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Improving The Exposure Of The Left Hilum For Lung Transplantation: The Value Of A Simple Pericardial Stitch.

P. Saxena, D. McGiffin, Adam D. Zimmet, J. Gooi, S. Marasco, Justin C Negri, A. Pick
Published 2015 · Medicine

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We read with interest the recently published article by Calcaterra and colleagues [1] on their surgical technique of exposure of a difficult left lung hilum during bilateral sequential lung transplantation, especially in the setting of idiopathic pulmonary fibrosis (IPF). The authors have adopted a technique used during off-pump coronary artery bypass procedures to facilitate the exposure of the left lung hilum. After pericardiotomy, the authors have used a pericardial stitch, an episiotomy pack, and a snugger to lift the heart. The authors use their technique in the setting of IPF to expose the left lung hilum to avoid mechanical retraction of the heart and the associated hemodynamic compromise, which may need cardiopulmonary bypass support. The authors are to be congratulated on their description of an elegant technique. We would like to describe a simple technique for the exposure of the left lung hilum during lung transplantation to avoid mechanical retraction of the heart, which achieves the same result as the technique used by Calcaterra and colleagues. In general, we routinely use a bilateral anterolateral thoracotomy incision without division of the sternum during bilateral sequential lung transplantation. We agree with the authors on the issue of selective use of cardiopulmonary bypass in the setting of severe pulmonary hypertension. We use a 0 or 20 pledgetted braided suture passed through the pericardium near the apex of the heart, inferior to the left hilum and posterior to the left phrenic nerve (Fig 1). The suture is placed under tension by attaching it to the drapes on the right side. This rotates and dislocates the heart toward the right side and also brings up the hilum toward the thoracotomy wound. As a result, no mechanical retraction is required during pneumonectomy and lung implantation. Our technique can be used routinely during left lung transplantation and more so in patients with difficult exposure of the left lung hilum, as in IPF.
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