Ann Thorac Surg 2001;72:1405-1406
© 2001 The Society of Thoracic Surgeons
How to do it
Modification of bicaval anastomosis technique for orthotopic heart transplantation
Soichiro Kitamura, MDa,
Takeshi Nakatani, MDa,
Ko Bando, MDa,
Yoshikado Sasako, MDa,
Junjiro Kobayashi, MDa,
Toshikatsu Yagihara, MDa
a Department of Cardiovascular Surgery, National Cardiovascular Center, Osaka, Japan
Accepted for publication May 16, 2001.
Address reprint requests to Dr Kitamura, Department of Cardiovascular Surgery, National Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
e-mail: skitamur{at}hsp.ncvc.go.jp
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Abstract
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A modified bicaval anastomosis technique was utilized for 4 consecutive patients undergoing heart transplantation. Instead of transecting the superior and inferior vena cavae, a strip of the posterior right atrial wall was left undivided as a bridge connecting the superior and inferior vena cavae. This minor modification perfectly prevented shrinkage and retraction of the caval tissue, thus providing easier anastomotic orientation and better estimation of the appropriate tissue length that fits well, particularly when a small donor heart was available.
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Introduction
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Four consecutive patients (44-year-old woman, 14-year-old boy, 55-year-old man, and 32-year-old man) with end-stage dilated cardiomyopathy, who had undergone implantation of a paracorporeal left ventricular assist system (LVAS) of the National Cardiovascular Center (NCVC) type [1, 2] 7.5 to 22 months before, and had been on the waiting list of the Japan Organ Transplant Network as a status I candidate, underwent heart transplantation. Appropriate donors appeared at distant hospitals, and the donor heart was arrested, excised, and preserved in a cold St.Thomas solution, and transported to the NCVC within 2 hours by jet plane and ambulance.
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Technique
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At operation, a median resternotomy incision was made and the adhesions around the heart due to previous operations (tricuspid or mitral annuloplasty, partial left ventriculectomy, and LVAS implantation) were totally dissected. Cardiopulmonary bypass was commenced with bicaval and aortic cannulation, and then the LVAS was terminated. The LVAS inlet (from the left ventricular apex) and outlet (to the aorta) lines were divided from the pericardial sac and removed later. Cardiectomy was carried out leaving the left and right atrial cuffs in the usual fashion. Then, most of the right atrial wall was excised, only leaving a strip of the posterior wall as a bridging tissue between the superior and inferior vena cavae, as illustrated in Figure 1. The distance between the upper and lower right atrial cuffs connected with a bridge of the posterior wall was adjusted to the donor heart size. Cardiac anastomosis was carried out by the bicaval anastomosis technique. With this modified technique, caval anastomosis was easier than the usual method of dividing the vena cavae, because the bridging posterior right atrial wall served as a landmark of the distorted right atrial cuff by caval snares. In addition, adjustment of the length between the superior and inferior vena cavae was easy for the small donor heart, owing to the absence of shrinkage and retraction of the divided atrial cuffs as suggested by Dr B. Reitz (personal communication). Retrograde and then antegrade reperfusion cardioplegia using leukocyte-depleted warm blood was applied before aortic declamping [3, 4]. The heart recovered quite well and cardiopulmonary bypass was ceased without difficulty. The total ischemic time was less than 4 hours, including transportation time, in all patients. The patient recovery was uneventful, with regular immunosuppressive regimens including cyclosporin (Neoral), mycophenolate mophetil (Cellcept), and prednisolone (Prednine).
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Fig 1. A modified bicaval anastomosis technique. Instead of transecting the superior and inferior vena cavae, a strip of the posterior right atrial wall was left undivided as a bridge connecting both vena cavae. The dotted line indicates a suture line.
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Comment
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In 1960, Lower and Shumway [5] first described the technique of experimental orthotopic heart transplantation. Since then, this method has been applied to humans as a standard technique for heart transplantation and proved quite useful. Since 1991, a few transplant teams [6–8] have reported a modified method called bicaval anastomosis. In this method, the recipient right atrium was excised by transecting the superior vena cava and the junction between the right atrium and the inferior vena cava. The left atrium may also be excised leaving two cuffs of the left atrial wall, the first including the right pulmonary veins, and the second including the left veins. The benefit of the bicaval anastomosis over the standard method seems to maintain the right atrial architecture better with less distortion of the right atrial dimension and apparatus. Aziz and associates [9] reported in 1999 that the bicaval anastomosis method yielded a better 5-year survival rate than the standard method owing to the lower incidence of right heart failure. This benefit is probably secondary to better preservation of the tricuspid valve function, right atrial dimension and contraction, and sinus node activity with the new technique.
When the superior and inferior vena cavae are transected for bicaval anastomosis, they are shrunk and retracted. In addition, with the presence of snares for caval drainage cannulae for cardiopulmonary bypass, the anatomical orientation can be lost by transection that may result in twisted or kinked anastomosis with excessive suture line tension [8]. This may make the passage of a biopsy catheter difficult at the site of superior caval anastomosis [10]. By leaving a thin strip of the posterior wall of the right atrium as a bridge connecting the superior and inferior vena cavae, it is easy to adjust the amount of atrial excision to the donor heart size, particularly when it is smaller than the recipient one. Also, twisting at the anastomotic site can never occur. Late anastomotic stricture may also be less frequent with this modification because the anastomosis can be performed with no tension or kinking. Bleeding from the posterior right atrial bridge was easily controlled by electrocautery. We consider that this modification, though it is minor, may further facilitate the bicaval anastomosis technique, particularly when the donor heart is small.
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Acknowledgments
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This work was supported in part by a Grant-in-Aid for Research on Human Genome, Tissue Engineering Food Biotechnology, Health Sciences Research Grants, Ministry of Health, Labor and Welfare of Japan.
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References
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Abstract
Introduction
