Adult

Heart-Lung Transplantation
Teimour Nasirov, Yasuhiro Shudo, JW MacArthur, Elisabeth Martin, Stefan Elde,
Y. Joseph Woo, and Michael Ma

Heart-lung transplantation (HLT) frequency has decreased over the years due to the fact
that most right-sided heart failure can recover without heart-lung transplantation. However,
there is still a subset of the patient population suffering from end-stage cardiopulmonary
disease who would benefit from combined heart-lung transplantation. The main indication
for continues to be pulmonary hypertension due to idiopathic pulmonary arterial hyperten-
sion or secondary to congenital heart disease, accounting for 60%-70% of heart-lung trans-
plants during the past 3 decades. This paper provided updated detailed illustrated
technique for combined pediatric and adult heart-lung transplantation practiced at Stanford
University School of Medicine and Lucile Packard Children's Hospital at Stanford. A total
of, 185 of combined heart-lung transplants have performed at our institution since 1990.
Operative Techniques in Thoracic and Cardiovasculary Surgery 27:392 404 Ó 2022 Elsevier
Inc. All rights reserved.

KEYWORDS Heart, lung, transplantation, donor, recipient

Central Message An additional application of heart-lung transplantation is a

This article describes our current techniques in
Heart-Lung transplantation in adult and pediat-
ric population at our institution.
The first successful human heart-lung transplant (HLT)
was performed at Stanford University Medical Center in
1981 by Dr. Bruce Reitz.1 The International Society of Heart
and Lung Transplantation (ISHLT) reports over 4800 of
pediatric and adult heart-lung transplants have been per-
formed worldwide since 1990.2 The Organ Procurement and
Transplantation Network reports that approximately 1235
HLTs have been performed in the United States since 1990.
A total of, 185 of those HLTs were carried out at Stanford
University Medical Center during the same time period. HLT
frequency has decreased over the years due to the fact that
most right-sided heart failure can recover without heart-lung
transplantation. However, there is still a subset of the patient
population suffering from end-stage cardiopulmonary dis-
ease who would benefit from combined heart-lung trans-
plantation. The main indication for continues to be
pulmonary hypertension due to idiopathic pulmonary arte-
rial hypertension or secondary to congenital heart disease,
accounting for 60%-70% of heart-lung transplants during
the past 3 decades.3
The authors declare no conflicts of interest.
Stanford Health Care, Lucile Packard Children’s Hospital, Department of
Cardiac Surgery, Palo Alto, CA
Address reprint requests to: Teimour Nasirov, MD MBA, Department of
Cardiac Surgery, 780 Welch Rd, Falk Bldg CVRC MC 5407, Palo Alto,
CA, 94304, Tel.: (650)-723-5771. E-mail: tnasirov@stanford.edu
392
domino procedure. The procedure involves implanting a
heart-lung block into a patient with end-stage lung disease
whose explanted normal heart is then given to an isolated
heart transplant candidate.4 This procedure is designed for
the patients undergoing en bloc heart and lung transplant
for primary lung diseases, such as cystic fibrosis, bronchiec-
tasis, and pulmonary hypertension. In most cases, the heart-
lung recipient's heart itself demonstrates appropriate
function for use as a transplanted organ. This procedure is
extremely rare due to both the significant decrease in heart-
lung transplantation as well as the allocation of donor organs.
The last adult domino procedure was performed at Stanford
in 2016.
Thorough donor evaluation is imperative. This should
include history and physical, serologies, CXR, computed
tomography, arterial partial oxygen pressures of at least 300
mmHg on 100% of inspired oxygen, bronchoscopic evalua-
tion, sputum cultures, 12 lead EKG and echocardiogram.
Coronary angiograms are requested in donors older than
40 years of age. Suitable donors are typically less than
50 years of age and have minimal smoking history. Meticu-
lous attention for harvest technique is of extreme importance
(Figs. 1-4).5 Specific strategies in both procurement and
implantation are highlighted in Surgical Technique. The
most challenging aspect of the overall operation surrounds
the excision of the recipient heart and lungs (Figs. 5-11).
Function of the phrenic and vagus nerves (recurrent branch)
must be preserved. Hemostasis must be meticulous in the
posterior mediastinum as the donor graft will reduce visibil-
ity to this area when implantation is complete.
1522-2942/$ see front matter © 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1053/j.optechstcvs.2022.06.001
Heart-Lung Transplantation 393

Figure 1 After conducting flexible bronchoscopy for airway anatomy and possible secretions, a median sternotomy is performed. The pleura is
opened bilaterally, pericardial cradle created and each lobe is examined for damage and palpated for edema, atelectasis, contusion, nodules, or
other pathology. The pericardial cavity is opened and Valsalva maneuver applied to inflate all lobes. The heart is evaluated for contractility and
coronary anatomy examined. Cardiac dissection begins by dissecting the ascending aorta of the main pulmonary artery (mPA). The superior
vena cava (SVC) is dissected of the right pulmonary artery (PA). During SVC dissection, the azygos vein is identified and doubly ligated. Next,
the inferior vena cava is isolated circumferentially to achieve sufficient length. The aorta is retracted medially and the superior vena cava
retracted laterally to expose the trachea. The posterior pericardium is opened, and the trachea is mobilized as cephalad as possible, retaining at
least five or six tracheal rings above the bifurcation.
394 T. Nasirov<?A3B2 show et al.

Figure 2 Once cardioplegia (typically 1 liter for an adult patient) and pulmonoplegia (3 liters) are completed, the aortic cross-clamp, cardiople-
gia line, and pulmonoplegia cannulas are removed. The IVC is transected and dissected to the level of the right atrium, remaining mindful of
the nearby coronary sinus and right inferior pulmonary vein. This is followed by transection of SVC cephalad to the azygos vein with creation
of an innominate cuff, and transection of the aortic arch distal to the innominate artery origin, after which the aortic cross clamp is removed.
The heart is retracted by gently elevating the apex anteriorly, to expose the posterior pericardium near the diaphragmatic border. The pericar-
dium is opened here, to expose a plane posterior to the pericardium but anterior to the posterior mediastinal contents (ie, esophagus). The
space anterior to the esophagus is cleared up to the inferior pulmonary veins and in back of the left atrium using blunt dissection with a supi-
nated hand. The trachea is gently dissected off the esophagus manually, as sharp instrumentation in this area can damage the tracheal posterior
membrane. The left lung is gently retracted superiorly and to the right to expose its posterior surface. The pleural incision from the inferior pul-
monary ligament is extended posterior to the hilum of the left lung. The pleural incision is continued over the aorta anteriorly to join with the
point of pericardial excision over the aorta. Care must be taken to avoid injury to the left pulmonary artery. We routinely take a part of the
descending aorta to ensure enough distance from the left PA.
Heart-Lung Transplantation 395

Figure 3 The right lung is retracted anteriorly. The inferior pulmonary ligament is divided up to the inferior pulmonary veins. The pleural inci-
sion is extended along the surface of the esophagus over the posterior aspect of the pulmonary hilum. The azygos vein is ligated and divided.
Care is taken not to injure the right bronchus due to acute angle. The pleural incision is extended anteriorly to join with the point of pericardial
excision anterior to the superior vena cava.
396 T. Nasirov<?A3B2 show et al.

Figure 4 The heart-lung bloc is then removed from the thoracic cavity, inspected for injury and pathology and placed in preservative solution in
sealed bags with ice within a cooler.
Heart-Lung Transplantation 397

Figure 5 Our incision of choice is the median sternotomy. Thoracosternotomy, or 'clamshell' incision as well as anterolateral thoracotomies with
sternal sparing remain valid and sometimes preferred approaches at other institutions. The pericardium is opened in the midline, and both
pleural spaces are opened widely. Retraction stitches are placed on the pericardial edge. Some of the dissection can be done before the institu-
tion of cardiopulmonary bypass, but eventually it is necessary to establish bypass using 2 venous uptake cannula, with oxygenated blood
returned to the ascending aorta. Cardiectomy is performed exactly as described for cardiac transplantation. An incision is made in the pericar-
dium just anterior to the left pulmonary veins and well behind the phrenic nerve. Dissection extends anterior to the pulmonary veins until the
pleural space is entered. The incision is extended superiorly and inferiorly for a few centimeters, leaving the phrenic nerve anterior on the pleu-
ropericardial flap. The left atrium is divided through the oblique sinus between the left and right pulmonary veins. The pericardial reflection on
the posterosuperior aspect of the left atrium is divided to free the 2 halves of the left atrium.
398 T. Nasirov<?A3B2 show et al.

Figure 6 Dissection continues posteriorly on the surface of the left pulmonary veins. The left atrial remnant may be pushed through beneath the
phrenic nerve into the pleural space. The left bronchus and left pulmonary artery are exposed. The pulmonary artery is divided proximal to the
first bifurcation. The inferior pulmonary ligament on the left side is divided up to the inferior pulmonary veins. The left lung is retracted anteri-
orly so that the pleural incision can be continued on the posterior aspect of the hilum in front of the aorta. The left bronchus is closed by sta-
ples. The bronchus is divided distal to the staple line, and the left lung is removed.
Heart-Lung Transplantation 399

Figure 7 The right lung is resected next. An incision in the pericardium, anterior to the right pulmonary veins, is made into the right pleural
space so that the right phrenic nerve remains intact on the pleuropericardial flap. The left atrium is incised posterior to the interatrial groove
on the right side to allow the pulmonary veins to separate from the cardiac remnant. The remainder of the left atrium is resected from the atrial
septum, working anteriorly from the left side of the septum. This leaves only the rim of atrial septum continuous with the right atrium near
the atrioventricular groove for anastomosis to the transplant graft. The right inferior pulmonary ligament is divided, and the lung is mobilized
posterior and anterior to the hilum as described for the left side. As the right pulmonary veins are mobilized to the right, the right pulmonary
artery comes into view. It is divided. All that remains is the underlying right bronchus. It is dissected free of surrounding mediastinal tissues.
The right bronchus is closed by staples. The bronchus is divided distal to the staple line, and the right lung is removed from the chest. The
mediastinum is carefully inspected, and all bleeding points are meticulously controlled.
400 T. Nasirov<?A3B2 show et al.

Figure 8 The trachea is divided just above the bifurcation. It is prepared for anastomosis by careful inspection of mediastinal surfaces posterior
to it. Excess remnants of the right and left pulmonary arteries are removed. It is advisable to leave behind a small island of the left pulmonary
artery near the ductal insertion to minimize injury to the left recurrent laryngeal nerve. Appropriate time should be expended at this stage of
the operation for hemostasis. The posterior mediastinum is well collateralized with arterial vessels (ie, bronchial arteries, lymphatic arteries,
aortoesophageal tributaries) that may be refractory to medical management, and this area is very difficult to visualize once the donor allograft
is implanted.
Heart-Lung Transplantation 401

Figure 9 The heart-lung block is placed into the recipient thorax. The right lung is passed behind the pleuropericardial flap into the right hemi-
thorax. The left lung is passed behind the pleuropericardial flap into the left hemithorax. The trachea, aorta, and right atria are aligned for anas-
tomosis.
402 T. Nasirov<?A3B2 show et al.

Figure 10 Downward retraction on the distal donor aorta adequately exposes the 2 tracheal ends, thus providing good visualization for perfor-
mance of a single layer running anastomosis using a 3-0 or 4-0 polypropylene monofilament suture. The posterior membranous tissue is
approximated in an imbricated fashion, first from the inside and from the left to right side of the patient. Thereafter, the cartilaginous portion
of the anastomosis is easily completed. Insufflation to a pressure of 20-30 cmH2O is performed. The anastomosis must be meticulous and
accurate, with the ends abutting precisely without buckling. Attention to detail is extremely important to prevent leakage at this critical anasto-
mosis.
Heart-Lung Transplantation 403

Figure 11 The inferior vena is anastomosed by continuous 4/0 polypropylene suture. The main pulmonary artery anastomosis is then com-
pleted using continuous 5-0 Prolene suture. The superior vena cavae anastomosis is completed using continuous 5-0 Prolene suture. Finally,
the aortic anastomosis is performed, using continuous 5-0 polypropylene suture. Before final closure of this suture line, the left heart is thor-
oughly de-aired, and the aortic cross clamp removed. The heart is re-perfused to restore cardiac contraction, and ventilation is reestablished to
the transplanted lungs. We typically re-perfuse around 45 minutes to an hour regardless of ischemia time.
404
SURGICAL TECHNIQUE
DONOR OPERATION
Systemic heparinization is then instituted with 400 units/kg,
an antegrade cardioplegia cannula is inserted into the aorta,
de-aired, and connected to a hypothermic systemic perfusion
line. The mPA is cannulated proximally with EOPA 3-D dis-
persion tipped cannula (Medtronic, Minneapolis, Minn,
United States). Following cannula placement, 500 mg of pros-
taglandin E-1 (0.5 mg/mL) is administered into the main pul-
monary artery to transiently reduce pulmonary vascular
resistance and allow uniform distribution of pulmonoplegia
solution. The SVC is then clamped above the azygos vein
(ensuring the central venous catheter has been withdrawn)
and the left atrial appendage is widely opened to vent the left
ventricle. The inferior vena cava (IVC) is partially divided at
this time and the aortic cross-clamp applied. Hypothermic
antegrade cardioplegia with University of Wisconsin (UW)
solution and pulmonoplegia with Perfadex (XVIVO, Gothen-
burg, Sweden) are then infused through the aorta and PA,
respectively, and ice slush is placed into the chest cavity for
topical cooling (with frequent reinstallation). The heart is typi-
cally arrested before initiating the pulmonoplegia.6 The lungs
are gentle ventilated at 10 breath per minute. Proper PA can-
nula positioning must be maintained during slush insertion
or manipulation of the heart. The aortic root pressure is peri-
odically checked by palpitation as is the efflux from the left
atrial appendage and inferior vena cava to ensure adequate
pulmonoplegia and cardioplegia respectively.
CONCLUSION
Technical aspects of surgery are extremely important in
achieving the optimal outcomes. Excellent hemostasis prior
T. Nasirov<?A3B2 show et al.
to implantation, appropriate tailoring of tracheal anastomosis
with preservation of surrounding tissue, timing and sequence
of anastomosis, and organ preservation play important roles
in intraoperative care and subsequent recovery. The median
survival for heart-lung transplant recipients was 2.1 years for
transplants between 1982 and 1993, 3.7 years for transplants
between 1994 and 2003, and 5.8 years for transplants
between 2004 and June 2016. While heart-lung transplanta-
tion remains the last resort for patients with end-stage heart
and lung failure, combined heart-lung transplantation is a
viable therapy where acceptable outcomes and can be
achieved when the patient selection is appropriate for surgi-
cal expertise.7
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