Ann Thorac Surg 2006;81:381-382
© 2006 The Society of Thoracic Surgeons
How to do it
Alternative Technique of the Right Atrial Anastomosis (Cavo-Atrial) in Orthotopic Heart Transplantation
Sandra Fraund, MD
*
,
Aziz Rahimi, MD,
Stefan Hirt, PhD,
Felix Schöneich, MD,
Andreas Böning, PhD,
Jochen Cremer, PhD
Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Kiel, Germany
Accepted for publication August 26, 2004.
* Address correspondence to Dr Fraund, Department of Cardiovascular Surgery, University of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str 7, 24105 Kiel, Germany. (Email: sfraund{at}kielheart-uni-kiel.de).
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Abstract
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An alternative technique of the right atrial anastomosis in heart transplantation, which allows a more anatomical reconstruction of the right atrium and is easier in handling than bi-caval anastomoses is described.
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Introduction
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Heart transplantation has become a widely used therapeutic option for the treatment of end-stage heart failure. Since the first human orthotopic heart transplant in the late 1960s [1, 2], the surgical technique has undergone several refinements. Complicating atrial arrhythmias and atrioventricular conduction disturbances in the standard bi-atrial technique as well as discussion about tricuspid insufficiency have lead to the bi-caval technique for cardiac transplantation [3].
Although this seems to preserve the right atrial anatomy in a superior way the bi-caval technique may have the risk of stenosis of the venae cavae and is surgically more demanding.
Therefore, we would like to present our alternative technique by Rahimi who has invented a combination of the two methods described as the "cavo-atrial anastomosis" technique.
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Technique
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The donor heart is excised with an intact right atrium and long venae cavae and is stored in the standard manner. In the recipient, cardiopulmonary bypass is initiated by means of placing the cannulas in the superior vena cava (SVC), the inferior vena cava (IVC), and the ascending aorta. Bypass circuit is started and the patient is cooled down to 30°C. The donor left atrium is sutured to the recipient's left atrium with continuous 3-0 Prolene suture (Ethicon, Somerville, NJ) in the usual fashion. Then, with our technique the donor right atrium is opened posterior along the inferior vena cava extended to the superior vena cava, avoiding damage of the sinus node and preserving the donor atrial appendage (Fig 1A). Under inclusion of the left atrial septum, the donor right atrium is then anastomosed to the recipients cavo-atrial cuff (Fig 1B, 1C).
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Fig 1. (A) The donor atrium is opened along the posterior wall preserving sinus node and right atrial appendage. (B) Under inclusion of the left atrial septum the donor right atrium is anastomosed to the recipient's tailored cavo-atrial cuff. (C) Completed anastomoses with preservation of the right atrial anatomy.
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This is in contrast to the usual bi-atrial technique in which the atriotomy of the donor heart is performed from the inferior vena cava curving toward the base of the right atrial appendage avoiding the sinus node. The donor's superior vena cava is then ligated and persists as a blind sac.
Thereafter, the great arteries are connected with continuous 4-0 Prolene suture (Ethicon) in the usual fashion. A cross clamp is released and operation is finished in the standard manner.
This technique is applied by preference of individual surgeons in our institution since January 1997, now with 30 patients (8 woman and 22 men; mean age 54.8 ± 8.8 years) who are operated on in this way. Operative times were acceptable with a mean bypass time of 131 ± 18.3 minutes, cross-clamp time of 73 ± 11.5 minutes, with state of reoperation in 9 patients (30%). The follow-up echocardiographic results are summarized in Table 1.
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Comment
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The technique of Lower and Shumway [1] has been the gold standard for orthotopic heart transplantation for the past 35 years. However, there is concern about the loss of normal right and left heart atrial anatomy and their contribution to normal cardiac function. This includes tricuspid and mitral regurgitation, enlarged left and right atria with thrombus formation in the atrial suture line, asynchronous contraction of the donor and recipient's atria, and right ventricular dysfunction in the early postoperative period.
Therefore the bi-caval technique was introduced and is now the most frequently used technique in the majority of transplant procedures; only 22% of the centers use the standard technique, which was the most frequently used technique in the past [4].
In our technique, the natural right atrial geometry is preserved with normal diameters and without any excluded and thrombogenic part as the ligated superior vena cava may represent. The sinus node is not endangered by starting the incision and suture line on the backside of the donor's atrium. Another aspect is a superior functional preservation of the tricuspid valve with a reduced rate of regurgitation; therefore, there is a lower need for medical treatment to counteract right heart failure.
We applied our technique now in more than 30 patients with satisfying results. We are convinced that our technique of special cavo-atrial anastomosis for orthotopic heart transplantation may improve the surgical results and clinical outcome.
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References
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- Lower RR, Stofer RC, Shumway NE. Homovital transplantation of the heart J Thorac Cardiovasc Surg 1961;41:169-204.[Medline]
- Shumway NE, Lower R, Stofer RC. Transplantation of the heart Adv Surg 1966;2:265-284.[Medline]
- Dreyfu BBG, Jebara V, Mihaileanu S, Carpentier AF. Total orthotopic heart transplantationalternative to the standard technique. Ann Thorac Surg 1991;52:1181-1184.[Abstract]
- Aziz TM, Burgess MI, El-Gamel A, et al. Orthotopic cardiac transplantation techniquea survey of current practice. Ann Thorac Surg 1999;68:1242-1246.[Abstract/Free Full Text]
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Abstract
Introduction
