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Fig. 18.6 The common incisions for lung transplantation. (a) Clamshell or transverse thoraco-sternotomy, (b) Anterolateral thoracotomy, (c)
median sternotomy
P. Kaul et al.
For bilateral sequential lung transplantation, the recip-
6. Divide the pulmonary vessels using the vascular
ient lung with worse function is usually transplanted
first. If both lungs show similar function in the transplant
7. Dissect around the main bronchus. Care must be taken to
assessment, the right side is usually done first because
the right hilum is easier to access. Bilateral lung ventilation shall be used for as long as possible during the oper-
8. Divide the bronchus using a scalpel and remove the
ation. Single lung ventilation can be trialled to assess the
extent of hypoxia and hypercapnoea, while waiting for
9. Trim the main bronchus back to the level suitable for
the donor lungs to arrive.
Pneumonectomy of the rst lung is usually started before
the donor lungs arrive at the theatre
1. Carefully divide any pleural adhesions and inferior
pulmonary ligament to mobilise the lung. This step
may be challenging due to adhesions if the recipient
has had thoracic surgery or severe intrapleural sepsis
10. Divide the pericardial reection around the pulmonary
in the past.
2. Divide the pleural reection over the hilum with utmost
care taken to prevent damage to the phrenic nerve.
3. Identify and isolate the superior and inferior pulmonary
veins with both sharp and blunt dissection. Pass ties or
slings around them to facilitate manipulation, further dissection, and safe passage of staplers.
11. Mobilise the PA in the similar fashion. On the right side,
4. Identify and isolate the PA.This may be helped by pulling the superior pulmonary vein caudally. If the PA cannot be safely dissected at this stage, postpone this step
until the superior pulmonary vein is divided.
12. Check the hilar area and pleural space to ensure that
5. Perform the PA clamp test and assess the cardiac function
using the trans-oesophageal echocardiography.
Once the donor lungs are delivered to the theatre
donor lung block is divided and prepared at this stage
staplers.
avoid damaging the vagus nerve while operating in the
area posterior to the hilum.
explanted lung.
bronchial anastomosis. The excision must be made
between the cartilages to avoid leaving any broken cartilage in the bronchial stump. Do not pull on the membranous part of the bronchus while dividing to prevent
excessive shortening of the membranous trachea.
Cauterise with low energy or ligate any bronchial arteries for haemostasis.
veins to create space around the left atrium for clamp
application. At the posterior aspect, pull the pulmonary
veins upwards to divide the pericardial reection
between the oblique and transverse sinuses. On the right
side, Waterson’s groove can be developed to provide
adequate space for clamping.
separating PA from the posterior aspect of SVC helps
provide adequate length of PA for clamp application
later.
adequate haemostasis has been achieved (Fig.18.7).
If bilateral sequential lung transplant is performed, the
Azygos v
Pulmonary veins
b
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135
Right PA
Right main
bronchus
ein
Fig. 18.7 The right hilar structures after pneumonectomy
13. Remove the donor lung block from the icebox, while
maintaining sterility. Place it in its anatomical position
in a sterile bowl.
14. Excise the excess tissues like pericardium, adipose and
connective tissues, and aortic arch.
15. Divide the left atrial back wall in the middle and leave
adequate muscular cuffs around both sets of pulmonary
veins.
16. Divide the PA trunk through the raphe to ensure that
both sides have adequate length of PA.
17. Staple the left main bronchus and divide it close to the
carina (Fig.18.8).
18. Pack the second lung in three layers of plastic bags with
cold saline or pulmonary ush solution and place it back
in the icebox for preservation.
c
a
Fig. 18.8 Preparation of the donor lung block for implantation. (a)
Division of the left atrial back wall, (b) division of the pulmonary artery
trunk, (c) division at the proximal left main bronchus close to the carina
The rst lung is then moved to the operating table for
implantation
19. If the right lung is implanted rst, trim the donor bron-
chus back to 1–2 cartilaginous rings proximal to the origin of the right upper lobe bronchus. Ensure adequate
adipose tissue is left around the bronchus to cover the
anastomosis after its completion.
20. Avoid using “cell saver” device when the bronchi are
open to prevent contamination of the collected blood
with the microbes resident in the donor and recipient airways. Wash the pleural cavity and bronchial stump with
antimicrobial solution to reduce bronchial anastomotic
complication and pleural sepsis, especially in the cystic
brosis recipients with drug-resistant organisms.
Bronchial anastomosis:
21. Place a stay suture each at the superior and inferior junc-
tions of the membranous and cartilaginous parts of both
the donor and recipient main bronchi.
Fig. 18.9 Anastomosis of the membranous part of the right main
bronchus
22. Use a running 4–0 PDS suture to anastomose the membranous trachea. After 2–3 stitches, parachute the lung
into the pleural cavity and ensure that none of the lobes
is twisted. Complete the anastomosis of the membranous part of the bronchi and tie the suture to the inferior
stay suture (Fig.18.9).
23. Complete the anastomosis of the cartilaginous part of
the bronchi by using the same running suture or interrupted 4–0 Prolene sutures (Fig.18.10). Correct the discrepancy in size of the donor and recipient main bronchi
gradually across the anastomosis if there is any.
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Recipient atrium
Donor atrium
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Fig. 18.10 Bronchial anastomosis. (a) Anastomosis of the membranous part of the main bronchi using a running suture, (b) anastomosis of the
cartilaginous part of the main bronchi using interrupted sutures
P. Kaul et al.
24. Suture the peri-bronchial adipose tissue over the bronchial anastomosis.
Pulmonary vein anastomosis:
25. Use two Ellis clamps to lift the recipient pulmonary
veins up and apply a vascular clamp on the recipient left
atrium.
26. Open the pulmonary veins close to the staple lines and
join them.
27. Orientate the donor pulmonary venous cuff. Place a stay
suture at the inferior ends of the donor and recipient pulmonary venous cuffs.
28. Use a 3–0 or 4–0 Proline running suture to start the anastomosis at the superior ends of the donor and recipient
pulmonary venous cuffs. Complete the anastomosis of
the posterior wall rst and continue it into the anterior
wall (Fig.18.11). Once the circumferential anastomosis
is completed, use a clamp to secure the two ends of the
suture without tying a knot.
Fig. 18.11 Anastomosis of the posterior wall of the pulmonary venous
cuffs
Pulmonary artery anastomosis:
the circumferential anastomosis is completed, use a
29. Apply a vascular clamp across the recipient’s PA in the
direction that the anterior and posterior walls of the PA
are opposed to each other. Trim both donor and recipient
PA appropriately to prevent kinking of the PA
clamp to secure the two ends of the suture without tying
a knot.
32. Administer 500 mg of Methylprednisolone intravenously prior to reperfusion.
anastomosis.
30. Look into the donor PA and identify the truncus anterior
De-airing routine:
branch orice, which denes the superior end of the
donor PA.Place a stay suture at the inferior ends of the
donor and recipient PA.
31. Use a 5–0 Proline running suture to start the anastomosis
at the superior ends of the donor and recipient
PA.Complete the anastomosis of the posterior wall rst
and continue it into the anterior wall (Fig.18.12). Once
33. Open the pulmonary venous cuff suture line and remove
the clamp on the recipient left atrium to deair the left
atrium. Apply the clamp back to the recipient left atrium
and tie the pulmonary venous cuff sutures.
34. Open the PA suture line and slowly release the clamp on
the recipient PA with an open suture line, to avoid per-
PA
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Fig. 18.12 Anastomosis of the posterior wall of the pulmonary artery
fusing the donor lung while de-airing the PA.Apply the
clamp back to the recipient PA.
35. Remove the left atrium clamp to allow retrograde deairing through the loose PA suture line. The efuent
needs to be removed from the surgical eld using a suction device to minimise the risk of hypotension during
the lung reperfusion. Inform the anaesthetist to monitor
for any haemodynamic instability.
36. Slowly remove the PA clamp over a period of
5–10minutes.
37. Use lung protective ventilation with a tidal volume of
3–5mL/kg of body weight, FiO2 of 21% and peak endexpiratory pressure of 5–10 cmH2O. Peak inspiratory
pressure in the transplanted lung shall be kept below
25cmH2O.
38. Once the PA clamp is removed and the transplanted lung
is ventilated, wait for 15–20minutes before proceeding
to the second lung implantation. This is to ensure that
the transplanted lung is functioning well and capable of
supporting ventilation during the implantation of the
other lung.
The second lung implantation follows the same surgical
steps as detailed above. Generally, the left lung implantation
is more difcult than the right side, due to the presence of
heart in the left pleural space. A deep pericardial stay suture
placed posterior to the phrenic nerve or cardiac suction cups
can be used to displace the heart to improve the access for
anastomosis. During left lung pneumonectomy, care shall be
taken to avoid injury to left recurrent laryngeal nerve, when
137
dissecting in the aortopulmonary window. If transplant is
performed with mechanical circulatory support, reduce the
ow through the ECMO or cardiopulmonary bypass circuit
to encourage some ejection into the rst transplanted lung.
After implantation is completed and haemostasis is
achieved, place two drains, one apical and one basal, into
each pleural cavity. Close the incision in layers in the same
ways as for other cardiothoracic procedures. In the cases of
clamshell incision, use stainless steel wire or X plates to x
the sternum.
There may be haemodynamic instability during chest closure due to the tamponade effect, especially in the cases
where the donor lungs are oversized. If difculty encounters
at this stage, a reduction pneumoplasty, such as wedge resection or middle lobectomy on the right side, can be considered
to provide room for safe closure. In the extreme cases, the
recipients may have to leave theatre with their chest open and
return to theatre for closure after the donor allograft oedema
settles.
Once the operation is completed, the double lumen endotracheal tube can be changed into a single lumen tube. A
exible bronchoscopy is optional to check the bronchial
anastomosis and clear the airway. The lung protective ventilation setting is preferrable with the FiO2 adjusted to achieve
adequate oxygenation. In some centres, there is a low threshold for putting the recipient on VV ECMO if FiO2 greater
than 60% is needed for adequate oxygenation. In patients
with signicant pulmonary hypertension, it may be advisable
to leave the recipient on partial VA ECMO support for
24–48hours to prevent primary graft dysfunction (Figs.18.6,
18.7, 18.8, 18.9, 18.10, 18.11, and 18.12).
Special Considerations inthePresence
ofCongenital andIatrogenic Anatomical
Anomalies
Signicant parenchymal injury can be stapled or sutured to
minimise air leak post-transplant.
If the donor pulmonary venous cuff is too small, it can be
reconstructed using extra vascular tissue, such as aorta, or
pericardium (Fig.18.13).
In some donors, the right upper lobe bronchus arises
directly from the trachea. If this is a segmental bronchus, it
can be closed and divided from the trachea. Collateral ventilation from other segments will reach this segment. If this is
the bronchus for the entire right upper lobe, either an upper
lobectomy needs to be performed or the upper lobe bronchus
needs to be implanted into the intermediate bronchus
(Fig.18.13).
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Fig. 18.13 Reconstruction of
the donor pulmonary venous
cuff. (a) Reconstruction of the
anterior half of the cuff, (b)
reconstruction of the entire
cuff
P. Kaul et al.
References
1. Sundaresan S, Trachiotis GD, Aoe M, Patterson GA, Cooper
JD. Donor lung procurement: assessment and operative technique. Ann Thorac Surg. 1993;56(6):1409–13. https://doi.
org/10.1016/0003- 4975(93)90699- i.
Suggested Reading
Copeland H.Donor heart and lung procurement: a consensus statement.
J Heart Lung Transplant. 2020;39(6):501–17.
Hayanga JW, D‘Cunha J. Surgical technique for bilateral sequential
lung transplantation. J Thorac Dis. 2014;6(8):1063–9.
Weill D. Lung transplantation: indications and contraindications. J
Thorac Dis. 2018;10(7):4574–87.
Orthotopic Heart Transplantation
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AhmedAl-Adhami andStevenTsui
19
Heart transplantation is the treatment of choice for eligible patients with advanced heart failure refractory to
medical therapy. The aetiologies for advanced heart failure include ischaemic, dilated, valvular, hypertrophic
and restrictive cardiomyopathies, congenital heart disease, amyloidosis amongst others. Over the years, a
number of surgical techniques for heart transplantation
have been described. Of these, the bi-caval technique has
emerged as the most widely adopted approach. In this
chapter, we shall detail the operative aspects of heart
transplantation.
Donor Selection
Factors that must be taken into account when matching
donors to recipients include their histocompatibility
(ABO and HLA compatibility), gender, height, weight
and respective predicted heart masses. Other donor factors to consider include age, cause of death, inotropic
requirement, cardiac function and risk factors for coronary artery disease. Important recipient factors to consider include their clinical urgency, transpulmonary
gradient and pulmonary vascular resistance, potential of
restricted pericardial space (e.g. a history of mediastinal
irradiation, patients implanted with a total articial heart
or multiple previous sternotomies). Finally, the transport
time and the anticipated total ischaemia time must also be
taken into account.
A. Al-Adhami ∙ S. Tsui (*)
Department of Cardiothoracic Surgery and Transplantation, Royal
Papworth Hospital, Cambridge, UK
e-mail: Ahmed.Al-Adhami@glasgow.ac.uk; steven.tsui@nhs.net
Preoperative Preparation
Classically, after conrming a suitable heart donor through
review of history and echocardiography, a suitable recipient
is selected and brought to the transplant centre whilst the
donor organ retrieval teams are mobilised to attend the donor
hospital. Right heart catheterisation and operative inspection
are then performed before a nal decision is made whether to
accept the donor heart for transplantation.
Timing ofSurgery
It is important to coordinate the timings of the donor and recipient operations so that the donor heart ischaemic time is kept to
the minimum. When using cold static donor heart storage, the
total ischaemic time should ideally be kept below 4h. If the
retrieved donor heart was placed in normothermic machine
perfusion, the machine perfusion time should ideally be kept
below 4h and preferably less than 6h. For recipient undergoing a re-sternotomy or those requiring LVAD explant, a longer
surgical dissection time is to be anticipated and must be taken
into account when planning for donor aortic cross-clamp.
Recipient Preparation
The recipient is anaesthetised with arterial and central venous
pressure monitoring. In addition, a pulmonary artery catheter
sheath and a transoesophageal echocardiography probe are
inserted. If the recipient has a cardiac debrillator in situ,
this is switched off. The recipient is prepared and draped
from chin to knee.
A median sternotomy is performed, any pericardial adhesions over the ascending aorta and the cavae are divided, and
the ascending aorta is separated from the pulmonary trunk.
The recipient is heparinised to achieve an activated clotting
time of >400s.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
F. C. Wells (ed.), Atlas of Cardiac Surgery, Springer Surgery Atlas Series, https://doi.org/10.1007/978-3-031-43195-1_19
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A. Al-Adhami and S. Tsui
Cardiopulmonary bypass (CPB) is established with a 24
Fr aortic cannula inserted in the proximal aortic arch, a 28 Fr
right angled cannula in the superior vena cava (SVC), and a
30 Fr straight cannula in the inferior vena cava (IVC). The
preferred location for IVC cannulation is the most inferolateral aspect of the right atrium. This is to ensure that the
narrowest part of the recipient right atrium just cranial to the
IVC is available for anastomosis with the donor IVC to optimise size match. The recipient is cooled on CPB to
30°C.Umbilical tapes are placed around the cavae. To pre-
a
vent atelectasis and its possible detrimental effect on right
ventricular afterload following transplantation, the recipient
is kept ventilated throughout CPB (50–100% tidal volume
and PEEP of 5 cmH2O).
When the donor heart is within 20min of reaching the
recipient hospital, the recipient aorta is clamped and the
caval snares are tightened. A vent can be inserted directly
into the left ventricular apex with a stab incision to ensure
that the pulmonary circulation is decompressed (Fig.
19.1a). The recipient right atrium (RA) is incised along the
b
Fossa
ovalis
Opening of
coronary
sinus
Valve of
inferior
vena cava
Valve of
coronary
sinus
POSTERIOR
SVC
SVC
AO
PA
RIGHT LEFT
ANTERIOR
Fig. 19.1 (a–d) Recipient preparation and cardiectomy. Dashed lines denote incision lines
19 Orthotopic Heart Transplantation
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anterior atrioventricular groove starting near the RA
appendage and progressed caudally (or clockwise for a surgeon looking at the heart from the right side of the chest)
towards the coronary sinus. The RA incision is then
extended cranially (anticlockwise) between the aortic root
and the SVC towards the roof of the left atrium (LA). If
debrillator and pacing leads are present, the SVC snare is
temporarily relaxed and the leads transected under traction
so that the wire stumps can retract above the SVC snare.
The left atrium (LA) is then entered via a stab incision at
the point at which the RA, the interatrial septum, and the
roof of the LA meet, which is just to the right of the aortic
root. This entry point is then extended along the interatrial
septum caudally towards the mouth of the coronary sinus
(Fig.19.1b). The aorta is transected at the sinotubular junction. The pulmonary trunk is then transected just cranial to
the pulmonary valve with the line of the cut directed
towards the patient’s sacrum to preserve length posteriorly.
Transecting the aorta and PA exposes the roof of the LA
which is incised transversely towards the posterior margin
of the LA appendage, excising any LA appendage tissue
with a pectinated inner surface. At this point, the LA incision is re-directed anteriorly towards the posterior mitral
valve annulus and then along the annulus until it reaches
the incision previously made in the atrial septum and mouth
of the coronary sinus (Fig.19.1c, d). The recipient heart is
then lifted anteriorly to draw up the fat pad in the posterior
atrioventricular groove so that it can be shaved off the
external surface of the cut edge of the LA.
The SVC is transected immediately cranial to its junction
with the RA.The SVC stump is then dissected off the underlying right pulmonary artery. The interatrial groove is developed, and the IVC is prepared by tailoring a 2.5cm cuff of
RA tissue around the IVC cannula. Excess redundant RA
tissue remaining attached to the LA is excised with diathermy (Fig.19.2).
141
Left atrium
Fig. 19.2 Recipient chest cavity after cardiectomy and preparation of
the vascular cuffs
A 14 Fr vent cannula is inserted into the LV via the right
superior pulmonary vein (RSPV).A DLP cannula is inserted
into the anterior surface of the ascending aorta for subsequent de-airing. Retraction sutures are placed at the 4 and 6
o’clock positions on the free margin of the recipient LA
(Fig.19.4). Finally, an extra-long 3-0 polypropylene suture
is placed at the 2 o’clock position in readiness for donor
heart implantation (Figs.19.2 and 19.4).
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Anastomosis stitch
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A. Al-Adhami and S. Tsui
Donor Heart Preparation
The donor heart is removed from storage and placed in a
small bowl. A 4-0 polypropylene U-stitch is placed at the
ostium of the coronary sinus via the IVC stump, and a coronary sinus catheter is secured in place with a snugger. The
recipient is given 1g of methylprednisolone intravenously.
Continuous retrograde cold blood cardioplegia is commenced
with a maximum infusion pressure of 25mmHg and the ow
rate adjusted accordingly (between 30 and 100mL/min).
The rectangular patch of donor LA between the four pulmonary veins is excised leaving a circular donor LA cuff
(Fig.19.3). The mitral valve is inspected, and the interatrial
septum is checked for the presence of a patent foramen ovale
(found in around 20% of donor hearts) or atrial septal defect.
If present, this is closed with a 4-0 polypropylene running
suture. The aorta and pulmonary trunk are separated, and the
Fig. 19.4 Left atrial
anastomosis. The donor heart
is rested on the recipient’s left
chest wall back to front with
the opened LA cuff facing
uppermost and the donor LA
appendage oriented towards
the surgeon, i.e. at the 10
o’clock position. The
extra-long (130cm) 3-0
polypropylene suture
previously placed at the 2
o’clock position in the
recipient LA is passed
through the donor LA cuff at
the base of the LA appendage,
i.e. the 10 o’clock position.
The 6 o’clock stay suture
from the recipient LA cuff is
passed through the
corresponding point on the
donor LA cuff. The LA
anastomosis is performed
using the extra-long 3-0
polypropylene suture at the 2
o’clock position running
towards the 4 o’clock and
then the 6 o’clock stay sutures
in turn in an everting
longitudinal mattress fashion,
ensuring endocardial to
endocardial approximation
2cm
Separated aorta
and pulmonary
artery
Superior
Pulmonary artery
Repaired left
atrial appendage
Fig. 19.3 Donor heart preparation. A rectangular patch of left atrium
between the four pulmonary veins is excised. Forceps are placed
through opposite pulmonary veins to delineate the incision lines
vena cava
Aorta
Forceps
Inferior
vena cava
Inferior vena
2cm
cava donor
Stay stitch
Rotate aotic cross clamp
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respective valves are inspected. If present, the pulmonary
artery bifurcation is excised leaving the pulmonary trunk for
the anastomosis. If the LA appendage was vented during
retrieval, this is oversewn with a continuous 4-0 polypropylene suture (Fig.19.3).
Implantation
Left Atrial Anastomosis
Correct alignment of the donor and recipient LA cuff is paramount since this ensures that the donor heart is in the correct
orientation in the recipient mediastinum. The LA anastomosis
is the most posterior and is always performed rst. The donor
heart is rested on the recipient’s left chest wall back to front
with the opened LA cuff facing uppermost and the donor LA
appendage oriented towards the surgeon, i.e. at the 10 o’clock
position. The extra-long (130cm) 3-0 polypropylene suture
previously placed at the 2 o’clock position in the recipient
LA is passed through the donor LA cuff at the base of the LA
appendage, i.e. the 10 o’clock position. The 6 o’clock stay
suture from the recipient LA cuff is passed through the corresponding point on the donor LA cuff. Finally, the 4 o’clock
stay suture from the recipient LA cuff is passed through the
donor LA cuff at the 8 o’clock position. The donor heart is
then lowered into the pericardial cavity. Traction on all three
sutures will align the donor and recipient LA cuffs and elevate their edges to facilitate suturing for the LA anastomosis.
The LA anastomosis is performed using the extra-long 3-0
polypropylene suture already placed at the 2 o’clock position
in the recipient LA cuff. The rst arm of this suture is run
towards the 4 o’clock and then the 6 o’clock stay sutures in
turn in an everting longitudinal mattress fashion, ensuring
endocardial to endocardial approximation (Fig.19.4). After
each stay suture is reached, the stay suture is removed, and
the anastomosis is continued until it reaches the inferior margin of the recipient’s interatrial septum and the opening of
the coronary sinus (6–7 o’clock position). At this point, the
tip of the RSPV vent previously placed in the recipient LA
can be directed across the mitral valve of the donor heart and
into the donor LV.The second arm of the LA suture is then
run along the roof of the LA in a counter clockwise fashion
until it reaches a point just to the right of the stump of the
aortic (10–11 o’clock position). In order to minimise ischaemic time, the nal third of the LA anastomosis can be
completed after donor heart reperfusion (Fig.19.4).
143
Roberts
artery forcep
Fig. 19.5 Pulmonary artery anastomosis. A Roberts clamp can be used
to retract the donor aorta, and the handle of the aortic cross-clamp can
be swivelled towards the left to allow better exposure of the pulmonary
artery. A retraction stay suture is placed at the 9 o’clock position on the
recipient PA (corresponding to site of the aortopulmonary window).
The suture line commences at the 4:30 position running in a clockwise
fashion to the 12 o’clock position. The remaining part of the PA anastomosis can be left until after aortic cross-clamp removal
with a Roberts artery forceps provides exposure for the PA
anastomosis (Fig.19.5). Swivelling the handle of the recipient
aortic cross-clamp to the left moves the recipient aortic stump
further to the right and can enhance the exposure. A stay suture
is then placed at the 9 o’clock position on the recipient and
donor PA.A 4-0 polypropylene running suture is used for the
PA anastomosis starting from outside in at the 4:30 position of
the recipient PA, progressing rightward along the posterior
wall of PA and up the right side of the anastomosis to the 12
o’clock position. The remainder of the PA anastomosis can be
completed at a later stage after removal of the aortic crossclamp to minimise ischaemic time (Fig.19.5).
Aortic Anastomosis
Pulmonary Artery Anastomosis
The partially completed LA anastomosis would secure the orientation of the donor heart. Caudal traction of the donor aorta
The donor and recipient aortas are trimmed to the correct
length allowing for minimal overlap and tension. If the ends
are left too long, the completed aorta will likely bow towards
the right causing SVC stretch or compression, compromising
upper body venous drainage. A 4-0 polypropylene running
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