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Ann Thorac Surg 1995;59:258-260
© 1995 The Society of Thoracic Surgeons
Wythenshawe Hospital Transplant Unit, Southmoor Rd, Manchester, United Kingdom M23 9LT
The Royal Victoria Hospital, Belfast, United Kingdom
To the Editor:
We read with interest the article ``Alternative Technique for Orthotopic Heart Transplantation'' by Blanche and associates [1] in which they described a technique for orthotopic cardiac transplantation that preserve the donor right atrium.
We previously have reported the bicaval technique [2] and stressed the importance of creating a cavoatrial cuff around not only the inferior vena cava but also the superior vena cava (SVC) (Fig 1
) to prevent any tension on the anastomosis and also to prevent the possibility of SVC narrowing or even SVC obstruction, which is more likely to happen with direct SVC to SVC anastomosis. We later learned an identical technique to that described by Blanche and associates was published by Sievers' group [3], in which direct SVC to SVC anastomosis was performed.
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). We have performed more than 50 transplantations to date with the new technique.
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References
Heart Transplantation Program, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd #6215, Los Angeles, CA 90048
To the Editor:
Since Dreyfus and associates' report [1] of an alternative technique for orthotopic heart transplantation, which consists of total excision of the recipient heart with pulmonary venous as well as bicaval anastomoses, we adopted this approach for all our routine orthotopic heart transplantations. We analyzed the first 40 consecutive patients who underwent transplantation in this fashion and compared them with the first 64 patients in whom the operation was performed with the standard technique [2]. We noted a significant reduction in the incidence of postoperative tricuspid regurgitation, as well as a trend in the reduction of mitral regurgitation. Similar to the findings of El Gamel and colleagues, we found that the need for pacemaker implantation was eliminated completely. Patients who underwent transplantation with this alternative technique showed improved survival at 6, 12, and 18 months. Although complications may occur with this modified surgical approach, we found this technique to be remarkably simple. Bleeding from the pulmonary venous anastomoses has not been a problem. However, early in our experience we encountered a case of superior vena caval stenosis in a patient who had excessive tension at the suture line. The patient subsequently had development of severe superior vena cava syndrome that required aortic allograft interposition between the donor's and recipient's superior venae cavae 1 month after transplantation. Since then we have modified our technique to include harvesting the entire length of the donor's superior vena cava. The distal opening is then cut into the opening of the azygos vein stump, which allows for a wide end-to-end anastomosis. Because the recipient's superior vena cava is transected at the cavoatrial junction, there is no need for a right atrial cuff. Superior vena caval stenosis has not occurred in subsequent patients as demonstrated by serial postoperative echocardiograms.
In our experience, the ischemic time is prolonged by an average of 21 minutes with this new approach (138.0 ± 32.7 minutes for the standard technique versus 159.3 ± 38.0 minutes for the alternative technique), which compares favorably with the ischemic time of 197 minutes using the bicaval technique described by El Gamel and colleagues. No hemodynamic consequence to the cardiac allograft has been noted due to the additional ischemic time using the alternative technique. Most importantly, this technique is compatible with harvesting of other organs, particularly lungs and liver. Occasionally, when both lungs are harvested, there is not enough posterior left atrial wall in the donor heart between the right and left pulmonary vein orifices. Consequently, the entire posterior wall of the left atrium must be excised. In those cases, we have modified this alternative technique using a left atrial to left atrial anastomosis, as in the standard technique. The right atrium is reconstructed using the bicaval technique to preserve the anatomic size and geometric configuration of the right atrial cavity. At the time we reported this technique [3], we were unaware of previous reports that were similar yet had important technical differences [4, 5]. In fact, this technique was originally described by Goldberg and colleagues [6] in an experimental model for transplantation of the canine heart in 1958.
I disagree with El Gamel and colleagues that the bicaval technique prevents right-sided failure after cardiac transplantation, as this complication is directly related to preoperative pulmonary vascular resistance. It also is difficult to understand how they found less mitral valve incompetence because the left atrium is anastomosed using the standard biatrial technique. Postoperative two-dimensional echocardiographic studies have demonstrated that mitral regurgitation occurs routinely after heart transplantation with the standard biatrial technique, and can be detected as early as 1 week postoperatively [7].
To date, we have performed transplantation successfully in 80 patients with the bicaval and pulmonary venous anastomoses technique as described by Dreyfus and associates [1] and modified by Blanche and co-workers [8]. In addition, another 8 patients have undergone transplantation successfully using the bicaval approach on the right atrium with a standard biatrial technique on the left atrium as reported [3]. I congratulate El Gamel and colleagues for their results, which confirm our observation that preservation of the geometric configuration and anatomic size of the atria is a more physiologic approach to transplantation and could, in fact, result in improved long-term hemodynamic results in heart transplant patients.
References
This article has been cited by other articles:
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  A. E. Gamel, N. A. Yonan, B. Keevil, R. Warbuton, J. Kakadellis, A. Woodcock, C. S. Campbell, A. N. Rahman, and A. K. Deiraniya Significance of Raised Natriuretic Peptides After Bicaval and Standard Cardiac Transplantation Ann. Thorac. Surg., April 1, 1997; 63(4): 1095 - 1100. [Abstract] [Full Text]
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