Use of an apical heart suction device to expose the left pulmonary veins during transsternal pneumonectomy.

Lung cancer operations are usually performed through a standard lateral or posterolateral thoracotomy. However, there are some difficult cases with an extended proximal invasion of the pulmonary vessels (artery and/or veins)1Venuta F. Ciccone A.M. Reconstruction of the pulmonary artery.Semin Thorac Cardiovasc Surg. 2006; 106: 104-108Abstract Full Text Full Text PDF Scopus (18) Google Scholar or the carina2De Perrot M. Fadel E. Mercier D. Mussot S. Chapelier A. Dartevelle P. Long-term results after carinal resection for carcinoma: does the benefit warrant the risk?.J Thorac Cardiovasc Surg. 2006; 131: 81-89Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar that may require a median sternotomy approach. This incision allows optimal control of the root of the vessels, the ideal exposure for complex vascular reconstructions, and the institution of cardiopulmonary bypass (CPB) with central cannulation if required. The latter may be indicated either to reconstruct a vessel invaded too proximally by the tumor or to address emergency situations. It could also be required to improve exposure of the posterior aspect of the heart and in particular the left atrium. It helps to decompress the cardiac chambers when the heart cannot be vertically lifted by hand retraction. In these situations, a median and upward retraction of the heart could lead to poor diastolic filling, hypotension, and hemodynamic instability. The use of the bypass machine has been shown to activate the inflammatory response,3Wan S. Le Clerc J.L. Vincent J.L. Inflammatory responses to cardiopulmonary bypass: mechanism involved and possible therapeutic strategies.Chest. 1997; 112: 676-692Crossref PubMed Scopus (731) Google Scholar require full systemic heparinization, and increase the need for blood transfusions,4Gammie G.S. Lee J.C. Pham S.M. Keenan R.J. Weyant R.J. Hattler B.G. et al.Cardiopulmonary bypass is associated with early allograft dysfunction but not death after douple-lung transplantation.J Thorac Cardiovasc Surg. 1998; 115: 990-994Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar especially during more complex operations. For these reasons, it should be avoided whenever possible during lung surgery. In a recent patient requiring left pneumonectomy through a median sternotomy, we used the Starfish heart positioning device (Medtronic, Inc, Minneapolis, Minn) to improve exposure and avoid CPB. A 55-year-old man was referred to our unit with a huge left upper lobe epidermoid carcinoma invading the left pulmonary artery up to the root (Figure 1) and the left upper pulmonary vein; the left main bronchus was also involved. Induction chemotherapy could not be considered because of concomitant piastrinopenia and liver cirrhosis. Pneumonectomy with reconstruction of the origin of the main pulmonary artery was considered the operation of choice; the potential need for CPB suggested a median sternotomy approach even if it was anticipated that it would have been more difficult to control and suture the venous side. At operation, the pericardium was opened wide and the origin of the left pulmonary artery was isolated, with enough space to place a vascular stapler. However, the venous side was impossible to control. The section of the upper pulmonary vein had to be performed very close to the atrium, and that site was not easy to prepare because the left side of the heart was enlarged (primary hypertension) and the venous orifice was completely covered. Upward retraction of the heart was not possible without causing serious hemodynamic instability. The possibility of instituting CPB to decompress the heart and facilitate cardiac manipulation was considered; this support would have been required not to perform a technically demanding reconstruction (as supposed preoperatively), but just to allow optimal exposure of the left pulmonary veins for a standard transsternal pneumonectomy. However, the patient had a reduced number of platelets that would have been damaged by the bypass system. To avoid the risks related to CPB, we placed the Starfish heart positioning device on the apex of the left ventricle, applied suction, and suspended the heart upward for optimal exposure of the posterior aspect of the left atrium (Figure 2), maintaining stable cardiac performance. The pulmonary artery and the two pulmonary veins were sutured and sectioned with a vascular Endo-GIA stapler (U. S. Surgical Corporation, Norwalk, Conn). Pneumonectomy was completed by preparing the left main bronchus transpericardially and sectioning it close to the carina after closure with a TA stapler (U. S. Surgical Corporation). The procedure was completed with radical lymphadenectomy. The heart retraction system was eventually removed, leaving a small hematoma on the surface of the heart. This has been previously described,5Lau C.L. Hoganson D.M. Meyers B.F. Damiano R.J. Patterson G.A. Use of an apical heart suction device for exposure in lung transplantation.Ann Thorac Surg. 2006; 81: 1524-1525Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar along with transient ST-segment electrocardiographic modifications related to the suction trauma. The postoperative course of the patient was uneventful, and he successfully also underwent adjuvant chemoradiotherapy. The apical suction device has been used frequently during coronary bypass procedures without any significant incidence of complications. It is extremely important to follow the manufacturer’s recommendations and avoid placement over a major epicardial coronary artery; this may cause ischemia and, if prolonged, myocardial infarction. The use of this system has been recently proposed also during sequential double lung transplantation to improve exposure of the left hilar structures, avoiding CPB and hemodynamic problems.5Lau C.L. Hoganson D.M. Meyers B.F. Damiano R.J. Patterson G.A. Use of an apical heart suction device for exposure in lung transplantation.Ann Thorac Surg. 2006; 81: 1524-1525Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar This new tool, often used by cardiac surgeons during coronary artery surgery, should also be kept in the surgical armamentarium of general thoracic surgeons; the availability of the apical retractor system could help to solve difficult situations, avoiding hemodynamic instability without instituting CPB. This apical suction system obviously cannot be used when CPB is required to perform complex vascular reconstructions.