Ann Thorac Surg 2002;74:1242-1244
© 2002 The Society of Thoracic Surgeons
Case report
Bicaval anastomosis in a heart transplant recipient with left superior vena cava
Gregorio Rábago, MD*a,
Alejandro Martín-Trenor, MDa,
José Luis López-Coronado, MDa,
Alfonso Macias, MDa,
Juan Cosín-Sales, MDa,
Jesús M. Herreros, MDa
a Department of Cardiovascular Surgery, Clínica Universitaria, University of Navarre, Pamplona, Spain
Accepted for publication May 19, 2002.
* Address reprint requests to Dr Rábago, Department of Cardiovascular Surgery, Clínica Universitaria, University of Navarre, Avda. Pío XII, 36, 31008 Pamplona, Spain
e-mail: grabago{at}unav.es
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Abstract
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We describe the surgical procedure of orthotopic heart transplantation (OHT) in a recipient with persistent left superior vena cava (LSVC) and isolated noncompaction of the left ventricle. The bicaval anastomosis technique was performed using and isolating his native coronary sinus to let the left superior vena cava drain into his own inferior vena cava through the native coronary sinus.
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Introduction
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Left superior vena cava is an infrequent congenital abnormality with a prevalence of 0.3% in the normal population and 2.8% to 4.3% in patients with some congenital cardiac disease [1]. Lower and Shumway introduced the surgical biatrial technique for cardiac transplantation more than 30 years ago and it has been used in more than 30,000 patients with excellent results. However, atrial arrhythmias and other conduction abnormalities have persisted and have resulted in the need for pacemakers in a significant number of patients. In the past years, with the more frequent use of transesophageal echocardiography, other abnormalities have been noted on follow-up of transplanted patients. These include tricuspid and mitral regurgitation, asynchronous contraction of donor’s and recipient’s, left and right atrial with thrombus formation in the atrial suture line, and right ventricular dysfunction in the early postoperative period. In the last 7 years, a new surgical technique has been used performing total excision of the recipient’s heart and individual’s caval and pulmonary vein anastomosis, the so-called bicaval anastomosis (BA). This technique seems to avoid the problems encountered with the biatrial technique and has become a standard technique in most heart transplant centers.
A 46-year-old man with persistent LSVC, atresia of the innominated vein, and dilated cardiomyopathy due to isolated noncompaction of the left ventricle received orthotopic heart transplantation with an ejection fraction of 15%. Prior to transplantation, and as part of our protocol, hemodynamic evaluation was carried out observing mild-to-severe pulmonary hypertension with a mean pulmonary pressure of 52 mmHg, pulmonary capillary wedge pressure of 24 mmHg, and pulmonary vascular resistance of 6.5 Wood units. Pressure dropped after vasodilator infusion protocol. A donor heart was available and, because the recipient had pulmonary hypertension, we decided to implant a large heart (ratio donor/recipient 1.27). Also, due to his pulmonary hypertension, we decided to perform BA because of the better hemodynamic performance of this technique.
Through midline sternotomy incision, cardiopulmonary bypass was established using an arterial cannula in the ascending aorta and direct cannulation of the superior vena cava (SVC) and inferior vena cava (IVC), close to pericardial and diaphragm reflection, respectively. Once both vena cavae were taped, we carefully inspected the LSVC that directly drained into the coronary sinus. We did not find any connection between the left and right side of the upper part of the body through the innominated vein. LSVC was taped and occluded and, because noncongestion of the upper side was observed, we did not cannulate the LSVC. Standard cardiectomy was carried out starting into the left atrium close to the interatrial grove. The incision was driven to the upper and lower part of the left atrium stopping close to the left pulmonary veins. The SVC, aorta, and pulmonary artery were transected in the standard fashion leaving enough cuffs for the anastomosis. Then, we isolated the coronary sinus (CS) making an incision in between the inferior border of the CS and the upper portion of the left pulmonary veins. We carefully tied the coronary veins arising from the CS. After that, the CS and LSVC were separated away from the left atrium leaving it completely isolated and only connected with the IVC. Finally, we made a large incision into the right atrium including the IVC and the origin of the native CS and, consequently, its connection with the LSVC (Fig 1). Once the CS was completely isolated, a routine OHT was performed, and the left atrium of the donor was anastomosed to the cuff containing the four pulmonary veins. Recipient IVC was anastomosed in a termino-terminal fashion requiring enlargement of the IVC orifice in the donor heart. SVC, pulmonary artery, and aorta were handled routinely. Cardiopulmonary bypass and ischemic time was 150 minutes and 215 minutes, respectively. The patient was transferred to the intensive care unit in normal sinus rhythm, and no major bleeding was observed through the chest tube. Antiplatelet therapy was started on the 3rd postoperative day. The postoperative course was uneventful without complication. The patient was discharged on the 7th postoperative day with the standard triple immunosuppressive therapy. Routine endomyocardial biopsy was performed according to our protocol. Echocardiography was performed observing excellent flow through the native coronary sinus coming from the LSVC. On the 21st day, an angiogram was performed proving good function of the LSVC with a large native coronary sinus (Fig 2).
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Fig 1. The chest cavity after recipient cardiectomy. Observe the connection between the left superior vena cava and inferior vena cava through the coronary sinus.
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Comment
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A number of innovative techniques have been described to preserve the LSVC in orthotopic heart transplant procedures. In many cases, it is enough to preserve a larger amount of the right atrium including the CS and LSVC [2] when the OHT is performed, using the technique described by Lower and Shumway. In some other cases, to drive the blood from the LSVC to the right atrium, interposition of a thoracic aortic homograft or synthetic tube was placed between the LSVC and the right atrial appendage [3, 4]. Another surgical approach has been described trying to preserve drainage of the left upper portion by direct anastomosis of the LSVC to the recipient’s innominate vein in patients with situs inversus [5]. In conclusion, the technique presented in this report to preserve the left superior vena cava is simple and free of late complications; it retains the benefits described by many other authors using the BA in OHT.
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References
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- Hammon J., Bender H.W. Major anomalies of pulmonary and thoracic systemic veins. In: Sabiston D.C., Spencer F.C., eds. . Surgery of chest. Philadelphia: Saunders, 1990:1274-1296.
- Lopez-Gonzalez A., Albertos J., Gonzalez de Diego J.F., et al. Trasplante cardiaco ortotopico en un paciente con persistencia de vena cava superior izquierda no diagnosticada previamente. Rev Esp Cardiol 1995;48:362-364.[Medline]
- Rubia J.E., D’Udekem Y., Slysmans T., et al. Orthotopic heart transplantation in situs inversus. Ann Thorac Surg 1995;60:460-462.[Abstract/Free Full Text]
- McGiffin D.C., Karp R.B. Cardiac transplant in a patient with persistent left superior vena cava and absent right superior vein. J Heart Transplant 1984;3:115-116.
- Vricella L.A., Razzouk A.J., Gundry S.R., et al. Heart transplantation in infants and children with situs inversus. J Thorac Cardiovasc Surg 1998;116:82-86.[Abstract/Free Full Text]
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Abstract
Introduction
