En Block Heart and Liver Procurement 3

Stepwise Description of En-bloc Heart–Liver Procurement.

By Dr. Sam Zeraatiannejaddavani, Cardiovascular Surgeon, Dean of IUMS OPO, and Advanced Fellow in Research and Clinical Thoracic Organ Transplantation.

1. Exposure and Preparation

The procedure begins with a midline sternotomy extended into a midline laparotomy, allowing simultaneous access to both the thoracic and abdominal cavities. The pericardium is opened widely and suspended, while the liver is mobilized by dividing the falciform ligament and exposing the suprahepatic and infrahepatic vena cava. Systemic heparinization is administered to prevent intravascular thrombosis.

2. Cannulation and Perfusion Setup

The ascending aorta is cannulated for administration of cold preservation solution, while the right atrium or inferior vena cava is prepared for venous venting. The portal vein is dissected free for later cannulation to ensure cold perfusion of the liver. Meticulous dissection is performed around the supra-celiac aorta and supra-diaphragmatic inferior vena cava to prepare for en-bloc removal.

3. Initiation of Cold Perfusion

Following cross-clamp of the ascending aorta, cold cardioplegia is infused to arrest the heart and protect myocardial tissue. Simultaneously, cold preservation solution is delivered through the portal vein to flush the hepatic circulation, ensuring rapid cooling and clearance of blood. Topical ice slush is applied to both the heart and liver to enhance hypothermic protection.

4. Mobilization of Organs

The suprahepatic and infrahepatic vena cava, portal vein, and abdominal aorta are fully encircled. The diaphragm is carefully divided around the supra-diaphragmatic IVC to maintain continuity. The thoracic aorta and great vessels are transected at appropriate levels, leaving sufficient length for implantation. All vascular structures are preserved with maximum care to avoid damage or shortening.

5. En-bloc Retrieval

With all inflow and outflow structures controlled, the heart and liver are lifted together in continuity as a single block. The en-bloc removal maintains vascular integrity between thoracic and abdominal organs, preventing ischemic damage and allowing subsequent precise back-table separation if required.

6. Back-table Preparation

Once the graft is placed in cold preservation solution, the heart and liver are inspected and flushed again. At this stage, the organs can either be transplanted en-bloc or separated, depending on the recipient surgical plan. Careful trimming of the suprahepatic IVC, portal vein, pulmonary artery, and ascending aorta ensures optimal anastomotic length for implantation.