In addition, he referred to the practice of other surgeons in leaving the posterior wall of the tracheal carina and main bronchi in situ. A more innovative approach to minimizing technical complications following HLT has been reported by Vouhe and Dartevelle in 1989. The authors emphasized the importance of a limited dissection of the posterior mediastinum, exposing only the distal trachea and both bronchi. They performed extrapericar-dial pneumonectomies and used surgical stapling as much as possible in dividing the left atrial wall and in creating appropriate-sized passages for the donor lungs. They made a routine practice of leaving the posterior wall of the left atrium, the pulmonary artery bifurcation, and the transpericardial aspect of the pulmonary pedicles in situ.

Prior to implantation of the donor heart-lung graft, fibrin glue was placed over the posterior mediastinum to achieve optimal hemostasis. Using this approach in 21 patients, the authors recorded a mean blood loss during the first 24 postoperative hours of 800 ┬▒ 350 ml. No patient in their experience or in our most recently operated-on group required reoperation for excessive postoperative hemorrhage. canadian family pharmacy online
In summary, bleeding has been a major complication of HLT because of the presence of large posterior mediastinal collaterals, coagulopathy from hepatic congestion due to right-sided heart failure, adhesions from previous thoracic operations, and the long cardiopulmonary bypass times that are required. The techniques that we have adopted should decrease the risk of hemorrhagic complications and the risks associated with multiple transfusions after HLT, and thus improve the early outcome after this procedure.