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Ann Thorac Surg 2007;84:314-316
© 2007 The Society of Thoracic Surgeons

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How To Do It

Prior Cardiac Surgery is Not a Contraindication for Lung Donor

Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Accepted for publication September 19, 2006.

^_* Address correspondence to Dr Toyoda, Division of Cardiac Surgery, University of Pittsburgh Medical Center, 200 Lothrop St, C-700 PUH, Pittsburgh, PA 15213 (Email: toyoday{at}upmc.edu).

	Abstract

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We present two successful lung transplants utilizing lungs from a donor who had a previous cardiac surgery. We describe tips and pitfalls of harvesting donor lungs from redo-chest operations.

	Introduction

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To maximize the utilization of donor organs in lung transplantation, many transplant centers have been liberalizing the donor lung selection criteria [1–4]. However, of the criteria, prior cardiopulmonary surgery seems to remain an exclusion criterion [1–2] and has not been fully evaluated. In this report we present two recent cases in which successful double-lung transplantations were performed utilizing the lungs from donors who already had previous open heart surgeries. Of note, these were the only two opportunities that were personally experienced.

	Technique

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Patient 1
The patient was a 46-year-old woman who had undergone right single-lung transplantation in April 2000 for -1 antitrypsin deficiency and progressive respiratory insufficiency. She had chronic rejection develop. She was evaluated for re-transplantation and was ultimately placed on the lung transplant waiting list for double-lung transplantation. Her height was 163 cm and her weight was 42 kg. A pulmonary function test in September 2004 showed a forced vital capacity (FVC) of 1.46 L (43% predicted), forced expiratory volume in 1 second (FEV₁) of 0.43 L (16% predicted), and FEV₁/FVC of 29%. A potential donor became available and she was taken to the operating room in March 2005. The donor was a 58-year-old woman who died of a stroke and was hospitalized for 3 days. The donor’s height was 173 cm and her weight was 69 kg. The donor had a history of hypertension, but no smoking history. The donor had undergone mitral valve replacement through a median sternotomy in 2002 for bacterial endocarditis. The donor’s medication included Coumadin (warfarin, Bristol-Myers Squibb, New York, NY) and metoprolol. A chest roentgenogram showed clear lungs, and a bronchoscopy showed a clear bronchial tree. Blood gas on PIO ₂ of 1.0 and positive end-expiratory pressure of 5 cm H₂O showed PaO ₂ of 526 mm Hg and PCO ₂ of 43 mm Hg. The donor lungs were harvested bilaterally through a redo median sternotomy without any injuries, using the technique described as follows. For the recipient, a clamshell incision and bilateral anterior thoracotomy through the fourth intercostal space extending across the midline were carried out. The adhesions due to prior single-lung transplant were quite dense and therefore were dissected out entirely. Double lung re-transplantation was performed in a usual fashion in which an end-to-end bronchial anastomosis was done with 3-0 Prolene [Ethicon, Somerville, NJ], an end-to-end pulmonary arterial anastomosis with 5-0 Prolene [Ethicon], and an end-to-end left atrial cuff with 4-0 Prolene [Ethicon] in a running fashion. For each side, 800 cc of cold pneumoplegia was given after the bronchial anastomosis, and 800 cc of warm pneumoplegia was given before reperfusion. The ischemic time of the left lung was 253 minutes and the right lung was 401 minutes. For immunosuppression, the patient received 30 mg of Campath (alemtuzumab, Berlex Laboratories, Wayne, NJ) as an induction at the start of the operation, 250 mg of Solu-Medrol (methylprednisolone, Pfizer, New York, NY) was given before reperfusion for each side, and tacrolimus-based maintenance therapy was used. The patient was extubated postoperatively on day 2, transferred to the floor on postoperative day 4, and discharged home on postoperative day 24 with oxygen saturation of 98% on room air. There were no significant air leaks postoperatively, and the four chest tubes (two in each chest) were removed by postoperative day 8. Her biopsy showed minimal acute cellular rejection and no evidence of obliterans bronchiolitis. She is doing well 1 year postoperatively, with FVC of 2.06 L (61% predicted), FEV₁ of 1.95 L (75% predicted), and FEV₁/FVC of 95%.

Patient 2
The patient was a 38-year-old woman who had undergone double-lung transplantation in August 2002 for pulmonary fibrosis and progressive respiratory insufficiency. She had chronic allograft dysfunction with bronchiolitis obliterans syndrome develop, and she was ultimately listed for a double-lung re-transplantation. Her height was 170 cm and her weight was 61 kg. A pulmonary function test in November 2004 showed a FVC of 1.64 L (44% predicted), FEV₁ of 0.48 L (17% predicted), and FEV₁/FVC of 29%. A potential donor became available and she was taken to the operating room in April 2005. The donor was a 54-year-old man who died of stroke and was hospitalized for 3 days. The donor’s height was 177 cm and his weight was 68 kg. The donor had a history of hypertension, hyperlipidemia, cerebrovascular accident with seizure, and end-stage renal dysfunction with hemodialysis since 2000; he had no smoking history. The donor had undergone mitral valve replacement through a median sternotomy in May 2004. The donor’s medication included aspirin, Plavix (clopidogrel, Apotex, Ontario, Canada), and Lipitor (atorvastatin, Pfizer, New York, NY). A chest roentgenogram showed atelectasis in the left base, otherwise clear lungs, and a bronchoscopy showed a clear bronchial tree. Blood gas on PIO₂ of 1.0 and positive end-expiratory pressure of 5 cm H₂O showed PaO ₂ of 510 mm Hg and PCO ₂ of 44 mm Hg. The donor lungs were harvested bilaterally without any injuries. The recipient received a clamshell incision and a bilateral anterior thoracotomy through the fourth intercostal space extending across the midline. The adhesions due to prior double-lung transplant were extremely dense and were dissected out entirely. Double-lung re-transplantation was performed in a way described in the first case, except for the bronchial anastomosis in which an end-to-end bronchial anastomosis was performed in an intussusceptive fashion using 3-0 Prolene running suture [Ethicon] for the membranous portion and 3-0 polydioxanone interrupted mattress suture for the rest, due to the size mismatch. The ischemic time of the right lung was 333 minutes and the left was 463 minutes. The patient was extubated postoperatively on day 1, transferred to the floor on postoperative day 3, and discharged home on postoperative day 15 with an oxygen saturation of 99% on room air. There were no significant air leaks postoperatively, but the four chest tubes (two in each chest) were removed by postoperative day 10 because of persistent pleural effusion, most likely due to adhesions in the redo double-lung transplantation. Biopsy showed no acute cellular rejection and no evidence of obliterans bronchiolitis. She is doing well 11 months postoperatively, with a FVC of 2.60 L (70% predicted), FEV₁ of 2.23 L (77% predicted), and FEV₁/FVC of 86%.

Donor Harvest Technique
The importance of the technique for donor harvesting is to avoid unnecessary dissection (especially behind the sternum, which can potentially cause injury to the lung, heart, or both) and to harvest quickly as other teams also harvest abdominal organs. The technique is described as follows, supposing that a single surgeon is harvesting the lungs with no assistants.

Median sternotomy: (1) usual skin incision followed by removing the previous wires; (2) sternotomy with oscillating saw: first the anterior plate and then the posterior plate with the lungs down; (3) dissect behind the sternum minimally enough to place a chest spreader; (4) putting a small retractor such as an Army-Navy in between the split sternum helps to keep the minimum space to access to the back of the sternum for dissection without tearing the right ventricle or the innominate vein.

1 Get into the pleural space without any damage to the lung and dissect the adhesion around the lung away from the lungs and close to the chest wall or parietal pleura and assess the lung in a usual manner. Do the same thing to the opposite lung and decide whether the lungs can be utilized for transplant. If necessary, a mammary retractor is useful at this point for the dissection of the adhesion around the lung if any. The innominate vein must be dissected free, then mobilize it and divide it if there is no central line from the left jugular or subclavian veins so that the chest spreader can be opened widely and the exposure will be better.

2 After making a decision to utilize the lungs, start dissecting the heart. First the diaphragmatic surface of the heart is dissected and the appropriate plane is found. Along the plane, dissection is carried toward the inferior vena cava, right atrium, and superior vena cava (SVC). Then the aorta is dissected and an umbilical tape is passed around the aorta. While retracting the aorta to the right, we dissect between the aorta and the pulmonary artery. The aorta becomes free from the main and right pulmonary artery. While retracting the aorta to the left, we dissect the SVC from the innominate vein and separate it from the right pulmonary artery. We go around the SVC and azygos vein with a heavy silk tie. The anterior surface of the heart, mainly the right ventricle, and the right side of the heart, the right atrium to the left atrium, and the right pulmonary veins, should be dissected out before cross-clamping. The rest of the surface of the heart, the left side and the posterior side of the surface of the heart, can be dissected before cross-clamping as long as the hemodynamics are stable with retracting and manipulating the heart, but this can be done quickly after cross-clamping.

3 The standard procurement procedure is as follows:

(1) Heparinize.

(2) Cannulate proximally on the main pulmonary artery.

(3) Tine and divide the azygos vein, and tie the SVC or the innominate veins.

(4) Inject prostaglandin E1 (Novopharm, Ontario, Canada) (500 mcg in 10 cc) with 0.9% NaCl into the main pulmonary artery (PA).

(5) Cut inferior vena cava.

(6) Cut left atrial appendage.

(7) Start perfusing Perfadex (Vitrolife, Stockholm, Sweden) (total of 70 cc/kg body weight, the first 1 L bag includes 500 mcg of prostaglandin E1 and 50 mg of nitroglycerin).

(8) Put ice into the chest cavity.

(9) Keep ventilating the lungs with reduced tidal volume (5 cc/kg).

(10) While giving Perfadex, one can cut the SVC, the innominate artery and the aorta without distorting the PA.

(11) After all the Perfadex (Vitrolife) is in, take out the cannula from the main PA and divide the main PA at the cannulation site.

(12) Start cutting left atrium along the atrioventricular groove from the opening in the left atrial appendage. On the right, we prefer to dissect the interatrial groove to make sure there is an adequate left atrial cuff. After the heart is out, take out the lung in a usual fashion. At this point, the adhesion behind the hilum can be safely dissected without damaging the lungs.

(13) At the back table, we perfuse 1 L of Perfadex from the pulmonary vein orifices for each lung.

	Comment

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This article shows that prior cardiac surgery is not an absolute contraindication for donor lung procurement. Although harvesting the lungs without any injuries from the redo chest is technically challenging, it can be done safely and quickly. From a technical aspect, the most important things are to cause no harm to the lungs and speed in harvesting. The surgeons have to be able to perform a redo sternotomy almost like the first time sternotomy, and dissect behind the sternum minimally enough to put a chest spreader in. If one dissects behind the sternum too much, the lungs will be injured. Before dissecting the heart, the surgeons have to dissect and inspect the lungs and make a decision whether or not to utilize the lungs. To obtain a good exposure by widely spreading the sternum, the surgeons must dissect the innominate vein free, and divide it if there is no central line from the left internal jugular or the left subclavian veins. As soon as it is decided to procure the lungs, contact with the recipient team should be made, giving them an estimated cross-clamp time. It usually takes 30 to 60 minutes to dissect the lungs and heart to make it ready for cross clamping, depending on the adhesion.

The heart will be dissected after the decision is made to utilize the lungs. At least the pulmonary artery must be exposed for pneumoplegia, the left atrial appendage for left-sided drainage and the inferior vena cava for right-sided drainage before cross clamping. Eventually, the pulmonary artery needs to be free from the aorta and SVC, and the pulmonary veins and left atrium need to be freed for adequate cuff. It is easier to dissect the front, right, and inferior aspect of the heart before cross clamping, and the left lateral and posterior aspects after cross clamping. All the remaining adhesions, mainly on the left to the posterior surface of the heart can be cleared quickly with blunt and sharp dissection after cross clamping.

Both donors in this report had undergone mitral surgery and had mild to moderate adhesions in the pleural spaces. As long as the surgeons dissect the lungs away from the lungs and close to the parietal pleura or the chest wall (we do not have to preserve phrenic nerves), the lungs should be able to be harvested without any injuries. Therefore, we believe we should be able to harvest lungs safely from a donor with previous coronary artery bypass grafting in which there may be more adhesions related to the left internal mammary artery harvest. To access to the inferior pulmonary ligament, the heart should be retracted toward the opposite side and placed in the contralateral chest cavity, and the pericardium should be cut transversely down to the inferior vena cava. The adhesions posterior to the hilum should be dissected after cross clamping to avoid too much stress to the heart and lungs.

This report shows that lungs from a donor with prior cardiac surgery can be successfully used for lung transplantation. The number of available donor lungs will be increased by this strategy described in this article.

	References

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1. de Perrot M, Weder W, Patterson GA, Keshavjee. Strategies to increase limited donor resources Eur Respir J 2004;23:477-482.[Abstract/Free Full Text]
2. Bhorade SM, Vigneswaran W, McCabe MA, Garrity ER. Liberalization of donor criteria may expand the donor pool without adverse consequence in lung transplantation J Heart Lung Transplant 2000;19:1199-1204.[Medline]
3. Gabbay E, Williams TJ, Griffiths AP, et al. Maximizing the utilization of donor organs offered for lung transplantation Am J Respir Crit Care Med 1999;160:265-271.[Abstract/Free Full Text]
4. Pierre AF, Sekine Y, Hutcheon MA, Waddell TK, Keshavjee SH. Marginal donor lungs: a reassessment J Thorac Cardiovasc Surg 2002;123:421-428.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yoshiya Toyoda Kenneth R. McCurry Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Toyoda, Y. Articles by McCurry, K. R. Search for Related Content PubMed PubMed Citation Articles by Toyoda, Y. Articles by McCurry, K. R. Related Collections Lung - transplantation