Ann Thorac Surg 1996;61:1549-1551
© 1996 The Society of Thoracic Surgeons
How to Do It
Alternative Method for Cardiac Transplantation: Surgical Considerations and Technical Aspects
Dan J. Aravot, MD,
Frank C. Wells, FRCS,
Stephen R. Large, FRCS,
John Wallwork, FRCS
Transplant Unit, Papworth Hospital, Cambridge, United Kingdom
Accepted for publication December 18, 1995.
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Abstract
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A simplified technique for complete orthotopic cardiac transplantation is described. The potential technical difficulties and surgical considerations are discussed.
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Introduction
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A technique of complete orthotopic cardiac transplantation described in 1991 in The Annals of Thoracic Surgery by Dreyfus and colleagues [1] was developed by the Harefield group and first reported in 1989 [2]. The rationale underlying this technique was that by anastomosing the systemic and pulmonary veins (instead of the atrial cuffs in the method of Shumway and associates [3]) the donor atria remain intact, which may improve the heart's electrical stability and pumping capacity. However, the alternative method presents a number of technical difficulties that may prolong the procedure and potential complications, which may outweigh its possible functional advantages. These include bleeding from suture lines that may be less accessible (posterior wall of pulmonary veins); reduced patency of pulmonary and systemic veins due to twisting or narrowing of the anastomoses; air in venous lines due to slipping of inferior vena cava (IVC) cuff; small pericardium in cases of restrictive cardiomyopathy or discrepancy between donor and recipient, which makes the anastomosis (mainly left pulmonary vein) rather difficult; potential damage to the sinoatrial node; and potential difficulty in performing biopsy of the endocardium due to possible narrowing of the superior vena cava (SVC). In view of these surgical considerations we report our experience with the surgical technique of this procedure.
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Surgical Technique
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Recipient Heart Explantation
The SVC is cannulated about 2 to 3 cm above the right atrial-SVC junction or, preferably, the innominate vein is cannulated, thus avoiding damage to the sinoatrial node. The IVC is cannulated as low as possible after its loose attachments to the diaphragm are dissected, thus obtaining the maximal length possible. An important consideration is to snug the IVC snare very tight so that the posterior wall of the IVC cuff will not slip back, making the anastomosis rather demanding. The heart is then explanted in the same way as in the conventional procedure, and only then the left and right atrial cuffs are trimmed to fashion the left and right pulmonary veins' cuffs and IVC and SVC cuffs. The latter should be left as long as possible, especially the posterior wall (Fig 1
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Fig 1. . Mediastinum after recipient heart explantation: separate left and right pulmonary cuffs, transected superior and inferior venae cavae, and the stumps of aorta and pulmonary artery.
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Donor Heart Procurement
Donor heart procurement is similar to donor heart procurement for the conventional method; however, when the donor's lungs are also being procured, one should try to leave enough tissue for each pulmonary vein cuff's anastomosis. A single left atrial anastomosis is sometimes necessary.
Donor Heart Implantation
The main difficulty is the left pulmonary vein anastomosis. This is made more demanding when the pericardial sac of the recipient is relatively small. To make the anastomosis easy and prevent twisting we have developed a simple method by which two stay stitches of 2-0 Prolene (Ethicon, Somerville, NJ) are placed, one at each end of the posterior walls of the recipient and donor's left pulmonary vein cuffs, and then fixed to the towels covering the patient's chest wall (Fig 2). This helps in aligning the posterior wall of the left pulmonary veins while the donor heart is placed in the normal orthotopic position, which makes the orientation rather straightforward. The left pulmonary vein anastomosis is then performed (requires only one assistant). In the same fashion the right pulmonary venous (Fig 3), IVC (Fig 4), and SVC anastomoses are carried out. After completion of the posterior wall suture line the stay stitches are removed and the anastomosis completed. The anastomotic patency of the left pulmonary vein is checked by introducing the index finger through the donor right pulmonary vein's cuff into the left superior and left inferior pulmonary veins.
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Fig 2. . Anastomosis of left pulmonary veins: two stay stitches are placed, one at each end of the posterior walls, to align them to facilitate the anastomosis.
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By leaving a long posterior wall of the IVC, which is snugged tight, the anastomosis can be carried out easily and fast. The SVC anastomosis should be wide and should not be tightened while tying, thus avoiding narrowing it, which may cause difficulties in subsequent performance of endomyocardial biopsies.
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Results
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From November 1990 to December 1991 56 consecutive patients were randomized to either complete (alternative) or partial (conventional) methods of orthotopic cardiac transplantation. There were 28 in each group, including 5 female patients in the first and 1 in the latter. The two groups were matched for age (47 ± 8.8 versus 48 ± 8.9 years [mean ± standard deviation]), weight (74 ± 12 versus 72 ± 13 kg), and preoperative diagnosis (50% end-stage ischemic heart disease and 42% cardiomyopathy in both groups). Table 1 summarizes the operative results.
The causes of death were not related to the method of connection, and were in the partial mode due to infection in 3 and stroke in 1 and in the complete mode due to infection in 2 and rejection in 1.
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Comment
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The main advantage of the conventional method for orthotopic cardiac transplantation is the technical ease with which it can be performed. This is achieved by anastomosing the remnants of the recipient atria to the widely opened donor atria. However these atrial connections may interfere with the electrical stability and functional integrity of the atria, which could seriously affect their pumping capacity and the pattern of ventricular filling. An alternative method of systemic and pulmonary venous connections has been developed and used in a limited number of patients. Because of its potential surgical difficulties a technique using stay stitches to align the posterior wall of the anastomoses has been applied, thus making them rather simple and fast. This method can be used also in the conventional Shumway technique and in heart-lung transplantation for the bicaval anastomoses when harvesting domino hearts. Our results in a prospective study on 56 patients show that this procedure can be performed with comparable bypass time, ischemic time, blood loss, morbidity, and mortality. Further studies are required to demonstrate advantages in the mechanical function and electrical integrity of the complete mode versus the partial (conventional) mode to consider it as an alternative method.
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Footnotes
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Address reprint requests to Dr Aravot, Heart & Lung Transplant Unit, Beilinson Hospital, Petach Tikva 49100, Israel.
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References
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- Dreyfus G, Jebara V, Mihaileanu S, Carpentier AF. Total orthotopic heart transplantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181–4.
- Yacoub MH, Banner NA. Recent developments in lung and heart-lung transplantation. In: Morris PJ, Tilney NE, eds. Transplantation reviews. Vol 3. Philadelphia: Saunders, 1989:1–29.
- Shumway NE, Lower RR, Stofer RC. Transplantation of the heart. Adv Surg 1966;2:265–89.[Medline]
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Abstract
Introduction
