Bilateral Lung Transplant

Cardiopulmonary bypass is established following systemic heparinization to achieve an activated clotting time greater than four hundred and eighty seconds.
Arterial cannulation is performed in the ascending aorta, while venous drainage is obtained using either bicaval cannulation or a single right atrial cannula, depending on exposure and surgeon preference.
Adequate venous return, arterial inflow, and complete cardiac decompression are confirmed before initiating bypass.

Cardiopulmonary bypass is initiated gradually to avoid hemodynamic instability.
Normothermia or mild hypothermia is maintained according to institutional protocol, and once full bypass support is achieved, mechanical ventilation is discontinued.

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Native lung explantation is performed sequentially, typically beginning with the more diseased lung.

For the right lung, the lung is retracted medially to expose the hilum.
The right pulmonary artery, superior and inferior pulmonary veins, and the right main bronchus are carefully identified and isolated.
The left atrium is opened to allow division of the pulmonary veins with preservation of a generous atrial cuff.
The right pulmonary artery is clamped and divided, ensuring adequate length for later anastomosis.
The right main bronchus is divided close to the carina, with care taken to minimize devascularization, and the native lung is removed.

The left lung is explanted in a similar fashion, with sequential division of the pulmonary artery, pulmonary veins with atrial cuff preservation, and the left main bronchus.

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Donor lung implantation is then performed sequentially, most commonly beginning with the right lung.

The bronchial anastomosis is completed first using an end-to-end technique with absorbable monofilament suture.
The posterior wall is constructed in a continuous fashion, followed by interrupted sutures anteriorly, ensuring a tension-free and well-vascularized anastomosis.

Next, the pulmonary artery anastomosis is performed in an end-to-end fashion using polypropylene suture, with meticulous de-airing prior to completion.
This is followed by the pulmonary venous anastomosis, in which the donor left atrial cuff is sewn to the recipient atriotomy using a running suture technique, again ensuring complete de-airing.

The left lung is implanted using the same sequence: bronchus, pulmonary artery, and pulmonary veins.

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Reperfusion is performed in a controlled manner.
Pulmonary arterial clamps are released gradually while maintaining low pulmonary artery pressures.
The lungs are ventilated using low tidal volumes, low inspired oxygen concentration, and moderate positive end-expiratory pressure.
Flexible bronchoscopy is performed to assess airway integrity, secretion clearance, and anastomotic bleeding.

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The patient is then weaned from cardiopulmonary bypass.
Rewarming to normothermia is performed gradually.
Right ventricular function is assessed using transesophageal echocardiography, and inotropic or pulmonary vasodilator support is initiated as needed.
Bypass flows are reduced incrementally once adequate gas exchange, hemodynamic stability, and surgical hemostasis are confirmed.

After successful separation from bypass, cannulas are removed, protamine is administered, and meticulous hemostasis is achieved.

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Chest tubes are placed bilaterally, with or without a mediastinal drain.
Final inspection confirms intact anastomoses and full lung expansion.
The sternum is closed with wires, followed by layered closure of soft tissues and skin.

Dr.Sam Zeraatian Nejad Davani, Cardiovascular and Transplant surgeon. Advanced Fellow of Thoracic Organs Transplantation Chicago Illinois.