Ann Thorac Surg 1998;65:1163-1164
© 1998 The Society of Thoracic Surgeons
How to Do It
Atrial Flap Anastomosis: An Alternative Technique for Orthotopic Heart Transplantation
Volker Döring, MD, PhDa,
Peter Marcsek, MDa
a Department of Thoracic and Cardiovascular Surgery, University Hospital Hamburg, Hamburg, Germany
Accepted for publication October 23, 1997.
Address reprint requests to Dr Döring, Department of Thoracic and Cardiovascular Surgery, University Hospital Hamburg, Martinistr 52, D-20246 Hamburg, Germany
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Abstract
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To combine the advantages of the standard technique and the bicaval technique of orthotopic heart transplantation, we use a muscular flap of recipient heart right atrium for connecting the superior vena cava with the donor heart right atrium. The results in respect to the maintenance of atrioventricular valve competence as well as atrial conduction are promising.
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Introduction
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Orthotopic heart transplantation as designed by Shumway and associates [1], consisting of two atrial and two arterial anastomoses, is still the gold standard in orthotopic heart transplantation. In recent years several authors [2, 3] have expressed their concern about some imperfections of this technique most likely resulting from alterations in atrial geometry. They reported on regurgitation of atrioventricular heart valves, especially of the tricuspid valve, being aggravated in patients with high pulmonary resistance and right heart failure. Furthermore, a higher incidence of postoperative sinoatrial conductance disturbances was observed, some of which require long-term pacing [4]. As an alternative technique, bicaval anastomoses were successfully reintroduced by some centers, resulting in considerably less tricuspid regurgitation at rest and stress [2]. In some cases this technique induced significant stenoses of the superior vena caval (SVC) anastomosis even when refined suture techniques were used [5]. Further problems may arise from a mismatch between the normal-sized donor SVC and a recipient SVC dilated by chronic right heart failure. To overcome these problems we use an alternative technique with anastomosis of the SVC and a flap of adjacent recipient right atrium (RA) with the donor RA.
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Technique
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Explantation of the donor heart
The heart is harvested in standard fashion including a long segment of SVC. The SVC is closed by a running suture about 2 cm cranial to the sinus node area. The inferior vena cava (IVC) is transected at the juncture with the RA.
Resection of the recipient heart
The distal ascending aorta, the IVC at the level of the diaphragm, and the distal SVC are cannulated. The aorta is cross-clamped. The ascending aorta and the pulmonary artery are transected. A generous right atrial flap of the SVC is created by dissecting the left atrium above the orifice of the right pulmonary vein at the site of insertion of the interatrial septum and furthermore by dissecting the cranial part of the interatrial septum and the cranial part of the RA (Fig 1). A smaller atrial cuff of the IVC is tailored in a similar way. The explantation is completed by dissecting the heart along the atrioventricular groove (Fig 2).
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Fig 1. Recipient heart: Sites of cannulation (black arrows), sites of clamping (bars), and sites of resection (lines of crosses) are shown on the right side. In the inset a perspective view of the atrial flap is depicted, showing its right atrial (A) and its atrial septal (S) part.
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Fig 2. Implantation of the donor heart: The recipient heart is resected except the right atrial flap of the superior vena cava, the right atrial cuff of the inferior vena cava, and the posterior part of the left atrium. With the exception of the right atrium the donor heart is prepared in standard technique. Note the incision in the cranial part of the right atrium to be anastomosed with the atrial flap.
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Implantation of the donor heart
The anastomoses of the left atrium, pulmonary artery, and ascending aorta are performed in standard fashion. The IVC with its atrial cuff is anastomosed with the RA by a running suture. The donor RA is incised about 1 cm centrally to the terminal groove and the incision is directed for about 1.5 cm to the right appendage (see Fig 2). The muscular atrial flap of the recipient heart is then anastomosed with the incision of the donor RA with a running 4-0 monofilament suture (Fig 3). After deairing of the heart the aortic clamp is released.
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Fig 3. The implanted donor heart with the superior vena cava and the atrial flap draining end-to-side into the donor heart right atrium.
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Results
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Eleven patients were operated on with the atrial flap technique described here without operative mortality. All patients regained sinus rhythm. Transesophageal Doppler echocardiography revealed normal atrioventricular valve function in 10 patients; in 1 patient a minor persisting isolated tricuspid regurgitation grade II of no hemodynamic relevance was recorded. One 64-year-old patient suffering from a dilated myocardiopathy in New York Heart Association functional class IV and cardiac cachexia died on the 13th postoperative day of pneumonia.
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Comment
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The Stanford method is the worldwide accepted standard technique of orthotopic heart transplantation. Success is guaranteed by its simplicity, reducing ischemia of the donor heart as well as operating time. Alternative techniques should be measured against this standard. The atrial flap technique described here was designed as a compromise between the advantages of the standard and the bicaval technique. The arterial and the left atrial anastomoses and the closure of the donor heart SVC are performed according to the standard protocol. The IVC is connected easily by an anastomosis between the donor heart RA and the atrial cuff of the recipient IVC.
The indirect connection of the SVC with the RA using the atrial flap has certain advantages: The anastomosis is performed simply and quickly with a running 4-0 suture. The risk of an anastomosis-induced stenosis of the SVC inflow tract is minimized even in case of a mismatch of the donor and the recipient SVC. There are only minor geometric changes in the donor heart RA. Because the terminal groove and the atrial incision are at least 1.0 cm from the flap suture line, the risk of sinus node dysfunction induced by edema or tension is minimal.
The clinical results of the atrial flap technique are promising. There were no adverse effects. All patients regained a sinus rhythm. In only 1 patient did Doppler echocardiography reveal a minor tricuspid regurgitation of unknown cause. However, a benefit of this technique in respect to long-term results can only be proved by a larger series of orthotopic heart transplantations with atrial flap anastomoses.
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References
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- Shumway N.E., Lower R.R., Stofer R.C. Transplantation of the heart. Adv Surg 1966;2:265-284.[Medline]
- Sievers H.H., Leyh R., Jahnke A., et al. Bicaval versus atrial anastomoses in cardiac transplantation. J Thorac Cardiovasc Surg 1994;108:780-784.[Abstract/Free Full Text]
- Dreyfus G., Jebara V., Mihaileanu S., Carpentier A.F. Total orthotopic heart transplantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181-1184.[Abstract]
- Nägele H., Döring V., Kalmar P., Rödiger W., Schmidek G., Stubbe H.M. Physiological pacemaker therapy after heart transplantation [Abstract]. J Heart Lung Transplant 1997;16:89.
- Pedrazzini G.B., Mohacsi P., Meyer B.J., Carrel T., Meier B. Percutaneous transvenous angioplasty of a stenosed bicaval anastomosis after orthotopic cardiac transplantation. J Thorac Cardiovasc Surg 1996;112:1667-1669.[Free Full Text]
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V. Doring and P. Marcsek
Reply
Ann. Thorac. Surg.,
November 1, 1998;
66(5):
1869 - 1869.
[Full Text]
[PDF]
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M. A. Sarsam
Atrial flap anastomosis: an alternative technique for orthotopic heart transplantation.
Ann. Thorac. Surg.,
November 1, 1998;
66(5):
1868 - 1869.
[Full Text]
[PDF]
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Abstract
Introduction
