Matthew M. Duda, MD, Yasuhiro Shudo, MD, PhD, John W. MacArthur, MD
Stanford University, Stanford, CA, USA
Essential Operative Steps
The following operative steps describe mixed techniques for donor heart procurement and
donor lung procurement from the perspective of the surgeon procuring both organs for
separate recipients.
- Appropriate donor and recipient selection based on cardiac and pulmonary function,
age, body size (weight/height), blood type, and human leukocyte antigen (HLA)
compatibility - Lines, monitoring, and general endotracheal anesthesia
- Flexible bronchoscopy to assess for airway anatomic variation, intrabronchial masses,
mucopurulent secretions, and/or aspiration - Pre-oxygenate with an inspired oxygen fraction of 100%, tidal volume of 10mL/kg, and PEEP of 5mmHg to ensure ABG
PaO2 > 300mmHg - Median sternotomy
- Access bilateral pleural spaces
- Inspect lungs for surface injury, masses, consolidation, and/or contusion
- Valsalva maneuver to confirm uniform inflation and relieve atelectasis
- Disconnect patient from ventilator to assess compliance
- Pericardiotomy
- Inspect cardiac appearance, size, weight, and contractility to confirm suitability for donation
- Palpate coronary arteries for evidence of disease
- Palpate ascending aorta for calcification, and identify a safe cannulation site
- Mobilize the ascending aorta and pulmonary artery for safe manipulation
- Mobilize the SVC and right pulmonary artery
- Encircle the SVC with a Rummel tourniquet superior to the azygos vein without snaring, and suture ligate azygos vein
- Circumferentially isolate the IVC
- Administer intravenous heparin (300 u/kg)
- After heparin circulates for 3 minutes, insert an antegrade perfusate cannula into the ascending aorta at the predetermined
cannulation site, and insert main pulmonary artery perfusion cannula proximal to the bifurcation and 1-2cm distal to
pulmonary valve - Deai, and connect the cannulae to a hypothermic systemic perfusion system
- Inject 500µg 0.5mg/mL prostaglandin E into the MPA distal to cannula
- Insert multiple suction devices into pericardial well and bilateral pleural spaces to prevent donor blood from warming
organs - After prostaglandin E circulates for >1-minute, initiate antegrade perfusion with hypothermic perfusate in the following
sequence:
a. Snare the SVC Rummel tourniquet to obliterate venous return
b. Partially divide the IVC to vent the right heart and obliterate venous return
c. Incise the LAA to vent the left heart
d. Apply ascending aorta crossclamp
e. Administer hypothermic perfusate - Install ice slush into the pericardial well and bilateral pleural spaces for topical cooling (replace as needed)
- Examine IVC and LAA efflux to ensure adequate perfusion, donor blood clearance, and cardiac decompression
- Examine cardiac monitor for electrical quiescence and heart for arrested cardiac activity
- Continue ventilation during perfusion to improve pulmonoplegia distribution and prevent atelectasis
- Confirm equal flow from MPA cannula to bilateral PAs
- After perfusing 1L of antegrade cardioplegia through the coronary circulation and 3L pulmonoplegia through the
pulmonary circulation, remove the aortic crossclamp and perfusate cannulae - Transect the IVC, azygos vein, and then the SVC cranial to the azygos vein
- Transect the aorta distal to the innominate artery origin
- Transect the pulmonary artery at the bifurcation (or 2-3cm above the pulmonic valve commissures if the lungs are also
procured) - Retract the heart cranially and incise the left atrium between the inferior pulmonary veins and coronary sinus
- Retract the heart to the patient’s right and continue the incision superiorly between the left superior pulmonary vein and
LAA - Retract the heart to the patient’s left and continue the incision superiorly along Sondergaard’s groove and then toward the
left atrial incision - Inspect the explanted heart for injury, patent foramen ovale, valves for significant abnormalities, and vessels for patency
- Repair LAA incision and patent foramen ovale as needed
- Immerse the heart in hypothermic saline and secure it in a cooler with ice for transport
- Flush the individual pulmonary veins using 500cc Perfadex solution each via retrograde cannula, inspecting PA efflux to
confirm cannula placement and assess for blood clots - Holding ventilation, incise the inferior pulmonary ligaments and dissect along the esophagus toward the hilum
- Rotate the lungs out of pleural spaces to facilitate dissection and resume ventilation
- Transect the suture-ligated azygos vein if not already done, right mammary vein, and surrounding soft tissue
- Mobilize the left PA and proximal descending thoracic aorta; divide the ligamentum arteriosum to separate the
aortopulmonary window - Transect the left mammary vein and surrounding soft tissue
- Mobilize the trachea and esophagus using blunt dissection
- Inflate lungs (25mmHg if traveling by ground; 20mmHg if traveling by plane to avoid overexpansion at high altitude)
- Divide trachea using stapler and sharp dissection
- Secure the proximal trachea with a clamp and paint with betadine to prevent tracheal contents from contaminating the
surgical field - Inspect explanted bilateral lung block for injury, appropriate inflation, and other abnormalities
- Immerse the lungs in hypothermic saline and secure them in a cooler with ice for transport
Potential Complications and Pitfalls
- Prevent innominate vein bleeding by avoiding dissection during pericardiotomy
- If there is concern about a particular pulmonary segment’s oxygenation, assess ABGs from individual pulmonary veins
prior to crossclamp - Prostaglandin E injection may cause hypotension
- Optimal MPA cannula positioning is essential to avoid preferentially perfusing a single lung
- If MPA flow is inconsistent, consider manually repositioning the cannula every 2 minutes to direct flow to bilateral PAs
or directing flow toward the pulmonary valve for retrograde distribution - Ensure adequate perfusate distribution, inflow to the ascending aorta, and efflux from the IVC and left atrium to prevent
irreversible allograft damage - Ensure no pulmonoplegia enters coronary circulation and no cardioplegia enters pulmonary circulation
- Transect the suture ligated azygos vein during the cardiectomy instead of prior to crossclamping to avoid unnecessary
bleeding - Avoid coronary sinus injury at IVC transection
- If a persistent left SVC is present, procure bilateral SVCs with additional length for the recipient team to reconstruct as
needed at implantation - Aim left atrial incision toward LAA base to ensure adequate left atrial cuff for the left superior pulmonary vein
- Avoid excessive heart retraction to prevent stretching the pulmonary veins and inadvertently shortening the left atrial cuff
- Communicate clearly with the abdominal and lung procurement teams to ensure adequate IVC, pulmonary artery, and
left atrial cuff lengths without injuring the coronary sinus or other structures - Coordinate closely with the recipient implant team and delay donor aortic crossclamp time as needed to ensure sufficient
lead time and minimize allograft cold ischemic time, especially for reoperative recipients - For donor heart-lung en bloc procurement, the MPA and left atrium remain intact
Template Dictation
Preoperative Diagnosis: Deceased organ donor heart and lung donation
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Deceased organ donor heart and lung procurement
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE]-year-old [SEX] was evaluated, and brain death was confirmed. Preoperative
echocardiography and catheterization, if obtained, demonstrated [FINDINGS]. The patient was determined to be a suitable
organ donor based on cardiac and pulmonary function, age, body size, blood type, and HLA compatibility. The patient or the
patient’s family consented to organ donation.
Description of the Procedure: The patient was taken to the operating room on [DATE]. After commemorating the patient’s
life and acknowledging the patient’s gift of organ donation, the operating room team placed the patient on the operating room
table in the supine position. A radial artery line was inserted, and general endotracheal anesthesia was administered. Flexible
bronchoscopy was performed to assess for airway anatomic variation, intrabronchial masses, mucopurulent secretions, and
aspiration. Pre-oxygenation was performed with an inspired oxygen fraction of 100%, tidal volume of 10mL/kg, and PEEP of
5mmHg to ensure ABG PaO2> 300mmHg. The patient was then prepped and draped in the usual sterile fashion.
The chest was opened through a median sternotomy incision. The bilateral pleural spaces were accessed using blunt dissection.
The lungs were inspected for surface injury, masses, consolidation, and contusion. A Valsalva maneuver was performed to
confirm uniform inflation and relieve atelectasis. The ventilator was disconnected to assess lung compliance. The pericardium
was then accessed and retracted using pericardial retention sutures. The heart was inspected for appropriate appearance, size,
weight, and contractility to confirm suitability for donation. The coronary arteries were palpated to assess for evidence of
disease. The ascending aorta was palpated to assess for calcification and identify a suitable cannulation site. The ascending
aorta, main pulmonary artery, superior vena cava, and right pulmonary artery were mobilized. The superior vena cava was
encircled using a Rummel tourniquet superior to the azygos vein. The azygos vein was suture ligated. The inferior vena cava
was isolated circumferentially.
300u/kg heparin were administered intravenously. After 3 minutes to allow heparin circulation, a pursestring suture was placed
in the ascending aorta and an antegrade perfusion cannula was inserted. A second pursestring suture was placed in the main
pulmonary artery proximal to the pulmonary bifurcation and 1-2cm distal to pulmonary valve, and a second antegrade perfusion
cannula was inserted here. The cannulae were deaired and connected to the hypothermic systemic perfusion system. 500µg
0.5mg/mL prostaglandin E was injected into the main pulmonary artery distal to the cannula to promote pulmonary
vasodilation. Multiple suction devices were inserted into the pericardial well and bilateral pleural spaces to prevent donor blood
from rewarming the organs during perfusion.
After 1 minute to allow prostaglandin E circulation, antegrade perfusion with hypothermic perfusate was initiated in the
following sequence: the superior vena cava was snared using the Rummel tourniquet, the inferior vena cava was partially
divided, the left atrial appendage was incised, an ascending aortic crossclamp was applied, and hypothermic perfusate was
administered. Ice slush was installed into the pericardial well and bilateral pleural spaces for topical cooling and replaced as
needed throughout perfusion. Adequate perfusion was confirmed by appropriate inferior vena cava and pulmonary vein efflux
clearance, cardiac decompression, electrical quiescence on the cardiac monitor, and arrested cardiac activity. Ventilation was
continued during perfusion to improve pulmonoplegia distribution and prevent atelectasis.
Equal flow was confirmed from the main pulmonary arterial cannula to the bilateral pulmonary arteries.
After perfusing 1L of antegrade cardioplegia through the coronary circulation and 3L pulmonoplegia through the pulmonary
circulation, the aortic crossclamp and perfusate cannula were removed and the pursestring suture was secured. The inferior
vena cava was transected at the prior incision, taking care to avoid injuring the coronary sinus. The azygos vein was transected
between the ligation sutures, and the superior vena cava was transected superior to the azygos vein. The aorta was transected
distal to the innominate artery, and the pulmonary artery was transected at its bifurcation.
The heart was retracted cranially to expose the inferior pulmonary veins, and the left atrium was incised between the inferior
pulmonary veins and coronary sinus. The heart was then retracted to the patient’s right to expose the left pulmonary veins, and
the incision was continued superiorly between the left superior pulmonary vein and left atrial appendage. The heart was
retracted to the patient’s left, and the incision was continued superiorly along Sondergaard’s groove then toward the left atrial
incision to complete the cardiectomy. The heart was explanted from the pericardial well and inspected on the back table for
any injury, patent foramen ovale, significant valvular abnormalities, and vessel patency. If present, the patent foramen ovale
was repaired. The heart was then immersed in hypothermic saline and secured in a cooler with ice for transport.
Attention was then returned to the lungs. The pulmonary veins were individually flushed using 500cc Perfadex solution via a
retrograde cannula, and the pulmonary artery efflux was inspected to confirm appropriate cannula placement and assess for
blood clots. Holding ventilation, the bilateral inferior pulmonary ligaments were incised, and blunt dissection was performed
along the esophagus toward the hila. The lungs were rotated out of the pleural spaces into the mediastinum to facilitate further
dissection and ventilation was resumed. The right mammary vein and surrounding soft tissue were transected. The left
pulmonary artery and proximal descending thoracic aorta were mobilized, and the ligamentum arteriosum was divided to
separate the aortopulmonary window. The left mammary vein and surrounding soft tissue were then transected. The trachea
and esophagus were mobilized using blunt dissection.
The lungs were inflated with 25mmHg pressure for ground travel (or 20mmHg for plane travel to avoid overexpansion at high
altitude), and the trachea was stapled and sharply divided. The proximal trachea was clamped and painted with betadine to
prevent tracheal contents from contaminating the surgical field. The bilateral lung block was explanted from the chest and
inspected on the back table for injury, appropriate inflation, and other abnormalities. The lung block was then immersed in
hypothermic saline and secured in a cooler with ice for transport.
Figure 1: Explanted donor heart examined on back table prior to implantation. Figure 2: Explanted donor lung block
prepared on back table prior to implantation. Figure 3: Explanted donor heart-lung block inspected on back table prior to
implantation.
Multiple Choice Question(s)
1. If the donor PaO2 is < 300mmHg, what is the next best course of action?
A. Reject the donor lungs
B. Ensure FiO2 > 100%
C. Ensure tidal volume 10mL/kg
D. Ensure PEEP 5mmHg
E. Individually assess pulmonary vein PaO2 to identify an affected area and attempt to improve any reversible causes
F. All of the above except
A Answer F. Pre-oxygenation with FiO2> 100%, tidal volume of 10mL/kg, and PEEP of 5mmHg to achieve PaO2> 300mmHg indicate suitable donor lungs. If the PaO2 remains <300mmHg despite the above measures, ABGs from each individual pulmonary vein can help localize and identify potentially reversible causes such as atelectatic lung segments.
- What measures can be taken to ensure an adequate left atrial cuff for both the donor heart and lungs?
A. Retract the heart caudally to expose the inferior pulmonary veins
B. Retract the heart to the patient’s left and right to expose the right and left pulmonary veins
C. Aim the left atrial cuff incision at the left atrial appendage base
D. Avoid excessive heart retraction to prevent stretching the pulmonary veins and inadvertently shortening the left atrial
cuff
E. All of the above
Answer E. All of the above measures help ensure an adequate left atrial cuff for both the donor heart and lungs
Sources
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Cardiovascular and Thoracic Annals. 2017;25(1):80-82.
Dalal AR, Rinewalt DE, MacArthur JW, Shudo Y, Woo YJ. Operative techniques and pitfalls in donor bilateral lung
procurement. Transplantation Proceedings. 2020 Apr;52(3):954-957.
Salna M, Shudo Y, Woo YJ. Operative techniques and pitfalls in donor heart- lung procurement. Transplantation
Proceedings. 2018;50(10):3111-3112.
