**7.4 Preparation of the heart**

In stable donors, after the liver surgeon prepares all prerequisites in the abdomen the heart and/or lung team will welcome to the operation field. All thoracic lymphatic regions must be accurately inspected for signs of occult malignancies such as metastasis or lymphoma and if needed biopsy should be done and sent for frozen section pathologic examination. Thymus gland should be resected first and pericardium is opened longitudinally and fixed to the edges of transected sternum in both sides. Intraoperative cardiac evaluation includes inspection for: signs of previous pericarditis, hematoma or ecchymosis (resulted from previous cardiopulmonary resuscitation), any cardiac anomalies, dyskinesia, scars, contusions, calcification of ascending aorta and coronary arteries, size of the great vessels and heart chambers. At the same time, the inotrope dosage should be reduced by the anesthesiologist to ensure that cardiac contractility is good enough without need of the inotropes. If there is any sign of right heart overloud immediate diuresis by furosemide and reducing the central venous pressure by avoiding any intravenous infusion of crystalloids is mandatory. All the data should transfer immediately to the recipient team so they can make decision on starting the recipient operation.

The window between ascending aorta and pulmonary trunk is opened and controlled by an umbilical tape. Superior and inferior vena cava is encircled with caution not to harm the sinoatrial region or jeopardize the pulmonary veins. For cardioplegic injection at the end of preparation a cannula should be inserted and the arc of aorta should be prepared for clamping before the origin of the innominate artery.

#### **7.5 Preparation of the lungs**

Both pleural spaces should be opened at this stage. Lungs are inspected for bullae, contusions, atelectasis, pneumonia and occult tumors. Tracheal tube is disconnected and both lungs are deflated transiently and then inflated again by a pressure of 15–30 cmH2O to better detect the pulmonary compliance (so called "collapse test") [28, 29]. Usually, most of the vascular dissections were done previous by the heart team including: separation of the pulmonary trunk and right pulmonary artery from posterior wall of the ascending aorta and superior vena cava, and opening the window between the lower right pulmonary vein and intrapericardial IVC (so called "oblique sinus"). The left innominate vein and artery is controlled by umbilical tape to expose the main trachea by retracting them toward the right and left, respectively. The azygous vein should be ligated at this stage to prevent rupture and bleeding. After inserting the cardioplegic cannula in the root of aorta and cannula should be inserted near the bifurcation of the pulmonary trunk for infusion of prostaglandin E1 and Perfadex for lung procurement at the end of all other organs' retrieval.

#### **7.6 Common steps at the end of the procedure**

When all dissections were done according to patient's stability and the retrievable organs prepared, great vessels' cannulation is done after full heparinization. The aorta is clamped at two levels: sub- or supra- diaphragmatic and at the end of ascending aorta. Blood evacuation is started by cutting the IVC just inferior to the right atrium or if dissections at this level is impossible, in the abdomen above the iliac vessels. Infusion of the cold preservatives (with cardioplegic effect if heart is being retrieved for transplantation) is started and supporting by the anesthesiologist is finished and the "definitive death" is announced. At the same time immersion of all the retrievable organ by slush ice should be accomplished. If lung procurement was programmed, infusion of Perfadex should be started at the same time and the pulmonary blood should be evacuated by cephalad retraction of the heart and incision of the left atrium between the two inferior pulmonary veins just below the Waterson's groove or "sulcus terminalis".

Infusion is continued till all the viscera are exsanguinated. Usually 2–3 lit of infusate through abdominal aorta, 1 lit through the portal vein, 1 lit for ascending aorta and 50 ml/kg of Perfadex is enough for complete blood evacuation. The superior mesenteric artery has to be ligated at this time for prevention of pancreas overperfusion which will severely affect graft function [30, 31]. If small intestinal retrieval is programmed, this step is forbidden, and portal perfusion should be omitted as well or performed through the IMV and only the aorta is perfused [30].

All the organs will be transferred after retrieval to an organ bag full of cold preservative and irrigated again if necessary. This bag should be packed and inserted to another bag filled with cold saline and again in the third bag full of slush ice and then in the cool box for transferring to the recipient ward or hospital. Sometimes especially when the transfer time is long or the donor is marginal the transplant team may decide to use cold or warm perfusion machines for better preservation of the organ.
