of 2 liters of cardioplegia solution is administered to the heart (University of Wisconsin/Celsior/HTK [histidine-tryptophan-ketoglutarate]/Del Nido as per our center’s preference). An additional 1 liter of cardioplegia solution can be started in order to continue cardioplegia administration while awaiting the completion of the pulmoplegia solution. This will keep the ascending aorta pressurized and prevent any pulmoplegia solution from entering the coronary arteries. This is also performed if the myocardium appears to be thick and additionally cardioplegia is deemed necessary.
Confirm rapid arrest of the heart by cessation of any contraction or electrical activity.

Donor Heart Excision

The inferior vena cava is completely transected, taking care not to injure the right inferior pulmonary vein.
The superior vena cava and azygous vein are transected below the silk ligature.
The aorta is then transected at the base of the innominate artery. The aorta can be dissected more distally and divided after the left carotid artery if more length of aortic tissue is required for implantation (in the case of a recipient with an LVAD where the outflow graft is inserted high onto the aorta, if the recipient has an aneurysmal aorta, or in some recipients with congenital defects). Avoid injury to the pulmonary artery at the attachment of the ligamentum arteriosum.
The main pulmonary artery is divided just proximal to the bifurcation, at the pulmoplegia cannulation site taking care to retain the bifurcation of the PA for the lung team.
The heart is then lifted, and an incision is made in the posterior left atrium, midway between both pulmonary veins, toward the base of the left atrial appendage, taking care to stay halfway between the left inferior pulmonary vein and coronary sinus.
A 1 cm cuff of tissue is kept on the left atrium to ensure adequate margin for lung implantation.
The heart is further elevated, and the rest of the left atrial excision is completed from inside the left atrium. All four pulmonary vein orifices should be visualized with adequate cuff margins retained on both the heart and lung blocks.

Donor Heart Transport

The heart is removed from the field and submerged in a sterile plastic bag or transport container with cold preservation solution. No ice is placed directly in the container.
The heart is inspected for any undetected pathology, valvular abnormalities, and a patent foramen ovale. If present, a patent foramen ovale is sutured closed.
Any iatrogenic injuries are promptly communicated to the implant surgeon.
The initial sterile bag or container is placed in a second sterile bag and this is filled with sterile ice slush to cover the heart.
The package is then placed in a third sterile bag and covered with sterile ice slush. This is then labeled and placed in an ice chest for transport.
Any donor pericardium or lymph tissue are placed in the ice chest as well.
Pertinent documents such as electrocardiogram, echocardiogram report, or cardiac catheterization reports are secured in or on the ice chest. The ice chest is closed securely for transport.
The recipient heart team is notified that the procurement has been successful. Any further abnormalities are reported. An estimated time of donor arrival is communicated.

Alternative Practices

Venting of the heart

The left atrial appendage can be incised to vent the left heart. This is often an attractive option as it allows great visualization of the drainage and it does not require manipulation of the heart. It is easily visualized even if the pericardial well is filled with blood from drainage and ice slush. However, left atrial appendage tissue is very thin and when venting at this site care must be taken not to tear the appendage down to its base which would risk injury to the circumflex coronary artery, whether through manipulation or by using a rigid vascular clamp. In addition, access through the appendage may not provide adequate drainage and an additional vent site may be required at a point in procurement where it is difficult to access the pulmonary veins or the interatrial groove. Furthermore, the left atrial appendage incision must be repaired/oversewn prior to implantation of the donor graft. This is the only form of venting that is performed when doing a combined heart-lung en bloc.
The interatrial (Sondergaard’s or Waterston’s) groove can be used for venting as well (towards the dome of the left atrium). This method has the advantage of not impacting the left atrial appendage, with no need for later repair. This approach is effective whether or not a lung team is present, although it may require confirmation of the atrial cuff by both teams prior to making the venting incision. It also allows for the venting incision to be extended for completion of the left atrial cuff during excision. This can be done from the patient’s right on the surgeon’s side without lifting the apex of the heart. Venting through the groove will not risk dynamic occlusion of the incision from the heart itself, as one may encounter when venting through the posterior left atrial wall. However, this site requires some dissection of interatrial groove before cross clamp and more manipulation of the heart, carrying the risk of hemodynamic compromise or atrial fibrillation.
The posterior left atrial wall between the pulmonary veins and the coronary sinus can be incised to vent the left heart. This approach also does not necessitate later appendage repair. A left atrial wall approach should be avoided if there is concomitant lung procurement. In addition, drainage may be difficult after the heart is released, since the heart may obstruct adequate drainage. If poor drainage does occur, a suction cannula may be placed into the incision. However, this will require lifting the heart again during cardioplegia infusion, which should be avoided if possible since it may cause aortic valve insufficiency and interrupt administration of cardioplegia.
An incision into the right superior pulmonary vein may be used to vent the left heart. This can be done from the patient’s right side (surgeon’s side). This approach may work well when the heart alone is being procured but should not be used if the lungs are also being procured.
Venting the heart into the right pleural space may be performed if the lungs are not being procured. The right pleural space may be entered and during excision the heart can be exsanguinated into the right chest, allowing an emptier pericardium and improved visualization during excision.

Sternal incision

An alternative to the classic single line sternal incision is a Y-shaped incision that allows the surgeon to begin more inferiorly to the sternal notch so as to leave the upper chest and neck free of scar. This may be beneficial for the donor’s eventual viewing and funeral arrangements and should be performed if specially requested.

Azygous vein dissection

The azygos vein does not need to by be encircled during initial dissection and can be later encircled and ligated during excision. This will minimize the chance of tearing this structure and causing hemorrhage during initial dissection or injuring the upper lobe branch of the right pulmonary artery which lies in close proximity.

Excision in isolated heart transplant

Pulmonary vein transection of each of the pulmonary veins at the level of the pericardium is preferable.
Pulmonary artery transection at the right and left pulmonary arteries is preferable.

Donation after cardiac death (DCD)

DCD procurements are donations of organs from a donor after cessation of all cardiopulmonary function. This may be a patient who has suffered devastating and irreversible injury, who is near death and in whom further treatment is futile, but who does not meet formal brain death criteria.
The procurement will occur at a time the family has decided to withdraw care. When life sustaining support is withdrawn, support is withdrawn, asystole is pronounced, death is declared, then the organs are immediately procured in the operating room.
- Withdrawal of life-sustaining support is planned and performed at a time to facilitate procurement of organs.
- After circulation has ceased for a period of several minutes (2-5 depending on local and institutional policies), death is declared.
- The donor can be declared in the operating room or can be taken rapidly to the operating room, prepped and draped, and the procurement commences.
The time from withdrawal of life-sustaining support to cardioplegia administration should be less than 30 minutes for donor heart grafts.
DCD procurement can most easily be performed when the donor and recipient are in a common location, or alternatively through the use of extracorporeal circulatory support devices.

Potential questions/alternative scenarios

Dysrhythmias during procurement

“You are harvesting a heart from an in-hospital donor patient, an ideal situation! This will allow for ease of communication between yourself and the recipient team, optimized timing for both procedures, and minimal ischemic time. As you begin the dissection of the donor heart the atria begin to fibrillate. You stop dissecting but the arrhythmia does not resolve. The ventricular rate is 142 and the blood pressure begins to fall, systolic blood pressure reaches 80. The anesthesia team asks if you would like to treat this with medication. However, you would prefer if the donor heart did not have medication on board during implantation. You ask for the defibrillator paddles and deliver a synchronized shock which restores normal sinus rhythm.”

Sinus tachycardia is the most common arrhythmia reported in during heart procurement and may ensue when there are elevated levels of catecholamines present, the donor is hypotensive, or there is significant anemia. This may also be caused by the use of vasoactive medications. In a young and healthy donor heart some degree of tachycardia may be well tolerated. If tachycardia is compromising heart function or causing hypotension, then it should be addressed. The tachycardia may be treated with short acting beta blocker such as esmolol or labetalol. The donor should be monitored closely as beta blockers can cause hypotension or bronchospasm.
Atrial fibrillation occurs in donor patients and will need to be addressed during procurement. It may be due to physiological stress, especially in a young healthy donor, but may also portend concurrent heart disease and warrants a careful evaluation for any pre-existing heart disease that was missed on initial donor evaluation. Atrial fibrillation may cause decreased cardiac output due to decreased diastolic filling time and loss of atrial kick, as well as clot formation and risk of embolization. Medications such as amiodarone, diltiazem, or esmolol may be administered in order to achieve cardioversion or rate control; however, ideally the donor would not be receiving these medications during implantation. Long-acting beta blockers and digoxin should not be used. If the ventricular response rate is greater than 130 bpm, and this is causing hypotension, then synchronous electrical cardioversion is indicated and is the preferred option.
Ventricular fibrillation can also occur during donor heart procurement and this may be due to physiological stress on the donor or excess manipulation of the heart. Prompt defibrillation with internal defibrillator paddles should be performed.

Left ventricular distention after cross-clamp application

“The heart is vented, and the aortic cross clamp is applied. Cardioplegia and pulmoplegia solution begins to run. Ice slush is placed on the heart and lungs. However, the left ventricle begins to distend. You manually decompress while confirming drainage from the left atrial appendage incision is running clear. However, the ventricle begins to distend again. What do you do?”

The procuring surgeon must be constantly watching and evaluating for left ventricular distention after the heart is vented, arrested, and the cross-clamp is applied. If the heart does not have adequate drainage, and the left ventricle begins to distend, then the surgeon must act expeditiously to remedy this situation. The left sided vent site should be checked for drainage and a sucker should be placed in the left heart or adjusted. If this does not decompress the left ventricle then the cardioplegia should be stopped, the cross-clamp released, the left ventricle manually decompressed. The cross-clamp can subsequently be reapplied and, if necessary, an additional vent site can be made (in the left atrial appendage or interatrial groove).

PART TWO – Bilateral lung procurement (lungs divided on back table for single lung)

Chief complaint

“Patient recipient is a 28-year-old woman with cystic fibrosis and chronic respiratory failure, a history of bronchopulmonary aspergillosis, with home oxygen requirements of 6L NC, who was admitted after suffering seizures at home and having worsening respiratory distress.”

Criteria for viable donor graft

Donor 55 years of age or younger
ABO compatibility
Smoking history less than 20 pack years
Arterial PO2 >300 mmHg on FiO2 of 100% and PEEP 5cm H2O
Normal chest radiograph
Sputum free of bacteria, fungus, significant numbers of white blood cells, on gram stain and fungal stain
Bronchoscopy showing absence of purulent secretions or signs of aspiration
Absence of the following:

Severe chest trauma with evidence or concern for lung injury
Sepsis or aspiration
Previous cardiopulmonary surgery
Prolonged cardiac arrest
Prolonged severe hypotension
Hemodynamic stability without high dose inotropic support (<15 ug/kg/min of dopamine for 24 hours)
Extra-cerebral malignancy and glioblastoma (excluding basal cell carcinoma or squamous cell carcinoma of the skin)
Positive serology for HIV, Hepatitis B, Hepatitis C (although Hepatitis C positive serology may be accepted in higher acuity situations)

Donor history and physical

“The donor is a 48-year-old woman who was found by her family, twenty minutes after she went to bed, with a noose around her neck and unresponsive. Her family performed ten minutes of CPR before EMS arrived. Initial rhythm was recorded as asystole. Return of spontaneous circulation was obtained after another 6 minutes of CPR by the emergency response team. On arrival to the ED the patient was hypotensive and unresponsive and was intubated for airway protection. The patient progressed to brain death and was pronounced by clinical exam and apnea test. The patient was confirmed as an organ donor and the family was in support.

The donor had a medical history significant for depression and menorrhagia from uterine fibroids. She had no history of smoking, alcohol use, or illicit drug use.

She was 163cm tall and weighed 153kg, giving her a BMI of 26 and her blood type was A.”

Tests

Chest radiograph and CT imaging if available (required if >20 pack-year smoking history, donor age greater than 55 years, or concern for pneumonia)
Arterial blood gases
Serologic screening: HIV, HepB sAg, hepatitis serology, HSV, CMV, RPR
Ventilator: Peak inspiratory pressure less than 30 cmH2O

Index scenario (additional information)

“Upon arrival to the donor medical facility you introduce yourself and your team to the operating room staff as well as the other procurement teams present, which happen to include a heart procurement team. You request to review the chest radiographs and any available computed tomography imaging. You confirm with the anesthesiologist the donor hemodynamics, inotropic/pressor requirements, and the most recent arterial blood gas. You request to see the donor history and physical documents, with results from any recent labs or cultures, including the certification of brain death documents from two sources. You confirm the donor and recipient blood typing and compatibility from two sources. You verify and sign that you have reviewed all the above items and that you are there to procure the lungs. You report to your home recipient team that there are no discrepancies or abnormalities with the donor organ thus far.”

Operative steps

Evaluation of Donor Lungs

Access is gained through a standard median sternotomy.
A bronchoscopy should be performed while the cardiac team continues opening the chest. This can be done simultaneously to opening, if the lung procurement surgeon is assisting in opening, and there is an additional member of the lung procurement team.
A pericardial well is created with three silk stay sutures on the surgeon’s side and three on the assistant side. These can be clamped all three together on each side with a single hemostat, allowing for easy access to the pleura by simply transferring the hemostat across the field, and tenting the pericardium away from the pleura.
The pleura is then entered bluntly on each side without cautery to avoid any risk of burn injury to the lung parenchyma.
The lungs are then visually inspected and palpated. The recruitment of any atelectatic segments is performed by gentle massage. The lungs should not be displaced from the pleural cavity or hyperinflated while attempting to resolve atelectatic segments as this risks injuring the lungs causing hemodynamic compromise.
The anesthesia team is asked to inflate the lungs and sustain 30cm H2O pressure while time is given to confirm adequate inflation.
With a small gauge needle and syringe, blood samples are taken from each of the pulmonary veins, being careful not to manipulate the heart too during this process. This final set of blood gases are sent for analysis. The ventilator settings while these samples are drawn must be FiO2 100% and PEEP 5.
The results of the initial donor organ exam, including donor hemodynamics and inotropic/pressor requirements, arterial blood gases, results of the bronchoscopic exam, as well as the anticipated cross clamp time, is now communicated to the recipient team.

Donor Lung Dissection

The heart procurement team will dissect free the great vessels
A 4-0 polypropylene horizontal mattress suture is placed at the distal main pulmonary artery for the pulmoplegia catheter, near or at the bifurcation of the main pulmonary artery (this should be 1-2 cm from the pulmonary valve to allow for enough pulmonary artery cuff during cardiac implantation).
The tip of the pulmoplegia cannula should be pointed back towards the pulmonary valve (not towards the bifurcation of the artery). This will ensure even distribution of pulmoplegia solution to each lung.
The posterior pericardium between the superior vena cava and the aorta, and superior to the right pulmonary artery, can be incised in order to allow palpation and gentle dissection of the trachea above the carina. Care must be taken not to dislodge the endotracheal tube. Importantly, the posterior membranous trachea must be handled with care as this tissue is fragile and prone to injury.
The anterior, lateral, and medial portions of the trachea can be dissected to facilitate easier subsequent resection.
The fascia between the trachea and the esophagus should be left untouched. This does not need to be dissected at this time and doing so may risk injury to the esophagus or dislodgement of the endotracheal tube.

Donor Lung Preservation

At this time the heart procurement team will ensure that all donor organ dissection is complete with the accompanying procurement teams.
Heparin dose of 30,000 units is administered via a central venous line. Several minutes should elapse prior to placement of cannulas.
During this brief period a final recruitment of atelectatic lung segments can be performed by the anesthesia team.
The cardioplegia (standard cannula) and pulmoplegia (6.5mm metal tip high flow) cannulas are placed, each Rummel is tightened, and infusion tubing is connected to the respective cannulas.
The lung team will administer a bolus of prostaglandin E1 into the main pulmonary artery adjacent to the pulmoplegia cannula to initiate lung preservation, this should be done several minutes before the cross-clamp is applied, allowing time for it to circulate. The donor will often become hypotensive after administration of PGE1, and thus all participating teams should be notified prior to its administration.
Ventilation should be with an FiO2 of 40% and a PEEP of 3-5 cm H2O.
The cardiac team will begin steps to decompress the heart and apply the aortic cross-clamp. The SVC is ligated, the left atrium is vented, and the IVC is partially transected. The aortic cross-clamp is then applied.
The cardioplegia solution is now infused. The pulmoplegia solution should be initiated after the heart arrests so as not to cause any distention of the heart via pulmonary venous return.
The pulmoplegia bag is hung from a high IV hook, ideally 1 meter above the patient, and is infused via gravity pressure. The pulmoplegia, Perfadex (Vitrolife Inc., Englewood, CO) is infused from two large bags (2.8 liters each) until one liter remains in the final bag. During infusion the lungs should be ventilated at half of the normal tidal volumes.
The anesthesia team is asked to decrease the ventilatory pressure to allow for saline ice slush to be placed in both pleural spaces.
The surgeon may visualize through the left atrial appendage incision that pulmoplegia solution is returning from all pulmonary veins. This confirms equal perfusion of both lungs. Additionally, both lungs should be visually inspected and blanching of the tissue should be noted to confirm adequate pulmoplegia administration.
Suction should be utilized to prevent leakage of pulmoplegia through the mitral valve causing distention of the left ventricle. The solution returning through the pulmonary veins should eventually be confirmed to be clear in appearance.
Continued cardioplegia until the completion of pulmoplegia will maintain aortic root distention and prevent leakage of any amount of pulmoplegia into the coronary arteries.

Donor Lung Excision

The heart excision is begun. The left atrial incision is made in the posterior left atrial wall, parallel to the atrioventricular groove, toward the base of the left atrial appendage. Taking care to stay halfway between the left inferior pulmonary vein and coronary sinus. The left atrial incision is then extended toward the inferior edge of the inferior vena cava on the right.
A cuff of tissue, one centimeter from the atrioventricular groove, is kept on the left atrium to ensure adequate margin for cardiac implantation.
The heart is further elevated, and the rest of the left atrial excision is completed from inside the left atrium. All four pulmonary vein orifices should be visualized with adequate cuff margins retained on both the heart and lung blocks. The heart excision is completed, and the heart is removed from the chest.
To begin the lung excision, the inferior pulmonary ligaments are carefully divided on both sides. Retracting the lung gently anteriorly will allow for better visualization of the ligament and lower risk of damaging lung parenchyma.
The pericardium is then divided on both sides, taking care to stay above the phrenic nerve, as this will avoid injury to hilar structures.
On the right side, the azygous vein must be divided in order to free the right lung. On the left side, the lung is freed up to the aortic arch taking care to avoid injury to the left main bronchus.
To separate the lungs from the esophagus, it is helpful if the NG tube remains in place, to allow easier handling of the esophagus.
The pericardium is freed from the diaphragm and reflected superiorly, along with the left atrial cuff and the hilar structures, to access the plane along the anterior surface of the esophagus. The lung bloc is then sharply dissected off of the esophagus, maintaining a plane close to the esophagus, and working from inferior to superior. Note: some institutions will harvest the esophagus and aorta with the lung bloc to facilitate bronchial artery revascularization or as per institutional protocol.
The inner curvature of the aorta may be left attached to the right pulmonary artery to prevent any damage to the pulmonary artery in trying to dissect it free. In addition, some aortic tissue may remain in the area of the ligamentum arteriosum so as not to injure the pulmonary artery.
The lungs should then be freed from any remaining aortic tissue and arch vessels as well as any other mediastinal tissue.
Recruitment before tracheal stapling should be at 60% tidal volume (this will prevent barotrauma while transporting the lungs at higher altitudes).
The endotracheal tube is pulled back, high into the trachea, to facilitate stapling.
The trachea is divided two finger breadths above the carina, or as high as possible. This is performed with two TIA 30 staple firings in succession (Auto Suture Company Division, United States Surgical Corporation, Norwalk, Connecticut). After the first staple line is fired on the distal trachea with the lungs remaining partially inflated, the endotracheal tube is removed completely, and the proximal staple line is applied. Then the trachea is transected between these staple lines with a fresh scalpel.
The lung block is dissected free from any remaining mediastinal fascia. The double lung block is removed from the chest cavity and brought to the back table. Here it is placed in a sterile plastic bag filled with Perfadex solution and no ice.
At this time, the remainder of the pulmoplegia solution is given in a retrograde fashion at the back table. A deflated Foley catheter tip may be fixed to the pulmoplegia tubing so that it may be gently positioned in the pulmonary veins. The total remaining liter of Perfadex solution is given in four approximate 250mL infusions directly into each of the four pulmonary veins. The return of clear solution from the pulmonary arteries should be confirmed. While this solution is given, gentle massage of the corresponding lobe can be performed, to flush any clot in the pulmonary arteries. The burden of clot in each lung may be reported to the implant team.
The lung block is preferably divided so that right and left lungs are stored separately. This allows for the second lung to remain cold and protected during implantation of the first lung.
The left atrial cuff and the pulmonary artery cuff are divided in the midline.
The airway is then isolated, taking care not to disrupt the vascular supply to the trachea and bronchi, and the left main stem bronchus (the longer of the two bronchi) is dissected free.
The left main stem bronchus is then divided by placing two TIA 30 staple lines, in succession, and transecting the bronchus between the staple lines. This should be done without compromising the carina but still preserving as much of the left mainstem bronchus as possible.
The lungs are inspected for any missed pathology, surgical damage, and adequate cuff margins. The separated lungs are each placed in their own sterile plastic bags filled with Perfadex solution and no ice. After final examination of the lungs the sterile bag is sealed.
The initial sterile bag or container is placed in a second sterile bag and this is filled with sterile ice slush to cover the lungs. The package is then placed in a third sterile bag and covered with sterile ice slush. This is then labeled and placed in an ice chest for transport. Any donor lymph tissue is placed in the ice chest as well. Pertinent documents, reports, or any radiographs are secured in or on the ice chest. The ice chest is closed securely for transport.
The recipient lung team is notified that the procurement has been successful. Any further abnormalities are reported. An estimated time of donor arrival is communicated.

Alternative Practices

Ex vivo lung perfusion (EVLP)

Donor lungs are placed in a sterile plastic device composed of a ventilator, pump, and filters. The pulmonary artery and left atria are cannulated, and the trachea is intubated. The circuit deoxygenates and filters the perfusate and the ventilator provides oxygen. This allows for further assessment and monitoring of the lungs as well as protection and optimization.

Donation after cardiac death (DCD)

Donation of organs from a donor after cessation of all cardiopulmonary function. This may be a patient who has suffered devastating and irreversible injury, who is near death and in whom further treatment is futile, but who does not meet formal brain death criteria.
The procurement will occur at a time the family has decided to withdraw care. When life sustaining support is withdrawn, support is withdrawn, asystole is pronounced, death is declared, then the organs are immediately procured in the operating room.
- Withdrawal of life-sustaining support is planned and performed at a time to facilitate procurement of organs.
- After circulation has ceased for a period of several minutes (2-5 depending on local and institutional policies), death is declared.
- The donor can be declared in the operating room or can be taken rapidly to the operating room, prepped and draped, and the procurement commences.
The time from withdrawal of life-sustaining support to cardioplegia administration should be less than 30 minutes for donor lung grafts.
DCD procurement can most easily be performed when the donor and recipient are in a common location, or alternatively using extracorporeal circulatory support devices.

Potential questions/alternative scenarios

Blood gases are poor upon arrival to procurement site

“On arrival to the donor site you review the latest arterial blood gas sent by the anesthesia team. They report PaO2 being 102 on FiO2 of 40% and PEEP 5.”

You are concerned about this discrepancy, and although the endotracheal tube appears to be correctly positioned above the carina on the last chest radiograph, you want to double check. You decide to perform a bronchoscopy at this time and in doing so note that the endotracheal tube has been inadvertently advanced into the right mainstem bronchus. You ask the anesthesia team to pull the endotracheal tube back. You also have them increase their FiO2 to 100% with PEEP 5 and you recheck arterial blood gases. This sample comes back with PaO2 of 318 and you are reassured that you are able to proceed with procurement.

“The cross-clamp is applied, and you start infusing the pulmoplegia solution. You inspect the lungs and note that the left lung is blanching much more than the right lung. You suspect that the right lung may not be receiving adequate perfusate. You confirm that the pulmoplegia is flowing well and so you suspect it may be due to the cannula position.”

Unequal distribution of pulmoplegia can compromise one lung. A pulmoplegia cannula placed too close to the bifurcation of the pulmonary artery, will usually favor the left main pulmonary artery, and the right lung will get less perfusate. The solution is to continually turn the cannula to the right and left side, thus manually perfusing both evenly. Or, to direct the tip of the cannula back towards the pulmonary valve (valve must be competent) and this will allow equal distribution of the pulmoplegia down the right and left pulmonary arteries.
You should also add additional ice slush to each lung to further protect the organs.

Pneumonia suspected in donor lungs

“You arrive to the procurement facility and review the donor patient’s history and physical documents. The chest radiograph from the previous day does not show any obvious consolidation. On bronchoscopy you find thick and purulent secretions in the right lower lobe that are re-pooling immediately after suctioning.”

In the case of procuring both donor lungs for a double lung implantation, signs of an infectious process can be discovered and subsequently managed after implantation, and thus the donor organ can often still be accepted if the arterial blood gases and further inspection of the lung tissue is not concerning. In the single lung recipient or a tenuous recipient this should not be accepted. If after the pleura is opened and the lungs are inspected, there is poor compliance or obvious consolidation, then the organ should not be accepted.

Adhesions found upon lung inspection

“While performing inspection and palpation of the lungs you note that the left lung has many pleural adhesions to the chest wall.”

When there are minimal adhesions, and they can be easily released without traumatizing the lung during excision, then the donor organ can be accepted. These should be released by staying close to the chest wall, even extrapleural where the adhesions are dense, so that the lung parenchyma is not injured. If the adhesions are extensive then the procurement should be aborted. The procuring surgeon may contact the implanting team to discuss this decision-making process.

Anatomical variants

“When performing bronchoscopy, you are concerned that the anatomy of the right mainstem bronchus is not as expected. You are able to visualize the right upper lobe bronchus prior to the level of the carina.”

You should initially ensure the correct placement of the endotracheal tube. You must orient the bronchoscope to the membranous trachea and confirm the location of the carina. If you visualize the right upper lobe from the trachea, prior to reaching the carina, you must suspect a pig bronchus anatomical variant. You should stop and contact the implanting team at your home institution, since this makes implantation difficult. The bronchial anastomosis is one of the most vulnerable aspects of the implantation operation and can have many complications. A pig bronchus would require more complexity during implantation and may include patching or reimplantation techniques.
When performing the inspection of the lungs and subsequent excision, any anomalous systemic or pulmonary venous drainage should be noted as this will also create difficulty during implantation.

Unexpected findings

“As you are inspecting the lungs there is an abdominal team proceeding with their procurement operation. An unsuspected tumor is found in the tail of the pancreas.”

This was biopsied and found to be a neuroendocrine tumor. Although these have an indolent course, and good prognosis when resected, the lungs are not accepted.
Consider these expanded donor criteria:
- Age >60 years
- History of malignancy in certain specific cases can be accepted, such as thyroid tumor papillary carcinoma or low grade astrocytoma, if this has been treated and the patient has no evidence of recurrence on imaging.
- Greater than 20 pack-year smoking history
- Previous cardiothoracic surgery is no longer a contraindication for accepting donor lungs
- Serology positive for treatable infections, such as Hepatitis C
- Donation after death from drowning or hanging. This may cause significant pulmonary edema in the donor organ. If the arterial blood gases prior to procurement are adequate, these donor lungs may still be used, with no increase in complications for the recipient.

PART THREE – Summary

Procurement Checklist

Before Skin Incision

Consent for Donation
Blood type for donor and recipient, match, two accounts
Brain death certification, two accounts
Serologies
Supplies

Lung

Chest radiograph and CT imaging
Bronchoscopy
Arterial blood gases
Ventilator settings of FiO2 100% and PEEP 5
Limit IV fluids

Heart

Electrocardiogram
Echocardiogram
Cardiac catheterization
Inotropic and pressor requirements

Before Harvesting

Lungs

Inspect and palpate for any nodules
Selective arterial blood gases drawn from pulmonary veins
Evaluation for atelectasis, recoil, and lung compliance
Inspection for contusions, consolidations, edema

Heart

Inspect for any pericardial effusion
Evaluate contractility of the right ventricle and left ventricle
Inspect and palpate for any coronary calcification
Inspect and palpate for any aortic calcification

Pearls/pitfalls

Be collaborative, cooperative, and respectful to all teams present during a procurement.

Determine whether a more cosmetic Y-shaped incision is requested by family, funeral home, or donor organization prior to making incision.

Determine the agreed upon locations for venting incisions and tissue cuffs among all procurement teams.

Take care to identify any structural abnormalities of the heart.

The azygous vein can be tied off, without being fully divided until the time of excision, to prevent any risk of hemorrhage or injury to the first branch of the right pulmonary artery.

Do not forget to heparinize.

Decide whether the left atrium will be vented through the interatrial groove or the left atrial appendage, or another site. There are risks and benefits to each method.

Take care not to back-wall the aorta with the cardioplegia cannula.

Do not apply the aortic cross-clamp before venting the left heart and ensuring decompression.

Confirm adequate cardioplegia administration by rapid cessation of contraction and pressurization of the aortic root.

Confirm adequate decompression of the left ventricle and address any signs of distention immediately by placing a sucker into the left ventricle.

Ensure adequate cuff of the left atrium for both cardiac and pulmonary procurements.

Ensure adequate cuff of IVC if there is an abdominal organ procurement and stay supradiaphragmatic when dividing this.

Do not forget to perform a bronchoscopy upon initial assessment of the lungs.

Identify any anatomic variants or structural abnormalities.

Assess pulmonary venous saturations to evaluate the lungs.

Examine the lungs within the chest, without entirely eviscerating them, so as to avoid injury or hemodynamic compromise.

Do not over-inflate the lungs when attempting to resolve atelectasis.

Do not divide the trachea and esophagus prior to excision, to avoid injury to either.

The pulmonary artery cannulation site should be approximately 1.5cm from the pulmonary valve to maintain adequate length of pulmonary cuff and the pulmoplegia cannula tip should be directed towards the pulmonary valve to ensure even perfusion of both lungs.

Confirm that both lungs blanch when pulmoplegia solution is given.

When giving retrograde pulmoplegia, confirm that there is adequate return from the ipsilateral pulmonary artery.

Suggested readings

Pasque MK. Standardizing thoracic organ procurement for transplantation. J Thorac Cardiovasc Surg. 2010;139(1):13-7.

Powner DJ, Allison TA. Cardiac dysrhythmias during donor care. Prog Transplant. 2006;16(1):74-80.

Dorent R, Gandjbakhch E, Goeminne C, et al. Assessment of potential heart donors: A statement from the French heart transplant community. Arch Cardiovasc Dis. 2018;111(2):126-139.

Baran DA, Tallaj J, Hall S. Heart Failure and Transplantation Core Competency Curriculum. Version one, updated. International Society for Heart and Lung Transplantation. May 2017.

Loor G, Shumway S, McCurry K, et al. Process Improvement in Thoracic Donor Organ Procurement: Implementation of a Donor Assessment Checklist. Ann Thorac Surg. 2016;102(6):1872-1877.

Cohn LH, Adams DH. Heart Transplantation. Lung Transplantation and Heart-Lung Transplantation. Chapters 60 and 61. Cardiac Surgery in the Adult, Fifth Edition. 2018.

Leard L, Dellegren G, Dilling D. Lung Transplantation Core Competency Curriculum. Second edition. International Society for Heart and Lung Transplantation. June 2017.

Orens JB, Boehler A, de Perrot M, et al. A review of lung transplant donor acceptability criteria. J Heart Lung Transplant. 2003;22(11):1183-200.

de Perrot M, Bonser RS, Dark J, et al. Report of the ISHLT Working Group on Primary Lung Graft Dysfunction part III: donor-related risk factors and markers. J Heart Lung Transplant. 2005;24(10):1460-7.

Shigemura N, Bhama J, Nguyen D, et al. Pitfalls in donor lung procurements: how should the procedure be taught to transplant trainees? J Thorac Cardiovasc Surg. 2009;138(2):486-90.

Tane S, Noda, K, Shigemura N. Ex Vivo Lung Perfusion: A Key Tool for Translational Science in the Lungs. Chest. 2017;151(6):1220-1228.

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