Infant En Bloc Lung Transplantation

Abstract

•The en bloc double lung transplantation technique involves only three anastomosis, reducing cardiopulmonary bypass times and theoretically reducing graft ischemic times. •In our Institution, the en bloc double lung transplantation is the preferred technique for infant population, with favorable outcomes. Only a handful of highly specialized transplant centers across the world are performing pediatric lung transplantation. Growing experience with sequential bilateral transplants has resulted in improved outcomes and it has mostly replaced the en bloc double lung transplant technique. In our institution, however, we preferentially adopted this technique for the infant population and we have noted favorable outcomes with this approach. Median sternotomy and dissection of the aorta, aortopulmonary window and right pulmonary artery is performed. The trachea is exposed between the aorta and the superior vena cava. The lungs are mobilized and the hilar structures are isolated extrapericardially. The pericardium is opened on both sides and pleuropericardial windows are developed. The recipient is cannulated at the ascending aorta, superior vena cava and IVC. Each lung is removed sequentially with the division of the pulmonary veins, pulmonary arteries, and main bronchi all extrapericardially. The donor right and the left lungs are prepared and passed into the respective hemithoraces through their respective pericardial windows. The donor distal trachea is then taken into the posterior mediastinum between the superior vena cava and aortic arch and suture anastomosed with recipient trachea. The recipient main pulmonary artery is divided just proximal to its bifurcation and main pulmonary artery to main pulmonary artery end to end anastomosis is carried out. An oblique atriotomy is made between the ligated stumps of the right and left pulmonary veins, and extended into the left atrial appendage. The donor left atrial cuff is anastomosed to this atriotomy. The lungs are slowly reinflated and ventilated. Only a handful of highly specialized transplant centers across the world are performing pediatric lung transplantation. Growing experience with sequential bilateral transplants has resulted in improved outcomes and it has mostly replaced the en bloc double lung transplant technique. In our institution, however, we preferentially adopted this technique for the infant population and we have noted favorable outcomes with this approach. Median sternotomy and dissection of the aorta, aortopulmonary window and right pulmonary artery is performed. The trachea is exposed between the aorta and the superior vena cava. The lungs are mobilized and the hilar structures are isolated extrapericardially. The pericardium is opened on both sides and pleuropericardial windows are developed. The recipient is cannulated at the ascending aorta, superior vena cava and IVC. Each lung is removed sequentially with the division of the pulmonary veins, pulmonary arteries, and main bronchi all extrapericardially. The donor right and the left lungs are prepared and passed into the respective hemithoraces through their respective pericardial windows. The donor distal trachea is then taken into the posterior mediastinum between the superior vena cava and aortic arch and suture anastomosed with recipient trachea. The recipient main pulmonary artery is divided just proximal to its bifurcation and main pulmonary artery to main pulmonary artery end to end anastomosis is carried out. An oblique atriotomy is made between the ligated stumps of the right and left pulmonary veins, and extended into the left atrial appendage. The donor left atrial cuff is anastomosed to this atriotomy. The lungs are slowly reinflated and ventilated.