**8. Techniques of pulmonary artery flush**


Following instillation of the Perfadex solution, the cannula is removed. The lungs are then recruited with Valsalva maneuver at 30 cm H2O and both lungs are sequentially examined in standard fashion. The heart is then excised in standard fashion. In certain instances, there is consent for homograft valves and sufficient care needs to be exercised while excising the heart to preserve the valves [20].

Next, dissection begins first by dividing the inferior pulmonary ligament (bilateral) and the posterior pericardium. The main and right pulmonary artery are dissected away from the aorta. Bilaterally, the inferior pericardium is then divided at

the level of the esophagus. Then the posterior pericardium is divided in a horizontal fashion just above the esophagus to the level of the pulmonary veins. The aortic arch is then transected. The superior aspect of the arch is then exposed and divided as distal as possible along the arch vessels so that a portion of the wall of the arch and descending aorta are left as a cuff to prevent dividing the ligamentum arteriosum.

Attention is then turned to the trachea which is isolated just above the carina with blunt dissection. A TA-30 stapler is passed around the trachea 3 rings above the carina [21]. The lungs are inflated to 60% tidal volume-to avoid baro-trauma (especially if the lungs are being flown back to the recipient institution), and the endotracheal tube is withdrawn. The stapler is used to divide the trachea. The lung bloc is removed from the donor after division of any remaining attachments.

The lung bloc is taken to the back table. Retrograde flush is performed at 250–500 cc/vein x4. If lot of clots/thrombi are seen exiting the PA during retro flush one can take a call regarding quality (small clots are not uncommon).

The double lung bloc is then examined for compliance, color, any areas of inadequate perfusion, atelectasis etc. (refer to DBD procurement of lungs section). Once the procurement surgeon is satisfied that the lungs are suitable for transplantation the recipient surgeon is called, and if accepted the lungs are then split on the back table and packed in standard fashion. The main PA is divided at the insertion site of the pulmonary artery cannula. The atrial cuff is then created approximately 1 cm from insertion of the pulmonary veins into the left atrium. The atrium is then divided in the midline with scissors. The left mainstem bronchus is divided with a TA-30 stapler near the hilum. An additional liter of cold Perfadex solution is instilled bilaterally via the pulmonary veins with a balloon catheter. The lungs are packed first in a bag containing Perfadex, followed by 2 bags containing ice cold saline slurry. The organs are subsequently transported to their respective transplant centers.
