Ann Thorac Surg 2001;71:1046-1047
© 2001 The Society of Thoracic Surgeons
How to do it
Pulmonary venous drainage into the left atrial appendage facilitates transplantation of the left lung with difficult exposure
Malek G. Massad, MDa,
Christian Sirois, MDa,
Sanji Tripathy, MDa,
Howard A. Jaffe, MDa,
Norman Snow, MDa,
Alexander S. Geha, MDa
a The Section of Thoracic Organ Transplantation, Division of Cardiothoracic Surgery, The University of Illinois at Chicago, Chicago, Illinois, USA
Accepted for publication September 19, 2000.
Address reprint requests to Dr Massad, Division of Cardiothoracic Surgery (MC 958), The University of Illinois at Chicago, 840 South Wood St, CSB Suite 417, Chicago, IL 60612
e-mail: mmassad{at}uic.edu
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Abstract
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Heterotopic implantation of the pulmonary venous confluence into the left atrial appendage during left lung transplantation is a reasonable alternative technique to reestablish venous drainage when exposure of the native left pulmonary veno-atrial connection may be problematic. We used this approach in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a clam-shell approach. Dense hilar scarring and a small left atrial size made exposure of the native left pulmonary veno-atrial connection difficult.
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Introduction
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Complications related to the pulmonary venous anastomosis have been reported to occur in 1% to 2% of patients undergoing lung transplantation [1, 2], and are often associated with a high morbidity and mortality [3–5]. These include thrombosis of one or both pulmonary veins or the left atrial suture line [2, 4, 6], anastomotic stenosis, and pulmonary venous obstruction or narrowing caused either by external compression or by enfolding of a redundant donor pulmonary venous atrial cuff into the lumen [2, 5]. They have also been described when the donor atrial cuff around the orifice of the pulmonary vein(s) is short [4]. Previously published data suggest that complications involving the pulmonary veins after lung transplantation may be more common than suspected. Pulmonary venous abnormalities have been detected in 10% to 29% of lung transplant recipients who were screened by transesophageal echocardiography [5, 7].
In situations when exposure of the native left pulmonary venous confluence is difficult, heterotopic reimplantation of the confluence into the left atrial appendage is a valid alternative to reestablish pulmonary venous drainage. In this communication, we describe this technique in a 39-year-old woman with chronic bronchiectasis who underwent bilateral sequential lung transplantation through a bilateral transverse thoracosternotomy (clam-shell approach). Dense central adhesions, hilar adenopathy and scarring, and a small left atrial size made exposure of the native left pulmonary veno-atrial connection through the clam shell approach difficult.
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Technique
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Presently, and in most instances, we reestablish the pulmonary veno-atrial connection by sewing the donor atrial cuff around the pulmonary venous confluence to its native counterpart. This is accomplished by applying a Satinsky vascular clamp to the left atrial wall proximal to the pulmonary venous confluence to include a half-inch cuff of native left atrial tissue around the confluence of the left superior and inferior pulmonary veins. The pulmonary venous connection is then reestablished by sewing the respective left atrial cuffs of the donor and recipient with running sutures.
Use of the left atrial appendage for pulmonary venous drainage may be considered in situations when exposure of the native pulmonary venous confluence is difficult to obtain and when the left atrial appendage is well developed with a wide waist to prevent narrowing and pulmonary venous congestion. The conditions that may be associated with difficult exposure of the left pulmonary venous confluence during left lung transplantation include: clam shell approach, previous pulmonary resection, pulmonary retransplantation, hilar scarring or adenopathy, small native left atrial size, pediatric or neonatal transplants, and lobar transplantation. In such instances, a longitudinal pericardial incision is made posterior to the phrenic nerve to expose the appendage. The native pulmonary venous stumps are doubly ligated or stapled proximally. After completion of the bronchial and pulmonary arterial anastomoses, a large Satinsky vascular clamp is applied at the base of the left atrial appendage. A wide incision is made over the dome of the appendage or, alternatively, the dome of the appendage is truncated to accommodate the donor pulmonary atrial cuff (Fig 1A). It is important to divide the various trabeculations within the appendage to ensure that the anastomosis will be wide open. The anastomosis is then performed with a running 4-0 nonabsorbable monofilament suture that is interrupted in two positions to avoid a purse-string effect. The vascular clamp at the base of the appendage is then briefly released to allow back-flow of blood through the venous suture line and to eliminate any air entrapped in the appendage during sewing from entering the left atrium. The pulmonary arterial clamp is then partially released to flush the newly implanted lung and to eliminate any residual air from entering the left heart. This is accomplished by flushing the newly implanted lung with blood through the pulmonary artery and allowing the blood to drain through the untied venous suture line. After securing the venous anastomosis, the clamp at the base of the appendage is removed (Fig 1B). Low-pressure reperfusion of the lung is maintained for a period of 10 minutes to avoid reperfusion injury.
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Fig 1. (A) Dome of the left atrial appendage is truncated to accommodate the donor pulmonary atrial cuff. (B) Anastomosis is performed with a running nonabsorbable suture interrupted in two positions to avoid purse string effect. (LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; LPA = left pulmonary artery; LPVC = left pulmonary venous confluence).
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Comment
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The feasibility of use of the left atrial appendage for pulmonary venous drainage has been previously investigated in an animal model [8]. In evaluating the feasibility of use of lobar transplantation among neonates and in the pediatric patient population, Cromblehome and associates in 1990, utilized the left atrial appendage for the venous anastomosis while performing left lower lobar transplantation in nine pairs of York-Hampshire pigs [8]. They have argued that because the venous portion of the atria of animals and human neonates is very small, clamping of the atrium may result in hemodynamic compromise, necessitating cardiopulmonary bypass. In addition, little recipient atrial tissue is available for sewing the atrial patch of the donor lobe. To obviate these problems, they anastomosed the donor’s left inferior pulmonary vein to the recipient’s left atrial appendage. They found that the technique was straightforward and did not result in hemodynamic compromise. They suggested that anastomosis to the recipient atrial appendage results in a tripod configuration of the arterial, venous, and bronchial anastomoses, which may prevent torsion of the graft.
The technique described minimizes the amount of dissection and bleeding in the left hilum, especially because circumferential intrapericardial dissection of the pulmonary venous confluence is avoided. This is particularly important in lung transplants requiring full heparinization and cardiopulmonary bypass. It also decreases the cold ischemia time of the donor lung, especially in situations when bilateral sequential transplantation is performed. It is very uncommon for thrombi to form in the short pulmonary venous stumps, as the condition is rare to occur in the pulmonary venous stump after a lobectomy or pneumonectomy. In addition, we have not encountered any supraventricular tachyarrhythmias related to the manipulation of the left atrial appendage. The patient’s postoperative course was uneventful and she continues to do well at 9 months of follow-up with good allograft function. A potential drawback of this approach is the risk of clamping the atrial appendage in the midst of dense scar tissue. This could be overcome with careful and meticulous dissection around the appendage.
We propose considering this alternative technique in situations when exposure of the native left pulmonary venous confluence is difficult.
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References
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Cooper J.D. Current status of lung transplantation. Transplant Proc 1991;23:2107-2119.[Medline]
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Griffith B.P., Magee M.J., Gonzalez I.F., et al. Anastomotic pitfalls in lung transplantation. J Thorac Cardiovasc Surg 1994;107:743-753.[Abstract/Free Full Text]
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Clark S.C., Levine A.J., Hasan A., et al. Vascular complications of lung transplantation. Ann Thorac Surg 1996;61:1079-1082.
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Sarsam M., Yonan N.A., Beton D., McMaster D., Deiraniya A.K. Early pulmonary vein thrombosis after single lung transplantation. J Heart Lung Transplant 1993;12:17-19.[Medline]
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Leibowitz D.W., Smith C.R., Michler R.E., et al. Incidence of pulmonary vein complications after lung transplantation: a prospective transesophageal echocardiographic study. J Am Coll Cardiol 1994;24:671-675.[Abstract]
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Schmid C., Gulba D.C., Heublein B., et al. Systemic recombinant tissue plasmogen activator lysis for left atrial thrombus formation after single lung re-transplantation. Ann Thorac Surg 1992;53:338-340.[Abstract]
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Hausmann D., Daniel W., Mugge A., et al. Imaging of pulmonary artery and vein anastomoses by transesophageal echocardiography after lung transplantation. Circulation 1992;86(Suppl II):251-258.
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Abstract
Introduction
