Orthotopic Heart Transplantation

Despite the emergence of various innovative therapies for individuals suffering from advanced heart failure, such as significant advancements in mechanical circulatory support, biventricular pacing, and stem cell treatments, heart transplantation remains the preferred and most effective treatment option.

This is a surgical video demonstrating an orthotopic heart transplant using the bicaval technique.



Orthotopic heart transplantation involving the bicaval anastomosis technique consists of several key steps. First, left atrial anastomosis was performed. The anastomosis was initiated by using a lengthy 4-0 Prolene suture starting near the left atrial cuff close to the left superior pulmonary vein. This suture was passed through the donor left atrial cuff adjacent to the left atrial appendage. Initially, this was done with the donor heart positioned at the sternal edge level, and then the heart was lowered into the pericardial space. The posterior left atrial suture line was completed first, followed by the anterior suture line. To minimize the risk of left atrial thrombus formation, an everting suture technique was employed to ensure a smooth fit between the endocardial surfaces of the donor and recipient left atrial tissues. A left ventricular vent can be introduced through an opening between the two untied left atrial sutures to assist with deairing.

The next step involves the anastomosis of the inferior vena cava using 5-0 Prolene sutures. While performing the inferior vena cava anastomosis, special care was taken to avoid deep sutures around the donor coronary sinus ostium to prevent potential damage to the conduction tissue.

Next, aortic anastomosis was completed with 5-0 Prolene continuous sutures, avoiding any redundancy of the aortic length. Equidistant hemostatic sutures were then placed. A pericardial strip may be used posteriorly if the recipient aorta is unhealthy.

During the pulmonary artery anastomosis, it was important to avoid excessive length of the pulmonary artery to prevent telescoping at the anastomosis level. This anastomosis was performed using 5-0 Prolene suture.

The last anastomosis performed was of the superior vena cava. Attention was paid to avoid excessive "purse-stringing" of the superior vena cava anastomosis, as this can inadvertently narrow the connection point. The posterior layer was completed with 6-0 Prolene continuous sutures. The Swan Ganz pulmonary artery catheter was then advanced into the right atrium. The anterior layer was completed with 6-0 Prolene interrupted sutures.

If the ischemic time is a concern, the aortic anastomosis can be completed after the LA anastomosis and the cross clamp maybe released.

These meticulous surgical steps are essential for the success and safety of orthotopic heart transplantation using the bicaval anastomosis technique.

References

1. John R, Liao K.Orthotopic Heart Transplantation. Operative Techniques in Thoracic and Cardiovascular Surgery, 15(2): 138–146. doi:10.1053/j.optechstcvs.2010.04.001.
2. Aziz T, Burgess M, Khafagy R, et al: Bicaval and standard techniques in orthotopic heart transplantation: Medium term performance in cardiac performance and survival. J Thorac Cardiovasc Surg 118: 115-122, 1996

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