Extended Pneumonectomy With Partial Resection of the Left Atrium, Without Cardiopulmonary Bypass, for Lung Cancer Lorenzo Spaggiari, MD, PhD, Massimiliano.

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Extended Pneumonectomy With Partial Resection of the Left Atrium, Without Cardiopulmonary Bypass, for Lung Cancer Lorenzo Spaggiari, MD, PhD, Massimiliano D' Aiuto, MD, Giulia Veronesi, MD, Giuseppe Pelosi, MD, Tommaso de Pas, MD, Gianpiero Catalano, MD, Filippo de Braud, MD The Annals of Thoracic Surgery Volume 79, Issue 1, Pages 234-240 (January 2005) DOI: 10.1016/j.athoracsur.2004.06.100 Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Preoperative chest computed tomography scan after induction chemotherapy. The tumor has diffusely invaded the left atrium. Note the interatrial groove (arrow) which must be dissected in order to safely clamp the left atrium (LA) to perform the complete resection. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 The Sondergaard technique, in which the dissection of the interatrial groove during right pneumonectomy permits elongation of the left atrial cuff to about 2 cm. The dashed line represents the incision on the LA. (LA = left atrium; RA = right atrium.) The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 After dissection of the interatrial groove, and before resection, the left atrial wall is clamped with a large Satinsky clamp. This allows the identification of any cardiac alterations. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 The resection and subsequent atrial reconstruction with double running sutures of 2-0 polypropylene are in progress. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Operative picture shows extended left pneumonectomy with partial resection of the left atrium and thoracic aorta. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Survival curve (Kaplan-Meier method) of patients who underwent extended pneumonectomy with partial resection of the left atrium for lung cancer, without cardiopulmonary bypass. The 3-year probability of survival was 39%; the patients at risk at 12, 24, and 36 months were 12, 11, and 9 respectively. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Same patient as in Figure 1. Left atrial wall resection after right pneumonectomy. Note the large portion of the atrial wall resected without cardiopulmonary bypass. (LA = left atrium.) The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 8 Same patient as in Figure 1. Operative view after extended right pneumonectomy with partial resection of the left atrium. Note the left-atrial volume reduction. Note the double 2-0 polypropylene suture (continuous arrow) with polytetrafluoroethylene reinforcements (dotted arrow) being used on the heart. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions

Fig 9 Same patient as in Figure 1. Computed tomography thoracic scan taken at 1 month follow-up. Note the left atrium volume reduction (continuous arrow) and the origin of the (left) contralateral inferior pulmonary vein (dotted arrow). This resection was performed without cardiopulmonary bypass. The Annals of Thoracic Surgery 2005 79, 234-240DOI: (10.1016/j.athoracsur.2004.06.100) Copyright © 2005 The Society of Thoracic Surgeons Terms and Conditions