Lung Transplantation

TSRA Content:

Authors: Lin Chen, BA, and John Barron, MD

This is a revision and update from the previous edition of the TSRA Primer in Cardiothoracic Surgery written by Alexis Shafii, MD, and Nicco Brozzi, MD

Preoperative Evaluation

Referral for lung transplantation is a time-consuming process that should ideally be started well before anticipated need for transplantation. Assessment focuses on evaluation of not only lung disease severity, but also factors such as additional comorbidities, frailty, psychosocial health, immunization status, and substance abuse, with the ultimate goal being to identify modifiable risk factors and determine if the patient is likely to demonstrate a survival benefit with transplantation.

Key components of the preoperative evaluation are as follows:

• Pulmonary function testing, room air ABG, DLCO, and 6-minute walk test
• CXR, CT chest, and quantitative V/Q scan
• EKG, echocardiogram, right and left heart catheterization
• Esophageal manometry and pH testing for gastroesophageal reflux
• Age-appropriate cancer screening
• Blood work, including blood type, panel reactive antibody (PRA), and viral serologies
• Psychiatric evaluation and social/resource assessment

Indications

Patients with end-stage lung disease due to the conditions listed below account for the large majority of lung transplants. While the specific criteria warranting referral and eventual transplantation vary between conditions, the following thresholds warrant workup for transplantation: FEV1 < 25% predicted, pulmonary fibrosis with FVC < 80% predicted, onset of NYHA Class III or IV symptoms, or rapid disease progression. For patients with COPD, the BODE (BMI, obstruction, dyspnea, and exercise capacity) index may guide need for transplant, with index >5 indication for referral.

Common indications for lung transplantation:

• COPD/Emphysema
• Interstitial lung disease
• Cystic fibrosis
• Pulmonary hypertension
• Bronchiectasis
• Sarcoidosis

Absolute Contraindications:

• Non-adherence or lack of social support
• Septic shock
• Disseminated infection or active tuberculosis
• Malignancy with high risk of recurrence or cancer-related death
• Liver cirrhosis or acute liver failure (unless considering multi-organ transplant)
• Acute renal failure or chronic kidney disease with GFR <40 ml/min
• Recent stroke (within 30 days)
• Active substance abuse (tobacco, marijuana, IV drugs, vaping)
• Worsening cognitive impairment
• Recent acute coronary syndrome or myocardial infarction (within 30 days)
• HIV infection with detectable viral load

Wait List

Donor lungs are allocated on the basis of the Lung Allocation Score (LAS). LAS is calculated from a number of variables, including age, BMI, etiology of respiratory failure, functional status, diabetes, O₂ requirement, spirometry findings, pCO₂, 6-minute walk distance, serum creatinine and bilirubin, pulmonary artery pressures, cardiac index, and need for assisted ventilation. Since its implementation in 2005, use of the LAS score has resulted in increased transplantation of the sickest patients, rather than those with the longest waitlist time. As patients undergoing transplantation have become older and sicker, bridge to transplant with mechanical ventilatory support or extra-corporeal membrane oxygenation (ECMO) has become more common. Despite increased risk of early post-operative complications and mortality, comparable long-term survival with patients bridged to transplant with ECMO has been demonstrated in carefully selected patients. Patients with LAS >50 require frequent reassessment for accurate LAS calculation and organ allocation. Wait list mortality remains high, approximately 15 deaths/100 wait list years.

Choice of Procedure

For patients with cystic fibrosis (CF) and other forms of bronchiectasis or septic lung lung disease, double lung transplant is preferred, as leaving a chronically infected contralateral lung risks transmitting infection to the allograft. Double lung transplantation (DLTx) is also the preferred procedure for idiopathic pulmonary arterial hypertension (IPAH) and patients with severe secondary pulmonary hypertension. DLTx effectively unloads the right ventricle and ensures that cardiac output is evenly distributed between both lungs, which prevents the preferential over-circulation that would occur with single lung transplantation (SLTx). Bilateral sequential lung transplantation has become the preferred technique for DLTx candidates due to lower risk of airway ischemia.

For COPD and IPF however, both SLTx and DLTx are suitable options in the absence of pulmonary hypertension. Various studies have supported a net survival benefit for DLTx in COPD patients <60 years old, and for this reason, it is the procedure of choice for this patient population.

However, idiopathic pulmonary fibrosis (IPF), which is a more rapidly progressive disease, any survival benefit that is provided with DLTx is offset by waitlist mortality, such that either SLTx or DLTx is acceptable. In the absence of associated pulmonary hypertension, SLTx is also the preferred procedure for COPD and IPF patients >60 years old because of the increased operative morbidity and mortality of DLTx.

For SLTx candidates, the decision of whether to transplant the right or left lung is determined by preoperative evaluation of split lung ventilation/perfusion. If a significant discrepancy exists, the worse lung should be transplanted to preserve the residual function of the contralateral native lung.

As of 2017, the International Society for Heart and Lung Transplantation (ISHLT) reported 3,626 adult DLTx and 826 SLTx, reflecting the preference for bilateral versus single lung transplant. This is the preference at our center, with demonstrated long term survival benefit of DLTx vs SLTx. Given the shortage of donor organs, with 1.2 patients on the waiting list for each donor, according to the 2019 OPTN/SRTR annual data report, select centers have preferred SLTx for selected patients to maximize the benefit of donor lungs.

Surgical Approach

Single lung transplants are typically performed through an anterolateral thoracotomy, whereas double lung transplants can be undertaken either through double sequential anterior thoracotomies, clam-shell incision (bilateral thoracosternotomy), or a median sternotomy. The clamshell approach is the preference at our center for cystic fibrosis, suppurative lung disease, and redo LTx, or history of thoracic procedure, with the disadvantage being morbidity related to transverse sternal division. Bilateral sternal sparing anterior thoracotomy can be considered in cases of favorable anatomy or obstructive or fibrotic lung disease cases. We prefer median sternotomy in the setting of DLTx requiring bronchial artery revascularization (BAR), pulmonary hypertension, or concomitant cardiac procedure. When a median sternotomy is used, cardiac manipulation is often required for exposure, necessitating intraoperative MCS. Relative contraindications include excessive pleural adhesions and small pleural spaces, as measured on CT imaging.

All thoracotomy incisions are performed through the 4th intercostal space. Vascular access for intraoperative or postoperative ECMO is prepped in advance. The decision to use cardiopulmonary bypass (CPB), veno-venous extracorporeal membrane oxygenation (ECMO), or veno-arterial ECMO is primarily based on the patient’s ability to tolerate single lung ventilation and the hemodynamic alterations that occur during cardiac and hilar manipulation. ECMO is increasingly favored at our center compared to bypass, with evidence suggesting lower rates of primary graft dysfunction, in-hospital complications, and intubation time.

When performing a single lung transplant, if the split ventilation perfusion is preferential to the contralateral lung, isolated lung ventilation is usually tolerated and can be performed without CPB or ECMO. However, in the presence of even moderate pulmonary hypertension (MPAP> 35 mmHg) or cardiac dysfunction, intolerance of pulmonary vascular isolation and the associated increased right ventricular after load may necessitate CPB or ECMO. For this reason, there should always be a formulated plan for rapid institution of CPB or ECMO during a single lung transplant procedure performed through thoracotomy. Multiple options exist, including cannulation of the right atrium and ascending aorta through a right thoracotomy or cannulation of the pulmonary trunk and the descending aorta from the left. Femoral cannulation is a reliable option for either CPB or ECMO initiation in patients without significant peripheral vascular disease.

Intraoperative Considerations

SLTx requires lung isolation that is typically achieved by double lumen endotracheal intubation. A left-sided double-lumen ET tube is sufficient for both left and right SLTx, since the bronchial anastomosis occurs at the level of the distal main stem bronchus. DLTx being done without CPB also requires a double-lumen ET tube. DLTx performed with CPB may utilize a single-lumen ET tube. Central venous access and Swan-Ganz catheter placement are crucial for volume replacement and monitoring of pulmonary artery pressures. Intraoperative TEE is standard. Patients are positioned in a semi-lateral position for SLTx and in a supine position for double lung transplant. Full lateral decubitus position may be preferable for left SLTx, because the heart can obscure the hilum on the left. The patient's arms should be tucked for median sternotomy. If a clamshell incision is being used, the patient’s arms should be padded and suspended from an ether screen or with armrests so that the lateral chest wall is accessible down to the bed. Patients should be prepped and draped to the level of the knees to permit access to the femoral vessels for peripheral cannulation for CPB or post-transplant ECMO.

Prior to incision, perioperative antibiotics, and steroid immunosuppression, should be administered. Induction immunosuppression, such as an IL-2 receptor blocker (ex. basiliximab/Simulect) or thymoglobulin may also be given for lymphocyte depletion. Antibiotic prophylaxis is administered in accordance with the institution and addressing any known resistant organisms harbored by the recipient, including fungi.

Recipient Lung Explantation

Pre-operative VQ scan guides which lung should be transplanted first. Upon entry, the inferior pulmonary ligament is divided, adhesions to the chest wall are lysed, the mediastinal pleura is dissected, and the hilar vessels are isolated. The phrenic nerve is identified and protected, avoiding manipulation, and using low cautery settings when nearby, as injury is not well tolerated in the post lung-transplant patient. The vagus nerve is avoided. When dissecting pleural adhesions, extra care should be taken to prevent injury to the native lung. Air leak complications may present difficulties with ventilation, requiring unplanned intraoperative MCS.

Entering the pericardium may facilitate isolation of the vascular pedicles and help safeguard control of a vascular injury. If performing the transplant without CPB, single lung ventilation may cause a significant shunt through the unventilated lung resulting in rapid desaturation. Temporary occlusion of the main pulmonary artery by digital compression in this situation can decrease the shunt and rapidly improve hypoxemia.

Prior to ligation of vascular structures, the main pulmonary artery should also be temporarily occluded to assess the hemodynamic response. In the event that the PA pressures rise precipitously, or systemic pressures fall to unsafe levels, full mechanical ventilation is reinstituted, the patient is heparinized, and CPB is initiated prior to proceeding. If temporary occlusion of the PA is well tolerated, or once CPB is begun (if applicable), the pulmonary arteries and veins are ligated. Ligation with vascular staplers is performed at secondary branch points, such that adequate length is preserved for the anastomoses. The bronchial arteries and peribronchial lymphatics are ligated, and the main stem bronchus is divided by scalpel just proximal to its bifurcation.

Once the lung is removed and hemostasis is achieved, the pericardium can be cleared around the hilar structures to prepare for mobilization for anastomosis. Posterior chest tube and peri-costal sutures may be placed, and the PA and left atrial cuffs are dissected proximally, so that enough distance exists to place vascular clamps and perform the anastomoses.

On the right side, the left atrial cuff is typically foreshortened secondary to the overlying right atrium and requires dissection of the inter-atrial groove to achieve adequate cuff length.

Appropriate timing of explanation is critical for minimizing ischemia time. The native lung(s) and hilar structures should be dissected before the donor lung arrives. This is especially important in order to facilitate timely removal of the second lung during DLTx. Excellent hemostasis is imperative, as any bleeding becomes much more difficult to control following graft implantation and heparinization.

Donor Lung Preparation

Donor lung preparation is usually performed on the back-table by the procurement surgeon. If a double lung transplant is being performed, the lung block is first divided evenly, with transection of the left mainstem bronchus and inclusion of the tracheal segment with the right lung.

The remainder of donor lung preparation entails isolation of the pulmonary vessels from within the hilum, removal of excess pericardial tissue, and shortening of the mainstem bronchus. In order to prevent ischemic bronchial anastomotic complications, it is essential to shorten the donor bronchus to within one cartilaginous ring of the lobar division. Given the propensity for ischemic injury in the donor bronchus, trimming and handling of the bronchus should be performed sharply with scalpel and atraumatic forceps. Donor bronchial specimens should be submitted for culture and sensitivity, and all secretions cleared from the bronchial lumen. The lung should remain on ice during back-table preparation and implantation until the time of reperfusion.

Implantation

Implementation starts with the bronchial anastomosis, which is performed with either a continuous running suture throughout the circumference of the anastomosis, or with a continuous running suture along the posterior membranous tissue and an interrupted suture for the anterior cartilaginous portion. 4-0 PDS suture is typically employed. Donor and recipient bronchial size discrepancies can be managed by adjustment of bite size, or in more pronounced cases, “telescoping” of the smaller bronchus within the larger. Reinforcement of the bronchial anastomosis can be achieved by buttressing adjacent nodal or adipose tissue. The anastomosis can be evaluated by anesthesia via bronchoscopy following completion, as well as an intraoperative leak test. Pulmonary artery reconstruction is typically performed next. After applying a vascular clamp to the recipient PA stump, the staple line is resected. The donor PA is trimmed to appropriate length to avoid redundancy and the potential for kinking after lung inflation, especially on the right. The anastomosis is performed in continuous end-to-end fashion with a double armed 5-0 polypropylene suture.

Lastly, our attention is turned to the left atrial cuff anastomosis. A large Satinsky clamp is first applied to the recipient atrial cuff, and the staple line on the pulmonary vein stump is removed. The intervening segment of atrial tissue between the upper and lower pulmonary veins is divided to create a single orifice. The anastomosis is performed in running fashion with 4-0 polypropylene. The tissue can be imbricated to approximate the endocardial surface and exclude thrombogenic atrial muscle. Prior to cinching and tying the atrial anastomosis, the lung graft is de-aired by partially releasing the vascular clamp on the pulmonary artery to allow blood to flow through the pulmonary vasculature and vent from the atrial cuff anastomosis. If the procedure is being performed with CPB, enough blood volume must be returned from the circuit to adequately fill the heart for deairing. The Satinsky clamp from the atrial cuff is removed and the suture line is tied snugly. The pulmonary artery clamp is slowly removed over several minutes, allowing for gradual reperfusion in an effort to prevent acute reperfusion injury. All anastomoses are inspected for hemostasis and repaired as necessary.

If performing a DLTx, the removal and implantation of the second lung is carried out in similar fashion. A lung-protective ventilation strategy is employed, utilizing tidal volumes of 6-8 ml/kg and the minimum FiO₂ to maintain oxygen saturations greater than 90%. Permissive hypercapnia is employed to minimize barotrauma. Once ventilation is re-established, CPB is weaned (if applicable), chest tubes are positioned, peri-costal sutures placed, and the thoracotomy or clamshell incision is closed. When reapproximating a clamshell incision, care should be taken while closing the transverse sternotomy due to risk for subsequent complications with sternal healing. The double lumen endotracheal tube is converted to a single lumen tube, and bronchoscopy is performed to inspect the bronchial anastomosis and clear secretions.

Postoperative Care

Key components in the management of lung transplant patients include immunosuppression, weaning from mechanical ventilation, and post-surgical care.

Conventional immunosuppression includes triple therapy with a calcineurin inhibitor (tacrolimus or cyclosporine), an antiproliferative agent (mycophenolate or azathioprine) and a corticosteroid, such as methlyprednisone. Tacrolimus trough levels are followed daily and dosage is tailored accordingly with renal function in mind. Goal trough levels range from 8-15 ng/mL. Prednisone dosage is weaned gradually in the first week to a discharge dosage of 10 mg daily. In the instance of impaired peri-operative renal function or development of postoperative acute renal failure, calcineurin inhibitors are withheld and therapy with rabbit or equine anti-thymocyte globulin may be utilized. Infection prophylaxis includes broad spectrum antibiotic and antifungal prophylaxis, tailored to cultures, with duration per institutional protocol, often ~72 hours. CMV prophylaxis for seropositive donors/recipients may be given initially as IV ganciclovir, followed by valganciclovir once tolerating PO medications or acyclovir for seronegative patients. Trimethoprim-sulfamethoxazole is started once tolerating PO for Pneumocystis jirovecii (PCP) prophylaxis. Most centers also administer voriconazole for anti-fungal prophylaxis, either universally or for high-risk patients.

Weaning from mechanical ventilation may be difficult because of the secondary effects of chronic lung disease on respiratory mechanics. Ventilator management after SLTx for COPD can be particularly challenging due to hyperinflation of the remaining native lung. Differential ventilation of the individual lungs through a double lumen endotracheal tube may be helpful in this situation. Inability to wean from mechanical ventilation should be managed with early tracheostomy and an attributable cause determined. The most common complications contributing to inability to wean from the ventilator are primary graft dysfunction (PGD), acute rejection, and pneumonia. PGD occurs within the first 72 hours following transplantation and mimics ARDS with ineffective gas exchange and interstitial infiltrates. Similar to ARDS, PGD is classified based on the PaO₂/FiO₂ ratio and the presence of pulmonary edema on chest radiograph, with severity graded 1-3. It occurs in 10-30% of recipients and increases the risk of short-term mortality, as well as long term chronic rejection. Acute management is supportive, consisting of lung protective ventilation and judicious fluid resuscitation. Severe PGD may require ventilation assisted by neuromuscular paralysis, institution of inhaled nitric oxide, or in refractory cases, initiation of ECMO. Importantly, ECMO allows for avoidance of the deleterious effects of increased ventilator requirements, such as elevated FiO₂ and tidal volumes.

Acute rejection can cause clinical decline post-transplant but usually occurs later than PGD. Radiographic features suggestive of acute cellular rejection (ACR) include perihilar and multifocal opacities, as well as pleural effusions. ACR is typically diagnosed by histopathologic examination of transbronchial lung biopsies and graded A0 (absent) to A4 (severe). Treatment consists of pulse dose steroids and possibly anti-thymocyte globulin. Plasmapheresis is performed when antibody mediated rejection is identified.

Postoperative pneumonia in the lung transplant recipient may occur at any time. An early pneumonic process is frequently transmitted with the donor organ, and donor bronchial cultures obtained at the time of back-table organ preparation may help guide antimicrobial therapy. Additional bronchoalveolar lavage specimens should be obtained by bronchoscopy if pneumonia is suspected. Preoperative colonization of the recipient should also be considered when determining initial empiric therapy.

Additional post-surgical care specific to the lung transplant recipient includes routine surveillance for rejection. Patients are routinely surveyed with bronchoscopy with transbronchial biopsies, performed 3- and 6-weeks post-transplant, and then at 3-month intervals for the first year. Adjustment of immunosuppression according to histopathologic findings is a crucial aspect of long-term management. Trends in PFTs are routinely surveyed to evaluate for decreases in FEV₁. Patients routinely undergo post-operative pH testing, due to the high prevalence of post-operative gastroesophageal reflux disease (GERD). GERD has been implicated in the development of chronic lung allograft dysfunction (CLAD), with multiple retrospective studies suggesting that early fundoplication has the potential to ameliorate the detrimental long-term effects of reflux on pulmonary function.

Lung Procurement

Logistics of the Procurement:
Prior to leaving for the procurement, discuss with the coordinator and the implanting surgeon to identify any concerns. Make sure to have a concrete sense of the travel arrangements (where you are going, what hospital, how you are traveling, plane tail number, pilot cell phone number). In addition, know who the surgical recovery coordinator on site is and their phone number. Know the blood type of the recipient, the donor, and the UNOS identification number. Clear knowledge of any particular anatomic or recipient issues is key. In general, an acceptable ischemia time is 6-8 hours.

When on site, review that the correct donor is identified. Confirm the UNOS identification as well as the donor blood type (x 2 separate blood tests). Examine the history and physical with attention to details that may suggest the presence of pulmonary disease, such as smoking history. Review the past medical history, cause of death, death note, and the consent for donation. Bold-faced items are critical. Review chest imaging, donor virology and sputum/blood culture results. Fungus may be a contradiction to transplant.

Obtain an arterial blood gas on the requested FiO2 and PEEP of the implanting surgeon. In general, pO2 should be >300 on 100% FiO2 and/or >100 on 40% FiO2. Perform a flexible bronchoscopy to visualize the anatomy, tracheal mucosa, and secretions. Discuss with the anesthesia team the need to minimize volume administered during the procurement, as well as ventilation strategy, with a tidal volume goal of 6-8 ml/kg. Ask that vasopressors be used if necessary. Keep the CVP less than 10. If the CVP rises or the lungs appear edematous with "thumbprinting" on visualization, furosemide may be administered.

There are typically 5 phone calls to the implanting surgeon. (1) prior to leaving to know the plan. (2) on site after the oxygen challenge and after visualizing the lungs; make this phone call as soon as possible and relay the condition of the lungs, any anatomic abnormalities or adhesions, bronchoscopy findings, ABG results, and the estimated cross clamp time. (3) confirm the cross-clamp time. (4) upon leaving the donor hospital; relay any procurement issues and confirm the estimated time of return to the implanting institution. (5) upon landing at home airport.

Visualization and Dissection:
Perform a generous median sternotomy in the standard fashion. Open and "T" the pericardium. Retract the pericardium with 3 retention sutures on each side. Do not tie these to the patient; clamp to the towel so access to the lungs can be obtained. Make sure to communicate with the anesthesia team during the dissection so that any manipulation of the heart or great vessels may be anticipated and blood pressure optimally managed.

After the heart team has visualized the heart, hold ventilations and open each pleura widely from the apex to the diaphragm. Resume ventilation and evaluate the lungs for consolidation, atelectasis, contusion, bullae, masses, adhesions, or injury.

Perform as much dissection as possible while the abdominal team is working. Open the pleura above the pulmonary arteries straight down as far back as possible. Intermittently hold ventilation if need be. Mobilize the superior vena cava and aorta. Open the plane between the right superior pulmonary vein and the right pulmonary artery. Develop the plane between the SVC and aorta down to the trachea. The aorta and SVC can be retracted with tapes. Dissect the trachea and encircle if possible. Take care to identify the azygous vein. Do not take down the inferior pulmonary ligament as the blood pressure may be compromised with this maneuver. With the cautery on 10, or with a blade, dissect the inter-atrial groove with the cardiac team to agree on an adequate atrial cuff for both teams.

Cross-Clamp and Removal:
Set up the sterile pressure tubing and perfusate. 60 ml/kg Perfadex is used (~4L for a 70 kg person). Set the pressure bag at 140 mmHg or suspend the bag at least 30 cm above the donor. 75% of the volume is used for the antegrade flush and 25% for the retrograde flush. After confirming clamp time with the other teams and the implanting institution, systemically heparinize with 300 U/kg. Place a 4-0 polypropylene purse string into the main PA just proximal to the bifurcation, followed by a PA vent or infusion catheter into the main PA in the standard fashion and secure with a Rummel tourniquet. Flush the lines and connect to the cannula. Inject prostaglandin E₁ (500 mcg alprostadil) into the right atrial appendage, or preferably, the main PA adjacent to the catheter. This results in pulmonary vascular dilation, allowing for improved flushing, but will cause the systemic hypotension, so do this immediately prior to cross-clamp.

Clamp or ligate the SVC, transect the IVC, place the aortic cross clamp, and start the antegrade pulmonary perfusion. The left heart should be vented by resection of the tip of the left atrial appendage. See the "Heart Procurement" chapter for further heart procurement logistics. Move the pericardial retention sutures and place copious amounts of saline ice slush into the pleural spaces and a suction inside the IVC. The goal is to cool the organs as quickly as possible. Make sure that the anesthetists continue ventilating; decrease tidal volumes to 250-300 ml while maintaining PEEP.

Work with the heart team to open Sondergaard's groove into the left atrium at the previously made dissection point. Elevate the heart and carry the left atrial incision inferiorly over to the left pulmonary veins, come up, and split the distance between the left pulmonary veins and the left atrial appendage and complete along the superior dome of the atrium. Separate the main PA from the bifurcation at the level of the pulmonary plegia catheter site. With the heart removed, one can perform the retrograde flush now, or later, on the back table. With a 14 Fr retrograde cardioplegia catheter or Foley, infuse ~250 cc of Perfadex into each pulmonary vein. The effluent from the pulmonary artery should turn clear. Remove all tubing from the field. Divide the inferior pericardial reflection posteriorly to the inferior pulmonary ligament and connect the incisions so that the pericardium is incised completely inferiorly. On one side, then the other, divide the inferior pulmonary ligament. Externalize one lung. Bluntly develop a pleural plane posterior to the pulmonary veins to above the level of the pulmonary artery. Open the pleura. Return the lung to the chest and perform on the other side. Carry this dissection up to the trachea.

Dissect the posterior pericardium off of the spine, esophagus and aorta, proceeding superiorly. Elevate the pulmonary veins and artery until the trachea is encountered. Dissect the areolar tissue above the aorta, esophagus, and vertebrae. Dissect the trachea from the esophagus for 4-5 cm. Pull the endotracheal tube back to -20 cm. Inflate the lungs to remove atelectasis and then partially deflate the lungs and fire a TA-30 green load across the trachea. Stop ventilations. Refire the stapler just distal to the first load and transect the trachea between the loads. Lyse any remaining bands or tissues. Remove the lungs.

Packaging:
If the retrograde flush was not performed in situ, it should be performed on the back table, as previously described. If the lungs are to be split on site, discuss the arrangement with the other lung team as to who gets the carina; this will typically go with the right lung.

Staple the left main stem bronchus with 2 green loads of a TA-30 stapler and transect between them. Place the lung(s) in their respective container(s) and cover with laparotomy pads. Place ice slush over the lap pads and fill the remainder of the container with ice-cold saline. Purge any air from the container prior to sealing. Place the container in 2 heavy plastic bags for transport with sterile technique. Individually tie each bag and make sure the first bag is completely within the second. Purge air from the bags prior to tying. Place the bag in the cooler and cover with ice. Make sure blood for prospective crossmatch and lymph nodes are included. Seal the cooler. Obtain your copy of the donor and UNOS paperwork, as well as virology testing. Sign the organ procurement organization's operative report. Make sure you have the correct organ, and you 're off!

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