4. Organ Procurement
Organization and communication
Behind the scenes
Lifesource call: Blood type
Age, sex, race, height, and weight
Time of brain death
mechanism of injury, thoracic trauma
Pre hospital course: resuscitation, aspiration,
intubation, joules
PMHx: ETOH, drugs, smoking, HTN,
diabetes, malignancy…….
Serologies: hepatitis, HIV, CMV, syphilis
5. Organ Procurement
Behind the scenes:
Cardiac evaluation:
Inotropes
Hemodynamics and fluid status CVP
Labs: troponin
EKG
ECHO
Angiograms: men 35y, female 40y
Acceptable ischemia times 4-5 hours for adults, 8 hours for
infants
6. Organ Procurement
Behind the scenes:
Acceptable cardiac donors:
Age: newborn to 60+
No history of active cardiac disease
No history of severe thoracic trauma
No prolonged CPR, hypotension, hypoxia
Normal EKG
Normal ECHO
Inotrope < 10 mg/kg/h of dopa or dobuta with
a CVP 8-12
7. Organ Procurement
Behind the scenes:
Lung evaluation:
Oxygen challenge 100%/40%
Vent settings
CXR
Sputum: gs/cx fungus
Bronch
Fluid status
Acceptable ischemia time of 6-10
8. Organ Procurement
Behind the scenes
Acceptable lung donors:
Age: newborn to 60+yrs
No history of pulmonary disease
No history of long term smoking >40py
100% FiO2 >300 PaO2,
40% FiO2 > 100 PaO2
normal serologies, normal paranchyma,
acceptable oxygenation
9. Organ Procurement
Organization and Communication
Coordinator: Notifies patients and institutes travel plan
Plans timing with lifesource coordinator
Notifies admissions office and 6C/D
Sets up OR and anesthesia times
Notifies junior resident
Clarifies immunosuppression orders and
study patients
Tracks down all charts, labs and x-rays
Organizes fellows for donor run and OR
Organizes transportation for donor run with
Lifesource
Verifies ABO and PRA
10.
11.
12. Organ Procurement
The procurement site
You represent the University of Minnesota
Be polite
The cardiac team needs to lead the coordinated effort of all
the organ teams. Our organ must be removed first. We,
with consideration of the other teams, need to set the cross
clamp time.
13. Organ Procurement
The Procurement Site
Check the records: death note, blood type, all of the labs
Check the films and angiograms
Repeat the bronch at staff request
Open the chest as soon as possible to inspect the organs
Timing is everything, estimate cross clamp time
Call transplant surgeon (1st call)
Communicate plan with rest of procurement teams
Keep an eye on anesthesia
17. Organ Procurement
The Procurement Site
Preparing for cross clamp
dissect completely the aorta, SVC, IVC, and PA
loop the SVC
place cannulation sutures in aorta and PA (prolene)
open pleura widely
dissect intra atrial groove
Call transplant surgeon to confirm timing of cross clamp
(2nd call)
18. Organ Procurement
The Procurement Site
Don’t forget to give the heparin
Tie off SVC……stay away from the SA node
Cut IVC…….keep an eye on the abdominal team
Cross clamp and give plegia
Cut off the tip of left atrium (even if we are not taking the lungs)
Continue to ventilate the donor
Cover heart and lungs with soft slush
Suckers in the chest 2-3
19. Organ Procurement
The Procurement Site
Perfusion solution
Cardiac Gopher cardioplegic solution (GCS)
KCL 32.0 mEq/L
bicarb 26 mEq/L
Mannitol 13 gm/L
Dextrose 10 mL of 50%
Volume 1-2 liters for adults, 500-1000ml for children, and
250-500ml for infants
Pressure bags set at 140 mm Hg
20. Organ Procurement
The Procurement Site
Perfusion solution
Lung Perfadex and Prostaglandin
Volume 60 ml/kg with pressure bag set at 140 mm/Hg
21. Organ Procurement
The Procurement Site
Don’t cut anything you can’t see
Heart only: Divide SVC above tie
Divide IVC
Divide aorta at head and neck vessels
Divide pulmonary artery at branches
Open left atrium in the groove swing inferior,
then up toward the appendage. Tip the
heart superiorly and divide the roof of the left
atrium
Pack in container of iced saline solution, evacuate all air
24. Organ Procurement
The Procurement Site
Heart-lung block: Divide the SVC above the tie
Divide the IVC
Divide the aorta at the vessels
Right lung divide the IPL, dissect
posterior to the hilum in the pre
esophageal plane
Repeat on left side
Inflate lungs staple trachea
Pack in container of iced saline solution, evacuate all air
25. Organ Procurement
Returning home
Make sure to secure the cooler in the plane
Have the Lifesource coordinator call the transplant surgeon
or the U of M coordinator when you leave with the
cross clamp time (3rd call)
When you land, call the U of M coordinator or the OR
(4th call)
Accompany organs to the operating room to receive
appropriate compliments on your surgical skills
31. Recipient Set-UP
• Reprogram PM or AICD
• SG catheter to measure PAP
• Prepare for groin cannulation in multiple
redo or LVAD patients
• TEE probe placement
• CO2 tube in the operative field
32. Bypass Set-UP
• Aortic cannulation as distal as possible, esp
in previous CABGs and LVAD pts.
• Bicaval cannulation at posterolateral
cavoatrial junction, cava snares
• Bypass initiation when donor heart lands in
the airport
• Cool to 28 to 30’ C
• Aortic x-clamp when donor heart in OR
38. Recipient and Donor Heart Preparation
• Trim the recipient cardiac chambers and great
vessels based on the size of donor heart
• Inspect donor cardiac chambers for debris or clots
• Inspect PFO in donor heart
• 400 cc retrograde cardiopleagia for donor heart
39. Implantation – biatrial anastomosis technique
• Originally described by Lower and
Shumway
• 3-0 prolene sutures for both atrial
anastomoses, 4-0 prolene sutures for both
aorta and PA vessel anastomoses
• Donor right atrial incision modified by
Bernard
55. Biatrial vs Bicaval Anastomosis Techaniques
• Biatrial: easy to perform, time tested technique,
good long-term outcome for both cardiac function
and patient survival.
• Bicaval: less atrial rhythm disturbance, improved
ECHO findings: smaller LA, RA; less TR, better
atrial function; ? Shorter LOS, ? Less RV failure.
Technically more challenge esp. in redo, AICD
and LVAD pts, size mismatch, SVC stenosis
• Lack of long-term study comparing both function
and survivals in these two groups
56.
57.
58.
59. Technical Safeguards
• Aggressive de-air measures.
• Keep PA graft short to prevent kinking.
• Keep Aortic graft long.
• Enough reperfusion time for donor heart.
• Double check anastomotic lines when
partially supported by bypass
63. History of Lung Transplantation
• 1963 Hardy
• 1963 – 1973 36 Patients Worldwide
• 1973 – 1983 Hiatus
• March 9, 1981 First Successful Heart-Lung Transplant
• 1983 First Successful Single Lung Transplant
Cooper in Toronto
64. Recipient Selection Guidelines
• Clinically and physiologically severe disease
• Medical therapy ineffective or unavailable
• Substantial limitation in activities of daily living
• Limited life expectancy
• Adequate cardiac function without significant coronary
artery disease
• Ambulatory with rehabilitation potential
• Acceptable nutritional status
• Satisfactory psychosocial profile and emotional support
system
66. Lung and Heart-Lung Donor
Criteria
• Conventional
• ABO compatibility
• Thoracic size match
• Age less than 50 years (heart-lung)
• Age less than 55 years (lung)
• Normal troponin levels (heart-lung)
• Lack of ventricular hypertrophy (heart-lung)
• No history of respiratory disease
• No significant smoking history
67. Lung and Heart-Lung Donor
Criteria
• No active pulmonary infection
• No significant chest trauma or history of aspiration or
cardiopulmonary resuscitation
• No prior cardiac or pulmonary surgery
• Short intubation time
• Lack of purulent secretions; no gram-negative bacteria or
fungi on gram stain
• Clear chest X-ray without infiltrates
• Challenge gas greater than 300mm Hg on 100% oxygen
68. Marginal Donors
• Age over 55 years (lung)
• Age over 50 years (heart-lung)
• Tobacco history longer than 20 pack-years
• Presence of infiltrate on chest X-ray
• Donor ventilation time longer than 5 days
• Donor use of inhaled drugs
69. Donor Operation
• Check Chart Brain Dead, Blood Type, ABG
• CXR
• CT Scan
• Bronchoscopy
• Recruitment Measures
• Serial ABGS
• Pulmonary Vein Gases
• Do no cut what you cannot see
• Prostaglandin
• Pneumoplegia
• Gentle ventilation
• Heart Excision after development of interatrial groove
70. Recruitment Maneuvers
• Bronchoscopy
• Diuresis
• Bag lungs / Eviscerate as gently as possible
• Peep 10
• Low dose Vasopressin 0.04
71. Recipient Operation
• SLT
• Older recipient
• COPD or IPF
• Groin available especially for LSLT
• Amount of pulmonary hypertension
• Snaring of PA or surgeon finger pinch
• Patulous LA anastomosis
72. Recipient Operation
• BSLT
• Surgical Approaches
• Bilateral transaxillary Toyoda at Pittsburgh
• Bilateral posterolateral
• Bilateral anterolateral Patterson at Wash U St. Louis
• Clamshell
• Use of CPB for left lung
73. CPB / ECMO
• OR
• Difficult Transport
• Hemodynamically unstable
• Unable to oxygenate
• May have to crash on via femoral vessels, then position
patient
• Postoperatively Primary graft dysfucntion
• Ischemia-reperfusion injury
• Humoral rejection
• Uncommon
76. Registry 2009
Bilateral 69% of all lung transplants
Survival 1994 – June 2007
89% at 3 months
79% at 1 year
64% at 3 years
52% at 5 years
29% at 10 years
77. Clinical Experience With a New Removable
Tracheobronchial Stent in the Management of Airway
Complications After Lung Transplantation
S Fernandez-Bussy et al.
JHLT July 2009
Between February 2007 and April 2008
24 patients underwent stent placement
49 stents were placed for 36 anastomoses at risk
Airway complications in up to 27% of lung transplant recipients
Indications: Bronchial stenosis 12
Bronchomalacia 12
Both 20
Partial bronchial dehiscence 5
78. Abdominal Complications after Lung Transplantation
PC Smith et al.
JHLT January/February 1995
January 1988 and July 1993
75 lung transplants
Early Prolonged adynamic ileus (4)
Diaphragmatic hernia after omental wrap (3)
Ischemic bowel (2)
Colitis with hemorrhage (1)
Splenic injury after colonoscopy (1)
79. Abdominal Complications after Lung Transplantation
PC Smith et al.
JHLT January/February 1995
Colonic perforation (4)
Late Cholilithiasis / choledocholithiasis (2)
Mesenteric pseudoaneurysm (1)
Fungal hepatic abscess (1)
Intraabdominal hemorrhage (1)
80. Risk Factors For The Development of Bronchiolitis
Obliterans Syndrome
Acute Rejection Episodes
Lymphocytic Bronchiolitis
Cytomegalovirus Pneumonitis
Medication Noncompliance
Reperfusion Injury
Bacterial Pneumonia
Donor Antigen-Specific Reactivity
Gastroesophageal Reflux
Elevated Transforming Growth Factor-Beta
Expression
81. Causes of Death
First 30 days: Graft Failure
Non-CMV Infections
After First Year: BOS
Non-CMV Infections
Between 5 and 10 years: malignancy 12%
