P-230left Atrial Anastomosis During Bilateral Lung Transplantation: A Complex Hilum Made Easy

Objectives: To describe a technique of heart mobilization able to improve the access to the left hilum during lung transplantation (LTx). Case description: In a recent case of bilateral LTx for cystic fibrosis, left hilum exposure was very difficult to obtain. The manoeuvres to displace medially the pericardial sac in order to perform atrial anastomosis were not tolerated haemodynamically because of severe systemic hypotension. A wide inverted T-shaped incision was performed on the pericardium, but haemodynamic parameters showed an unacceptable risk of sustained systemic hypoperfusion. Cardiopulmonary bypass seemed to be unavoidable. We decided to mobilize the heart with a pericardial stitch, usually performed during revascularization on a beating heart: 2 heavy sutures (0 polyester) were placed along the left pericardial border. The heart was temporarly lifted in order to expose the pericardial oblique sinus, where a deep pericardial traction stitch (2-0 polyester) was placed. The suture was passed through a long wet gauze and then snared down to the pericardium by means of a long rubber tourniquet. Upward traction was applied on the tourniquet, that was fixated to the surgical drapes. Such a manoeuvre lifted the apex of the heart, which was placed in vertical position. The heart was secured by means of the 2 arms of the gauze, which were crossed and wrapped around the ventricles and fixated with clamps to the surgical draping. The sutures on the left pericardial border were pulled upwards. The exposure of the left hilum was excellent and haemodynamics remained stable and satisfactory during the atrial cuff anastomosis of the left lung. The traction on pericardium and the luxation of the heart avoided the need of veno-arterial extracorporeal membrane oxygenation. Conclusions: This technique can provide a good exposure of the left hilum, avoiding in some cases cardiopulmonary bypass during lung transplantation. Disclosure: No significant relationships.