Surgical Considerations in Infant Lung Transplantation

Challenges and Opportunities

John P. Costello; Horacio G. Carvajal; Aaron M. Abarbanell; Pirooz Eghtesady; Dilip S. Nath


American Journal of Transplantation. 2021;21(1):15-20. 

In This Article

Surgical Technique

Bilateral Sequential Lung Transplant

Bilateral sequential lung transplantation can be performed via various approaches: bilateral thoracosternotomy (clamshell incision), median sternotomy, and bilateral thoracotomies. All of these approaches allow for transplant completion either with or without cardiopulmonary bypass support. In children requiring concurrent intracardiac repair at the time of lung transplantation, the bilateral thoracosternotomy or median sternotomy approaches can be employed to facilitate cardioplegic arrest for any necessary cardiac procedures.[23] In infants, children weighing less than 15 kg, and those bridged on a PLAD, a median sternotomy or a clamshell incision can be used. The majority of pediatric lung transplants are performed with the use of cardiopulmonary bypass, although the use of ECMO during transplant has also been described in infants and children.[23–25] Following entry with the appropriate incision, the patient is placed on cardiopulmonary bypass via ascending aortic and single venous cannulation under normothermic conditions. It may also be necessary to add a venous cannula in the superior vena cava to avoid interfering with the venous return to the heart when manipulating the right lung hilum. Starting with the initial side, the inferior pulmonary ligament is taken down, and hilar dissection is then carried out with great care taken to avoid injuring the phrenic nerve. With the hilar structures dissected, the pulmonary veins, pulmonary artery, and main bronchus are divided sequentially with a stapling device or tied off and divided to complete the pneumonectomy. To prepare the hilar structures for implantation of the new lung, the pericardium should be opened circumferentially around the hilum. Implantation of the donor lung is then undertaken, with the bronchus anastomosed first, followed by the pulmonary artery, and finally the left atrial cuff to complete the pulmonary venous anastomosis.[26] This technique can vary, with some surgeons electing to perform the pulmonary venous anastomosis before the pulmonary arterial anastomosis. Once completed, the lung is re-perfused and hemostasis obtained. The pneumonectomy and implantation of the contralateral lung is then performed in a similar fashion.

En Bloc Double Lung Transplant

When pursuing the en bloc double lung transplant technique, a median sternotomy or clamshell approach is required. Cardiopulmonary bypass is established following aortobicaval cannulation. Hilar dissection and bilateral pneumonectomies are performed as per the same technique described in the bilateral sequential operation. The next step is the final preparation of the donor organ bloc on the back table. Once the branch pulmonary arteries have been mobilized and the ligamentum arteriosum divided, the donor bloc is ready for implantation. Back at the operating table, the recipient's carina and bilateral mainstem bronchi are excised. While doing so, it is paramount to avoid lateral dissection of the trachea as much as possible to preserve the crucial lateral blood supply of the trachea. The donor organ bloc is then positioned in the chest in a transpericardial manner so that the central portion of the graft is positioned posterior to both the heart and phrenic nerves bilaterally. The tracheal anastomosis is completed first, followed by the main pulmonary artery anastomosis. To re-establish the pulmonary venous return, a single left atrial anastomosis can be performed while the aorta is cross clamped; however, the pulmonary venous anastomoses can be done separately with the heart beating if preferred.[20,27] The main pulmonary arterial anastomosis can also be performed before the pulmonary venous anastomosis if desired by the surgeon. This technique, currently the preferred method for infants transplanted at SLCH, is illustrated in the accompanying operative video (Video S1).

En Bloc Double Lung Transplant With Bronchial Artery Revascularization

Surgical technique when using BAR closely follows that of the regular en bloc approach. Appropriate procurement of the lung bloc is crucial and should include the aorta (up to approximately the level of the inferior pulmonary vein on the left) and intercostal arteries arising from the aorta to ensure bilateral preservation of the bronchial arteries; if this is not done carefully, then BAR is not possible. On the back table, at least one bronchial artery to each mainstem bronchus should be identified and prepared as an aortic button with a cuff of aortic tissue still intact.[20] Median sternotomy or clamshell is performed for the recipient. Following bilateral pneumonectomies and appropriate preparation of the recipient trachea, the donor bloc is placed into the chest transpericardially. The bronchial artery buttons with their respective aortic cuffs, rather than the actual bronchial arteries themselves, are then anastomosed to the recipient's descending thoracic aorta, with the anastomosis completed in a continuous fashion with monofilament, nonabsorbable suture. Of note, this contrasts with the technique described in adults, where connection to the aorta is made via the left internal mammary artery.[27] The bronchial arteries are now reperfused, and the tracheal anastomosis is performed, followed by the single left atrial anastomosis under aortic cross clamp. With the cross clamp removed, the pulmonary artery anastomosis is completed.[20]