Anesthetic considerations during heart-lung transplantation in a patient with an unresectable pulmonary artery sarcoma

Corresponding author: In-Cheol Choi, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Pungnap 2-dong, Songpa-gu, Seoul 138-736, Korea. Tel: 82-2-3010-3862, Fax: 82-2-3010-6790, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC Since the first report of a primary pulmonary artery sarcoma in 1923 [1], several hundred patients have been described. The diagnosis of such sarcomas is often delayed or established after death because the symptoms are nonspecific and survival time is limited. Mean survival time without surgical resection is 1.5 months, but may be as long as 10 months after surgical resection [2]. Early diagnosis and radical resection, including pneumonectomy, local excision, and endarterectomy, are necessary for more favorable survival outcomes. Heart-lung transplantation (HLT) is considered an alternative for patients who cannot undergo complete surgical resection. We describe here the outcomes of HLT in a patient with an unresectable pulmonary artery sarcoma. A 49-year-old female patient was admitted with progressive dyspnea and cough of 10 months’ duration. She was diagnosed with a pulmonary artery sarcoma, which could not be resected completely. We therefore elected to perform HLT. Prior to induction, a 5-lead electrograph, non-invasive hemo dynamometer, pulse oximeter, BIS sensor, and cerebral oxymetry sensor were placed and monitored. Anesthesia was induced with bolus doses of etomidate and rocuronium and a continuous infusion of 2% propofol and remifentanil. Endotracheal intubation with a 37 French double lumen tube was performed uneventfully. A central venous catheter with a Swan-Ganz catheter was placed in the left internal jugular vein and another central venous catheter was placed in the right subclavian vein. During the procedure, anesthesia was maintained with oxygen and a continuous infusion of remifentanil, propofol and rocuronium. HLT was performed through a median sternotomy. To reduce cardiopulmonary bypass (CPB) time, we attempted to dissect the lung using one-lung ventilation. During the CPB period, a double lumen tube was changed to a single lumen tube of internal diameter 7.0 mm. CPB was started in the usual manner with bicaval cannulation and aortic cross-clamping, followed by cardiectomy. The bronchi were clamped, and both lungs were removed separately. Only the posterior pericardium, the right atrial cuff with the vena cavae, and the cut ends of the distal trachea and the proximal ascending aorta were left in the thorax. After the donor heart-lung bloc was placed in the recipient’s chest, tracheal anastomoses were performed. The endotracheal tube was placed exactly at the anastomosis site by checking the position of the tip of the tube using a fiberoptic bronchoscope, followed by anastomosis of the right atrium and aorta. Following completion of the aortic anastomosis, ventilation with low tidal volume (4-5 ml/kg) was started. The patient was given prostaglandin E1 (PGE1) 0.05 μg/kg/min, inhaled prostacyclin I2 (PGI2) 60 μg and 20 ppm of inhaled NO to prevent pulmonary hypertension. Isoproterenol 0.05 μg/kg/ min and dopamine 5 μg//kg/min were started and the infusion rate was titrated to yield a heart rate of 90 to 100 beats/min. CPB was discontinued without difficulty, and vital signs after weaning were stable (Table 1), with a mean arterial pressure of 65 mmHg, a mean pulmonary arterial pressure of 16 mmHg, a heart rate of 118 beats/min, and a central venous pressure of 12 mmHg. The total ischemic time was 136 minutes and the CPB time was 192 minutes. During surgery, the patient received 2 units of packed red blood cells, 3 units of fresh frozen plasma,