Jessica G.Y. Luc, MD and James G. Abel, MD, MSc
University of British Columbia, Vancouver, BC, Canada
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Alexandra Tuluca, MD and Hari Mallidi, MD, FRCSC.
Essential Operative Steps
- Communication with implant team throughout procedure
- Final checklist at the site:
a. Donor consent and certification of brain death
b. Past medical conditions and cause of death of donor including down time and CPR
c. ABO compatibility
d. Serology (HIV, HCV, HbsAg, and CMV)
e. Height and weight of donor and recipient (donor to recipient weight ratio of at least 0.7)
f. Laboratory findings (Troponin, Na, ABG)
g. ECG (look for ischemia, atrial fibrillation, bundle blocks, AV blocks, signs of hypertrophy, and/or long QT)
h. Echocardiography (assess valvular abnormalities, LV/RV function, wall motion, wall thickness)
i. Review chest xray and chest CT
j. Coronary angiogram (if performed, prefer in males >45 years old, females >50 years old, and those with any risk
factors of coronary artery disease)
k. Medications during ICU course (especially catecholamine requirements) - Lines and monitoring
- General endotracheal anesthesia
- Coordination with the operating room staff about specific instrument needs, setup, and orientation to your team’s specific
perfusion arrangement - Median sternotomy
- Dissect and remove thymus
- Open pericardium and place pericardial stay sutures
- Expose the great vessels, including the aortic arch branch vessels
- Visual inspection and palpation of the heart for injury, lesions, and anomalies (e.g. left sided superior vena cava)
- Ligate the azygos vein by exclusion flush with the SVC
- Dissect out and encircle the SVC with snare
- Dissect out the IVC by opening the oblique sinus
- Separate the aorta and pulmonary artery. Free posteriorly the aorta from the right pulmonary artery
- Insert the antegrade cardioplegia cannula in the ascending aorta
- Systemic heparin (400 u/kg)
- Ask anesthesia to withdraw any venous neck lines they have in the patient
- Snare the SVC above the azygos vein
- Crossclamp the aorta and start cardioplegia
- Incise IVC supradiaphragmatic or start bleedout if the abdominal IVC is cannulated – check with liver team
- Incise the right superior pulmonary vein to vent the heart if there is no lung retrieval; incise the left atrial appendage if
the lungs are being recovered - Once cardioplegia and pulmonary perfusion are completed, develop the interatrial groove medially to maximize
pulmonary vein and left atrial cuffs if retrieving the lungs as well - Transect the IVC – check with liver team
- If heart alone: transect the right and left pulmonary veins, flush to the pericardium, and dissect the left atrium off the
pericardium - If lungs: enter the left atrium in the interatrial groove, divide the left atrial cuffs evenly superiorly and inferiorly, and
visualize the pulmonary veins from inside the left atrium - Remove the tourniquet from the SVC and transect the SVC at its origin; preserve the innominate vein continuity if special
conditions are required in the recipient - Divide the azygos vein
- Remove the aortic crossclamp
- Transect the head vessels, aorta (usually the distal arch with preservation of the arch vessel origins), and the pulmonary
artery to the bifurcation (if harvesting the heart alone for complex congenital transplant, divide the pulmonary artery at
the branch pulmonary artery level) - Remove the heart and inspect it again for lesions, contusions, surgical damage, patent foramen ovale, coronary ostia,
anomalies, sewing cuffs, etc. - Store the heart in a sterile bag (3 bag method: first with cold perfusion solution, outer two with ice water)
Potential Complications and Pitfalls
- Inadequate communication with recipient team: this can lead to unnecessary donor ischemic time. Ideally, necessary
timestamps for communication include arrival of donor procurement team, upon donor skin incision, after inspection of
donor heart, prior to anticipated crossclamp, on departure from the donor operating room, on flight departure and arrival
(or estimated ground travel time), and where possible, approximately 10 minutes away from the recipient operating room.
With longer travel times, wait for below diaphragm team to finish as much of the dissection warm (pre-crossclamp) - Inadequate communication with rest of procurement team (in settings of multi-organ procurement): lack of mutual
agreements upon excision of donor organs can lead to inadequate cuff lengths of donor organs for either procurement
team. In addition, if there is a lung procurement team, it is vital to ensure adequate venting via the left atrial appendage
and heart arrest prior to beginning lung perfusion (this prevents the lung perfusate from washing out the cardioplegia
solution from the aortic root and cardiac distention) - Failure to identify structural abnormalities: this can lead to unnecessary challenges in donor heart implant and poor post
transplant outcomes - Excessive manipulation of the donor heart prior to being ready for crossclamp: this can cause hemodynamic instability of
the donor heart requiring resuscitation and stabilization - Forgetting to heparinize: this can lead to thrombosis and distal embolization
- Allowing ventricular distension or failure to adequately cool and preserve the heart: this can be deleterious to the
posttransplant function of the donor heart with graft dysfunction or graft failure - Allowing the aortic root pressure to get too high when administering cardioplegia: infusion bag pressure is usually
regulated based on specific cannula sizes to ensure physiologic root pressures - Excessive manipulation of the donor heart during cardioplegia administration: this can cause transient aortic valve
incompetence leading to ventricular distension - Not enough length on the SVC, IVC, or the great vessels: this can lead to anastomoses under tension in the recipient
which may be more prone to bleeding, tears, or damage. In addition, inadequate length of the SVC can lead to sinoatrial
node damage - Injuring to the right atrium/dome of left atrium when preserving the right superior pulmonary vein for the lung team: this
would require reconstruction if the donor heart is to be used. If the damage is serious, this may lead to the donor heart
being discarded - Injuring the coronary sinus during IVC transection: this would require reconstruction if the donor heart is to be used. If
the damage is serious, this may lead to the donor heart being discarded
Template Dictation
Preoperative Diagnosis: Heart organ donor
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Donor heart procurement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] who was certified as brain dead following [CAUSE OF DEATH].
Preoperative echocardiography revealed [FINDINGS].
Operative Findings: [INSERT AS APPLICABLE]
Description of the Procedure: The donor was positioned supine, prepped, and draped in standard sterile fashion from the
sternal notch to below the pubic symphysis. A standard median sternotomy is performed. The thymus is removed and the
pericardium is opened. A pericardial well is created and pericardial stay sutures are placed. The great vessels are exposed. The
heart is visually inspected for heart function and anomalies. In addition, the heart is palpated to identify any myocardial
contusions, coronary atherosclerosis, and/or previous infarction. Figure 1 demonstrates the line of incisions necessary (not all
inclusive) to explant the donor heart.
The heart was mobilized by dissecting the SVC from the right atrium to the innominate vein. The azygous vein was ligated by
exclusion flush to the SVC. The SVC was encircled with heavy ligature and passed through a Rummel tourniquet. The IVC
was mobilized circumferentially by opening the oblique sinus. Next, the aorta was separated from the pulmonary artery and
isolated with umbilical tape. The aortic arch and great vessels were further mobilized. A cardioplegia cannula was inserted in
the ascending aorta through a pursestring suture and secured with a Rummel tourniquet.
Once confirmation was obtained that the recipient team and the below diaphragm team were ready, the patient was administered
400 u/kg of heparin intravenously. Anesthesia was asked to withdraw any venous neck lines they have in the patient and the
SVC tourniquet was tightened. The right pericardium was opened. The IVC was incised anteriorly and blood was allowed to
drain into the pericardium and right chest. The heart was further vented by incising the right superior or inferior pulmonary
vein at the level of the pericardium (Variation for lung or heart-lung procurement: the left atrial appendage was incised to
vent the heart). After ensuring that the heart was empty, the aortic crossclamp was applied just proximal to the takeoff of the
innominate artery. The heart was covered with slush and arrested with a single flush of 2500mL of cold crystalloid cardioplegia
solution. Care was taken to ensure that the maximum cardioplegia bag pressure was around 150mmHg. The aortic root was
appropriately distended with quick cessation of electrical activity and the left ventricle was not distended. (Variation for left
ventricular distension: The cardioplegia was stopped upon left ventricular distension and the heart was lifted to invoke mitral
valve insufficiency to decompress the heart. Following this, the rest of the cardioplegia solution was delivered).
The IVC was transected at the level of the diaphragm (Variation if liver is being procured: the IVC was transected leaving
a 3-4mm cuff in coordination with the liver procurement team). The heart was lifted superiorly, and dissection was carried
along the oblique pericardial sinus reflection until the right pulmonary veins (taking care to not damage the coronary sinus
during the division of the IVC and left atrium (Figure 2)). (Variation if a persistent LSVC is noted: The persistent left sided
SVC was identified, dissected out, and ligated proximal to its drainage into the coronary sinus). The right pulmonary veins
were then transected flush to the pericardium and the dissection was extended to the back of the left atrium off the pericardium.
The left pulmonary veins were then transected flush to the pericardium and the heart was returned to the pericardial sac.
The innominate vein was then tied off with silk and divided. The tourniquet from the SVC was removed and the SVC was
dissected as high as possible (Note: if there are unusual recipient requirements, one may elect to include the innominate vein
in the distal extent of procurement) and divided cephalad to the azygos vein. The azygos vein was then divided and tied off.
The aortic crossclamp was then removed and downward traction was applied to the aorta. The aorta was transected as high as
possible (Note: if there are unusual recipient requirements, one may elect to include the aortic arch and part of descending
aorta in the distal extent of procurement) and mobilized off the right pulmonary artery posteriorly. The right and left pulmonary
arteries were transected at their origin from the main pulmonary artery, maximizing the length of the pulmonary artery.
Remaining attachments of the heart to the pericardium were divided and the heart was then delivered to the back table.
A rapid assessment was then performed on the donor heart at the back table to assess for any surgical damage and the presence
of a patent foramen ovale (which should be closed). The coronary ostia were inspected to rule out any undetected coronary
artery disease or abnormal takeoffs. In addition, the IVC and left atrial cuffs were examined to ensure adequate rim of tissue
for anastomosis. The heart was then placed in a sterile bag with perfusion solution, followed by two additional outer bags. The
package was then placed in a cooler with ice and transported to the recipient hospital.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Figure 1: Line of incisions shown in red that are necessary (not all inclusive) to explant the donor heart. Abbreviations: IVC,
inferior vena cava; SA node, sinoatrial node; SVC, superior vena cava.
Figure 2: Cardiac apex elevated out of the pericardium exposing the posterior surface of the heart and the relation of the
coronary sinus with the left atrium, IVC, and pulmonary veins. Abbreviations: IVC, inferior vena cava; SVC, superior vena
cava.
Multiple Choice Question(s)
After transecting the IVC and lifting the heart superiorly to carry the dissection along the oblique pericardial sinus reflection
until the right pulmonary veins, what structure should one take care to not damage?
A. SVC
B. Right pulmonary artery
C. Coronary sinus
D. Left atrial appendage
E. None of the above
Answer: C.
Sources
Khonsari S, Chen JM. Cardiac Surgery: Safeguards and Pitfalls in Operative Technique. 5th Ed. Philadelphia, PA: Wolters
Kluwer Health; 2017, p190-196.
Sellke FW, Ruel M. Atlas of Cardiac Surgical Techniques. 2nd Edition. Philadephia, PA. Elsevier; 2019, p546-566.
Connellan M, Cardio FC, Dhital K. Donor Heart Procurement from the Donation after Circulatory Death Pathway. Operative
Techniques in Thoracic and Cardiovascular Surgery. 2017;22:58-67.
