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Ann Thorac Surg 1998;66:1868-1869
© 1998 The Society of Thoracic Surgeons

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Correspondence

Atrial flap anastomosis: an alternative technique for orthotopic heart transplantation

^a Department of Cardiothoracic Surgery, The Royal Group of Hospitals and Dental Wards, 13/14 Grosvenor Rd, Belfast BT12 6BA, Ireland

To the Editor

I read with interest the article "Atrial Flap Anastomosis: An Alternative Technique for Orthotopic Heart Transplantation" by Döring and associates [1]. The rationale stated by the authors for the introduction of this modification is the prevention of superior vena cava (SVC) anastomotic stenosis in the bicaval technique. There are currently three techniques for heart transplantation; the standard (lower Shumway) [2], the technique of total heart transplantation (Yacoub Dreyfus) [3, 4] and the bicaval technique (Sarsam Sievers) [5, 6]. We introduced our technique of bicaval heart transplantation in May 1991 that was reported in the Journal of Cardiac Surgery in May 1993. The technique relies on harvesting 2 to 3 cm of atrial cuff around both the SVC and the inferior vena cava (IVC). To prevent any SVC narrowing, the donor SVC was cut obliquely. If a discrepancy in size still exists, the SVC opening can be enlarged by an incision onto the roof of the right atrium that avoids the sinus node artery. This ensures a tension-free wide anastomosis at both the SVC and the IVC areas. Superior vena cava narrowing or obstruction has not occurred with this technique. We have demonstrated several advantages, including lower incidence of right ventricular failure postoperatively compared with the standard technique, lower incidence of tachy and brady arrhythmias and requirement for pacemaker, reduced requirement for diuretics, and shorter hospital stay [7]. It is gratifying to see in a recent survey of transplant units in Europe that nearly two thirds of units have adopted our bicaval technique for heart transplantation (personal communication).

The alternative technique of bicaval anastomosis, which was described by the Sievers group, relies on harvesting a 0.5-cm cuff around the IVC. Superior vena cavas are anastomosed directly without a cuff. There is some concern that this may lead in the future to SVC narrowing or stenosis at the site of the anastomosis, and this has indeed been confirmed in the reports cited by my article [8].

Although there may be a small place for this new modification, I believe that if my technique is followed as described, there is no need for such a modification involving an additional incision in the right atrium in an area that is particularly thin, the need to suture or tie the donor SVC leaving a stump and the resulting change in the shape of the right atrium, even if minor, may be significant if the donor heart is small. It is my belief that any surgical modification has to be an improvement on the already existing techniques.

References

1. Döring V., Marcsek P. Atrial flap anastomosis: an alternative technique for orthotopic heart transplantation. Ann Thorac Surg 1998;65:1163-1164.[Abstract/Free Full Text]
2. Shumway N.E., Lower R.R., Stofer R.C. Transplantation of the heart. Adv Surg 1966;2:265-284.[Medline]
3. Yacoub M., Mankad P., Ledingham S. Donor procurement and surgical techniques for cardiac transplantation. Semin Thorac Cardiovasc Surg 1990;2:153-161.[Medline]
4. Dreyfus G., Jebara V., Mihaileanu S., et al. Total orthotopic transplantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181-1184.[Abstract]
5. Sarsam M.A.I., Campbell C.S., Yonan N.A., et al. An alternative surgical technique in orthotopic transplantation. J Card Surg 1993;8:334-349.
6. Sievers H.H., Weyand M., Kraatz E.G., et al. An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium. Thorac Cardiovasc Surg 1991;39:70-72.[Medline]
7. El Gamel A., Yonan N.A., Grant S., et al. Orthotopic cardiac transplantation: comparison of standard and bicaval Wythenshawe techniques. J Thorac Cardiovasc Surg 1995;109:721-730.[Abstract/Free Full Text]
8. Pedrazzini G.B., Mohacsi P., Meyer B.J., et al. Percutaneous transvenous angioplasty of a stenosed bicaval anastomosis after orthotopic cardiac transplantation. J Thorac Cardiovasc Surg 1996;112:1167-1169.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mazin A. Sarsam Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Sarsam, M. A. Search for Related Content PubMed Articles by Sarsam, M. A.