Martin, Archer Kilbourne

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.

ABSTRACTIntroductionLung transplantation has been evolving since its inception in 1963. Over recent years, literature has suggested a shift in the perioperative strategy of mechanical support toward extracorporeal membrane oxygenation (ECMO) as the preferred modality of extracorporeal life support (ECLS) in lung transplantation. The Survey of ECLS Application in Lung transplantation (SEAL) was designed to elucidate the current practice patterns of perioperative ECLS within the United States.MethodsIn this cross‐sectional study, a physician from 62 adult lung transplantation centers across the United States of America (USA) was surveyed on their institutional practices regarding the perioperative management of lung transplantation patients, with a focus on mechanical support.ResultsThe survey completion rate was 74% (46/62 eligible institutions). Most transplant centers utilize venoarterial (VA) ECMO (78%, 36/46) and/or venovenous (VV) ECMO (93%, 29/43) as a bridge to lung transplantation. When ECLS is used intraoperatively, 61% of (28/46) responding programs use VA ECMO as their preferred support. All programs use transesophageal echocardiography (TEE) intraoperatively, 85% (33/39) cannulate for ECMO centrally, and 74% (29/39) use a combination of inhaled and intravenous anesthesia while using ECMO intraoperatively. Most programs do not use antifibrinolytic during VA ECMO (62%, 28/45). Anticoagulation management and VA ECMO flows throughout the procedure showed considerable variation.ConclusionData from SEAL illustrates that though there are some practice commonalities within the United States, there is also quite a bit of variability in practice. Multiple dominant practices within the USA are consistent with a recently published International Society of Heart and Lung Transplantation consensus.

This review highlights key studies examining perioperative management of cardiothoracic transplantation published in 2023. Articles were manually screened after searching Scopus, PubMed, and Google Scholar databases for manuscripts related to cardiothoracic transplantation, which yielded 343 papers with 15 qualitatively selected as the most salient for readers. Overarching themes include differences in outcomes across the various etiologies of end-stage lung disease, novel developments to expand the donor pool, and multi-organ transplantation.