Ann Thorac Surg 2001;71:1373-1374
© 2001 The Society of Thoracic Surgeons
How to do it
Pulmonary vein augmentation for single lung transplantation
Roberto P. Casula, FETCSa,
Serban C. Stoica, AFRCSa,
John Wallwork, FRCSa,
John Dunning, FRCS(CTh)a
a Department of Cardiothoracic Surgery and Transplantation, Papworth Hospital, Cambridge, United Kingdom
Accepted for publication August 28, 2000.
Address reprint requests to Mr Dunning, Department of Cardiothoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK
e-mail: john.dunning{at}papworth-tr.anglox.nhs.uk
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Abstract
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We describe a simple method of augmenting pulmonary veins using the donor pericardium in lung grafts which have been procured without an adequate donor left atrial cuff. The method allows making use of lungs procured with suboptimal surgical technique, such as those with short atrial cuffs or completely separated superior and inferior pulmonary veins. We also have applied it equally successfully on the right lung.
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Introduction
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Single lung transplantation is now well established as a useful therapy for patients with end-stage lung disease. Its success is dependent upon a number of factors including appropriate selection of donor and recipients, good management of the donor prior to and during organ procurement, and meticulous surgical technique in both the donor and the recipient procedures. During the harvesting procedure, the surgeon should carefully preserve an adequate donor left atrial cuff around the confluence of the superior and inferior pulmonary veins [1, 2]. The donor left atrium is usually divided halfway between the left venous confluence and the coronary sinus, thus providing for a straightforward single anastomosis with the left atrium of the recipient. Due to technical errors at the time of procurement, donor lungs are sometimes made available with little or no atrial tissue around the venous confluence. This tends to occur especially when the heart and lungs are explanted separately and the intrathoracic organs are dispatched to different centers. If the veins are cut flush with the pericardium, they will inevitably be too short, and conventional techniques are modified of necessity. We describe an easy technique which we employed in 2 patients to overcome the problem of left donor lungs procured with separated pulmonary veins. The donor pericardium is used to construct an in situ patch for anastomosis of the donor pulmonary veins to the recipient’s left atrium.
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Technique
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During procurement of lungs for transplantation, it is common practice to leave a large pericardial cuff around the hilum of each lung. If the pulmonary veins are cut too short during the donor procedure, their separate orifices are observed within the area of surrounding pericardium (Fig 1). We constructed a "neoatrial cuff" by performing a running suture of 5-0 Polypropilene (Prolene; Ethicon, Somerville, NJ) around the divided edges of each of the two pulmonary veins. The veins were thus firmly attached to the pericardium that naturally surrounded them (Fig 2). The pericardium was then separated from the pulmonary artery and bronchus as shown, resulting in a new cuff for use in the atrial anastomosis. This additional maneuver is easily performed on a side table just before graft implantation. The resultant pericardial cuff was finally trimmed to match the recipient left atrium. A simple continuous anastomosis was then carried out between the minimally modified graft and the native left atrium. Both patients made an uneventful recovery. There was no clinical evidence of stenosis at the anastomotic level and long-term follow-up showed good graft function 1-year postoperatively.
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Fig 1. The pericardium surrounding the hilum of the left lung. The inferior part of the inset shows how the pulmonary veins were cut short and tend to retract into the hilum.
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Fig 2. The separate running sutures between the pericardium and the pericardial opening of the pulmonary veins are completed. The newly formed cuff is cut with scissors.
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Comment
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Describing a similar case of "lung graft salvaging" Kirby and Birnbaum [3] advocated suturing the pulmonary veins back together to reconstruct the atrial cuff. We believe this would not have been feasible in our two grafts in which the pulmonary veins had not just been separated from each other but also cut too short, thus retracting into the pulmonary hilum. Due to the increasing shortage of donor organs, it is important to maximize the utilization of donor organs available, even when faced with technical difficulties. Unfortunately, some problems only become apparent late in the transplant operation, requiring improvization by the surgeon to achieve a successful outcome. Our method exemplifies a simple way to overcome a disadvantageous situation. This resulted in a technically satisfactory anastomosis of the neoatrial cuff to the recipient left atrium. Since then, we have applied the method successfully to the same problem occurring in the right lung. Although we have not required this so far, the same technique can be, in theory, applied to create an additional length of pulmonary artery.
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References
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Todd R.E., Goldberg M., Koshal A., et al. Separate extraction of cardiac and pulmonary grafts from a single organ donor. Ann Thorac Surg 1988;46:356-359.[Abstract/Free Full Text]
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Grebenik C.R., Hinds C.J. Management of the multiple organ donor. Br J Hosp Med 1987;38:62-65.[Medline]
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Kirby T.J., Birnbaum P.L. Technique of single lung transplantation. In: Patterson G.A., Couraud L., eds. Lung transplantation. New York: Elsevier, 1995:195-202.
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Abstract
Introduction
