**6. Final steps**

After explantation of the heart, the surgeon should check for a patent foramen ovale (PFO); if one does exist, then a PFO closure using a 4–0 prolene suture should be performed as quickly as possible before putting the heart in the cooler. Inspect the pulmonary artery and aorta, mitral valve, tricuspid valve for any anatomical abnormalities/clots/vegetations/iatrogenic damage. At this point, inform the recipient surgeon if there is any injury. If there is, then donor pericardium can be packed to repair these injuries in the recipient OR.

Some teams prefer to leave the cardioplegia cannula attached to the donor aorta. In these centers the cardioplegia cannula can be placed lower down on the aorta. However, if the cannula is removed and the suture tied to mark the point of cannulation, the cannulation site can be higher up and the same can be excised/trimmed prior to implantation.

Pack the heart in the preservative solution and ensure it is completely immersed in it. The first bag should not contain any ice, while the second and third bags do contain ice. There are special containers that maintain uniform cooling of the heart (Paragonix SherpaPak™) in 4 degrees centigrade [8]. These containers help to optimize donor heart transport by maintaining uniform cooling and perhaps extend the donor warm ischemia time.

### **6.1 DBD- procurement of heart and lung for separate centers**

In this section we want to discuss procurement of both the lungs and the heart as separate organs from the same donor but for different recipients. (Note: the procurement surgeon however might still be from the same center) In this scenario, the heart is being taken for transplant, while simultaneously, the lungs are being procured either as double lung, single lung, or two single lungs. This implies that both the heart surgeon and lung surgeon (unless one surgeon is taking both for two separate patients in the same center) will be present.

Assuming that each of the two lungs are being taken by different centers, and the heart is being taken by another center, up to three different surgeons could be present for procurement of the thoracic organs. It requires the utmost cooperation and communication with each other to be able to successfully execute such a multiorgan procedure.

We recommend the heart surgeon start first and inspect the heart. The sternotomy is performed in the midline once all teams are present, signed in and the basic checks are conducted. Hemostasis is achieved using ample amounts of bone wax. The pericardium should be split down the middle. Three pericardial stay sutures should be put on either side of the pericardial opening and tag them to hemostats. Based on our practice we recommend that the pericardial stay sutures not be hitched up to the drapes at this point. The reason for this is it causes tension on the pericardium, and when the lung surgeon is trying to inspect and recruit the lungs with a Valsalva maneuver it squeezes the heart to cause hemodynamic compromise [9].

Once the heart is appropriately visualized, the heart surgeon should check the quality of the heart by palpating the coronary arteries to assess for atherosclerosis, visually confirm the heart's contractility, and by checking the right atrium, the right ventricle, the pulmonary artery and the aorta. It is also important to check if there are any
