JTCS Sign the Guestbook
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
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):
Andres Varela
Carlos García Montero
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 Varela, A.
Right arrow Articles by Ugarte, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Varela, A.
Right arrow Articles by Ugarte, J.

J Thorac Cardiovasc Surg 2000;119:402-403
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Transcutaneous extracorporeal cannulation for bilateral lung transplantation without splitting the sternum

Andres Varela, MD, Carlos García Montero, MD, Evaristo Castedo, MD, Jorge Roda, MD, Pablo Gámez, MD, Luis Madrigal, MD, Juan Ugarte, MD

Thoracic & Cardiovascular Surgery
Hospital Puerta de Hierro
c/ San Martin de Porres n4
Madrid 28035, Spain

To the Editor:

Bilateral sequential lung transplantation without sternal division has recently been recommended as a less-invasive approach than sternotomy.Go Go 1,2 Two separate bilateral anterolateral thoracotomies in selected patients eliminate post-transplantation sternal complications and improve functional recovery. Actually, this is our routine approach for bilateral lung transplantation.

When cardiopulmonary bypass (CPB) is electively or urgently required during the procedure, we use two different approaches. Cannulation of the aorta and right atrium can be done through a right thoracotomy or transcutaneously in the 3rd and 4th intercostal spaces. We report the case of a patient requiring elective CPB in a bilateral lung transplantation setting.

Clinical summary.
A 49-year-old man with {alpha}1-antitrypsin emphysema and secondary pulmonary hypertension (systolic pulmonary artery pressure 80 mm Hg) was accepted for bilateral lung transplantation. When a donor became available, we decided to use two sequential anterolateral thoracotomies and elective CPB.

After dissection of the right hilar structures, the aortic cannula (Stöckert 5.2 mm, Munich, Germany) was introduced through the skin and right 3rd parasternal intercostal space. The cannula was later used for apical chest tube drainage (Fig 1). The single 2-stage venous cannula (Bard 46F-34F, C.R. Bard, Inc, Haverhill, Mass) was introduced through the skin and right 4th parasternal intercostal space, just in front of the right atrial appendage.



View larger version (143K):
[in this window]
[in a new window]
  		Fig. 1. Right anterior thoracotomy showing cannulation of the aorta (small arrow) and right atrial appendage (large arrow).

 
This particular case involved a long-distance procurement with an ischemic time of 4 hours 10 minutes on arrival at our institution. When CPB was instituted and right pneumonectomy followed by lung implantation was performed, the ischemic time was 6 hours 15 minutes). The left lung was transplanted sequentially, with an ischemic time of 7 hours 25 minutes. The total CPB time was 3 hours 15 minutes. The first PO 2 reading with 100% inspired oxygen fraction was 520 mm Hg. Recovery was uneventful, without ischemia-reperfusion injury.

Discussion.
There is no doubt that a smaller incision produces less trauma and less pain, reduces the risk of wound complications, and facilitates recovery. On the other hand, the minimally invasive approaches have the disadvantage of producing a smaller surgical field. The majority of bilateral lung transplantations have been performed through an anterolateral thoracosternotomy known as the "clamshell" incision.Go Go 3-5 The introduction of a less invasive incision, the two sequential anterolateral thoracotomies, has the challenge of performing the conventional lung transplantation through a minimally invasive approach.

When CPB is necessary, the surgeon faces the challenge of finding a way to perform cannulation with the same type of cannulas and without increasing the size of the small incision. Femoral cannulation may be an alternative but is associated with important vascular complications.

The transcutaneous extracorporeal cannulation technique herein described is very helpful in these patients. The cannulas are left in place away from the thoracotomy opening and provide adequate drainage of the ventricles without hampering the operation. Furthermore, exposure of the hilar structures is greatly improved, and the course of the procedure may progress smoothly without increasing the skin incision.



View larger version (145K):
[in this window]
[in a new window]
  		Fig. 2. Transcutaneous approach for cannulation in right anterior thoracotomy (arrow). No sternal split is necessary.

 
12/8/104343

References

  1. Bryan F, Meyers R, Sudaresan S, et al. Bilateral sequential lung transplantation without sternal division eliminates posttransplantation sternal complications. J Thorac Cardiovasc Surg 1999;117:358-64. [Abstract/Free Full Text]
  2. Taghavi S, Birsa T, Seitelberger R, et al. Initial experience with two sequential anterolateral thoracotomies for bilateral lung transplantation. Ann Thorac Surg 1999;67:1440-3. [Abstract/Free Full Text]
  3. Bains MS, Ginsberg RJ, Jones WG, et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30-3. [Abstract]
  4. Brown RP, Esmore DS, Lawson C. Improved sternal fixation in the transsternal bilateral thoracotomy incision. J Thorac Cardiovasc Surg 1996;112:137-41. [Abstract/Free Full Text]
  5. Wright C. Transverse sternothoracotomy. Chest Surg Clin North Am 1996;6:149-56. [Medline]



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
T. Oto, R. Venkatachalam, Y. S. Morsi, S. Marasco, A. Pick, M. Rabinov, and F. Rosenfeldt
A reinforced sternal wiring technique for transverse thoracosternotomy closure in bilateral lung transplantation: From biomechanical test to clinical application
J. Thorac. Cardiovasc. Surg., July 1, 2007; 134(1): 218 - 224.
[Abstract] [Full Text] [PDF]

Home page
 Eur. J. Cardiothorac. Surg.Home page
F. Venuta, E. A. Rendina, T. De Giacomo, A. M. Ciccone, M. Moretti, E. Mercadante, M. Anile, and G. F. Coloni
Bilateral sequential lung transplantation without sternal division
Eur. J. Cardiothorac. Surg., June 1, 2003; 23(6): 894 - 897.
[Abstract] [Full Text] [PDF]

This Article
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):
Andres Varela
Carlos García Montero
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 Varela, A.
Right arrow Articles by Ugarte, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Varela, A.
Right arrow Articles by Ugarte, J.

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