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Ann Thorac Surg 1999;68:1242-1246
© 1999 The Society of Thoracic Surgeons

Original Articles

Orthotopic cardiac transplantation technique: a survey of current practice

Tarek M. Aziz, FRCSa, Malcolm I. Burgess, MRCPa, Ahamed El-Gamel, FRCSa, Colin S. Campbell, FRCSa, Ali N. Rahman, FRCSa, Abdul K. Deiraniya, FRCSa, Nizar A. Yonan, FRCSa

a Cardiac Transplantation Unit, Wythenshawe Hospital, Manchester, England, UK

Address reprint requests to Dr Yonan, Cardiac Transplantation Unit, Wythenshawe Hospital, Southmoor Rd, Manchester M23 9LT, England


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. The Lower and Shumway technique has been the gold standard for orthotopic heart transplantation (OHT) for the past 35 years. In the last decade the bicaval and total techniques have been introduced but it is unclear how these alternative techniques have influenced the current surgical practice of OHT.

Methods. A worldwide survey of 210 International Society of Heart and Lung Transplantation centers was conducted by questionnaire: 169 replies were received; a response rate of 80%.

Results. Seventy-four centers (44%) use a combination of more than one technique with the remaining centers (n = 95 centers) employing one technique exclusively. The bicaval technique is the most frequently used technique in the majority of transplant procedures in 92 (54%) centers. In only 38 centers (22%), the standard technique was the most frequently employed technique. The total technique was the choice in 8 centers (5%). The maximum acceptable ischemic time varied from 3 to 9 hours with a median of 5.7 hours. Only 92 centers (54%) do not use cardioplegia during implantation.

Conclusions. Since its introduction, the bicaval technique has become the most commonly used procedure for OHT. The long-term advantage of right atrial preservation with the bicaval technique will require further studies.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Heart transplantation is the treatment of choice for patients with end-stage heart failure. Since it was first described by Lower [1] and Shumway [2] and their associate, the standard technique of cardiac transplantation has remained unchanged. It is a simple and efficient method that has been used successfully for more than 20 years worldwide. Nevertheless, anastomoses of donor and recipient atria according to this technique create large atrial cavities with abnormal geometry (Fig 1A) [3]. The loss of atrial anatomy has been demonstrated to be responsible for the development of posttransplant complications such as mitral and tricuspid regurgitation [4], atrial septal aneurysm, atrial thrombus formation [4], and tachyarrhythmia [5].



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  		Fig 1. Preparation of the recipient’s mediastinum prior to heart transplantation. The main difference in the methods of recipient heart explantation are displayed. (A) Standard: The main bulk of right and left atria are preserved. (B) Total: Left and right pulmonary veins cuffs are prepared for total atrioventricular transplantation. (C) Bicaval: The donor left atrium is anastomosed to small recipient’s left atrial cuff, which includes the pulmonary veins.

 
Two alternative surgical techniques (total (Fig 1B) [6] and bicaval (Fig 1C) [7, 8]) have been developed during the last 10 years in an attempt to retain normal shaped atria which may, in turn, preserve atrial contractility, sinus node function, and atrioventricular valve competence [4, 5]. This study was designed to evaluate current surgical practice of orthotopic heart transplantation, particularly in relation to technique.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
A questionnaire was sent to all cardiac transplant surgeon members of the International Society of Heart and Lung Transplantation (ISHLT) based at centers performing greater than five cardiac transplantation procedures per year. At least one reply from each of 169 heart transplantation units was received (80% response rate).

Respondents were asked about the annual heart transplant procedures carried out at their center. The questionnaire included direct questions about the date of implementation of each technique, number of transplant procedures performed by each technique, maximal acceptable ischemic time, surgical implantation time, and myocardial preservation during transplantation. The incidence of postoperative pacemaker use and right ventricular failure were requested. We also asked each center, if relevant, why practice had changed from a standard to adopt a nonstandard technique.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Of the 169 centers contacted, 164 respondents completed the questionnaire fully. Data from 94 centers from North America, 66 from Europe, 4 from Asia, 3 from South America and 2 from Australia were included in the analysis. One hundred and forty (82%) centers commenced heart transplantation prior to 1990 and started transplantation according to the standard technique of Lower and Shumway (2 centers before 1975, 11 centers between 1975 and 1980, 41 centers between 1981 and 1985, and 86 centers between 1986 and 1990). Twenty-eight centers commenced activity in heart transplantation after 1991. During the period 1991 to 1993, 131 (77%) centers introduced an alternative technique (predominantly bicaval). As shown in Table 1, 95 (56%) of these centers use one technique exclusively. The bicaval technique is employed in more than half of transplant procedures in 92 (54%) centers, whereas the standard technique is used in more than half of the procedures only in 38 (22.5%) centers. The total technique is currently used in only 8 (4.5%) centers. The major reasons for the change in surgical practice from the standard to a nonstandard technique were tricuspid valve dysfunction (83%), right ventricular performance (68%), and arrhythmias or heart block (25%). The total and annual numbers of transplantation procedures per center are shown in Tables 2 and 3. The mean surgical implantation time was 60 minutes (range 45 to 60 minutes) for both the standard and bicaval techniques. Implantation time was significantly longer, however, in centers employing the total technique (mean = 75, range 50 to 100 minutes).


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  		Table 1. Percentage of Standard, Bicaval, and Total OHT Procedures Performed Among the Participating Centers

 

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  		Table 2. Total Number of Heart Transplantation Procedures Performed Among 169 Participating Centers

 
The mean acceptable ischemic time is 5.7 hours with 35 (20%) centers reporting an acceptable ischemic time of 7 hours or more (Fig 2). The method of myocardial preservation during implantation varies between different centers. Seventy-three (43%) centers do not use intraoperative cardioplegia during implantation, whereas 92 (54%) infuse cardioplegia. (Four centers did not answer this question.) Route of cardioplegia administration was via the aortic root cannula in 87 (51%) centers. Three centers used the combined ante/retrograde cardioplegia and two centers used the retrograde route exclusively. Blood cardioplegia is applied in 69 (41%) centers and crystalloid cardioplegia in 23 (13%) centers. The frequency of cardioplegic use also varied considerably between different centers. Twelve centers used cardioplegia once or twice, 30 centers use cardioplegia at intervals of 15 to 20 minutes, and 41 centers infuse cardioplegia at intervals of 25 to 30 minutes during transplantation. Four centers infuse cardioplegia at intervals of 40 minutes, and continuous infusion is employed in one center. Ninety-nine (59%) centers perform the entire procedure with aortic crossclamping whereas 70 (41%) centers perform the caval or right atrium anastomosis without crossclamp.



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  		Fig 2. Maximum acceptable ischemic time among the participating centers (6 centers perform pediatric cardiac transplantation exclusively).

 
The incidence of need for permanent postoperative pacing ranges from 0.0% to 10%. The lowest incidence of pacemaker use was reported among centers employing the total technique (0% to 2%), and an equal incidence of pacemaker requirement was reported between standard and bicaval techniques (5% to 10%). The incidence of postoperative right side failure ranges from 5% to 50% and it was not correlated with the use of a particular technique.


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  		Table 3. Annual Performance of Heart Transplantation Among Participating Centers

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Heart transplantation was first successfully performed in 1967, and until 1980 fewer than 360 procedures had been performed worldwide [9]. However, during the past 2 decades, heart transplantation has become an established treatment for end-stage heart failure. Between 1980 and 1996, more than 34,000 procedures have been reported to the ISHT Registry. During the same period, there has been an exponential growth in the number of heart transplant centers from 17 in 1980 to 271 centers in 1996 [10]. Modification of surgical technique, changes in the sequence of performing vascular anastomoses, alteration in myocardial preservation methodology, and expansion in the acceptable ischemic time have all taken place in the last 10 years and considerably influenced the surgical practice of OHT.

Surgical techniques
At an early stage, Lower, Shumway, and their associate [1, 2] recognized that systemic and pulmonary venous connections could be simplified with atrial cuffs, therefore avoiding the technical difficulty of separate caval and pulmonary anastomoses. Reitz [11] introduced the domino procedure using technical modifications for OHT. In addition, Yacoub and Banner [12] introduced modifications to the original description by Lower, Shumway, and associate [1, 2]. Orthotopic cardiac transplantation with the use of bicaval anastomoses was first proposed by Webb and associates in 1959 [13]. However, preference for complete excision of recipient heart and bicaval anastomoses for orthotopic heart and heart-lung transplantation emerged only 30 years later. The total technique (complete atrioventricular cardiac transplantation with separate caval and pulmonary vein anastomoses) was introduced into clinical practice by the Harefield group [12] before it was reported by Carpentier’s group in 1989 [6], primarily as a result of persistent problems with the conventional technique of OHT, including sinus node injury, enlarged atria with atrioventricular valve insufficiency, and altered hemodynamics. The bicaval technique was initially reported in clinical practice of OHT by Siever and colleagues in 1991 [7]. Sarsam and associates subsequently described the bicaval Wythenshawe technique in 1993 [8]. This includes separate anastomoses of superior and inferior vena cavae and the left atrial cuff of the donor heart is anastomosed to the pulmonary venous cuff on the recipient side with a single suture line.

Advantages of alternative surgical techniques in heart transplantation
This survey covers over 75% of the current world practice in heart transplantation and demonstrates that the bicaval technique is currently the most frequently used technique. It retains normal atrial morphology with the theoretical advantages of preserved synchronous atrial contractility, sinus node function, and improved atrioventricular valve competence. Because of its simplicity and effectiveness, the bicaval technique has been rapidly accepted as a replacement for the Shumway technique. The bicaval technique has avoided the technical difficulties reported with the total technique such as bleeding from inaccessible suture lines located in the posterior wall pulmonary veins, reduced patency of pulmonary veins due to twisting or narrowing of the anastomosis, a small pericardium in cases of restrictive cardiomyopathy, or discrepancy between donor and recipient size often leading to difficulty with the surgical anastomosis, particularly the left pulmonary vein [14]. These technical difficulties associated with the total technique may prolong the procedure and increase operative complication rates thus outweighing any possible functional advantages. It was evident in this study that the total technique requires longer implantation time. The Wythenshawe group reported that better right ventricular performance, lower right atrial pressure, greater cardiac output, and lower incidence of tricuspid incompetence were the major advantages of their bicaval technique [15, 16]. Improvement of hemodynamics, cardiac chamber dimensions, and exercise capacity in recipients undergoing the bicaval technique compared to the standard technique have been confirmed by subsequent studies [17, 18]. The contribution of the bicaval technique to the reduction in the incidence of early and late postoperative atrial arrhythmias has also been reported [19].

The same benefits of right atrial preservation such as improved right heart performance, lower incidence of tricuspid valve dysfunction, and less requirement for permanent pacemaker implantation have also been reported with the total technique [20]. In addition, the advantages of an intact left atrium, such as a lower incidence of mitral regurgitation [20], smaller left atrial size [21], and lower incidence of left atrial thrombus formation have been also described with this technique [22]. Our survey, however, demonstrated that the total technique is employed infrequently in current clinical practice. Potential reasons for this include technical difficulties associated with the performance of a separate pulmonary venous anastomoses as described before. In addition, it might be impossible to preserve enough left atrial tissues to perform the total technique especially if the lungs are going to be retrieved from the same donor. A proper randomized study is required to compare the outcome of the bicaval and total techniques.

Ischemic time and myocardial preservation
Cardioplegic solutions originally developed for myocardial preservation during cardiac surgery are now also widely used for the preservation of donor hearts for transplantation. Preservation of donor hearts for periods of less than approximately 4 hours, has been the standard maximum acceptable ischemic time in heart transplantation. Data from the International Society of Heart and Lung Transplantation [23] suggested significant correlation between ischemic time and first year mortality following OHT, particularly for ischemic times longer than 6 hours. Wicomb and colleagues [24] published the first experience of cardiac transplantation following prolonged storage of donor hearts by a portable hypothermic perfusion system after an ischemic time of 6 to 16 hours. Obadia and coworkers [25] reported encouraging results of OHT in 13 recipients following a long ischemic time of 10 to 13 hours. In the present report, we have shown a clinical trend toward an expansion in the acceptable ischemic time for OHT to nearly 6 hours. There was no significant difference in the maximum acceptable ischemic time between European (mean = 5.9 hours) and American centers (mean = 5.7 hours). Over 20% of centers (6 centers perform pediatric OHT exclusively) accept ischemic times of at least 7 hours.

Summary
Since its introduction, the bicaval technique has rapidly gained worldwide acceptance as the procedure of choice in OHT. This is likely to be largely due to its merits in maintaining the integrity of the right atrium, minimizing the incidence of tricuspid regurgitation, maintaining right heart function, and lowering the incidence of postoperative tachyarrhythmia. Further studies are required to determine the long-term contribution of the bicaval technique in the clinical practice of orthotopic heart transplantation.


   Acknowledgments
 
The Wythenshawe Heart Transplant Group sincerely acknowledges the contribution of the heart transplant surgeons from 169 participating centers all over the world for their input in this study.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Lower R.R., Stofer R.C., Shumway N.E. Homovital transplantation of the heart. J Thorac Cardiovasc Surg 1961;41:196-201.
  2. Shumway N.E., Lower R., Stofer R.C. Transplantation of the heart. Adv Surg 1966;2:265-284.[Medline]
  3. Rees A.P., Milani R.V., Lavie C.J., Smart F.W., Ventura H.O. Valvular regurgitation and right-side cardiac pressures in heart transplant recipients by complete Doppler and color flow evaluation. Chest 1993;104:82-87.[Abstract/Free Full Text]
  4. Angerman C.E., Spes C.H., Tammen A., et al. Anatomic characteristics and valvular function of the transplanted heart. J Heart Transplant 1990;9:331-338.[Medline]
  5. Jacquet L., Ziady G., Stein K., et al. Cardiac rhythm disturbance early after orthotopic heart transplantation. J Am Coll Cardiol 1990;16:832-837.[Abstract]
  6. Drefus G., Jebara V., Mihaileaunu S., Carpentier A. Total orthotopic heart transplantation. Ann Thorac Surg 1991;52:1181-1184.[Abstract/Free Full Text]
  7. Sievers H.H., Weyend M., Kraatz E.G., Bernhard A. An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium. Thorac Cardiovasc 1991;39:70-72.
  8. Sarsam M.A., Campbell C.S., Yonan N.A., Deiraniya A.K., Rahman A.N. An alternative technique in orthotopic cardiac transplantation. J Cardiovasc Surg 1993;8:344-349.
  9. Kriett J.M., Kaye M. The registry of the International Society for Heart Transplantation. J Heart Transplant 1990;9:323-330.[Medline]
  10. Hosenpud J.D., Novick R.J., Bennett L.E., Keck B.M., Fiol B., Daily P. The registry of the International Society of Heart and Lung Transplantation. J Heart Lung Transplant 1996;15:655-674.[Medline]
  11. Reitz B.A. Heart and lung transplantation. In: Baumgartner W.A., Reitz B.A., Achuff S.C., eds. Heart and heart-lung transplantation. Philadelphia: WB Saunders, 1990:338-339.
  12. Yacoub M.H., Banner N.A. Recent development in lung and heart-lung transplantation. In: Morris P.J., Tilney N.E., eds. . Transplantation reviews. Philadelphia: WB Saunders, 1989:1-29.
  13. Webb W., Howard H., Neely W. Practical method of homologous cardiac transplantation. J Thorac Surg 1959;37:361-366.
  14. Aravot D.J., Wells F.C., Large S.R., Wallwork J. Alternative method for cardiac transplantation. Ann Thorac Surg 1996;61:1549-1551.[Abstract/Free Full Text]
  15. El-Gamel A., Yonan N.A., Grant S., Deiraniya A.K., Rahman A.N., Campbell C.S. Orthotopic heart transplantation, a comparison between the standard and the bicaval Wythenshawe technique. J Thorac Cardiovasc Surg 1995;109:721-730.[Abstract/Free Full Text]
  16. El-Gamel A., Deiraniya A.K., Rahman A.N., Campbell C.S., Yonan N.A. Orthotopic heart transplantation hemodynamics. J Heart Lung Transplant 1996;15:564-571.[Medline]
  17. Deleuze P.H., Benvenuti C., Mazzuotelli J.P., et al. Orthotopic cardiac transplantation with direct caval anastomosis. J Thorac Cardiovasc Surg 1995;109:731-737.[Abstract/Free Full Text]
  18. Leyh R.G., Jahnke A.W., Kraatz E.G., Sievers H.H. Cardiovascular dynamics and dimensions after bicaval and standard cardiac transplantation. Ann Thorac Surg 1995;59:1489-1500.
  19. Brandt M., Harringer W., Hirt S.W., Cremer J., Sievers H.H., Haverich A. Influence of bicaval anastomosis on late occurrence of atrial arrhythmia after heart transplantation. Ann Thorac Surg 1997;64:70-72.[Abstract/Free Full Text]
  20. Blanche C., Nessim S., Quartel A., Takkenberg J.J., Czer L.S., Trento A. Heart transplantation with bicaval and pulmonary venous anastomoses. J Cardiovasc Surg (Torino) 1997;38:561-566.[Medline]
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Accepted for publication March 24, 1999.




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