Complete Heart Decompression During Bilateral Lung Transplantation

For complete cardiac decompression during bilateral lung transplantation using cardiopulmonary bypass (CPB) or central VA-ECMO, establish central cannulation through a median sternotomy (or extended anterior thoracotomy as your exposure allows), systemically heparinize and place an arterial cannula in the ascending aorta for return while obtaining robust venous drainage with bicaval cannulation (SVC and IVC) or an IVC + right atrial cannula to isolate and offload the right heart. Transecting or venting the main pulmonary arteries (and/or placing a dedicated PA vent or pulmonary venous/left atrial vent) allows rapid decompression of both right and left-sided chambers and prevents back-pressurization of the implanted lungs during implantation. If using central VA-ECMO rather than full CPB, configure the circuit for adequate venous drainage (central venous cannulae or a ProtekDuo/venopulmonary option for RV unloading) and ensure the pump flow is sufficient to keep cardiac chambers decompressed while maintaining physiologic arterial pressure. Place caval tapes and snare the cavae when needed to prevent recirculation into the native heart, monitor chamber volumes and ventricular decompression visually and with TEE, and adjust venous drainage or add vents (LV/LA) if residual distension persists. Finally, perform careful de-airing before reperfusion and wean/convert circulatory support per your institutional protocol once the pulmonary anastomoses are secure and graft function demonstrably adequate.