How to Teach: Orthotopic Heart Transplantation

Background
In the last 54 years, advances in organ preservation, surgical technique, and immunosuppression have resulted in improved outcomes following heart transplantation. (1,2) These advances and the increased frequency of heart transplants have led to this procedure being part of the training curriculum for trainees. (3) Teaching this procedure presents unique challenges, but also opportunities to incorporate the teaching of re-do sternotomies and rescue options when problems arise.

Preparation
In our institution, the residents and fellows are involved in all aspects of care prior to the heart transplant. Pre-operatively we review all imaging- if the patient is a redo sternotomy, of which 50% of our transplants are, we discuss redo approaches and bail out options. We discuss ischemic times and if a long ischemic time is anticipated we review changes to the standard implementation scheme. The implanting team is in constant communication with the procurement team to optimize timing and for updates on the status of the procurement. We have the resident help decide when we will start the recipient side of the operation, taking into consideration how long we anticipate the recipient cardiectomy will take and travel time duration.

Technique
This video demonstrates detailed tips and tricks in teaching orthotopic heart transplantation using a standard bicaval technique. The narration details recipient cardiectomy, preparation of the donor heart, and implantation. Specific key elements for effectively teaching this operation include:
- For the cardiectomy this is a “no rush” period where a constant dialogue with the resident avoids unneeded injury.
- Following the cardiectomy, adequate exposure is gained by placing multiple stay sutures, these also serve as markers during the anastomoses.
- The left atrial anastomosis is best facilitated by splaying the donor left atrium with the assistant’s (attending’s) hand, stretching and lining up the tissue and ensuring both the operating surgeon and assistant can see well. If as an educator you cannot see it, you cannot teach it.
- Determining cuff length, in particular pulmonary artery and aorta length, can be challenging for residents. A “measure twice, cut once” approach where you allow them to measure and make their own assessment, and then mark it and measure again and ensure that the attending’s measurement aligns with the resident’s prediction is a good way to allow safe autonomy.
- To save time remember that the entire case can effectively be done from the left side of the table. If the resident is progressing too slowly, performing more or less of the anastomosis from the teaching side is an option, rather than making the resident switch sides.

Comment
Post-operatively we discuss what worked well and areas for improvement, including areas to improve efficiency to reduce ischemic time. Our patients are cared for by a multi-disciplinary team with continued involvement of our surgical residents at all times. An institution that is well equipped to provide multi-disciplinary care has been essential in the recovery of these patients.

References

1. Stehlik, J, Kobashigawa J, Hunt SA, Reichenspurner H, Kirklin JK. Honoring 50 Years of Clinical Heart Transplantation in Circulation: In-Depth State-of-the-Art Review. Circulation. 2018; 137(1):71-87. Doi: 10.1161/CIRCULAIONAHA.117.029753
2. Li Y. Three preservation solutions for cold storage of heart allografts: A systematic review and meta-analysis of heart preservation solution. Artificial organs. 05/2016;40(5):489-496. Doi: 10.111/aor.12585
3. Wilson HH, Feins RH, Heathcote SA Sr, Caranasos TG. A High-Fidelity, Tissue-Based Simulation for Cardiac Transplantation. Ann Thorac Surg. 2020;109(2):e147-e148.doi:10.1016/j.athoracsur.2019.08.081

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