Allen, Wesley L.

Lung transplantation presents numerous intraoperative challenges, particularly related to pulmonary artery and vein anastomotic integrity and hemodynamic stability. We present 3 cases where intraoperative transesophageal echocardiography (TEE) provided real-time diagnostic insights that directly altered surgical decision-making. Case 1 highlights pulmonary vein flow acceleration initially concerning for ostial stenosis, ultimately diagnosed as external compression from a retractor. Case 2 demonstrates true right pulmonary vein stenosis requiring immediate revision. Case 3 illustrates severe right pulmonary artery narrowing, detected by TEE and corrected intraoperatively to prevent early graft dysfunction. These cases underscore the critical role of intraoperative TEE in detecting subtle anastomotic abnormalities, distinguishing functional from structural stenosis, and guiding timely surgical correction. Incorporating comprehensive 2D and 3D TEE evaluation into routine lung transplant protocols enhances diagnostic accuracy, reduces postoperative complications, and contributes to improved long-term allograft function. Intraoperative 3D TEE should be considered an essential imaging modality in cardiothoracic transplantation and an invaluable educational tool for perioperative teams.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease involving the upper and lower motor neurons. Perioperative management of patients with ALS can be challenging due to the risk of hemodynamic instability, aspiration, and ventilatory failure. We discuss a 58-year-old male patient with ALS who underwent open abdominal surgery under regional anesthesia utilizing a remimazolam infusion for sedation. While various sedation agents have been used successfully in patients with ALS, remimazolam, a new short-acting benzodiazepine with unique pharmacologic properties and reversible anxiolysis, provides amnesia while avoiding ventilatory depression.

Portopulmonary hypertension is a relatively common pathologic condition in patients with end-stage liver disease. Traditionally, severe pulmonary hypertension is regarded as a contraindication to liver transplantation (LT) due to a high perioperative mortality rate. Recently, extracorporeal membrane oxygenation (ECMO) has been utilized for intraoperative management of LT. As venoarterial (VA) ECMO may benefit certain high-risk LT patients by reducing the ventricular workload by the equivalent of the programmed flow rate, its usage requires multidisciplinary planning with considerations of the associated complications. We highlighted two cases at our single-center institution as examples of high-risk pulmonary hypertension patients undergoing LT on planned VA ECMO. These patients both survived the intraoperative period; however, they had drastically different postoperative outcomes, generating discussions on the importance of judicious patient selection. Since ECMO has removed the barrier of intraoperative survivability, the patient selection process may need to put weight on the patient’s potential for postoperative recovery and rehabilitation. Considerations on LT recipients undergoing preemptive ECMO need to expand from the ability of the patients to withstand the demands of the surgery during the immediate perioperative period to the long-term postoperative recovery course.

Extracorporeal circulation (ECC) support using intraoperative extracorporeal membrane oxygenation (ECMO) during lung transplantation (LTx) is now a routine practice for many high volume centers. Circuits that are dedicated to ECMO alone can be expensive and do not allow full cardiopulmonary bypass (CPB) to be performed. We describe our technique of instituting venoarterial ECMO during LTx using a less-expensive hybrid circuit that facilitates easy and immediate conversion to full CPB if needed, without interruption of ECC.