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J Thorac Cardiovasc Surg 1994;108:992-993
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Invited letter concerning: Double lung transplantation in situs inversus with Kartagener's syndrome

Yale University
New Haven, CT 06510

To the Editor:

I read with great interest the paper by Dr. Macchiarini and his colleagues in Paris describing their direct and effective technical approach to bilateral lung transplantation in patients with Kartagener's syndrome (J THORAC CARDIOVASC SURG 1994;108:86-91).

They describe a sensible approach to cannulation and cardiopulmonary bypass, with cannulation of the ascending aorta, bicaval venous cannulation, and preservation of the drainage from the large azygos vein. In their double lung transplant approach to this disease, they have carefully discussed and described the bronchial surgical anatomy and iterated two important principles. One is the great utility of the approach to the carina between the aorta and superior vena cava. This approach, pioneered by Perelman ¹ and others, has been shown to have broad application in the treatment of a variety of lesions, including postpneumonectomy bronchopleural fistula. ² It is also used in the cardiopulmonary donor operation, because it facilitates the clamping of the trachea well above the carina and permits avoidance of excessive dissection and devascularization of the proximal main stem bronchi.

This leads to the second important principle of this paper, the avoidance of devascularizing the carina, leaving it "with its original vascularization, because it is the milieu at higher risk of ischemia in en bloc DLT with tracheal anastomosis."

The article that they cite to support the importance of collateral circulation in bronchial healing reported a 50% overall incidence of major ischemic airway complications (8 of 16 patients), with 13 tracheal anastomoses (7 complications) and 3 bilateral bronchial anastomoses (1 complication). ³

Because of the early establishment of coronary to bronchial collateral circulation, airway ischemic complications are extremely unusual after combined heart-lung transplantation. ⁴ Moreover, in contrast to the authors' contention in this article, the risk of cardiac rejection in heart-lung transplantation is small, so that surveillance cardiac biopsies are not required. Thus the advantages of the combined heart-lung approach must be considered against the single legitimate negative concern, the potential "loss" of a donor heart in cases in which heart replacement is not strictly necessitated by the pathophysiology.

In the present allograft era, this is a significant concern. When xenograft strategies are available, the surgical advantages of the combined cardiopulmonary technique may be reconsidered.

References

1. Perelman MI. Late treatment of chronic bronchopleural fistula with long stump after pneumonectomy. In: Eschapasse H, Grillo H, eds. International trends in general thoracic surgery. Vol 2. Philadelphia: WB Saunders.
   
2. Baldwin JC, Mark JBD. Treatment of bronchopleural fistula after pneumonectomy. J THORAC CARDIOVASC SURG 1985;90:813-7.[Abstract]
   
3. Patterson GA, Todd TR, Cooper JD, et al. Airway complications after double lung transplantation. J THORAC CARDIOVASC SURG 1990;99:14-21.[Abstract]
   
4. Baldwin JC, Jamieson SW, Oyer PE, et al. Bronchoscopy after cardiopulmonary transplantation. J THORAC CARDIOVASC SURG 1985;89:1-8.[Abstract]
   

This Article Alert me when this article is cited Alert me if a correction is posted 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): John C. Baldwin Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Baldwin, J. C. Search for Related Content PubMed PubMed Citation Articles by Baldwin, J. C.