Heart-lung transplantation. Technical modifications that may improve the early outcome.

After heart-lung transplantation, mortality and morbidity remain related, to a significant degree, to surgical problems such as uncontrollable bleeding, phrenic nerve palsy, and dehiscence of the tracheal anastomosis. The following modifications of the original Stanford technique were designed: (1) Back bleeding from the graft is avoided; (2) dissection of the posterior mediastinum is limited as much as possible, with only the tracheobronchial bifurcation being dissected free; (3) surgical stapling is extensively used to optimize hemostasis; (4) the surgical procedure is kept away from the phrenic and vagus nerves; (5) early corticosteroid therapy is avoided and the tracheal anastomosis may be wrapped with a pedicle of great omentum. These techniques were used in 21 patients. Postoperative bleeding remained minimal and never necessitated reoperation. There was no instance of phrenic nerve palsy. Dehiscence of the tracheal anastomosis occurred in two patients during the initial experience, but in subsequent patients this complication was prevented by adequate improvements (omentoplasty and avoidance of corticosteroids). Our technical modifications may reduce the risk of early surgical complications and thereby improve the early outcome and leave the patient in better condition to face the other hazards of heart-lung transplantation.