Ann Thorac Surg 2003;75:1333-1334
© 2003 The Society of Thoracic Surgeons
How to do it
Modification of bicaval anastomosis: an alternative technique for orthotopic cardiac transplantation
Nikolaos B. Tsilimingas, MDa*
a Department of Thoracic and Cardiovascular Surgery, University-Hospital Hamburg-Eppendorf, Hamburg, Germany
Accepted for publication September 28, 2002.
* Address reprint requests to Dr Tsilimingas, Department of Thoracic and Cardiovascular Surgery, University-Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany.
e-mail: tsilimingas{at}uke.uni-hamburg.de
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Abstract
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We describe an alternative technique for orthotopic cardiac transplantation (OCT), which we use to combine the advantages of the conventional technique (Lower and Shumway) and the bicaval anastomosis. The modified technique was utilized in 31 consecutive patients undergoing heart transplantation by one surgeon in our hospital since 1998.
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Introduction
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Cardiac transplantation is the treatment of choice for patients with end-stage heart failure. The Lower and Shumway [1] technique has been the gold standard for orthotopic cardiac transplantation (OCT) for the past 37 years. Two alternative surgical techniques, bicaval [2] and total [3], have been developed during the last 12 years in an attempt to preserve atrial contractility, sinus node function, and atrioventricular valve competence. The alternative surgical technique sometimes induced significant stenoses of the venae cavae anastomoses due to tension, twisting, or kinking [4]. To overcome all these problems, we designed an alternative technique, which offers the best conditions to perform an optimal cava anastomosis.
The principle of this technique consists of leaving the superior vena cava (SVC) and inferior vena cava (IVC) undivided, connected with a trapezoidal strip of the posterior wall of the right atrium as a bridge to the left atrium. Additionally the superior and inferior vena cavae are then anastomosed in a telescopic fashion. The anastomoses of the left atrium, aorta and pulmonary artery are reconstructed in the usual manner.
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Technique
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The donor heart is harvested in the usual fashion, except that the SVC is transected at the azygos vein and the IVC at the diaphragmatic reflection. The distal ascending aorta of the recipient heart, the distal SVC and the IVC at the level of the diaphragm are cannulated. After cross-clamping the aorta, the cardiectomy was carried out, leaving the left atrium cuff in the usual fashion. The right atrial wall was also excised, leaving only a small trapezoidal strip of the posterior wall, as a connection between SVC, left atrium and IVC, as illustrated in Figure 1.
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Fig 1. Recipient heart after cardiectomy. The left atrium is resected by the conventional technique. The posterior aspect of the right atrium is resected, leaving a trapezoidal connection to the left atrium and both venae cavea.
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The anastomosis of the left atrium is performed first by the conventional technique. The pulmonary arteries and aortae are anastomosed in an end-to-end fashion. The IVC is then anastomosed in a telescopic fashion. After that the heart is deairing and the aorta clamp is released. The last anastomosis of the SVC should be done in partial bypass and by beating heart. This then allows us to perform an exact anastomosis, without tension, twisting or kinking, even in a
telescopic fashion, as illustrated in Figures 2 and 3.
This also shortens the ischemic period.
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Comment
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In 1959 Webb and associates [5] first proposed the use of bicaval anastomoses in OCT. The total method with separate caval and pulmonary vein anastomoses was introduced into clinical practice by Yacoub and Banner in 1989 [2]. Since its introduction, the bicaval technique has gained acceptance as the procedure of choice in OCT worldwide. We adopted this technique too, and we describe our modifications here.
The left atrial cuff on the donor heart is anastomosed to the left atrial cuff on the recipient side, in the conventional way, which eliminates the difficulties of a total cardiac transplantation. In addition, it may be impossible to preserve enough tissues for the total technique if the lungs are also donated. By leaving a trapezoidal fine strip of the posterior wall of the right atrium as a connection to SVC-left atrium-IVC the cavale anastomoses are easier to perform, with optimal anastomotic orientation and flexibility. Retraction, tension or kinking do not occur, particularly because we perform the SVC anastomoses in partial bypass with a filled right atrium. In this way we create an exact estimation of the appropriate tissue length of the venae cavae. In addition, the principle of telescopic anastomosis seems to serve as an ideal technique to compensate for massive caliber mismatch. The smaller vena cava of the donor heart is splinted by the larger one and tension or kinking is prevented. Thus, we decrease the risk of late caval narrowing.
The modified technique was utilized between 1998 and 2001 for 31 consecutive patients undergoing cardiac transplantation in our university hospital by one surgeon. The clinical results are very promising, comparable with the results of other institutions, and confirm the advantages of preserving geometric shape, anatomic size, and physiologic function of the right atrium. We present our modified technique that may facilitate the bicaval anastomosis, particularly by small cardiac donors and in respect to more technical flexibility and better long-term results.
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References
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- Lower R.R., Stofer R.C., Shumway N.E. Homovital transplantation of the heart. J Thorac Cardiovasc Surg 1961;41:196-201.
- Yacoub M.H., Banner N.A. Recent development in lung and heart-lung transplantation. In: Moris P.J., Tilney N.E., eds. . Transplantation reviews. Philadelphia: WB Saunders, 1989:1-29.
- Dreyfus G., Jebara V., Mihailueanue S., Carpentier A.F. Total orthotopic heart transpantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181-1184.[Abstract/Free Full Text]
- Pedrazzini G.B., Mohacsi P., Meyer B.J., Carrel T., Meier B. Percutaneous tranvenous angioplasty of a stenosed bicaval anastomosis after orthotopic cardiac tranplantation. J Thorac Cardiovasc Surg 1996;112:1667-1669.[Free Full Text]
- Webb W., Howard H., Neely W. Practical method of homologous cardiac transplantation. J Thorac Surg 1959;37:361-366.
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