Ann Thorac Surg 2006;81:1524-1525
© 2006 The Society of Thoracic Surgeons
How to do it
Use of an Apical Heart Suction Device for Exposure in Lung Transplantation
Christine L. Lau, MD
*
,
David M. Hoganson, MD,
Bryan F. Meyers, MD,
Ralph J. Damiano, Jr, MD,
G. Alexander Patterson, MD
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
Accepted for publication February 17, 2005.
* Address correspondence to Dr Lau, 1 Barnes-Jewish Hospital, Department of Surgery, Division of Cardiothoracic Surgery, Suite 3108 Queeny Tower, St. Louis, MO 63110 (Email: lauch{at}msnotes.wustl.edu).
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Abstract
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Cardiopulmonary bypass is not necessary for the performance of bilateral sequential lung transplantation in most circumstances. Inadequate exposure to the left hilum is occasionally the sole indication for institution of cardiopulmonary bypass. We report the use of a suction heart positioning device to allow lifting of the heart for improvement of left hilar exposure. This technique has decreased the need for cardiopulmonary bypass when bypass is indicated due to difficult operative exposure.
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Introduction
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With the introduction of bilateral sequential pulmonary transplantation [1], cardiopulmonary bypass is not usually required. The use of cardiopulmonary bypass in the performance of lung transplantation remains a surgeon and institutional preference. Opponents of the use of cardiopulmonary bypass cite experimental [2] and clinical studies [3, 4] suggesting its use during lung transplantation results in increased incidence of acute lung injury and allograft dysfunction. The pro-inflammatory nature of cardiopulmonary bypass is well documented. The use of the bypass machine has been shown to activate neutrophils, cytokines, and the complement cascade [5]. Furthermore, cardiopulmonary bypass increases the requirement for blood transfusion [3, 6]. Obviously full-systemic heparinization is required for cardiopulmonary bypass. Alternatively, cardiopulmonary bypass decreases perfusion to the first implanted lung during implantation of the second lung and allows more controlled reperfusion. In particular, with septic lung disease, cardiopulmonary bypass allows initial excision of both lungs, thereby decreasing the risk of contamination of the donor lungs. Finally, cardiopulmonary bypass allows emptying of the heart and improved exposure of the left hilar structures [6].
We avoid cardiopulmonary bypass during bilateral sequential lung transplant recipients whenever possible. Elective bypass is reserved for children and small adults (patients in whom a double lumen tube cannot be placed), bilateral lobar transplants, recipients for whom intracardiac procedures are planned, and most patients with pulmonary hypertension. In some cases, the decision to place the patient on cardiopulmonary bypass is made when the first allograft is in and the recipient develops acute, severe pulmonary hypertension or pulmonary edema. Occasionally, especially in patients with cystic fibrosis or pulmonary fibrosis, it is necessary to use cardiopulmonary bypass to allow the heart to decompress and improve exposure to the left hilar structures, in particular the left atrial anastomosis. In these patients, vigorous medial and upward retraction of the heart can lead to poor diastolic filling, hypotension, and hemodynamic instability. In 3 recent patients we have utilized the Urchin heart positioning device (Medtronic, Inc, Minneapolis, MN) to improve exposure. This instrument is commonly used in off-pump coronary artery bypass surgery to position the heart for improved exposure to the coronary arteries. This technique may help reduce the need for cardiopulmonary bypass in lung transplantation when difficult exposure precludes safe performance of the left-sided anastomoses.
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Technique
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Our standard exposure for bilateral lung transplant is to use bilateral anterolateral thoracotomies as previously described [7]. For patients with pulmonary hypertension or idiopathic pulmonary fibrosis, sternal division is required at times [8]. We have utilized the Urchin heart positioning device with our two common incisions for bilateral transplantation (ie, bilateral anterolateral thoracotomies and the sternal dividing "clamshell" incision). Both incisions provide adequate exposure to the heart to allow placement of the Urchin device. After removal of the left lung and prior to starting the transplant anastomoses (bronchus, artery, and atrium), the pericardium is opened vertically in the midline to expose the heart. The Urchin device is placed on the apex of the left ventricle, suction is applied, and the heart is positioned for optimal exposure to the left hilar structures (Fig 1). As with our standard approach, we find it simplest to perform the anastomoses from posterior to anterior in the following sequence: bronchus, artery, and atrium.
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Fig 1. Operative photograph showing placement of the Urchin apical heart suction device (Medtronic, Inc, Minneapolis, MN) on the apex of the left ventricle. The left lung has already been removed and the left side is prepared for donor lung implantation. The exposure for the left-sided anastomoses is greatly improved with the use of the Urchin device.
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Following completion of the three anastomoses, the lung is reinflated and slowly reperfused while the atrial anastomosis is left intentionally loose to allow the graft to be flushed of preservative perfusate and for the removal of air. The atrial sutures are then tied. All suture lines as well as the cut edges of pericardium are then checked for hemostasis as ventilation and perfusion are restored. Once this has been completed, the suction on the Urchin device is released, and the heart is returned to the pericardium.
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Comment
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Although certain circumstances demand the need for cardiopulmonary bypass in lung transplantation, on occasion its sole use is to allow for decompression of the heart to enable adequate exposure for the left hilar anastomoses. We have used the Urchin device to allow the heart to be safely retracted and provide optimal exposure. In all four cases, exposure was substantially improved with the use of the Urchin device. One potential problem with the use of this device to retract the heart is hemodynamic instability. When this does occur, the vacuum on the device is simply released, and the heart is returned to its normal anatomic location. Fortunately, none of our patients showed any signs of hemodynamic instability and the device was well tolerated.
The Urchin device has been employed in thousands of coronary bypass procedures without any significant incidence of complications. It does create an apical hematoma on the heart, that while impressive at first, does not result in any long-term sequelae. Some patients will have short-term ST segment changes from the trauma. Despite its relative safety, there are a few precautions that are needed when using this device. It is important that the surgeon follow the manufacturer's recommendations for suction. Excessive suction can result in epicardial evulsion, and significant bleeding. In patients on chronic steroids, our group has seen occasional evulsion of the epicardium even with the recommended suction. This can usually be treated with topical hemostatic agents. Finally, it is important for the surgeon not to place this device over a major epicardial coronary artery. This can create myocardial ischemia, and if left on for a prolonged time, may result in myocardial infarction. On removing the device, there rarely may be ventricular arrhythmias, but this is unusual.
We have utilized this technique as an alternative to cardiopulmonary bypass on three recent occasions in lung transplantation. We have also used the Urchin device once for exposure on a nontransplant patient with bilateral posterior lower lobe masses that were removed through a median sternotomy. The use of the Urchin apical heart suction device may prevent unnecessary use of cardiopulmonary bypass in lung transplantation for cases when it is required solely for exposure.
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References
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- Pasque MK, Cooper JD, Kaiser LR, et al. An improved technique for bilateral lung transplantationrationale and initial clinical experience. Ann Thorac Surg 1990;49:785-791.[Abstract]
- Fullerton DA, McIntyre RC, Mitchell MB, et al. Lung transplantation with cardiopulmonary bypass exaggerates pulmonary vasomotor dysfunction in the transplanted lung J Thorac Cardiovasc Surg 1995;109:212-217.[Abstract/Free Full Text]
- Gammie JS, Lee J-C, Pham SM, et al. Cardiopulmonary bypass is associated with early allograft dysfunction but not death after double-lung transplantation J Thorac Cardiovasc Surg 1998;115:990-994.[Abstract/Free Full Text]
- Aeba R, Griffith BP, Kormos RL, et al. Effect of cardiopulmonary bypass on early graft dysfunction in clinical lung transplantation Ann Thorac Surg 1994;57:715-722.[Abstract]
- Wan S, LeClerc JL, Vincent JL. Inflammatory responses to cardiopulmonary bypassmechanism involved and possible therapeutic strategies. Chest 1997;112:676-692.[Abstract/Free Full Text]
- Szeto WY, Kreisel D, Karakousis GC, et al. Cardiopulmonary bypass for bilateral sequential lung transplantation in patients with chronic obstructive pulmonary disease without adverse effect on lung function or clinical outcome J Thorac Cardiovasc Surg 2002;124:241-249.[Abstract/Free Full Text]
- Meyers BF, Sundaresan RS, Guthrie T, et al. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications J Thorac Cardiovasc Surg 1998;117:358-364.
- Lau C, Patterson GA. Technical considerations in lung transplantation Chest Surg Clin N Am 2003;13:463-483.[Medline]
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Abstract
Introduction
