Lung Transplantation and the Routine Use of Cardiopulmonary Bypass and Median Sternotomy: Experience at the Ochsner Multi-Organ Transplant Institute.
BACKGROUND
From 1990-2005 at Ochsner Medical Center in New Orleans, LA, cardiopulmonary bypass (CPB) was used only when necessary during lung transplantation surgeries. Ochsner's lung transplant program was closed for more than 4 years after Hurricane Katrina, and since the program's reestablishment in 2010, the majority of lung transplantation surgeries have been performed with the patient on CPB and with a median sternotomy incision. The purpose of this study was to compare the outcomes of the CPB and non-CPB groups.


METHODS
After institutional review board approval, we conducted a retrospective review of the entire program using the Ochsner lung transplant database to identify patients in the non-CPB group from 1990-2005 and in the CPB group from 2010-2014. We calculated 1- and 3-year survival rates for each patient and reviewed medical records for evidence of stroke, the need for operative reexploration, and venous stenosis. We also performed a subgroup analysis of the first 20 consecutive patients undergoing lung transplantation on CPB with median sternotomy from February 2010 through April 2011 to examine intraoperative blood product use, the quantity of blood products administered, CPB cannulation and pump complications, ischemic time, and primary graft dysfunction.


RESULTS
Of the 208 patients in the non-CPB group, 74% had 1-year graft survival and 55% had 3-year survival following transplantation. After February 2010, 79 patients underwent lung transplantation on CPB with median sternotomy, and 90% of those patients had 1-year graft survival. Of the 46 patients available for 3-year follow-up, 59% were alive with functional grafts. The difference in 1-year survival rates between the 2 cohorts was statistically significant. Two deaths, 3 strokes, and 5 reexplorations of the chest for bleeding occurred during the perioperative time period in the CPB group, but no mortality was associated with these perioperative events. One patient who had perioperative complications died within the first year; the death was attributable to gastric perforation.


CONCLUSIONS
Patients' early outcomes appear to have improved with the use of CPB and median sternotomy; however, 3-year survival is similar to the non-CPB group. Technical benefits of CPB with median sternotomy include decreased warm ischemia time during graft implantation, controlled hemodynamics and reperfusion, avoidance of single-lung ventilation of a freshly implanted graft, and the option to open the left atrium for implantation of a venous cuff without using a clamp. The surgical exposure facilitated by CPB with median sternotomy for lung transplantation appears to be a safe and feasible approach for lung transplantations.
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
Michael
M
Bates
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA.
Matthew
M
Factor
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
P Eugene
PE
Parrino
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
Aditya
A
Bansal
Multi-Organ Transplant Institute, Ochsner Clinic Foundation, New Orleans, LA.
Reinaldo
R
Rampolla
The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA ; Department of Pulmonary/Critical Care, Ochsner Clinic Foundation, New Orleans, LA.
Leonardo
L
Seoane
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA.
Jose
J
Mena
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA ; The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
Matthew
M
Gaudet
Section of Cardiothoracic Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA.
William
W
Smith
Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
P Michael
PM
McFadden
Cardiopulmonary bypass; intraoperative complications; lung transplantation; sternotomy; thoracic surgery