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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4110_Библиотеки_им_академика_М_И_Перельмана
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sutures on the anterior cartilaginous portion. Prior to completing the suture line, a suction catheter was advanced into the left
bronchus and placed on low continuous suction. A large vascular clamp was placed across the base of the donor pulmonary
veins, the staple lines were excised and the recipient pulmonary veins were opened creating a common orifice. An end-to-end
left atrium to recipient pulmonary vein anastomosis was then performed using running 4-0 polypropylene suture. Prior to
completing the suture line, cold preservative solution was instilled into the pulmonary artery to de-air the pulmonary veins.
The suture line was then completed. An atraumatic snare was passed around the pulmonary veins and the vascular clamp was
removed. An end-to-end pulmonary artery anastomosis was then performed using running 5-0 polypropylene suture. The suture
line was completed. The lung was packed in ice and attention was then turned to the right side. In a similar fashion, the right
lung was implanted. During the final anastomosis, the patient was rewarmed. A bronchoscopy was carried out by the
anesthesia team to clear the airway of secretions and confirm patency of the airways. The lungs were then ventilated. After
complete rewarming and institution of prostaglandin infusion and inotropic agents, the patient was slowly weaned from
cardiopulmonary bypass over approximately 15 minutes to avoid re-perfusion injury [Variation: Inhaled nitric oxide was
administered]. Both lungs inflated well and appeared to be a good size match. There was excellent early graft function, with
PaO2 of greater than 200 on an FIO2 of 0.40 [Variation: Initial saturations were in the high 80s to low 90s, but with time,
these improved, and prior to leaving the operating room, the PaO2 was greater than 120 mmHg on an FiO2 of 0.50]. Protamine
was administered and the patient was sequentially decannulated. Hemostasis was assured. The pleural spaces and
mediastinum were irrigated with copious amounts of warm antibiotic saline irrigation. The pericardial edges were loosely
reapproximated. Bilateral anterior and posterior chest tubes were placed. The sternal edges were reapproximated using
stainless steel wires. The rib edges were reapproximated using interrupted absorbable pericostal sutures. The muscle and soft
tissues were closed in multiple layers using running absorbable suture. The skin edges were reapproximated using a running
absorbable subcuticular stitch. Sterile dressings were applied.
Cardiopulmonary bypass time was [BLANK] minutes. Donor ischemic time was [BLANK] hours and [BLANK] minutes.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
Suggested Readings:
1. Michler RE, Pediatric Lung Transplantation. In Kapoor AS, Laks H (eds). Atlas of Heart-Lung Transplantation;
McGraw-Hill, New York, NY; 1994, p 141-157.
2. Spray TL, Mallory G, Canter CE, et al. Pediatric lung transplantation: indications, techniques and early results. J
Thorac Cardiovasc Surg 1994; 107: 990.
28. Pediatric Heart Transplantation
Brody Wehman, MD, MSc and Sunjay Kaushal, MD, PhD
University of Maryland Medical Center, Baltimore, MD
Essential Operative Steps
1. Confirm suitability of donor organ
2. Lines and monitoring
3. General endotracheal anesthesia
4. Intraoperative transesophageal echocardiogram
5. Median sternotomy
6. Open pericardium, create pericardial well
7. Systemic heparinization (400U/kg)
8. Arterial cannulation
9. Bicaval venous cannulation
10. Myocardial protection cannula placement in aortic root
11. Confirm ACT > 400 sec
12. Initiate CPB (goal 2.0-2.5L/min/m2)
13. Moderate hypothermia (28
o
C)
14. Cross-clamp aorta
15. Recipient cardiectomy
16. Divide SVC
17. Divide IVC
18. Divide great vessels
19. Create left atrial cuff
20. Donor heart brought to the field
21. Inspection for injury
22. Atrial cuff and great vessels appropriately trimmed
23. Left atrial anastomosis
24. IVC anastomosis
25. Aortic anastomosis
26. LV vent placed via left atrial appendage to de-air left heart
27. Aortic cross-clamp removed
28. Pulmonary artery anastomosis
29. SVC anastomosis
30. Rewarm
31. Ensure hemostasis
32. Wean from CPB
33. Venous decannulation
34. Protamine administration
35. Aortic decannulation
36. Placement of atrial and ventricular temporary pacer wires
37. Blake drainage tube placement
38. Sternal closure
Potential Complications and Pitfalls
1. Cardiac injury during the sternal re-entry can result into massive hemorrhage (if re-do sternotomy).
2. PA should be appropriately trimmed and kinking of PA from excess donor PA
3. SVC stenosis from purse-string of anastomoses
4. Bleeding from posterior anastomoses
5. Injury to SA nodal tissue from excessive manipulation or short donor SVC
6. Inability to wean from CPB (consider ischemia-reperfusion injury, elevated recipient PA pressures, hyperacute
rejection/graft failure)
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Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. End-stage dilated cardiomyopathy]
Post-operative Diagnosis: Same
Procedure(s) Performed: Bicaval, orthotopic heart transplantation
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Procuring Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: The patient is a [AGE] year old [GENDER] with [DURATION] history of [CO MPLAINT or
DIAGNO SIS e.g. worsening shortness of breath, history of dilated cardiomyopathy]. The patient was initially treated
medically yet has developed progressively worse left ventricular dysfunction as evidenced by echocardiogram (ejection
fraction 20%) and cardiac magnetic resonance imaging which has been refractory to inotropic therapy. A suitable donor heart
is now available for heart transplantation.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure were verified, and the patient was placed on the operating room table in the supine position. General anesthesia
was obtained. Monitoring lines were secured. The patient was prepped and draped in the usual sterile fashion. Median
sternotomy was performed and the mediastinum was entered without any complications. Systemic heparin was administered.
Cannulation sutures were placed in the distal ascending aorta, the SVC and the IVC. The aortic cannula was then inserted,
secured and de-aired. The venous cannulae were then inserted and secured. Cardiopulmonary bypass was then initiated and
we cooled the patient to 28
o
Celsius. An aortic cross-clamp was applied and snares were secured around the SVC and IVC
cannulae. The recipient heart was next excised starting with division of the SVC, IVC, left atrium and finally the great vessels.
The donor heart was then brought to the field, inspected and appropriately trimmed. An ice pack was placed around the heart.
The left atrial anastomosis was performed with a running #5-0 polypropylene suture. Next, the IVC anastomosis was
performed with a running #5-0 polypropylene suture. The aorta was then anastomosed with a running #5-0 polypropylene
suture. Once completed, an LV vent was then placed in the left atrial appendage. The left side of the heart was subsequently
de-aired and the aortic cross-clamp was removed. The pulmonary artery anastomosis was next performed with a running #5-0
polypropylene suture followed by the SVC anastomosis, which was performed with a #6-0 polypropylene suture.
Upon completion of anastomoses the patient was completely rewarmed. Normal sinus rhythm was regained. Hemostasis was
ensured at each anastomosis prior to weaning from cardiopulmonary bypass. We separated from cardiopulmonary bypass with
low inotropic support. A test dose of protamine was administered and patient was monitored for adverse reaction before the
full protamine dose was resumed. Decannulation was performed and the cannulation sutures tied down. Hemostasis was
achieved. Temporary atrial and ventricular wires were placed and tested for appropriate capture. A total of [NUMBER]
Blake tubes were placed in the mediastinum and the [LEFT/RIGHT] pleural space. The sternum was re-approximated with a
total number of [BLANK] stainless steel sternal wires. The wound was irrigated with Betadine and antibiotic saline solution.
The fascia was closed with a running #1 Vicryl suture and the deep dermal layer with a running #2-0 Vicryl suture. The skin
and subcuticular layer was closed with a running #3-0 Monocryl. The skin was cleansed with sterile saline and dressed with a
Primapore dressing.
All instrument, sponge and needle counts were confirmed to be correct x2 at the end of the operation. The patient was
subsequently transferred to the post-operative cardiac surgical intensive care unit in critical condition.
Ischemic donor time was [BLANK] minutes and and cardiopulmonary bypass time was [BLANK] minutes.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
*Size considerations: #5-0 polypropylene suture is used for left atrial, IVC and great vessel anastomoses and 6-0
polypropylene is used for the SVC anastomosis in infants and small children. However, the larger children and adolescents
generally required #4-0 and #5-0 polypropylene for the above-mentioned anastomoses, respectively.
This operative dictations guide was edited by the Thoracic Surgery Residents
Association (TSRA) and authored by more than 50 thoracic surgery residents from
programs around the country. The text was subject to 4 levels of peer review by
both residents and established faculty to ensure the accuracy of the published
material.
The book contains detailed descriptions, in a dictation template format, of
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
operations in the fields of General Thoracic Surgery, Adult Cardiac Surgery, and
Congenital Cardiac Surgery.
The TSRA is a resident-led organization which represents all thoracic surgery
residents in the United States.
TSRA
THORACIC SURGERY RESIDENTS ASSOCIATION
www.tsranet.org
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