Connor P. Callahan, MD, MSc,1 Jacob R. Miller, MD,2 Pirooz Eghtesady, MD, PhD2 and Dilip S. Nath, MD2
1Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
2 St. Louis Children’s Hospital, St. Louis, MO, USA
Essential Operative Steps
- Consider clinical ethics of proceeding with pediatric heart-lung transplantation
- Lines and monitoring
- General endotracheal anesthesia
- Intraoperative TEE
- Inspection of donor heart and lungs by the procurement team
- Confirmation of good quality of donor heart and lungs
- Administer induction immunosuppressives and steroids
- Start the recipient operation.
- Median Sternotomy
- Lysis of adhesions.
- Incise pericardium posterior to the phrenic nerve in longitudinal fashion bilaterally to create pleuropericardial
windows - Systemic heparinization (3-4 mg/Kg).
- Direct aortic cannulation.
- Bicaval venous cannulation.
- Establish Cardiopulmonary bypass (CPB) circuit.
- Check ACT >450.
- Initiate Cardiopulmonary bypass.
- Systemic hypothermia (cooling to 32o
C). - Recipient cardiectomy [Variation: en bloc cardiectomy and pneumonectomy]
- Start hilar dissection for recipient pneumonectomy, ideally separately.
- Control the branch pulmonary arteries with atraumatic snares
- Dissect pulmonary arteries in the pleural space and ligate distally beyond the first order bifurcation.
- Transect the pulmonary arteries.
- Divide the pulmonary veins with vascular staples.
- Avoid any bronchial contents spillage in the pleural space.
- Perform contralateral pneumonectomy in a similar fashion.
- Remove any remaining atrial and pulmonary artery tissue, with the exception of residual PA tissue on the
ligamentum arteriosum to prevent recurrent laryngeal nerve injury - Confirm the donor-recipient ABO compatibility and size matching.
- Prepare the donor heart-lung bloc.
- Perform an end-to-end tracheal anastomosis using running absorbable fine monofilament suture. [Variation:
bilateral mainstem bronchial anastomoses] - Consider wrapping airway anastomosis with available nearby viable soft tissue to separate anastomosis from
nearby vascular structures, specifically site of aortic anastomosis - Create end to end aortic anastomosis with running fine monofilament suture
- Create end to end IVC anastomosis with running fine monofilament suture
- Remove cross clamp
- Create end to end SVC anastomosis with running fine monofilament suture with heart re-perfused and beating
- Aortic root or left atrial appendage vent to deair
- Ventilate the donor lungs and perform bronchoscopy to clear the airway.
- To avoid the reperfusion injury, slowly wean from cardiopulmonary bypass
- [Note: Also avoid high FiO2, high PEEP and high airway pressures to avoid reperfusion/lung injury].
- Use Inotropes, vasopressors, prostaglandins infusion and inhaled nitric oxide as needed [Optional].
- Confirm the graft function, check the ABG and wean supplemental oxygen as tolerated.
- Administer protamine and sequentially decannulate.
- Ensure excellent hemostasis.
- Place mediastinal and bilateral pleural chest tubes.
- Standard sternal wound closure.
Potential Complications and Pitfalls
- In setting of redo sternotomy, consider isolating vessels in neck and groin for possible peripheral bypass
cannulation if dense adhesions encountered during sternal reentry necessitating bypass to safely complete
dissection. - Special attention should be paid to identify and preserve bilateral phrenic and vagal nerves.
- Separate cardiectomy and pneumonectomy allows for better visualization of surrounding nerves and vessels
- If adhesions too dense, can leave recipient pulmonary hilum behind
- Hemostasis critical after cardiectomy and pneumonectomy due to potential for dense collateral burden
- Avoid contamination of pleural space with bronchial secretions
- During the entire process of implantation, the heart-lung bloc should be kept cold within the thoracic cavity,
wrapped in ice cold saline sponges/laparotomy pads or a cooling jacket. - For the tracheal anastomosis technique, special attention should be paid to protecting the vagus nerve
- Can consider wrapping the airway anastomosis with viable local tissue to minimize risk of mycotic disruption of
the aortic anastomosis
Template Dictation
Preoperative Diagnosis: End stage heart and lung disease; Tetralogy of Fallot with multiple aortopulmonary
collaterals
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: On CPB, en-bloc heart-double lung transplantation
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Procuring Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] old [SEX] with DiGeorge syndrome and Tetralogy of Fallot/MAPCAS with endstage heart/lung disease who is currently on continuous milrinone/nocturnal supplemental oxygen/medications for
pulmonary hypertension. Surgical history notable for [BLANK]. Cardiac catheterization history notable for
[BLANK]. Consensus plan was to proceed with en bloc heart-double lung transplant once suitable donor became
available.
Operative Findings: There were minimal adhesions in the pleural spaces. The donor lungs were hyperexpanded. There
was mediastinal lymphadenopathy. The donor lungs were of good quality and good size match. The hilar structures
were only slightly larger than the recipient.
There was excellent early graft function, with PaO2 of >200 on an FiO2 of 0.40. Both lungs inflated well and appeared
to be a good size match.
Description of the Procedure: Patient was positioned supine. Induction/intubation, and radial arterial line placement
by anesthesia was performed. Following antiseptic prep/drape of right neck/anterior chest/abdomen/lower extremities
and antibiotics/ timeout, percutaneous left femoral arterial/venous catheters were inserted. Incision was made in right
groin and right femoral artery/vein were dissected. Incision was made in right neck over sternocleidomastoid. Muscle
was retracted laterally, and right carotid artery/internal jugular vein were dissected free. Redo median sternotomy was
performed. In pericardial space, dissection of aorta, branch pulmonary arteries, pulmonary veins, right superior vena
cava, inferior vena cava, right ventricle-pulmonary artery conduit was completed. Pericardium was incised posterior to
phrenic nerve bilaterally and hilar vessels were dissected out with pericardial window opening made for future
placement of donor lungs. Upon arrival of donor organs to and following systemic heparinization, bypass was
commenced with arterial cannula in ascending aorta and venous cannulae in right superior/inferior vena cavae. Patient
was cooled to 22 degrees. Aortic crossclamp was applied and recipient cardiectomy was completed. Bilateral
pneumonectomy commenced with removal of right lung before left lung. For both lungs, branch pulmonary arteries and
superior/inferior pulmonary veins were divided. Bronchus was divided prior to extraction of each lung from chest cavity.
ABO verification was completed. Donor heart-lungs (which had been prepared on back table ensuring suitable
aortic/superior/inferior vena cava cuffs and incising trachea to deflate lung/obtain airway culture samples) were
positioned into corresponding pleural space by passing lung parenchyma through the previously made pericardial
openings. Once lungs were ensured in each pleural space, recipient trachea was transected few rings proximal to carina
and similar segment was removed from donor airway. Using continuous 5-0 PDS, end-to-end donor/recipient tracheal
anastomosis was constructed. Using continuous 4-0 prolene, donor/recipient IVC anastomosis was completed. Using
continuous 4-0 prolene, donor/recipient aortic anastomosis was completed. Following deairing maneuvers, aortic
crossclamp was released. Using continuous 6-0 prolene, SVC anastomosis was completed. With rewarming completed,
child was weaned off cardiopulmonary bypass. Following modified ultrafiltration, protamine was administered and
cannulae were removed sequentially. 2 atrial/2 ventricular pacing were placed. 4 chest tubes in bilateral pleural
spaces/anterior mediastinum were positioned. Decision was reached to leave chest open to optimize hemodynamics and
silastic patch was sewn to skin edges. Right neck/groin incisions were closed using interrupted vicryl to deeper tissue,
continuous vicryl to superficial tissue and continuous monocryl to skin. Patient was transferred to CICU on moderate
inotropic/ventilatory support with open chest / iNO. Postoperative echocardiogram revealed preserved biventricular
function/satisfactory vascular anastomosis. Bronchoscopy revealed satisfactory tracheal anastomosis.
CPB time was [BLANK] minutes. Donor ischemic time was [BLANK] hours and [BLANK] minutes.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Figure 1: (A) Depiction of incisions of the pleuropericardial windows posterior to the respective phrenic nerve and (B)
placing the heart-lung bloc into the recipient with the right lung through its respective pleuropericardial window
Multiple Choice Question(s)
Which anastomosis in heart-lung transplantation is most likely to require reintervention?
A. Aortic anastomosis
B. Airway anastomosis
C. SVC anastomosis
D. IVC anastomosis
Answer: B. The airway anastomosis (whether bronchial or tracheal) is most prone to reintervention, often in the form
of bronchoscopic reintervention for anastomotic stricture.
Sources
Michler RE, Pediatric Lung Transplantation. In Kapoor AS, Laks H (eds). Atlas of Heart-Lung Transplantation;
McGraw-Hill, New York, NY; 1994, p 141-157.
Spray TL, Mallory G, Canter CE, et al. Pediatric lung transplantation: indications, techniques and early results. J Thorac
Cardiovasc Surg 1994; 107: 990.
Carvajal HG, Costello JP, Miller JR, Eghtesady P, Nath DS. Pediatric heart-lung transplantation: technique and special
considerations. J Heart Lung Transplant 2022; 41(3):271-278.
