Although anecdotes suggest that this approach is used in several centers, particularly in France and the United Kingdom, published information is scant. Machiarrini et al
Macchiarini P, Ladurie FL, Cerrina J, et al. Clamshell or sternotomy for double lung or heart-lung transplantation? Eur J Cardio-Thorac Surg.15:333-339.
described a short series of sternotomies (for both heart-lung and bilateral lung) and made comparisons with a contemporaneous cohort undergoing a clamshell incision. They reported development of much more chronic pain after clamshell incision. There were significantly better spirometry readings and peak expiratory flow at the same time after transplant. The only other publication is of a short series from Denmark.
Kohno M, Steinbruchel DA. Median sternotomy for double lung transplantation with cardiopulmonary bypass in seven consecutive patients. Surg Today 42:406-409.
Our own experience has been similar to that of the authors of the French article, with a shorter median time for ventilation and length of intensive therapy unit stay, albeit the patients were carefully selected.
The advantages of sternotomy are clear: rapid chest opening and closure, with very good pain control afterward. However, there are clearly some disadvantages. Most important in the current era is the need for cardiopulmonary bypass. Bypass is an important risk factor for primary graft dysfunction.
Diamond JM, Lee JC, Kawut SM, et al. Clinical risk factors for primary graft dysfunction after lung transplantation. Am J Respir Crit Care Med 187:527-534.
Many centers seek to avoid its use, particularly for the sort of straightforward patient we have in the past selected for the sternotomy approach. It may be that the near–simultaneous controlled reperfusion into the whole vascular bed and injury-sparing ventilation that our approach allows diminishes some of the deleterious effects of bypass.
More recently, we have adopted an extracorporeal membrane oxygenation-type circuit for recipients with pulmonary hypertension and adapted the sternotomy approach—this includes no reservoir, no cardiotomy suction, and minimal heparinization (activated clotting time: 18-220 s). There is no pulmonary artery vent, and we revert to a sequential single-lung philosophy, implanting the left lung first. In a small series, we have appreciated the reduced bleeding and almost no need for blood products, as well as excellent immediate function of the lung.
Finally, the tricks learned from this evolution of the sternotomy approach can also be applied to other unique situations. One of these is the setting of lung transplant after previous pneumonectomy. Bypass is mandatory, and anatomical distortion is often extreme. The largest published experience is from a French group
Le Pimpec-Barthes F, Thomas PA, Bonnette P, et al. Single-lung transplantation in patients with previous contralateral pneumonectomy: technical aspects and results. Eur J Cardio-Thorac Surg 36:927-932.
that enrolled 14 patients, with 4 patients undergoing sternotomy.
In conclusion, the sternotomy incision, with some of the technical approaches described in this article, permits straightforward lung transplantation, albeit with a mandatory use of cardiopulmonary bypass. It is particularly suited to surgical and anesthetic teams with cardiac rather than thoracic surgical expertise. The approach is very good for teaching, with excellent vision during all stages of the operation. Benefits to the patient of a reliably healing and, compared with lateral thoracotomy, almost pain-free incision may overcome some of the other disadvantages. It can be adapted to the use of extracorporeal membrane oxygenation-type technology, exemplified by recipients who have pulmonary arterial hypertension who inevitably need cardiopulmonary bypass. Familiarity with the techniques also equips the surgeon for some rare and complex recipients who need novel thinking.