OPERATIVE STRATEGIES AND BLTX VS HLTX
The standard surgical approach for patients with PH is bilateral lung
transplantation under cardiopulmonary bypass. Heart-lung transplantation
is usually only performed in patients with PH and irreparable cardiac
defect 16. Furthermore, heart-lung blocs have been
increasingly rare in the USA with seven or fewer heart-lung transplants
performed in the pediatric age group in each of the last ten years
(UNOS.org reference). Furthermore, clinical experience has shown good
recovery of cardiac function in virtually all infants, children and
adolescents with severe PH who survive the early post-operative period.
Single lung transplant is rarely performed in pediatrics, particularly
for patients with PH due to adverse outcomes like pulmonary edema and
graft dysfunction 17.
Cardiopulmonary bypass (CPB) is used in pediatric patients due to
challenges utilizing double lumen endobronchial tubes in small airways
to provide single lung ventilation 17. As well, in PH
patients, CPB provides hemodynamic stability in presence of increased
pulmonary vascular resistance (PVR) 18. In some adult
transplant centers, ECMO has become the preferred intra-operative
support as it is associated with reduced complications and improved
survival 19. ECMO can also be extended
post-operatively to support patients either to prevent or in selected
patients with significant graft dysfunction 20.