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Eur J Cardiothorac Surg 1999;15:333-339
© 1999 Elsevier Science NL

Clamshell or sternotomy for double lung or heart-lung transplantation?¹

Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Hôpital Marie-Lannelongue (Paris-Sud University), 133, Avenue de la Resistance, 92350 Le Plessis Robinson, France

Received 22 September 1998; received in revised form 7 December 1998; accepted 22 December 1998.

Corresponding author. Department of Thoracic and Vascular Surgery, Heidehaus Hospital (Hannover Medical School), 70 Am Leineufer, D-30419 Hannover, Germany. Tel.: +49-511-7906277; e-mail: paolo@pratique.fr

Objective: To evaluate the influence of either incision on the lungs and chest wall. Methods: Ninety-two double lung (DLT) or heart-lung (HLT) transplantations were done since January 1990. There were 22 (24%) hospital deaths, leaving 70 patients with complete data for evaluation. We did 38 DLT and 32 HLT for end-stage chronic respiratory failure (n=22) and primary (n=34) or secondary (n=14) pulmonary hypertension, using 37 fourth or fifth interspace clamshell incisions and 33 median sternotomies. Results: The clamshell group included a higher percentage of DLTs (73 vs. 33%, P=0.001) but recipient age, gender, preoperative diagnosis, bronchial anastomotic complications, number of cytomegalovirus infection, episode of acute rejection per patient-months and incidence of bronchiolitis obliterans were not statistically different between the two groups. At a follow-up time of 3.7±2 years, the overall 5-year survival of 57% was not influenced by the type of incision. The clamshell incision caused sternal over-riding in 12 (32%) patients, and eight surgical clamshell revision were necessary as compared with one median sternotomy (P=0.02). The clamshell incision was associated with a significantly higher incidence of postoperative chronic pain (27 vs. 6%, P=0.02). Postoperative mechanical properties of the chest wall were significantly (P<0.0001) worse in the clamshell-group patients while the intrinsic properties of the airways were not different. Conclusions: The clamshell incision results in more postoperative deformity, chronic pain, and impaired function as compared with median sternotomy. A bilateral anterolateral thoracotomy without division of the sternum is proposed for the sequential bilateral lung transplantation technique.

Key Words: Clamshell • Median sternotomy • Surgical morbidity • Functional outcome • Sequential anterolateral thoracotomy • Sternum preservation

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