- Email: [email protected]
Heart-lung transplantation
J
THoRAc CARDIOVASC SURG
1989;97:906-10
Heart-lung transplantation Technical modifications that may improve the early outcome After heart-lung transplantation, mortality and morbidity remain related, to a significant degree, to surgical problems such as uncontrollable bleeding, phrenic nerve palsy, and dehiscence of the tracheal anastomosis. The following modifications of the original Stanford technique were designed: (1) Back bleeding from the graft is avoided; (2) dissection of the posterior mediastinum is limited as much as possible, with only the tracheobronchial bifurcation being dissected free; (3)surgical stapling is extensively used to optimize hemostasis; (4) the surgical procedure is kept away from the phrenic and vagus nerves;(5) early corticosteroid therapy is avoided and the tracheal anastomosis may be wrapped with a pedicle of great omentum. These techniques were used in 21 patients. Postoperative bleeding remairied minimal and never necessitated reoperation. There was no instance of phrenic nerve palsy. Dehiscence of the tracheal anastomosis occurred in two patients during the initial experience, but in subsequent patients this complication was prevented by adequate improvements (omentoplasty and avoidance of corticosteroids). Our technical modifications may reduce the risk of early surgical complications and thereby improve the early outcome and leave the patient in better condition to face the other hazards of heart-lung transplantation.
Pascal R. Vouhe, MD,a and Philippe G. Dartevelle, MD,b Paris, France
Combined heart and lung transplantation has become an accepted therapy for many patients with end-stage cardiac and pulmonary disease. Most early deaths after heart-lung transplantation are due to acute pulmonary failure or infectious complications." Nevertheless, to a significant degree, mortality and morbidity remain related to technical surgical problems, such as uncontrollable operative bleeding, phrenic nerve palsy, and dehiscence of the tracheal anastomosis.!" The operative technique described by the Stanford group" has been accepted worldwide. We use the same basic technique. However, we would like to report some modifications that may reduce the risk of early surgical complications. Operative technique The donor operation. The principles of the technique of harvesting are twofold: (I) Postoperative back bleeding from Fig. 1. Removal of recipient heart. From the Department of Cardiac Surgery, H6pital Laennec," and the Department of Thoracic Surgery, Centre Chirurgical MarieLannelongue," Paris, France. Received for publication April 6, 1988. Accepted for publication Nov. 3, 1988. Address for reprints: Philippe G. Dartevelle MD, Centre Chirurgical Marie-Lannelongue, 133, Avenue de la Resistance, 92350 Le Plessis Robinson, France.
906
the graft must be avoided and (2) the heart and lungs should be handled gently and as infrequently as possible. A median sternotomy is performed, and the pericardium and both pleurae are opened wide. The thymus or thymic remnants are removed. Both venae cavae are dissected free and encircled with umbilical tapes. The left innominate vein
Volume 97 Number 6 June 1989
Heart-lung transplantation 9 0 7
Fig. 2. Extrapericardial left pneumonectomy.
and the innominate artery are doubly ligated and divided. The trachea is dissected free between the superior vena cava and the ascending aorta and encircled as high as possible. This dissection is greatly facilitated by the previous division of the innominate vessels but should be done carefully, particularly by ligating on the graft side the mediastinal peritracheal tissue and lymphatic pathways. Heparin is administered intravenously. The heart is arrested with a conventional crystalloid cardioplegic solution. The lungs are perfused with a cold solution: Ringer's lactate (1000 ml), autologous blood (400 ml), 20% albumin (200 ml), 20% mannitol (200 ml), and prostacyclin (20 /oLg). This solution is infused into the main pulmonary artery under low pressure, to a total amount of 30 ml/kg of body weight. The superior vena cava is doubly stapled and the inferior vena cava is crossclamped. After the heart is allowed to empty, the aorta is crossclamped between the innominate and left carotid arteries. Both infusion solutions are administered. The inferior vena cava and the tip' of the left atrial appendage are cut to allow egress of the fluid from the heart-lung circulation. The anterior pericardium. including both phrenic nerves, is completely removed, and hemostasis of the pericardial vessels is carefully achieved. The superior vena cava is divided and the azygos vein is doubly ligated and divided. The lungs are then totally deflated, and the trachea is stapled as high as possible above the carina and cut above the stapling line. The aorta is divided at the level of the innominate artery. The heart-lung block is detached from the posterior mediastinum with the surgeon working from cephalad to caudal. The mediastinal tissue is carefully ligated on the graft side. The ligatures are placed in contact with the esophagus and the descending aorta to preserve, as much as possible, the bronchial blood supply. Finally, the pulmonary ligaments are ligated and divided. The heart-lung block is placed in cold Ringer's solution and packed for transportation. The recipient preparation. A standard median sternotomy is performed. The pericardium is incised anteriorly in the
Fig. 3. Dissection of left main bronchial stump. Peribronchial vessels are secured.
midline and the thymic fat pad is removed. Cardiopulmonary bypass is instituted after cannulation high in the aorta and cannulation of the venae cavae through the right atrium. The venae cavae are snared and the aorta is crossclamped. The aorta is transected at the level of the aortic valve commissures and the main pulmonary artery at its midpoint. The right atrial wall and the atrial septum are incised at the atrioventricular junction. The heart is then removed by dividing the left atrial wall with several staplings (Fig. I). There are almost always several collateral vessels terminating in the left atrial posterior wall; their ostia are sutured. Both pleural cavities are entered by dividing the pleura anterior to the pericardium, care being taken not to injure the phrenic nerve in the cephalad part of the incision. Stay sutures placed on the pleuropericardial edges are used to facilitate the exposure of one pleural cavity or the other. Any pleural adhesions are taken down with electrocautery. An extrapericardial pneumonectomy is performed, initially through the left pleural cavity. The pulmonary ligament is ligated and divided. The left pulmonary artery, the left main bronchus, and the rest of the left pulmonary pedicle are successively stapled and divided (Fig. 2). The left lung is removed. Tension applied to the bronchial stump progressively frees the left main bronchus from the mediastinal tissue, from distal to proximal up to the carina. The peribronchial vessels are individually secured with clips or ligatures (Fig. 3). A passage for the transplanted left lung is provided by incising the pericardium and pleura between the remnants of the left pulmonary pedicle and the left phrenic nerve. Attention is now turned to the right pleural cavity. An extrapericardial right pneumonectomy is performed. The
The Journal of
908
Vouhe and Dartevelle
Thoracic and Cardiovascular Surgery
,.;,
Fig. 4. Extrapericardial right pneumonectomy.
Fig. 5. Dissection of right main bronchial stump and removal of trancheobronchial bifurcation. This dissection is done through the right pleural cavity.
azygos vein is doubly ligated and divided. The right main bronchus and the pulmonary vacular pedicle are successively stapled and divided (Fig. 4). The right pulmonary ligament is divided and the lung is withdrawn from the chest. The next step is performed through the right pleural cavity. With tension applied to the right bronchial stump, the right main bronchus and the tracheobronchial bifurcation are freed from the surrounding tissue and the peribronchial vessels. Meanwhile, the left main bronchial stump is brought into the right pleural cavity (Fig. 5). Again, great care is taken to secure all peribronchial vessels.
Fig. 6. A passage for the left transplanted lung is created by incising the pericardium posterior to the left phrenic nerve. A passage for the right lung is managed by dividing the right main pulmonary artery and the posterior wall of the left atrium, posterior to the ostia of the right pulmonary veins. Thus the posterior wall of the left atrium, the pulmonary arterial bifurcation, and the transpericardial segment of the pulmonary pedicles are left in place.
In the midline, the posterior pericardium is incised between the superior vena cava and the ascending aorta, above the main right pulmonary artery; this allows communication between the pericardial cavity and the right pleural cavity. A passage for the right transplanted lung is then prepared by extending the previous pericardial incision (Fig. 6). The posterior pericardium, the main right pulmonary artery and, next, the posterior pericardium and the posterior wall of the left atrium posterior to the ostia of the right pulmonary veins are successively incised with a cutting stapler (GIA surgical stapling instrument, Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.). Care must be taken not to injure the esophagus and the right vagus nerve, particularly in the caudal part of the incision. A large communication is thus created, and the stumps of the left and right bronchi and the carina are easily exposed. Perfect hemostasis of the posterior mediastinum is achieved and this area is sealed with fibrin glue (Tisseel, Immuno AG, Vienna, Austria). If omentoplasty is performed, the median sternotomy is enlarged into the upper abdominal wall. The great omentum is mobilized. The pedicle of omentum is passed through the phrenic center and brought up into the tracheal area. The implantation (Fig. 7). The donor heart and lungs are passed onto the field, and the lungs are put into place. Thus the transplanted left pedicle is placed anterior to the remnants of the recipient left pedicle, and the transplanted right pedicle is placed posterior to the remnants of the native right pedicle (Fig. 8). Protection of the heart and lungs during implantation is maintained by continuous irrigation with cold electrolyte
Volume 97 Number 6
Heart-lung transplantation
June 1989
909
Fig. 8. Schematic drawing after implantation. The remnants of the recipient atria are in black. The transplanted right pedicle is placed posterior to the native right pedicle, and the transplanted left pedicle is placed anterior to the remnants of the recipient left pedicle.
Fig. 7. Implantation.
solution. A line is introduced into the left atrial appendage to improvetopical cardiac cooling and to remove air from the left cardiac cavities. When the ischemic time is prolonged (distal procurement), a blood cardioplegic solution is administered just before the implantation. The donor trachea is trimmed two or three tracheal rings above the carina and the recipient trachea is cut immediately above the carina. The tracheal anastomosis is performed with a continuous suture on the posterior membranous portion and interrupted sutures on the cartilaginous portion. The pedicle of omentum is wrapped around the tracheal anastomosis and gentle ventilation is commenced. The donor right atrial wall is incised in a curvilinear fashion soas to avoid the sinus node. The atrial and aortic anastomoses are performed with a continuous suture. The caval snares are removed, air is carefully removed from the heart, and the aortic crossclamp is released. Bypass is discontinued in the usual fashion.
Results Twenty-one patients, aged 9 to 53 years, underwent heart-lung transplantation. The indication was primary pulmonary hypertension in seven patients, Eisenmenger's syndrome in seven, diffuse pulmonary disease in five, cystic fibrosis in one, and multiple pulmonary
emboli in one. Seven patients had had a previous thoracic operation: ligation of a persistent ductus arteriosus in one, pulmonary artery banding through a sternotomy (truncus arteriosus) in one, and open lung biopsy in five. There were no operative deaths, six hospital deaths, and no late deaths. The actuarial probability of survival at I year was 71% ± 10%. The causes of the early deaths were early pulmonary failure in two patients (postoperative days 2 and 8) (pulmonary edema was present in both donors), dehiscence of the tracheal anastomosis with pyothorax in two (postoperative days I I and 42), and infectious complications in two (postoperative days 6 and 22). The mean blood loss within the first 24 postoperative hours was 800 ± 350 m!. No patient required reoperation for excessive hemorrhage. There were no instances of phrenic nerve palsy but two cases of persistent recurrent laryngeal nerve palsy. Two patients (in the early series) had gastrointestinal problems suggestive of vagus nerve palsy.
Comments During heart-lung transplantation, the main goals are (1) to ensure hemostasis, (2) to prevent injury to the thoracic nerves, and (3) to promote satisfactory healing of the tracheal anastomosis. Minimizing postoperative bleeding is of utmost importance. Excessive blood loss and subsequent important blood replacement may induce pulmonary edema and increase the severity of the lung implantation response. Postoperative bleeding was not a problem in
The Journal of
9 10 Vouhe and Dartevelle
our series, although seven patients had had a previous thoracotomy and extensive pleuropulmonary adhesions were found in two other patients. Several technical factors may reduce operative bleeding: 1. Back bleeding from the graft must be avoided. Hemostasis is obtained by careful ligation on the graft side of the vascular tissue that attaches the heart-lung block to the posterior mediastinum. 2. The dissection of the mediastinum should be as limited as possible. With our technical modifications, only the tracheobronchial bifurcation is dissected free. The posterior wall of the left atrium, the pulmonary arterial bifurcation, and the intrapericardial and transpericardial segments of both pulmonary vascular pedicles are left in place. Hemostasis of the peribronchial tissue is carefully maintained during dissection of the carinal area; clips or ligatures are preferred to electrocautery. Finally, the dissected area is sealed with fibrin glue. 3. Mechanical stapling is extensively used. It provides perfect hemostasis for the extrapericardial pneumonectomies and for creation of a passage for the transplanted right lung. Injury to the thoracic nerves must be prevented. Performing extrapericardial pneumonectomies and leaving in place the transpericardial segment of the pulmonary pedicles keeps the surgical procedure away from the phrenic and vagus nerves. The left recurrent laryngeal nerve is protected by avoiding dissecting the left main pulmonary artery and the area of the ligamentum arteriosum. Creating a passage for the transplanted right lung at the level of the posterior wall of the left atrium, posterior to the remnants of the native right pulmonary pedicle, leaves the right phrenic nerve far away from this surgical step. Two of our early patients had gastrointestinal symptoms suggestive of vagus nerve palsy. In subsequent patients, particular care was taken to avoid injuring the vagus nerves, especially during the extrapericardial pneumonectomies. Moreover, while the abdomen was opened for the omentoplasty, a closed pylorodilatation performed with a finger was systematically added, without surgical pyloromyotomy. Recently, in the last three patients, the pylorodigitoplasty was not done and no gastrointestinal disorders developed, which demonstrates that vagal nerve protection is adequate. At the beginning of our experience, healing of the tracheal anastomosis was a problem. Two patients died in the early postoperative period of dehiscence of this anastomosis with subsequent pyothorax. At that time,
Thoracic and Cardiovascular Surgery
the patients were receiving steroids after the operation and omentoplasty was not performed. The efficiency of an omental pedicle to nourish and protect a bronchial or tracheal anastomosis has been shown." Moreover, routine use of steroids is now avoided for the initial 3 weeks, except in the case of rejection. With these two modifications, healing of the tracheal suture line had been satisfactory in all but one of 15 consecutive patients. Meanwhile, reports from other groups have shown that omentoplasty may not be necessary.t' In our last three patients we did not perform omentoplasty and thereby avoided the probable deleterious effects of abdominal opening and diaphragmatic incision. Satisfactory tracheal healing was observed in each case. Thus the avoidance of early corticosteroid therapy is probably the major modification to promote adequate healing of the tracheal anastomosis. In conclusion, we believe that the modifications of the Stanford technique herein proposed reduce the magnitude of operative bleeding, preserve the thoracic nerves, and promote satisfactory healing of the trachea. The patient is probably left in better condition to face the other hazards of heart-lung transplantation. Early results may therefore be improved. We express our appreciation to Corinne Pasquet for her secretarial assistance. REFERENCES 1. Dawkins KD, Jamieson SW, Hunt SA, et al. Long-term
results, hemodynamics, and complications after combined heart and lung transplantation. Circulation 1985;71 :91926. 2. Griffith BP, Hardesty RL, Trento A, et al. Heart-lung
transplantation: lessons learned and future hopes. Ann Thorac Surg 1987;43:6-16. 3. Copeland JG. Heart-lung transplantation: current status. Ann Thorac Surg 1987;43:2-3. 4. Harjula A, Baldwin JC, Starnes V A, et al. Proper donor selection for heart-lung transplantation: the Stanford experience. J THoRAc CARDIOVASC SURG 1987;94:87480.
5. Hutter JA, Despins P, Higenbottam T, et al. Heart-lung transplantation: better use of resources. Am J Moo 1988; 85:4-11.
6. Jamieson SW, Stinson EB, Oyer PE, et al. Operative technique for heart-lung transplantation. J THoRAC CARD10VASC SURG 1984;87:930-5. 7. Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung transplantation in humans. J THORAC CARDIOVASC SURG 1987;93:173-81.
THoRAc CARDIOVASC SURG
1989;97:906-10
Heart-lung transplantation Technical modifications that may improve the early outcome After heart-lung transplantation, mortality and morbidity remain related, to a significant degree, to surgical problems such as uncontrollable bleeding, phrenic nerve palsy, and dehiscence of the tracheal anastomosis. The following modifications of the original Stanford technique were designed: (1) Back bleeding from the graft is avoided; (2) dissection of the posterior mediastinum is limited as much as possible, with only the tracheobronchial bifurcation being dissected free; (3)surgical stapling is extensively used to optimize hemostasis; (4) the surgical procedure is kept away from the phrenic and vagus nerves;(5) early corticosteroid therapy is avoided and the tracheal anastomosis may be wrapped with a pedicle of great omentum. These techniques were used in 21 patients. Postoperative bleeding remairied minimal and never necessitated reoperation. There was no instance of phrenic nerve palsy. Dehiscence of the tracheal anastomosis occurred in two patients during the initial experience, but in subsequent patients this complication was prevented by adequate improvements (omentoplasty and avoidance of corticosteroids). Our technical modifications may reduce the risk of early surgical complications and thereby improve the early outcome and leave the patient in better condition to face the other hazards of heart-lung transplantation.
Pascal R. Vouhe, MD,a and Philippe G. Dartevelle, MD,b Paris, France
Combined heart and lung transplantation has become an accepted therapy for many patients with end-stage cardiac and pulmonary disease. Most early deaths after heart-lung transplantation are due to acute pulmonary failure or infectious complications." Nevertheless, to a significant degree, mortality and morbidity remain related to technical surgical problems, such as uncontrollable operative bleeding, phrenic nerve palsy, and dehiscence of the tracheal anastomosis.!" The operative technique described by the Stanford group" has been accepted worldwide. We use the same basic technique. However, we would like to report some modifications that may reduce the risk of early surgical complications. Operative technique The donor operation. The principles of the technique of harvesting are twofold: (I) Postoperative back bleeding from Fig. 1. Removal of recipient heart. From the Department of Cardiac Surgery, H6pital Laennec," and the Department of Thoracic Surgery, Centre Chirurgical MarieLannelongue," Paris, France. Received for publication April 6, 1988. Accepted for publication Nov. 3, 1988. Address for reprints: Philippe G. Dartevelle MD, Centre Chirurgical Marie-Lannelongue, 133, Avenue de la Resistance, 92350 Le Plessis Robinson, France.
906
the graft must be avoided and (2) the heart and lungs should be handled gently and as infrequently as possible. A median sternotomy is performed, and the pericardium and both pleurae are opened wide. The thymus or thymic remnants are removed. Both venae cavae are dissected free and encircled with umbilical tapes. The left innominate vein
Volume 97 Number 6 June 1989
Heart-lung transplantation 9 0 7
Fig. 2. Extrapericardial left pneumonectomy.
and the innominate artery are doubly ligated and divided. The trachea is dissected free between the superior vena cava and the ascending aorta and encircled as high as possible. This dissection is greatly facilitated by the previous division of the innominate vessels but should be done carefully, particularly by ligating on the graft side the mediastinal peritracheal tissue and lymphatic pathways. Heparin is administered intravenously. The heart is arrested with a conventional crystalloid cardioplegic solution. The lungs are perfused with a cold solution: Ringer's lactate (1000 ml), autologous blood (400 ml), 20% albumin (200 ml), 20% mannitol (200 ml), and prostacyclin (20 /oLg). This solution is infused into the main pulmonary artery under low pressure, to a total amount of 30 ml/kg of body weight. The superior vena cava is doubly stapled and the inferior vena cava is crossclamped. After the heart is allowed to empty, the aorta is crossclamped between the innominate and left carotid arteries. Both infusion solutions are administered. The inferior vena cava and the tip' of the left atrial appendage are cut to allow egress of the fluid from the heart-lung circulation. The anterior pericardium. including both phrenic nerves, is completely removed, and hemostasis of the pericardial vessels is carefully achieved. The superior vena cava is divided and the azygos vein is doubly ligated and divided. The lungs are then totally deflated, and the trachea is stapled as high as possible above the carina and cut above the stapling line. The aorta is divided at the level of the innominate artery. The heart-lung block is detached from the posterior mediastinum with the surgeon working from cephalad to caudal. The mediastinal tissue is carefully ligated on the graft side. The ligatures are placed in contact with the esophagus and the descending aorta to preserve, as much as possible, the bronchial blood supply. Finally, the pulmonary ligaments are ligated and divided. The heart-lung block is placed in cold Ringer's solution and packed for transportation. The recipient preparation. A standard median sternotomy is performed. The pericardium is incised anteriorly in the
Fig. 3. Dissection of left main bronchial stump. Peribronchial vessels are secured.
midline and the thymic fat pad is removed. Cardiopulmonary bypass is instituted after cannulation high in the aorta and cannulation of the venae cavae through the right atrium. The venae cavae are snared and the aorta is crossclamped. The aorta is transected at the level of the aortic valve commissures and the main pulmonary artery at its midpoint. The right atrial wall and the atrial septum are incised at the atrioventricular junction. The heart is then removed by dividing the left atrial wall with several staplings (Fig. I). There are almost always several collateral vessels terminating in the left atrial posterior wall; their ostia are sutured. Both pleural cavities are entered by dividing the pleura anterior to the pericardium, care being taken not to injure the phrenic nerve in the cephalad part of the incision. Stay sutures placed on the pleuropericardial edges are used to facilitate the exposure of one pleural cavity or the other. Any pleural adhesions are taken down with electrocautery. An extrapericardial pneumonectomy is performed, initially through the left pleural cavity. The pulmonary ligament is ligated and divided. The left pulmonary artery, the left main bronchus, and the rest of the left pulmonary pedicle are successively stapled and divided (Fig. 2). The left lung is removed. Tension applied to the bronchial stump progressively frees the left main bronchus from the mediastinal tissue, from distal to proximal up to the carina. The peribronchial vessels are individually secured with clips or ligatures (Fig. 3). A passage for the transplanted left lung is provided by incising the pericardium and pleura between the remnants of the left pulmonary pedicle and the left phrenic nerve. Attention is now turned to the right pleural cavity. An extrapericardial right pneumonectomy is performed. The
The Journal of
908
Vouhe and Dartevelle
Thoracic and Cardiovascular Surgery
,.;,
Fig. 4. Extrapericardial right pneumonectomy.
Fig. 5. Dissection of right main bronchial stump and removal of trancheobronchial bifurcation. This dissection is done through the right pleural cavity.
azygos vein is doubly ligated and divided. The right main bronchus and the pulmonary vacular pedicle are successively stapled and divided (Fig. 4). The right pulmonary ligament is divided and the lung is withdrawn from the chest. The next step is performed through the right pleural cavity. With tension applied to the right bronchial stump, the right main bronchus and the tracheobronchial bifurcation are freed from the surrounding tissue and the peribronchial vessels. Meanwhile, the left main bronchial stump is brought into the right pleural cavity (Fig. 5). Again, great care is taken to secure all peribronchial vessels.
Fig. 6. A passage for the left transplanted lung is created by incising the pericardium posterior to the left phrenic nerve. A passage for the right lung is managed by dividing the right main pulmonary artery and the posterior wall of the left atrium, posterior to the ostia of the right pulmonary veins. Thus the posterior wall of the left atrium, the pulmonary arterial bifurcation, and the transpericardial segment of the pulmonary pedicles are left in place.
In the midline, the posterior pericardium is incised between the superior vena cava and the ascending aorta, above the main right pulmonary artery; this allows communication between the pericardial cavity and the right pleural cavity. A passage for the right transplanted lung is then prepared by extending the previous pericardial incision (Fig. 6). The posterior pericardium, the main right pulmonary artery and, next, the posterior pericardium and the posterior wall of the left atrium posterior to the ostia of the right pulmonary veins are successively incised with a cutting stapler (GIA surgical stapling instrument, Auto Suture Company Division, United States Surgical Corporation, Norwalk, Conn.). Care must be taken not to injure the esophagus and the right vagus nerve, particularly in the caudal part of the incision. A large communication is thus created, and the stumps of the left and right bronchi and the carina are easily exposed. Perfect hemostasis of the posterior mediastinum is achieved and this area is sealed with fibrin glue (Tisseel, Immuno AG, Vienna, Austria). If omentoplasty is performed, the median sternotomy is enlarged into the upper abdominal wall. The great omentum is mobilized. The pedicle of omentum is passed through the phrenic center and brought up into the tracheal area. The implantation (Fig. 7). The donor heart and lungs are passed onto the field, and the lungs are put into place. Thus the transplanted left pedicle is placed anterior to the remnants of the recipient left pedicle, and the transplanted right pedicle is placed posterior to the remnants of the native right pedicle (Fig. 8). Protection of the heart and lungs during implantation is maintained by continuous irrigation with cold electrolyte
Volume 97 Number 6
Heart-lung transplantation
June 1989
909
Fig. 8. Schematic drawing after implantation. The remnants of the recipient atria are in black. The transplanted right pedicle is placed posterior to the native right pedicle, and the transplanted left pedicle is placed anterior to the remnants of the recipient left pedicle.
Fig. 7. Implantation.
solution. A line is introduced into the left atrial appendage to improvetopical cardiac cooling and to remove air from the left cardiac cavities. When the ischemic time is prolonged (distal procurement), a blood cardioplegic solution is administered just before the implantation. The donor trachea is trimmed two or three tracheal rings above the carina and the recipient trachea is cut immediately above the carina. The tracheal anastomosis is performed with a continuous suture on the posterior membranous portion and interrupted sutures on the cartilaginous portion. The pedicle of omentum is wrapped around the tracheal anastomosis and gentle ventilation is commenced. The donor right atrial wall is incised in a curvilinear fashion soas to avoid the sinus node. The atrial and aortic anastomoses are performed with a continuous suture. The caval snares are removed, air is carefully removed from the heart, and the aortic crossclamp is released. Bypass is discontinued in the usual fashion.
Results Twenty-one patients, aged 9 to 53 years, underwent heart-lung transplantation. The indication was primary pulmonary hypertension in seven patients, Eisenmenger's syndrome in seven, diffuse pulmonary disease in five, cystic fibrosis in one, and multiple pulmonary
emboli in one. Seven patients had had a previous thoracic operation: ligation of a persistent ductus arteriosus in one, pulmonary artery banding through a sternotomy (truncus arteriosus) in one, and open lung biopsy in five. There were no operative deaths, six hospital deaths, and no late deaths. The actuarial probability of survival at I year was 71% ± 10%. The causes of the early deaths were early pulmonary failure in two patients (postoperative days 2 and 8) (pulmonary edema was present in both donors), dehiscence of the tracheal anastomosis with pyothorax in two (postoperative days I I and 42), and infectious complications in two (postoperative days 6 and 22). The mean blood loss within the first 24 postoperative hours was 800 ± 350 m!. No patient required reoperation for excessive hemorrhage. There were no instances of phrenic nerve palsy but two cases of persistent recurrent laryngeal nerve palsy. Two patients (in the early series) had gastrointestinal problems suggestive of vagus nerve palsy.
Comments During heart-lung transplantation, the main goals are (1) to ensure hemostasis, (2) to prevent injury to the thoracic nerves, and (3) to promote satisfactory healing of the tracheal anastomosis. Minimizing postoperative bleeding is of utmost importance. Excessive blood loss and subsequent important blood replacement may induce pulmonary edema and increase the severity of the lung implantation response. Postoperative bleeding was not a problem in
The Journal of
9 10 Vouhe and Dartevelle
our series, although seven patients had had a previous thoracotomy and extensive pleuropulmonary adhesions were found in two other patients. Several technical factors may reduce operative bleeding: 1. Back bleeding from the graft must be avoided. Hemostasis is obtained by careful ligation on the graft side of the vascular tissue that attaches the heart-lung block to the posterior mediastinum. 2. The dissection of the mediastinum should be as limited as possible. With our technical modifications, only the tracheobronchial bifurcation is dissected free. The posterior wall of the left atrium, the pulmonary arterial bifurcation, and the intrapericardial and transpericardial segments of both pulmonary vascular pedicles are left in place. Hemostasis of the peribronchial tissue is carefully maintained during dissection of the carinal area; clips or ligatures are preferred to electrocautery. Finally, the dissected area is sealed with fibrin glue. 3. Mechanical stapling is extensively used. It provides perfect hemostasis for the extrapericardial pneumonectomies and for creation of a passage for the transplanted right lung. Injury to the thoracic nerves must be prevented. Performing extrapericardial pneumonectomies and leaving in place the transpericardial segment of the pulmonary pedicles keeps the surgical procedure away from the phrenic and vagus nerves. The left recurrent laryngeal nerve is protected by avoiding dissecting the left main pulmonary artery and the area of the ligamentum arteriosum. Creating a passage for the transplanted right lung at the level of the posterior wall of the left atrium, posterior to the remnants of the native right pulmonary pedicle, leaves the right phrenic nerve far away from this surgical step. Two of our early patients had gastrointestinal symptoms suggestive of vagus nerve palsy. In subsequent patients, particular care was taken to avoid injuring the vagus nerves, especially during the extrapericardial pneumonectomies. Moreover, while the abdomen was opened for the omentoplasty, a closed pylorodilatation performed with a finger was systematically added, without surgical pyloromyotomy. Recently, in the last three patients, the pylorodigitoplasty was not done and no gastrointestinal disorders developed, which demonstrates that vagal nerve protection is adequate. At the beginning of our experience, healing of the tracheal anastomosis was a problem. Two patients died in the early postoperative period of dehiscence of this anastomosis with subsequent pyothorax. At that time,
Thoracic and Cardiovascular Surgery
the patients were receiving steroids after the operation and omentoplasty was not performed. The efficiency of an omental pedicle to nourish and protect a bronchial or tracheal anastomosis has been shown." Moreover, routine use of steroids is now avoided for the initial 3 weeks, except in the case of rejection. With these two modifications, healing of the tracheal suture line had been satisfactory in all but one of 15 consecutive patients. Meanwhile, reports from other groups have shown that omentoplasty may not be necessary.t' In our last three patients we did not perform omentoplasty and thereby avoided the probable deleterious effects of abdominal opening and diaphragmatic incision. Satisfactory tracheal healing was observed in each case. Thus the avoidance of early corticosteroid therapy is probably the major modification to promote adequate healing of the tracheal anastomosis. In conclusion, we believe that the modifications of the Stanford technique herein proposed reduce the magnitude of operative bleeding, preserve the thoracic nerves, and promote satisfactory healing of the trachea. The patient is probably left in better condition to face the other hazards of heart-lung transplantation. Early results may therefore be improved. We express our appreciation to Corinne Pasquet for her secretarial assistance. REFERENCES 1. Dawkins KD, Jamieson SW, Hunt SA, et al. Long-term
results, hemodynamics, and complications after combined heart and lung transplantation. Circulation 1985;71 :91926. 2. Griffith BP, Hardesty RL, Trento A, et al. Heart-lung
transplantation: lessons learned and future hopes. Ann Thorac Surg 1987;43:6-16. 3. Copeland JG. Heart-lung transplantation: current status. Ann Thorac Surg 1987;43:2-3. 4. Harjula A, Baldwin JC, Starnes V A, et al. Proper donor selection for heart-lung transplantation: the Stanford experience. J THoRAc CARDIOVASC SURG 1987;94:87480.
5. Hutter JA, Despins P, Higenbottam T, et al. Heart-lung transplantation: better use of resources. Am J Moo 1988; 85:4-11.
6. Jamieson SW, Stinson EB, Oyer PE, et al. Operative technique for heart-lung transplantation. J THoRAC CARD10VASC SURG 1984;87:930-5. 7. Cooper JD, Pearson FG, Patterson GA, et al. Technique of successful lung transplantation in humans. J THORAC CARDIOVASC SURG 1987;93:173-81.