JTCS Medtronic Endurant
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Klaus Kallenbach
Axel Haverich
Martin Strüber
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kallenbach, K.
Right arrow Articles by Strüber, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kallenbach, K.
Right arrow Articles by Strüber, M.
Related Collections
Right arrow Lung - transplantation
Right arrow Extracorporeal circulation
Right arrow Transplantation - heart

J Thorac Cardiovasc Surg 2007;134:543-544
© 2007 The American Association for Thoracic Surgery

Brief Communication

Heart–lung transplantation in a patient with large aortopulmonary collaterals by means of an extended approach

Klaus Kallenbach, MD*, Andre R. Simon, MD, Axel Haverich, MD, Martin Strüber, MD

Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany.

Received for publication January 12, 2007; accepted for publication January 23, 2007.

* Address for reprints: Klaus Kallenbach, MD, University Hospital Heidelberg, Department of Cardiac Surgery, INF 110, D-69120 Heidelberg, Germany. (Email: klaus.kallenbach{at}med.uni-heidelberg.de).

For combined heart–lung transplantation, median sternotomy represents the standard approach, allowing exposure of the ascending aorta, both caval veins, and the distal trachea.1Go However, aortopulmonary collaterals at the dorsal aspect of pulmonary vessels cannot be reached. Here we report of an innovative approach combined with atypical cannulation for cardiopulmonary bypass (CPB) to control severe aortopulmonary collaterals in a patient requiring combined heart–lung transplantation after multiple congenital heart operations.

Clinical Summary

A 25-year-old female patient presented with congestive heart failure of New York Heart Association class IV, vertigo, and central cyanosis. She was born with atresia of the pulmonary artery, a high ventricle septal defect, and multiple aortopulmonary collaterals, and she was operated on several times for re-establishment of pulmonary circulation: placement of a right-sited modified Blalock–Taussig shunt and unifocal attachment of a bronchial collateral vessel, resection of the infundibulum, and connection of the right ventricle to the pulmonary artery combined with closure of a ventricular septal defect and placement of a Blalock–Taussig shunt. Postoperative arterial pulmonary hypertension required reopening of the ventricular septal defect and banding of the homograft. However, arterial pulmonary hypertension persisted and finally led to Eisenmenger’s reaction combined with persistent aortopulmonary collaterals perfusing both the left and right pulmonary arteries (Figure 1). Because of rapid clinical deterioration but absence of alternate therapeutic options, the young patient was listed for high-urgency combined heart–lung transplantation.


Figure 1
View larger version (89K):
[in this window]
[in a new window]

  		Figure 1. Demonstration of large aortopulmonary collateral before combined heart–lung transplantation. A computed tomographic scan identifies large collaterals, with its origin from the middle portion of the descending aorta to both lungs.

 
After allocation of a suitable organ, the patient was prepared for transplantation. The chest was opened by using a clamshell incision. The ascending aorta, aortic arch, proximal descending aorta, and hilus of the left lung were prepared. Normothermic CPB was established by means of cannulation of the ascending aorta and percutaneous insertion of a long cannula reaching the right atrium (Heartport) through the left femoral vein. Then, a second aortic cannula was inserted into the distal descending aorta and connected to CPB, and the patient was cooled to 26°C. When the heart started to fibrillate, the aorta was clamped beneath the left subclavian artery and also directly above the distal cannulation. After left-sided pneumonectomy, several aortopulmonary collaterals of 5 to 8 mm connecting the clamped aorta and both pulmonary arteries were isolated and ligated. Aortic clamps were opened, and rewarming was initiated. Meanwhile, right pneumonectomy after mobilization of severe adhesions was undertaken. Thereafter, mobilization of the heart was commenced. Serious adhesions fixed the massively enlarged heart at its dorsal aspect, which was not reachable by using the clamshell approach. Therefore a partial caudal median sternotomy reaching from the transverse sternotomy to the xiphoid was conducted. By using this approach, all aspects of the heart were accessible. The ascending aorta was clamped, and the heart was excised. The trachea was shortened and prepared for anastomosis with the graft. Both phrenic nerves were preserved in cuffs. Before orthotopic implantation of the graft, the distal aortic cannula was removed, and CPB was continued through the cannula in the ascending aorta. The operation was continued in a standard fashion by anastomosing the trachea, aorta, and caval veins. After careful deairing, blood flow was revived, and the heart started beating in sinus rhythm after adequate reperfusion. Weaning from CPB was undertaken without problems. Both transverse and median sternotomies were readapted with sternal wires, and the thoracotomy was closed in a routine fashion.

Postoperatively, 2 rethoracotomies were required because of bleeding. Otherwise, the postoperative course was uneventful. Today, the patient is doing well and runs a business on an island. The incisions healed without complications but with excessive scar tissue, and the thorax is stabile (Figure 2).


Figure 2
View larger version (97K):
[in this window]
[in a new window]

  		Figure 2. Photograph of the patient’s frontal aspect 2 years postoperatively. The scar from an upper median sternotomy above the clamshell incision remains from congenital heart surgery during childhood.

 
Discussion

Median sternotomy represents the standard approach for combined heart–lung transplantation, allowing excellent access to the upper and anterior mediastinum.1Go However, a clamshell incision allows more extensive access to lung hili and dorsal mediastinum.2,3Go Marta and colleagues4Go reported an inverse T incision, combining a clamshell incision with a partial proximal median sternotomy for access to anterior, supra-aortic, and lateral mediastinal structures. However, the remaining caudal sternum makes access to the posterior and caudal aspects of the heart difficult. To allow mobilization and luxation of the severely adhered heart, we added a partial distal median sternotomy to the clamshell incision.

The combination of both incisions has not been reported previously. It allows excellent exposure to all relevant structures that must be dissected for heart–lung transplantation as a redo case but leaves the upper sternum intact. Possible injury of mediastinal structures during resternotomy can be avoided, and postoperative stability of the thorax with intact upper mediastinum will quicken recovery.

In anticipation of aortopulmonary collaterals, we chose the clamshell incision initially. With use of double cannulation for exclusion of the descending aorta from perfusion and establishment of hypothermia, we safely controlled the collaterals. This cannulation technique has not been described yet for controlling severe aortopulmonary collaterals during heart–lung transplantation but was the pivotal strategy to conduct the operation successfully. With increasing numbers of adults requiring heart–lung transplantation after correction of congenital heart disease but eventually development of Eisenmenger’s reaction,5Go our approach might help to reduce the operative risk.

References

  1. Harringer W, Haverich A. Heart and heart–lung transplantation: standards and improvements. World J Surg 2002;26:218-225.[Medline]
  2. Macchiarini P, Ladurie FL, Cerrina J, Fadel E, Chapelier A, Dartevelle P. Clamshell or sternotomy for double lung or heart–lung transplantation?. Eur J Cardiothorac Surg 1999;15:333-339.[Abstract/Free Full Text]
  3. Kaiser LR, Pasque MK, Trulock EP, Low DE, Dresler CM, Cooper JD. Bilateral sequential lung transplantation: the procedure of choice for double-lung replacement. Ann Thorac Surg 1991;52:438-445.[Abstract/Free Full Text]
  4. Marta GM, Aigner C, Klepetko W. Inverse T incision provides improved accessibility to the upper mediastinum. J Thorac Cardiovasc Surg 2005;129:221-223.[Free Full Text]
  5. Hosseinpour AR, Cullen S, Tsang VT. Transplantation for adults with congenital heart disease. Eur J Cardiothorac Surg 2006;30:508-514.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 World Journal for Pediatric and Congenital Heart SurgeryHome page
L. B. Pauliks and A. Undar
Heart Transplantation for Congenital Heart Disease
World Journal for Pediatric and Congenital Heart Surgery, October 1, 2011; 2(4): 603 - 608.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
K. Januszewska, E. Malec, G. Juchem, I. Kaczmarek, R. Sodian, P. Uberfuhr, and B. Reichart
Heart-lung transplantation in patients with pulmonary atresia and ventricular septal defect
J. Thorac. Cardiovasc. Surg., September 1, 2009; 138(3): 738 - 743.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Klaus Kallenbach
Axel Haverich
Martin Strüber
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kallenbach, K.
Right arrow Articles by Strüber, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kallenbach, K.
Right arrow Articles by Strüber, M.
Related Collections
Right arrow Lung - transplantation
Right arrow Extracorporeal circulation
Right arrow Transplantation - heart

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS