Technique of Successful Clinical Double-Lung Transplantation

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1 Technique of Successful Clinical Double-Lung Transplantation G. A. Patterson, M.D., F.R.C.S. (C), J. D. Cooper, M.D., F.R.C.S. (C), B. Goldman, M.D., F.R.C.S. (C), R. D. Weisel, M.D., F.R.C.S. (C), F. G. Pearson, M.D., F.R.C.S. (C), P. F. Waters, M.D., F.R.C.S. (C), T. R. Todd, M.D., F.R.C.S. (C), H. Scully, M.D., F.R.C.S. (C), M. Goldberg, M.D., F.R.C.S. (C), and R. J. Ginsberg, M.D., F.R.C.S. (C) ABSTRACT Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient s own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation. In the twenty years following the first human lung transplantation in 1963 [l], more than forty isolated lung transplantations were performed without a single longterm clinical success. With the availability of cyclosporine, the employment of bronchial anastomotic omentopexy, and improved criteria for donor and recipient selection, we have experienced success with unilateral lung transplantation in patients with pulmonary fibrosis [2, 31. However, a large number of patients with end-stage pulmonary disease are not candidates for single-lung transplantation. In patients with septic pulmonary disease (e.g., bronchiectasis, cystic fibrosis), the remaining native lung would serve as a focus of continuing sepsis in the immunosuppressed recipient subsequent to transplantation. In addition, emphysema is not well suited to single-lung transplantation. The overly compliant native lung would receive much of the ventilation, while perfusion would preferentially be directed to the transplanted normal lung. From the Divisions of Thoracic Surgery and Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ont, Canada. Presented at the Twenty-third Annual Meeting of The Society of Thoracic Surgeons, Toronto, Ont, Canada, Sept 21-23, Address reprint requests to Dr. Patterson, Division of Thoracic Surgery, Toronto General Hospital, Eaton Bldg N , Toronto, Ont, M5G 2C4, Canada. Combined heart-lung transplantation has been used with limited success in these patients. The ideal condition suited to combined heart-lung transplantation is primary pulmonary hypertension. Even in these patients, combined heart-lung transplantation is associated with significant operative mortality and limited one-year survival [4]. Generally the results of combined heartlung transplantation for primary parenchymal pulmonary disease are poorer than those observed for primary pulmonary hypertension. Many patients with terminal emphysema or septic lung disease retain adequate cardiac function. In this situation, transplantation of both lungs without the need for cardiac replacement would seem to be the ideal procedure. We have previously described a canine model of en bloc double-lung transplantation [5]. Utilization of this procedure in primate experiments and our initial clinical experience have also been reported [6]. Our current technique for en bloc double-lung transplantation is described here. Material and Methods Recipient Selection Six patients underwent en bloc double-lung transplantation. There were 4 female and 2 male patients ranging in age from 16 to 43 years. Five patients had emphysema. In 3, it was due to alpha,-antitrypsin deficiency. One patient had primary idiopathic bronchiolitis obliterans and another, eosinophilic granulomatosis. One patient had primary pulmonary hypertension. Each of these patients had demonstrated marked clinical deterioration within the year prior to transplantation. Four of the patients required constant oxygen supplementation, and all had marked restriction in exercise tolerance. Despite their clinical status, each of the 5 patients with emphysema was believed, on the basis of nuclear ventriculographic and clinical evaluations, to have preserved right ventricular systolic function. The right ventricular ejection fractions were moderately depressed (between 22 and 36%), but intrinsic right ventricular contractility was thought to be preserved. A 16-year-old boy with primary pulmonary hypertension had a right ventricular ejection fraction of 24% at the initial assessment. However, during the six months of waiting for a donor, his heart size increased radiographically and right ventricular ejection fraction fell to 16%. A doublelung transplantation was performed because intrinsic 626 Ann Thorac Surg 45:62&633, June Copyright by The Society of Thoracic Surgeons

2 627 Patterson et al: Double-Lung Transplantation right ventricular systolic function was thought to be preserved [7, 81. All 6 of these patients were judged to have a limited life expectancy, with death likely to occur within the ensuing year based on severity of disease and rate of progression. Donor Selection Donors were Selected on the basis of four major criteria: clear chest roentgenogram, adequate gas exchange, suitable size match, and ABO compatibility. A minimal pulmonary infiltrate on one side was accepted if other criteria were satisfactory. Gas exchange was judged adequate if arterial oxygen tension was greater than 300 mm Hg on 100% oxygen and 5 cm of positive endexpiratory pressure. A suitable size match was somewhat difficult to estimate, particularly in emphysematous recipients. A donor was acceptable if he or she was no smaller than the recipient by 20% in vertical lung height, transverse chest diameter, and chest circumference. The graft was procured from 3 donors in our hospital and 3 other donors at a distance. Time of graft ischemia ranged from 2 hours to 4 hours 20 minutes. Donor Operation A median sternotomy is performed, and the pericardium and pleural cavities are opened. The superior vena cava is mobilized above the azygos vein. The inferior vena cava is encircled from within the pericardium. The aorta and pulmonary artery are dissected free from one another and encircled. The trachea is identified in the posterior mediastinum by retracting the superior vena cava to the right and the ascending aorta to the left. The donor specimen consists of the two lungs including the distal trachea, the main pulmonary artery, and a cuff of left atrium containing the four pulmonary veins (Fig 1). To create this specimen in our first 2 patients, the donor heart-lung block was excised using the method previously described by Jamieson and colleagues [9]. Since the heart was not used, cardioplegia was not administered. The heart is separated from the donor lung block by dividing the atrial ventricular groove and entering the left atrium on the left side of the heart. This dissection is then continued, completely removing the ventricles from the atria. The right atrium and left atrial appendage are excised with an ample cuff of left atrium left on the donor side. The pulmonary artery and trachea are trimmed to length once they are placed in the recipient chest. As much pericardium as possible is left on the donor specimen. In 3 donors, the heart was used as a graft for another recipient. After appropriate dissection, low sodium crystalloid cardioplegia is administered and the heart is excised in situ, with care taken to preserve an adequate cuff of left atrium and enough pulmonary artery on the heart and lung side for subsequent anastomosis. The heart graft obtained in this manner was used successfully in each instance. We have preserved the donor grafts by immersion of Fig 1. The donor double-lung specimen contains a generous left atrial cuff and encompasses the prilmona y vein orifices, main pulmonary artery, and trachea. Large flaps of pericardium are attached and will subsequently be sutured to the inner aspect of the recipient pericardium. the partially inflated lungs in 4 C Euro-Collins solution with satisfactory function after ischemic periods of up to 4% hours. Recently, we have used pulmonary artery flush with 4 C Euro-Collins solution (30 ml per kilogram of body weight) prior to immersion; the results are similar. To keep fluid from entering the lungs during immersion, the donor trachea is stapled shut at the site of division in the midtrachea. Recipient Operation This operation is begun by placement of arterial, central venous, and Swan-Ganz monitoring lines. A Foley catheter is placed in the bladder. During induction of anesthesia and intubation, great care must be exercised in emphysematous patients to avoid overinflation of the lungs because this can produce a marked rise in pleural pressure and decreased venous return. A median sternotomy is performed with extension into the upper epigastrium. The omentum is freed from its attachments to the colon and pedicled on one of its major vessels to achieve adequate length for subsequent placement up into the posterior mediastinum around the tracheal anastomosis. The aorta is separated from the main pulmonary artery. Cardiopulmonary bypass is instituted using double venous (with caval tourniquets) and ascending aortic cannulation. Heparin sodium is administered in an initial dose of 200 Uikg, and the activated clotting time is allowed to fall as low as 200 seconds during the bypass procedure in an attempt to reduce postoperative bleed-

3 628 The Annals of Thoracic Surgery Vol 45 No 6 June 1988 Fig 2. (A) Anterior view of the recipient preparation and excision. The double uenous and aortic cannulation, right atrioventricular vent, and cardioplegia line are shown. Staple sites on pulmonary veins and arteries are visible. Pulmonary veins, arteries, and bronchi are divided outside the pericardium during extraction. The site of division of the trachea and pulmonary artery for anastomosis is also shown. (B) Posterior view of staple lines and points of venous, arterial, and airway transection. ing. Membrane oxygenators and intravenous administration of dipyridamole are also employed to preserve platelet function and reduce postoperative bleeding [ 10, 111. In addition, the patient is cooled to 30 C as soon as bypass is instituted to prolong the clotting time and reduce the heparin requirement. Bypass flows are kept higher than 2.5 L/min/m2 to maintain the mean arterial pressure greater than 75 mm Hg to provide adequate perfusion, particularly to the heart, during the pulmonary dissection. A separate vent is placed in the right atrium and directed through the tricuspid valve to the apex of the right ventricle to drain coronary sinus effluent from the right ventricle. The four pulmonary veins and each main pulmonary artery are stapled shut to prevent air from entering the beating heart during extraction of the lungs (Fig 2). On the right side, the pulmonary veins are dissected as they enter the pericardium, and each is stapled inside the pericardium. The right main pulmonary artery, medial to the superior vena cava, is similarly stapled. The left pulmonary veins are then stapled separately inside the pericardium. The left pulmonary artery is dissected and stapled outside the pericardium to ensure protection of the recurrent laryngeal nerve. All vessels are stapled using a 30-mm stapling instrument. Cardiac manipulation is restricted as much as possible during venous stapling to avoid cardiac distention. This was particularly difficult in the patient with primary pulmonary hypertension in view of the right ventricular hypertrophy and cardiomegaly. The lungs are then separately excised, lateral to the pericardium, using electrocautery; great care is taken to avoid injury to the phrenic nerves. The main bronchi are doubly stapled and divided to prevent contamination of the field by airway contents. Following removal of the lungs, the heart is lifted up out of the pericardium, and all attachments between the posterior wall of the left atrium and the pericardium are divided. Pericardial pleural windows are made behind the phrenic nerve on the left and behind the right atrium and venae cavae on the right. Through the right pleural space, the right main bronchus is grasped and pulled to the right behind the superior vena cava. Electrocautery is used to dissect the right main bronchus, carina, and left main bronchus from the mediastinurn, with care taken to remain on the bronchial wall during dissection up to the level of the second supracarinal tracheal ring. After both bronchial stumps and the distal trachea have been mobilized from the right side, the airway is brought up between the vena cava and the aorta for subsequent division of the

4 629 Patterson et al: Double-Lung Transplantation distal trachea and end-to-end anastomosis to the donor trachea as is employed in heart-lung transplantation. Meticulous hemostasis is achieved in the posterior mediastinum. At this point, a small transverse incision is made in the diaphragm 3 to 5 cm anterior to the esophageal hiatus. The omentum is brought up through this defect, across the posterior pericardium, and behind the heart to lie in the mediastinum posterior to the trachea. It is usually necessary to divide the right main pulmonary artery remnant within the pericardium lateral to the staple line to allow an adequate channel for passage of the omentum and donor trachea. The double-lung block is then brought into the field. The heart is retracted upward and to the right to allow passage of each lung through its respective pericardial pleural window. The trachea is drawn up into the posterior mediastinum, and an end-to-end tracheal anastomosis is created using a running suture of 4-0 Prolene on the membranous wall (Fig 3). The cartilaginous wall is anastomosed with interrupted sutures of 4-0 Vicryl. With the tracheal anastomosis complete and systemic hypothermia of 28"C, the aorta is cross-clamped and the heart arrested with 1 liter of cold cardioplegia to induce a myocardial temperature lower than 15 C. Total bypass is achieved by tightening caval snares. The heart is turned upward and to the right, thereby permitting exposure of the posterior wall of the left atrium. The left inferior pulmonary vein stump is then amputated (Fig 4). The defect in the atrial wall is elongated toward the orifice of the right inferior pulmonary vein and upward toward the left atrial appendage (see Fig 4). The atrial anastomosis is constructed using a running suture of 3-0 Prolene (Fig 5). The heart is returned to its normal position, and the donor and recipient pulmonary arteries are trimmed to size to allow end-to-end anastomosis with 5-0 Prolene (Fig 6). During the pulmonary artery anastomosis, the patient is rewarmed. On completion of the anastomosis, the vena caval snares are loosened and the heart is filled. Air is then removed from the right heart through the apex of the right ventricle, the right atrial appendage, and the pulmonary artery anastomosis. Following vigorous and repeated inflation of the lungs, air is removed from the left heart through the roof of the left atrium, the apex of the left ventricle, and the aortic root. The cardioplegia catheter is maintained on constant suction during the removal of air, and after the aortic cross-clamp has been removed, the suction is continued until the native circulation is restored with pulsatile output. After cardiopulmonary bypass is discontinued, the tracheal anastomosis is circumferentially wrapped with omentum (see Fig 3). The completed implantation is shown in Figure 7. The large flaps of donor pericardium are brought up inside and sewn to the recipient pericardium. This forms a "cradle" for the recipient heart and prevents herniation of the heart through the pleural pericardial windows, especially on the left side. When hemodynamic Fig 3. The tracheal anastomosis is constructed in the posterior mediastinuin, two rings above the donor carina. The previously positioned oiiientuni is rvrapped securely around the anastomosis and draped ozw the left main bronchus. stability and adequate hemostasis have been achieved, the chest is closed in the usual fashion with drains placed in the pleural spaces and mediastinum. Atrial and ventricular pacing wires are sutured in place. Immunosuppression The early immunosuppressive regimen consists of cyclosporine, Minnesota antilymphocyte globulin (MALS), and azathioprine. Cyclosporine is given orally in a dose of 10 ml/kg immediately prior to transplantation. Postoperative doses are administered to achieve plasma trough levels of 150 to 200 ng/l. MALS is administered intravenously in a dose of 10 to 20 mg/kg daily. This commences immediately following the operation after negative skin testing. MALS is gradually discontinued when satisfactory cyclosporine levels are observed. Azathioprine is administered in a dose of 1 to 2 mg/kg daily. Rejection episodes are treated with pulse doses of intravenous administration of methylprednisolone (500 to 1,000 mg). When satisfactory tracheal healing is observed after two to three weeks, oral administration of prednisone is introduced in a dose of 0.5 mg/kg/day. Results Six patients underwent double-lung transplantation. Operative time averaged 5 hours. Total bypass time ranged from 149 to 217 minutes and aortic cross clamp time, 33 to 52 minutes. Adequate postoperative gas exchange was present in all 6 patients. All 6 patients had a decrease in right ventricular volume and an increase in right ventricular ejection fraction in response to a decrease in right ventricular afterload. In 4 of the 6 patients, there was no obvious evidence of airway ischemia at any time during the immediate

5 630 The Annals of Thoracic Surgery Vol 45 No 6 June 1988 Fig 4. A posterior view of the heart showing the stapled pulmonary veins and pulmonary artery above. The left inferior pulmonary vein stump is amputated. This atriotomy is enlarged toward the right inferior vein stump and the left atrial appendage. The left atrial anastomosis is completed.,&/ postoperative course. Tracheal and main bronchial necrosis, which was apparent by the second postoperative day, developed in the patient with primary pulmonary hypertension. In this patient, perfusion pressure remained consistently low after he was weaned from cardiopulmonary bypass despite high cardiac output. Massive doses of vasoconstrictor medication and volume loading were required during the first 36 hours postoperatively to maintain a mean arterial pressure greater than 60 mm Hg. Following this, the patient s condition improved, and he appeared to be doing well. However, in the face of obvious necrosis of the trachea and main bronchi, we thought retransplantation was the only option. In spite of an urgent search, no suitable donor became available; we used an otherwise unsuitable donor for a heart-lung transplantation on the eleventh postoperative day. The transplanted organs failed to function normally, and the patient died on the second day following retransplantation. Our most recent patient, clinically well in his fifth postoperative week, has an asymptomatic localized area of necrosis involving only the membranous portion of the donor trachea. In the first recipient, symptoms of wheeze developed eight weeks postoperatively. Bronchoscopy revealed a short, circumferential stricture just distal to the origin of the left main bronchus. This was thought likely to be ischemic in origin. The patient had repeated bronchoscopic dilations of the stricture, but they failed to permanently resolve the problem. A Silastic stent 8 mm in diameter was placed bronchoscopically to maintain pa- Fig 5. An anterior view of the left atrial anastomosis. With the heart rotated upward and to the right, adequate exposure is achieved to permit the atriotomy and subsequent anastomosis, tency of the left main bronchus, and the patient has been well since. The other 3 patients have had normal airway healing and patency. Four of the 5 surviving patients have resumed a completely normal life-style and have required no oxygen following recovery. Each of these patients was discharged from the hospital within six weeks of trans-

6 631 Patterson et al: Double-Lung Transplantation Fig 6. Pulmonary artery anastomosis Fig 7. The completed implantation with the tracheal anastoniosis wrapped in onzentum, the left atrial anastomosis posterior to the heart, and the pulmonary artery anastomosis anterior. plantation and has been able to return to normal activities without restriction. The fifth patient requires no oxygen and is awaiting discharge from hospital. Comment We have previously reported our surgical technique [3] and successful clinical results [2] in single-lung transplantation. In an effort to avoid combined heart-lung transplantation in many patients with end-stage parenchymal pulmonary disease, we [5] developed an experimental model of en bloc double-lung transplantation that allows preservation of the recipient s own heart. We have achieved success with this procedure in experimental and clinical situations. Our early clinical results with the technique described in this report encourage us to continue employing this procedure. In addition to the obvious benefits of avoiding an unnecessary heart transplantation, the double-lung procedure offers an opportunity for transplantation to many more patients, as this procedure does not require utilization of the donor heart. With the marked rise in the number of cardiac transplant centers, particularly in North America during the past several years [12], the demand for satisfactory heart allografts is overwhelming and frequently precludes procurement of a graft for combined heart-lung transplantation. This is not surprising, since cardiac transplantation is a more routine technical procedure and is associated with short hospitalization times, low operative mortality, and excellent long-term survival in comparison with the results observed for combined heart-lung transplantation. A distinct advantage of double-lung transplantation and, for that matter, single-lung transplantation is the ability to extract a useful donor heart and lung graft from the same donor for use in two separate recipients. We have now used this technique successfully in three doublelung transplantations and five single-lung transplantations. The selection of patients for double-lung transplantation can be difficult. Right ventricular function must be carefully assessed by clinical examination and nuclear ventriculography [7, 81. Patients who have preserved intrinsic right ventricular contractility despite low ejection fractions induced by right ventricular dilatation in response to pulmonary hypertension will probably have an excellent result from double-lung transplantation. However, double-lung transplantation is likely not suited to patients who have advanced right ventricular fibrosis and persistent right ventricular dysfunction. We hope that our initial experience with this technique will lead to more precise criteria for recipient selection. The problem with adequate tracheal blood supply has not been completely resolved. While low perfusion pressure may well have contributed to airway necrosis in our single operative death, it was likely not the sole cause. Nonetheless, the retrograde pulmonary artery to bronchial artery collateral circulation described by the Pittsburgh group [13] would certainly have been reduced in our patient. At present, we are conducting a series of experiments to determine whether the bronchial artery circulation can be directly reconnected at the time of transplantation. We believe that the double-lung transplant procedure is a rational approach for the large number of patients

7 632 The Annals of Thoracic Surgery Vol 45 No 6 June 1988 with end-stage pulmonary disease and adequate cardiac function who are not candidates for single-lung transplantation. References 1. Hardy ID, Webb WR, Dalton ML Jr, Walker GR Jr: Lung homotransplantation in man: report of the initial case. JAMA 186:1065, Toronto Lung Transplant Group: Unilateral lung transplantation for pulmonary fibrosis. N Engl J Med 314:1140, Cooper JD, Pearson FG, Patterson GA, et al: Technique of successful lung transplantation in humans. J Thorac Cardiovasc Surg 94:173, Griffith BP, Hardesty RL, Trento A, et al: Heart-lung transplantation: lessons learned and future hopes. Ann Thorac Surg 43:6, Dark JH, Patterson GA, Al-Jilaihawi AN, et al: Experimental en bloc double-lung transplantation. Ann Thorac Surg 42:394, Patterson GA, Cooper JD, Dark JH, et al: Experimental and double lung transplantation. J Thorac Cardiovasc Surg (in press) 7. Christakis GT, Fremes SE, Weisel RD, et al: Right ventricular dysfunction following cold potassium cardioplegia. J Thorac Cardiovasc Surg 90:243, Mullen JC, Fremes SE, Weisel RD, et al: Right ventricular function: a comparison between blood and crystalloid cardioplegia. Ann Thorac Surg 43:17, Jamieson SW, Stinson EB, Oyer PE, et al: Operative technique for heart-lung transplantation. J Thorac Cardiovasc Surg 87:930, Teoh KH, Christakis GT, Weisel RD, et al: Blood conservation with membrane oxygenators and dipyridamole. Ann Thorac Surg 44:40, Teoh KH, Christakis GT, Weisel RD, et al: Prevention of myocardial platelet deposition and thromboxane release with dipyridamole. Circulation 74:Suppl 3: 145, Kaye MP: The Registry of the International Society for Heart Transplantation: fourth official report, Heart Transplant 6:63, Ladowski JS, Hardesty RL, Griffith BP: Pulmonary artery blood supply to the supracarinal trachea. Heart Transplant 4:40, 1984 Discussion DR. BARTLEY P. GRIFFITH (Pittsburgh, PA): I compliment Dr. Patterson and his co-workers for an excellently conceived, well-experimented, and beautifully carried out operation. Obviously it is premature to judge a new procedure, but I believe it is inherent to my role as a discussant to present its relevant benefits and its potential problems. With the proliferation in cardiac transplantation, many donors are buried with pulmonary allografts that could be used. Until this presentation, patients with obstructive, infected, and vascular pulmonary disease have not had the benefit of many of these potential donors. I will discuss the two major issues regarding double-lung transplantation. The first relates to the proper selection of candidates and the other, to observed problems from ischemia of the airways devoid of bronchial and pulmonary arterial blood supply. Most candidates for pulmonary transplantation have a degree of pulmonary hypertension and subsequent hypertrophy, dilatation, dysfunction of the right ventricle or a combination of these. While it has been recognized that the right ventricle can recover from the effects of increased afterload, most of our patients who received cardiopulmonary transplantation for first-degree pulmonary hypertension or Eisenmenger s syndrome had advanced failure of the right heart and would not likely have survived transplantation of the lungs alone. However, many if not most patients with obstructive or fibrotic diseases of the lung probably could have been treated with double-lung transplantation alone. Dr. Patterson might elaborate on this important aspect of selection, that is, the function of the right ventricle. We find it difficult to judge intrinsic preservation of contractility. Dr. Patterson has dealt with the problems in tracheal healing. It is important to stress that while an adequate blood supply to the airways and anastomosis is mandatory, the benefits of cyclosporine-based immunosuppression with avoidance of steroids, absence of rejection and infection, and early spontaneous ventilation are important factors. Dehiscence of the tracheal anastomosis can also occur following cardiopulmonary transplantation. We have used a wrap of omentum to aid in the repair of the problem in 1 patient, and believe that its prophylactic use is a reasonable consideration, especially when the recipient is cachetic and receiving maintenance steroids. The omentum can be wrapped circumferentially. We bring the vascularized pedicle anteriorly across the acute margin of the heart and are careful not to place bulk behind the membranous portion of the tracheal anastomosis. I am sure that double-lung transplantation will be an important option, especially since the potential for cardiopulmonary donation has been decreasing with the proliferation of cardiac transplantation. Thank you very much for an excellent presentation. DR. WILLIAM ANTHONY BAUMGARTNER (Baltimore, MD): I also congratulate Dr. Patterson and his group from Toronto. They clearly have led the way in single-lung and double-lung transplantation with excellent results in both categories. We have had experience with 2 patients who had cystic fibrosis and underwent heart-lung transplantation. Both patients exhibited extensive adhesions and apical fibrosis. It took more than 2 hours of cardiopulmonary bypass time to free up both lungs. If we were trying to preserve the heart in this situation of extensive adhesions, we believe that the considerable stress and trauma placed on the in situ heart might potentially result in difficulty in weaning the patient from cardiopulmonary bypass. I raise this as a concern in patients who have extensive adhesions. If adhesions are not present, we agree that bilateral lung transplantation is a viable option in the management of patients with cystic fibrosis who need transplantation. Have you had experience with extensive adhesions in this group of patients, and was cardiac function at all depressed in any of these patients? In addition, in May [1987], the heart of a patient with cystic fibrosis undergoing heart-lung transplantation was used as a donor heart for a recipient with end-stage cardiomyopathy. This represents another approach or available option in the utilization of all available organs. DR. PATTERSON: I thank Dr. Griffith and Dr. Baumgartner for their comments. Both of them have made substantial contributions to the field of cardiopulmonary transplantation. Dr. Griffith, I appreciate your discussion and general per-

8 633 Patterson et al: Double-Lung Transplantation spective on the availability of lung donors. It is clearly a major problem. We have had many patients on our waiting list die while awaiting a donor, not only for single-lung and doublelung transplantation, but heart-lung transplantation as well. We have recently undertaken separate procurement of the heart and lungs from the same donor for use in 2 recipients. In addition, we have recently employed distant procurement of pulmonary allografts. These steps have increased our donor supply and allowed us in the past year to procure nine lung grafts that would otherwise not have been available. Your comments about right ventricular function are quite germane to the application of this procedure. We have great difficulty assessing the adequacy of right ventricular function. For the most part, we have relied on measurement of first-pass radionuclide right ventricular ejection fraction. Each of these patients has had substantial pulmonary hypertension. Maintenance of ejection fraction higher than 20% in these pulmonary hypertensive patients has indicated reasonable right ventricular function. We believe each of our double-lung recipients has had adequate right ventricular function. The single patient who died following this operation was a 16-year-old boy with primary pulmonary hypertension and an ejection fraction of 16%. Immediately after operation, severe systemic vasodilatation with profound hypotension and increased cardiac output developed. We believe the fatal tracheal necrosis was in part due to this hemodynamic complication. A patient who has clinical right ventricular failure and cardiomegaly is not a suitable candidate because of the technical difficulty of performing the procedure in the presence of cardiomegaly. We have performed tracheal anastomotic omentopexy, not only because it provides collateral circulation, but also because the omentum contains the airway anastomosis and protects against mediastinal contamination should a partial disruption occur. I appreciate Dr. Baumgartner s comments as well. We have limited experience with cystic fibrosis. Three such patients on our waiting list died without a donor being found. We have performed double-lung transplantation in 1 patient with eosinophilic granuloma who had fused pleural spaces. This patient did have postoperative hemorrhage requiring reexploration. All of the patients with alpha,-antitrypsin deficiency had free pleural spaces and presented no technical difficulty in extraction of the native lungs. Notice from the Southern Thoracic Surgical Association The thirty-fifth Annual Meeting of the Southern Thoracic Surgical Association will be held at the Marriott s Marco Island Resort, Marco Island, FL, November 1G12, There will be a $125 registration fee for the scientific session for nonmember physicians except for guest speakers, authors and coauthors on the program, and residents. There will be a $50 registration fee for attendees of the Postgraduate Course on Thursday, November 10, 1988, from 7:30 AM to 12:30 PM. Please note: this course time has been moved from Saturday, November 12. The Postgraduate Course of the Southern Thoracic Surgical Association will provide in-depth coverage of thoracic surgical topics selected primarily as a means to enhance and broaden the knowledge of practicing thoracic and cardiac surgeons. Applications for membership should be completed by July 1, 1988, and forwarded to the Southern Thoracic Surgical Association, 111 East Wacker Dr, Chicago, IL Gordon F. Murray, M.D. Secretary-Treasurer Southern Thoracic Surgical Association Basic Science Center West Virginia University Medical Center Morgantown, WV 26506

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