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Alternative technique for orthotopic heart transplantation
Alternative Technique for Orthotopic Heart Transplantation Carlos Blanche, MD, Lawrence S. C. Czer, MD, Mario Valenza, MD, and Alfred0 Trento, MD Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
An alternative technique for orthotopic heart transplantation is described. The principle consists of total excision of the recipient’s right atrium with donor heart implantation performed using bicaval anastomoses; the left atrium is done in the standard fashion. This approach is technically simple and preserves the anatomic and physiologic function and integrity of the right atrium, especially the conduction system. (Ann Thorac Surg 1994;57:765-7)
wall with the orifices of the left and right pulmonary veins (Fig 2). The anastomosis of the left atrium is done first, as in the conventional technique, starting at the level of the left atrial appendage (Fig 3). The superior and inferior venae cavae are then anastomosed in an end-to-end fashion (Fig 4). The aorta and pulmonary artery are reconstructed in the usual manner.
T
A 61-year-old man underwent orthotopic heart transplantation using this surgical technique because of severely decompensated end-stage ischemic cardiomyopathy. He had undergone coronary revascularization in 1982. He also presented with end-stage renal disease secondary to nephrosclerosis, and he underwent renal transplantation with the right kidney from the same donor 12 hours later. The donor’s lungs and liver were also harvested for transplantation. The recipient’s postoperative recovery was uneventful, and he was discharged on the 13th postoperative day. Immunosuppression consisted of OKT-3 induction therapy and triple-drug immunosuppressive regimen. He remains well on long-term followUP.
raditionally, orthotopic heart transplantation has been done with the technique originally described by Lower and Shumway [l, 21. However, an alternative surgical technique of total orthotopic transplantation with total excision of the recipient atria was devised to circumvent some of the problems, especially related to conduction abnormalities and tricuspid regurgitation, observed with the original technique [3, 41. With the expanded number of organs from a donor being used in transplantation, this modified technique is not always possible, particularly when both lungs are harvested. We describe 3 cases in which the recipient’s right atrium was totally excised, with donor heart implantation performed using bicaval anastomoses; the left atrium was anastomosed in the standard fashion.
Surgical Technique Donor Heart Harvesting The donor heart is harvested in the usual fashion, except that the superior vena cava is transected at the azygos vein and the inferior vena cava at the diaphragmatic reflection (Fig 1).
Recipient Technique The cannulation technique is done in standard fashion. The pericardial reflection around the superior vena cava is divided, and the vena cava is dissected free circumferentially. The inferior vena cava is dissected off the diaphragm and cannulated as it emerges from the diaphragm. The heart is then explanted, with the superior vena cava transected at the caval-atrial junction, and the inferior vena cava is divided, leaving a cuff of right atrium. The left atrium is removed, leaving the posterior Accepted for publication Nov 2, 1993. Address reprint requests to Dr Blanche, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Rm 6215, Los Angeles, CA 90048.
0 1994 by The Society of Thoracic Surgeons
Case Reports Patient 1
Patient 2 A 55-year-old man presented with end-stage ischemic cardiomyopathy, having previously undergone myocardial revascularization in 1979 and again in 1981. He underwent orthotopic heart transplantation using the same surgical technique; the donor’s lungs, kidneys, and liver were harvested as well. The recipient was discharged 9 days after transplantation, having had an uncomplicated postoperative course, and remains well on longterm follow-up. The same immunosuppression protocol was used.
Patient 3 A 31-year-old man underwent aortic and mitral valve replacement for Q-fever endocarditis in 1992. Subsequently, progressive cardiomyopathy developed with severe biventricular failure and atrioventricular block that required a permanent pacemaker. The patient underwent orthotopic heart transplantation using the same surgical technique. The donor‘s lungs, kidneys, liver, and pancreas were also harvested. The recipient’s postoperative recovery was uneventful, and he was discharged on the 12th postoperative day. He remains well at follow-up. The same immunosuppression protocol was used. 0003-4975/94/$7.00
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HOW TO DO IT BLANCHE ET AL ALTERNATIVE HEART TRANSPLANTATION TECHNIQUE
Fig 1. Donor heart. The superior vena cava is transected at the azygas vein; the left atrium is opened in the standard fashion.
Comment From the early days of heart transplantation, the technique described by Shumway and associates [l, 21 has been commonly used. However, it has been shown by two-dimensional echocardiography that atrial size, shape, and geometry are distorted, with mitral and tricuspid
Fig 2. Recipient’s heart explanted. The venue cavae are transected circumferentially; the left atrium is resected as in the conventional technique.
Ann Thorac Surg 1994;577657
Fig 3 . Left atrial anastomosis is performed using the standard technique.
incompetence being a frequent finding after orthotopic heart transplantation. This is perhaps due to the abnormal atrial size and configuration created by the anastomosis of the donor and recipient atria, leading to impaired functional integrity of the valvular apparatus. Asynchronous contraction of the donor and recipient atria has also been demonstrated, which may further compound this problem [5, 61. The standard atrial anastomosis technique creates an hourglass-shaped atrium, with suture lines
Fig 4. The superior and inferior venue cavae are anastomosed in an end-to-end fashion.
Ann Thorac Surg 1994;577657
protruding into an enlarged atrial cavity. Furthermore, the heart is commonly found to be rotated clockwise with this technique [5, 61. Dreyfus and colleagues [3] reported an alternative technique of total orthotopic transplantation based on an experimental technique described by Webb and colleagues [7] and by Cass and Brock in 1959 [8]. This approach consists of total excision of the recipient heart, leaving the stumps of the superior and inferior venae cavae, as well as the right and left pulmonary veins with their respective cuffs of left atrium. The implantation technique of the donor heart is simple and consists of bicaval end-to-end anastomoses and pulmonary venous anastomoses to the corresponding orifice of the donor left atrium. The aorta and pulmonary artery anastomoses are performed in the standard fashion. However, this technique requires some modifications in harvesting the donor heart whereby the superior and inferior pulmonary veins are joined on each side, leaving a bridge of posterior left atrial wall between them. Additionally, the superior vena cava is transected at the azygos vein to obtain maximum length. We adopted this modified technique for all of our orthotopic heart transplantations in October 1991, and to date 56 patients have undergone transplantation in this fashion. Our initial experience with this technique in 24 patients has been reported [9]. We found a significant reduction in postoperative mitral and tricuspid regurgitation, as well as elimination of symptomatic bradyarrhythmias requiring a permanent pacemaker. Theoretically, interference with sinus node function is avoided and the integrity of the conduction system is preserved. Harvesting of the lungs for transplantation requires a cuff of left atrium with the pulmonary veins for the subsequent anastomosis [lo]. When both lungs are harvested, it might not be feasible to leave a bridge of posterior left atrial wall between the right and left pulmonary veins orifices in the donor heart, and so the entire back wall of the left atrium is resected as in the original technique described by Shumway and colleagues [I, 21. In this situation, such as the 3 cases described here, we use the technique described in this report. It consists of total excision of the recipient right atrium with donor heart implantation done using bicaval anastomoses to preserve the anatomic and physiologic integrity of the right atrium; the left atrium is done in the usual fashion. This approach is technically simple and holds promise for the reduction of serious tricuspid regurgitation that is occasionally seen with the standard technique, as well as the elimination of posttransplantation bradyarrhythmias requiring pacemaker implantation as a result of intraoperative sinus node injury. This functional advantage, perhaps due to less distortion of the right atrium, could improve longterm hemodynamic results in the heart transplant patients. Postoperative two-dimensional echocardiography in all 3 patients showed normal size and configuration of the right atrium, with no tricuspid regurgitation (Fig 5). We present this modified technique as an alternative modality for orthotopic heart transplantation; its main advantage rests in its simplicity and the preservation of
HOW TO DO IT BLANCHE ET AL ALTERNATIVE HEART TRANSPLANTATION TECHNIQUE
767
Fig 5. Postoperative transesophageal echocardiogram in patient 2. Note the normal configuration and the anatomic size and geometry of the right atrium. Also note the protruding anastomotic suture line with an hourglass configuration of the left atrium. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
geometric shape, anatomic size, and physiologic function of the right atrium.
Addendum Since the submission of the manuscript, 2 additional patients have undergone heart transplantation using the technique described in this report, with excellent results. We thank Ms Kathleen Farrington for the preparation of the manuscript and Ms Rosa Goldsmith for the illustrations.
References 1. Lower RR, Shumway NE. Studies on the orthotopic homo-
transplantation of the canine heart. Surg Forum 1960;11:1%9.
2. Shumway NE, Lower RR, Stofer RC. Transplantation of the
heart. Adv Surg 1966;2:26544. 3. Dreyfus G, Jebara V, Mihaileanu S, Carpentier AF. Total orthotopic heart transplantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181-4. 4. Couetil JP, Mihaileanu S, Lavergne T, et al. Total excision of the recipient atria (TERA) in orthotopic heart transplantation (OHT) as a new clinical procedure: Technical consideration and early results. J Heart Lung Transplant (Suppl) 1991;lO: 1(Pt 2):179. 5. Angermann CE, Spes CH, Tammen A, et al. Anatomic
characteristics and valvular function of the transplanted heart: transthoracic versus transesophageal echocardiographic findings. J Heart Transplant 1990;9:331-8.
6 . Stevenson LW, Dadourian BJ, Kobashigawa J, Child JS, Clark
SH, Laks H. Mitral regurgitation after cardiac transplantation. Am J Cardiol 1987;60:119-22. 7. Webb WR, Howard HS, Neely WA. Practical method of
homologous cardiac transplantation. J Thorac Surg 1959;37 361-6. 8. Cass MH, Brock R. Heart excision and replacement. Guy’s Hosp Rep 1959;108:28.590. 9. Czer LSC, Trento A, Blanche C, et al. Orthotopic heart transplantation: clinical experience with a new technique. J Am Coll Cardiol 1993;21(SupplA):168A. 10. Cooper JD. Lung Transplantation. In: Baumgartner WA, Reitz BA, Achuff SC, eds. Heart and heart-lung transplantation. Philadelphia: Saunders, 1990:347-71.
An alternative technique for orthotopic heart transplantation is described. The principle consists of total excision of the recipient’s right atrium with donor heart implantation performed using bicaval anastomoses; the left atrium is done in the standard fashion. This approach is technically simple and preserves the anatomic and physiologic function and integrity of the right atrium, especially the conduction system. (Ann Thorac Surg 1994;57:765-7)
wall with the orifices of the left and right pulmonary veins (Fig 2). The anastomosis of the left atrium is done first, as in the conventional technique, starting at the level of the left atrial appendage (Fig 3). The superior and inferior venae cavae are then anastomosed in an end-to-end fashion (Fig 4). The aorta and pulmonary artery are reconstructed in the usual manner.
T
A 61-year-old man underwent orthotopic heart transplantation using this surgical technique because of severely decompensated end-stage ischemic cardiomyopathy. He had undergone coronary revascularization in 1982. He also presented with end-stage renal disease secondary to nephrosclerosis, and he underwent renal transplantation with the right kidney from the same donor 12 hours later. The donor’s lungs and liver were also harvested for transplantation. The recipient’s postoperative recovery was uneventful, and he was discharged on the 13th postoperative day. Immunosuppression consisted of OKT-3 induction therapy and triple-drug immunosuppressive regimen. He remains well on long-term followUP.
raditionally, orthotopic heart transplantation has been done with the technique originally described by Lower and Shumway [l, 21. However, an alternative surgical technique of total orthotopic transplantation with total excision of the recipient atria was devised to circumvent some of the problems, especially related to conduction abnormalities and tricuspid regurgitation, observed with the original technique [3, 41. With the expanded number of organs from a donor being used in transplantation, this modified technique is not always possible, particularly when both lungs are harvested. We describe 3 cases in which the recipient’s right atrium was totally excised, with donor heart implantation performed using bicaval anastomoses; the left atrium was anastomosed in the standard fashion.
Surgical Technique Donor Heart Harvesting The donor heart is harvested in the usual fashion, except that the superior vena cava is transected at the azygos vein and the inferior vena cava at the diaphragmatic reflection (Fig 1).
Recipient Technique The cannulation technique is done in standard fashion. The pericardial reflection around the superior vena cava is divided, and the vena cava is dissected free circumferentially. The inferior vena cava is dissected off the diaphragm and cannulated as it emerges from the diaphragm. The heart is then explanted, with the superior vena cava transected at the caval-atrial junction, and the inferior vena cava is divided, leaving a cuff of right atrium. The left atrium is removed, leaving the posterior Accepted for publication Nov 2, 1993. Address reprint requests to Dr Blanche, Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, 8700 Beverly Blvd, Rm 6215, Los Angeles, CA 90048.
0 1994 by The Society of Thoracic Surgeons
Case Reports Patient 1
Patient 2 A 55-year-old man presented with end-stage ischemic cardiomyopathy, having previously undergone myocardial revascularization in 1979 and again in 1981. He underwent orthotopic heart transplantation using the same surgical technique; the donor’s lungs, kidneys, and liver were harvested as well. The recipient was discharged 9 days after transplantation, having had an uncomplicated postoperative course, and remains well on longterm follow-up. The same immunosuppression protocol was used.
Patient 3 A 31-year-old man underwent aortic and mitral valve replacement for Q-fever endocarditis in 1992. Subsequently, progressive cardiomyopathy developed with severe biventricular failure and atrioventricular block that required a permanent pacemaker. The patient underwent orthotopic heart transplantation using the same surgical technique. The donor‘s lungs, kidneys, liver, and pancreas were also harvested. The recipient’s postoperative recovery was uneventful, and he was discharged on the 12th postoperative day. He remains well at follow-up. The same immunosuppression protocol was used. 0003-4975/94/$7.00
766
HOW TO DO IT BLANCHE ET AL ALTERNATIVE HEART TRANSPLANTATION TECHNIQUE
Fig 1. Donor heart. The superior vena cava is transected at the azygas vein; the left atrium is opened in the standard fashion.
Comment From the early days of heart transplantation, the technique described by Shumway and associates [l, 21 has been commonly used. However, it has been shown by two-dimensional echocardiography that atrial size, shape, and geometry are distorted, with mitral and tricuspid
Fig 2. Recipient’s heart explanted. The venue cavae are transected circumferentially; the left atrium is resected as in the conventional technique.
Ann Thorac Surg 1994;577657
Fig 3 . Left atrial anastomosis is performed using the standard technique.
incompetence being a frequent finding after orthotopic heart transplantation. This is perhaps due to the abnormal atrial size and configuration created by the anastomosis of the donor and recipient atria, leading to impaired functional integrity of the valvular apparatus. Asynchronous contraction of the donor and recipient atria has also been demonstrated, which may further compound this problem [5, 61. The standard atrial anastomosis technique creates an hourglass-shaped atrium, with suture lines
Fig 4. The superior and inferior venue cavae are anastomosed in an end-to-end fashion.
Ann Thorac Surg 1994;577657
protruding into an enlarged atrial cavity. Furthermore, the heart is commonly found to be rotated clockwise with this technique [5, 61. Dreyfus and colleagues [3] reported an alternative technique of total orthotopic transplantation based on an experimental technique described by Webb and colleagues [7] and by Cass and Brock in 1959 [8]. This approach consists of total excision of the recipient heart, leaving the stumps of the superior and inferior venae cavae, as well as the right and left pulmonary veins with their respective cuffs of left atrium. The implantation technique of the donor heart is simple and consists of bicaval end-to-end anastomoses and pulmonary venous anastomoses to the corresponding orifice of the donor left atrium. The aorta and pulmonary artery anastomoses are performed in the standard fashion. However, this technique requires some modifications in harvesting the donor heart whereby the superior and inferior pulmonary veins are joined on each side, leaving a bridge of posterior left atrial wall between them. Additionally, the superior vena cava is transected at the azygos vein to obtain maximum length. We adopted this modified technique for all of our orthotopic heart transplantations in October 1991, and to date 56 patients have undergone transplantation in this fashion. Our initial experience with this technique in 24 patients has been reported [9]. We found a significant reduction in postoperative mitral and tricuspid regurgitation, as well as elimination of symptomatic bradyarrhythmias requiring a permanent pacemaker. Theoretically, interference with sinus node function is avoided and the integrity of the conduction system is preserved. Harvesting of the lungs for transplantation requires a cuff of left atrium with the pulmonary veins for the subsequent anastomosis [lo]. When both lungs are harvested, it might not be feasible to leave a bridge of posterior left atrial wall between the right and left pulmonary veins orifices in the donor heart, and so the entire back wall of the left atrium is resected as in the original technique described by Shumway and colleagues [I, 21. In this situation, such as the 3 cases described here, we use the technique described in this report. It consists of total excision of the recipient right atrium with donor heart implantation done using bicaval anastomoses to preserve the anatomic and physiologic integrity of the right atrium; the left atrium is done in the usual fashion. This approach is technically simple and holds promise for the reduction of serious tricuspid regurgitation that is occasionally seen with the standard technique, as well as the elimination of posttransplantation bradyarrhythmias requiring pacemaker implantation as a result of intraoperative sinus node injury. This functional advantage, perhaps due to less distortion of the right atrium, could improve longterm hemodynamic results in the heart transplant patients. Postoperative two-dimensional echocardiography in all 3 patients showed normal size and configuration of the right atrium, with no tricuspid regurgitation (Fig 5). We present this modified technique as an alternative modality for orthotopic heart transplantation; its main advantage rests in its simplicity and the preservation of
HOW TO DO IT BLANCHE ET AL ALTERNATIVE HEART TRANSPLANTATION TECHNIQUE
767
Fig 5. Postoperative transesophageal echocardiogram in patient 2. Note the normal configuration and the anatomic size and geometry of the right atrium. Also note the protruding anastomotic suture line with an hourglass configuration of the left atrium. (LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.)
geometric shape, anatomic size, and physiologic function of the right atrium.
Addendum Since the submission of the manuscript, 2 additional patients have undergone heart transplantation using the technique described in this report, with excellent results. We thank Ms Kathleen Farrington for the preparation of the manuscript and Ms Rosa Goldsmith for the illustrations.
References 1. Lower RR, Shumway NE. Studies on the orthotopic homo-
transplantation of the canine heart. Surg Forum 1960;11:1%9.
2. Shumway NE, Lower RR, Stofer RC. Transplantation of the
heart. Adv Surg 1966;2:26544. 3. Dreyfus G, Jebara V, Mihaileanu S, Carpentier AF. Total orthotopic heart transplantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181-4. 4. Couetil JP, Mihaileanu S, Lavergne T, et al. Total excision of the recipient atria (TERA) in orthotopic heart transplantation (OHT) as a new clinical procedure: Technical consideration and early results. J Heart Lung Transplant (Suppl) 1991;lO: 1(Pt 2):179. 5. Angermann CE, Spes CH, Tammen A, et al. Anatomic
characteristics and valvular function of the transplanted heart: transthoracic versus transesophageal echocardiographic findings. J Heart Transplant 1990;9:331-8.
6 . Stevenson LW, Dadourian BJ, Kobashigawa J, Child JS, Clark
SH, Laks H. Mitral regurgitation after cardiac transplantation. Am J Cardiol 1987;60:119-22. 7. Webb WR, Howard HS, Neely WA. Practical method of
homologous cardiac transplantation. J Thorac Surg 1959;37 361-6. 8. Cass MH, Brock R. Heart excision and replacement. Guy’s Hosp Rep 1959;108:28.590. 9. Czer LSC, Trento A, Blanche C, et al. Orthotopic heart transplantation: clinical experience with a new technique. J Am Coll Cardiol 1993;21(SupplA):168A. 10. Cooper JD. Lung Transplantation. In: Baumgartner WA, Reitz BA, Achuff SC, eds. Heart and heart-lung transplantation. Philadelphia: Saunders, 1990:347-71.