*Thoracic Organ Procurement during Multi-Organ Retrieval DOI: http://dx.doi.org/10.5772/intechopen.95793*

palpable thrills or any anomalies in the systemic venous drainage or pulmonary venous drainage. Our practice is to measure the intracardiac pressures; the PA, RA, and LA and communicate them with the implanting surgeon for cross check. It is important to avoid opening the pleura. This is when the lung surgeon steps into the limelight.

Once the lung surgeon approaches the table, the pleura should be opened widely. We recommend opening the pleura bluntly rather than using the diathermy. We have seen many instances where opening the pleura by a diathermy causes an air leak because it accidentally punctures the lung surface. These air leaks are difficult, notorious, and persistent. After one part of the pleura is opened bluntly, then the surgeon can insert one finger behind the pleura but above the lung tissue. The surgeon can now safely use a bovie with the finger protecting the lung in order to divide the rest of the pleura in standard fashion. At this stage inspect the lungs and recruit and atelectatic areas. The lung surgeon is now ready for Valsalva. After communicating this with the anesthesiologist, the lung surgeon reaches for the lower lobe, lifts it up and gives Valsalva at 30 cmH2O pressure [9]. It is important to refer here to the earlier point about leaving the pericardial stay sutures unhitched. If they had been hitched and the lung surgeons performed the Valsalva, the heart will get compressed between the hitched-up pericardium and the lung/s. This would cause a precipitous drop in blood pressure. Therefore, leave the pericardial stay sutures unhitched, and incise the pleura widely, so that the heart has more room to move. Once the lung surgeon has ascertained the quality of the lung by checking its compliance, and inspecting any abnormalities such as masses or contusions, then the stay sutures can be hitched up on either side. Depending on institution protocol, pulmonary vein blood gases are taken from the right upper, right lower, left upper and left lower pulmonary veins making sure the ventilator settings are on fiO2 of 100% and PEEP of 5.

The procurement then resumes in standard fashion. First the surgeon dissects the aorta and the pulmonary artery, then uses an umbilical tape to loop the aorta, while separating the svc from the pulmonary artery. Then the surgeon loops the SVC and ligates the azygos vein (this step is optional). The azygos vein is fragile and can be easily injured precipitating brisk bleeding which is difficult to manage. We prefer not to dissect the IVC or interatrial groove before heparin is given so that we avoid hemodynamic compromise and rhythm disturbances such as atrial fibrillation. Therefore, it is prudent to always have internal defibrillation paddles on the sterile table opened and ready to use during procurement. Standard dose of heparin is then given- 30,000 units (adjust according to patient weight). Then the cardioplegia stitch is taken, and the aorta is cannulated. We suggest a dual lumen cardioplegia cannula and transduce the pressure line to monitor the aortic root pressure of the patient. This helps us by telling us the cardioplegia perfusion pressure (ideal is 60–80 mmHg) [10].

Once the heart surgeon cannulates the aorta, the lung surgeon places the purse string on the PA. At this point the surgeons must decide where to divide the Pulmonary artery. On the one hand, one would want to keep an adequate length for the heart surgeon, so it is important to not cut it too short On the other hand, one would want to leave the bifurcation of the PA intact for the lung surgeon. Therefore, we usually use the right pulmonary arteries a guide and place the purse string suture at that level. Once the purse string suture is placed, we suggest using a right angle canula and directing the bevel of the cannula towards the pulmonary valve. The reason for this is to avoid improper perfusion of the pulmonary arterial flush. Often, novice procurement surgeons do everything correctly except turn the bevel of the cannula towards the left PA. This results in preferential flow into the left lung with minimal flow into the right lung, which causes mal perfusion with improper protection of the right lung. If using a different type of cannula, it is still important to ensure adequate distribution of the pulmoplegia.

Once all the teams are ready, the heart surgeon cross clamps the aorta and the lung surgeon administer the prostaglandin. The injection site should be as close to the purse string suture on the PA as possible to avoid additional puncture to that artery. This is when all the teams should be extremely alert because the prostaglandin causes the BP to drop. Then, the SVC is snared, and the left atrial appendage is divided by placing a Satinsky clamp on it and the tip is amputated. It is important not to put traction on the LAA while placing the clamp to avoid injury to the base of the appendage or Left Circiumflex artery. For this reason, some surgeons are averse to the idea of placing a clamp on the LAA [11].

However, if they are venting through the interatrial groove, then that that should be done first before dividing the IVC. The next step is to divide the anterior wall of the IVC. Wait for about 3–4 beats after this is done to. Be patient as the heart empties, and cross clamp the flaccid heart's aorta as distally as possible towards the arch vessels and start the infusion of the cardioplegia solution. Please note that it is not until the heart is noticed to be fully arrested that the lung team can start the Perfadex solution - be aware to not start them simultaneously. Meanwhile, the surgeon should be constantly observing the heart- feeling the left ventricle to make sure its soft and feeling the aorta to make sure it is firm.

When the Pulmoplegia is being perfused into the PA, note that one should see the efflux through the Left atrial appendage. Keep monitoring the color of the lungs to look for uniform blanching indicating even distribution of the flush solution whilst continuing to ventilate the lungs and simultaneously dropping the FIO2 to 50%. Avoid manipulating the heart during this process. If the LV distends for any reason, stop the cardioplegia and the pulmoplegia, release the cross clamp on the aorta and gently decompress the heart. and then reapply the cross clamp and resume cardioplegia, and pulmoplegia. If the distension continues, open the LA appendage more. If that still does not work, use the interatrial groove to vent. Usually around 4–6 liters of the perfadex solution is given but it varies per hospital protocol.

Keep the cardioplegia running if the perfadex is running. This makes sure the perfadex does not enter the coronaries and wash out the cardioplegia. If the cardioplegia is done before the pulmoplegia, then an aortotomy should be made while the clamp is still there, and a yonkaeur sucker should be inserted into the aorta to suction out and avoid any perfadex solution going into the heart. Once all the flush is done for both the heart and lung, the pulmonary artery cannula is removed, and the prolene suture is cut away. The IVC is then completely divided, taking care to avoid any injury to the right inferior pulmonary vein.

The next step is optimal division of the left atrium. Our recommended approach is to gently retract the heart up while we incise the posterior LA wall and proceed using a Metzenbaum scissors to enlarge the incision leaving an adequate cuff of LA for the lungs at least a 1 cm rim. On the right side, stop the dissection as you reach the IVC. At this point, we recommend the heart be retracted to the left. With the flaccid heart and bloodless field, it should be easier to dissect out the interatrial groove. and leave at least a one-centimeter cuff for the lung implant [12].

Finally, we can transect the aorta as high as possible depending on how much aorta is needed. For the PA extend the incision from where it has been cannulated. Visualize the carina of the PA. Make sure you can see the opening of the right PA. Divide the PA in such as fashion that the bifurcation remains with the lung block. Do not use too much traction while dividing the PA because that can cause distortion. Make sure that the original cut is perpendicular as to leave adequate PA for the heart team. Now that all the divisions are done, release the snare on the SVC, divide the SVC, the azygos vein and anything else holding the heart behind as it is gently lifted out.

The lungs are then harvested in standard fashion. It is always helpful to have the nasogastric tube so that one can feel the esophagus. The arch vessels and innominate
