Orthotopic cardiac transplantation with direct caval anastomosis: is it the optimal procedure?

Surgical Results of the Superior Vena Cava Intimal Layer-Only Suture Technique in Heart Transplantation

Background

Superior vena cava (SVC) stenosis during follow-up is a major concern after heart transplantation, and many technical modifications have been introduced. We analyzed the surgical results of the SVC intima layer-only suture technique in heart transplantation.

Methods

We performed SVC anastomosis with sutures placed only in the intima during heart transplantation. We measured the area of the SVC at 3 different points (above the anastomosis, at the anastomosis, and below the anastomosis) in an axial view by freely drawing regions of interest, and then evaluated the degree of stenosis. Patients who underwent cardiac computed tomography (CT) at 2 years postoperatively between June 2017 and May 2020 were included in this study.

Results

We performed heart transplantation in 41 patients. Among them, 24 patients (16 males and 8 females) underwent follow-up cardiac CT at 2 years postoperatively. The mean age at operation was 49.4±4.9 years. The diagnoses at time of operation were dilated cardiomyopathy (n=12), ischemic heart disease (n=8), valvular heart disease (n=2), hypertrophic cardiomyopathy (n=1), and congenital heart disease (n=1). No cases of postoperative bleeding requiring intervention occurred. The mean CT follow-up duration was 1.9±0.7 years. At follow-up, the mean areas at the 3 key points were 2.7±0.8 cm2, 2.7±0.8 cm2, and 2.7±1.0 cm2 (p=0.996). There were no SVC stenosis-related symptoms during follow-up.

Conclusion

The suture technique using only the SVC intimal layer is a safe and effective method for use in heart transplantation.

Atrial fibrillation following heart transplantation: A systematic review and meta-analysis of observational studies

OBJECTIVE

Previous studies have suggested a high incidence of atrial fibrillation (AF) in heart transplant recipients. However, incidence trends of AF in heart transplant recipients remain unclear. The study's aims were (1) to investigate the pooled incidence/incidence trends of AF following heart transplantation and (2) to assess the mortality risk of heart transplant recipients with AF.

METHODS

A literature search for studies that reported the incidence of AF following heart transplantation was conducted using MEDLINE, EMBASE, and The Cochrane Database from inception through March 2018. Pooled incidence and odds ratios (OR) with 95%CI were calculated using a random-effects model.

RESULTS

Eighteen studies (2 cohorts from clinical trials and 16 cohort studies) with 5393 heart transplant recipients were enrolled. The pooled estimated incidence of AF in heart transplant was 10.1% (95%CI: 7.6%-13.2%). Meta-analysis based on the type of anastomotic technique demonstrated a pooled estimated incidence of AF following heart transplantation of 18.7% (95%CI: 10.3%-31.5%) and 11.1% (95%CI: 6.5%-18.4%) by biatrial and bicaval techniques, respectively. There was a significant association between AF following a heart transplant and increased mortality risk with a pooled OR of 2.86 (95%CI: 2.08-3.93). Meta-regression analyses showed no significant correlations between the year of study and incidence of AF (P = 0.47) or mortality risk of AF after heart transplantation (P = 0.99).

CONCLUSIONS

The overall estimated incidence of AF following heart transplantation is 10.1%. There is a significant association between AF and increased mortality after transplantation. Furthermore, incidence and mortality risk of AF following heart transplant does not seem to decrease over time.

Electrocardiographic alterations associated with heart transplantation. Triggers, mechanisms and meaning

Introducción. Las alteraciones del ritmo cardíaco están asociadas con un aumento en la morbimortalidad; sin embargo, en pacientes con trasplante cardíaco no son claros sus desencadenantes ni implicaciones.Objetivos. Realizar una búsqueda en la literatura para identificar y explicar los determinantes en la generación de alteraciones de la conducción eléctrica en pacientes con trasplante cardíaco, así como describir las principales arritmias que pueden presentarse, explicando sus implicaciones patológicas.Materiales y métodos. Se realizó una búsqueda en la base de datos PubMed que arrojó un total de 411 resultados. Además, se buscaron las guías de práctica clínica sobre trasplante cardíaco, electrofisiología cardiovascular y endocarditis infecciosa. Se eligieron 60 artículos que lograban responder a los objetivos de este estudio.Resultados. La técnica quirúrgica, la denervación cardíaca, las lesiones del nodo sinusal, el rechazo del injerto, las biopsias endomiocárdicas y las infecciones son los principales factores que comprometen la viabilidad del órgano y la vida del paciente trasplantado, manifestándose como alteraciones del ritmo sinusal.Conclusiones. Ante la detección de alguna arritmia cardíaca, el equipo médico debe proporcionar un manejo que no se limite al control sintomático y del ritmo sinusal, sino que se debe iniciar una búsqueda activa de su etiología, ya que esta puede ser la manifestación de un proceso patológico subyacente.

Frequency of superior vena cava obstruction in pediatric heart transplant recipients and its relation to previous superior cavopulmonary anastomosis

The risk factors for superior vena cava (SVC) obstruction after pediatric orthotopic heart transplantation (OHT) have not been identified. This study tested the hypothesis that pretransplant superior cavopulmonary anastomosis (CPA) predisposes patients to SVC obstruction. A retrospective review of the Pediatric Cardiac Care Consortium registry from 1982 through 2007 was performed. Previous CPA, other cardiac surgeries, gender, age at transplantation, and weight at transplantation were assessed for the risk of developing SVC obstruction. Death, subsequent OHT, or reoperation involving the SVC were treated as competing risks. Of the 894 pediatric OHT patients identified, 3.1% (n = 28) developed SVC obstruction during median follow-up of 1.0 year (range: 0 to 19.5 years). Among patients who developed SVC obstruction, 32% (n = 9) had pretransplant CPA. SVC surgery before OHT was associated with posttransplant development of SVC obstruction (p <0.001) after adjustment for gender, age, and weight at OHT and year of OHT. Patients with previous CPA had increased risk for SVC obstruction compared with patients with no history of previous cardiac surgery (hazard ratio 10.6, 95% confidence interval: 3.5 to 31.7) and to patients with history of non-CPA cardiac surgery (hazard ratio 4.7, 95% confidence interval: 1.8 to 12.5). In conclusion, previous CPA is a significant risk factor for the development of post-heart transplant SVC obstruction.

Operative Technique and Atrial Tachyarrhythmias After Orthotopic Heart Transplantation

There is conflicting evidence that operative technique affects the risk of atrial tachyarrhythmia after orthotopic heart transplantation (OHT). We sought to determine whether OHT by bicaval (BC) technique is associated with a lower risk of atrial tachyarrhythmia than biatrial (BA) technique. Consecutive patients who underwent OHT between 1997 and 2007 at the University of Minnesota were included in this retrospective cohort study with follow-up through December 31, 2011. We included 260 OHT recipients (BA, 155; BC, 105). Fifty-nine patients (22.7%) developed early atrial tachyarrhythmias. The multivariable odds ratio (95% confidence interval [CI]) of BC technique for early atrial tachyarrhythmias was 0.85 (0.46-1.57), P=0.59. After a median follow-up of 4.9 years, 40 (15.4%) patients developed late atrial tachyarrhythmias. The multivariable hazard ratio (HR) (95% CI) of BC technique for late atrial tachyarrhythmias was 0.99 (0.50-1.96), P=0.98. Graft rejection was found to be a multivariate predictor of late atrial tachyarrhythmias (HR, 2.89; 95% CI, 1.48-5.65; P=0.002). In contrast to prior reports, we did not find an association between operative technique and early or late atrial tachyarrhythmias after OHT. Graft rejection is a risk factor for late atrial tachyarrhythmias after OHT.

Operative Technique and Atrial Tachyarrhythmias After Orthotopic Heart Transplantation

There is conflicting evidence that operative technique affects the risk of atrial tachyarrhythmia after orthotopic heart transplantation (OHT). We sought to determine whether OHT by bicaval (BC) technique is associated with a lower risk of atrial tachyarrhythmia than biatrial (BA) technique. Consecutive patients who underwent OHT between 1997 and 2007 at the University of Minnesota were included in this retrospective cohort study with follow-up through December 31, 2011. We included 260 OHT recipients (BA, 155; BC, 105). Fifty-nine patients (22.7%) developed early atrial tachyarrhythmias. The multivariable odds ratio (95% confidence interval [CI]) of BC technique for early atrial tachyarrhythmias was 0.85 (0.46-1.57), P=0.59. After a median follow-up of 4.9 years, 40 (15.4%) patients developed late atrial tachyarrhythmias. The multivariable hazard ratio (HR) (95% CI) of BC technique for late atrial tachyarrhythmias was 0.99 (0.50-1.96), P=0.98. Graft rejection was found to be a multivariate predictor of late atrial tachyarrhythmias (HR, 2.89; 95% CI, 1.48-5.65; P=0.002). In contrast to prior reports, we did not find an association between operative technique and early or late atrial tachyarrhythmias after OHT. Graft rejection is a risk factor for late atrial tachyarrhythmias after OHT.

Exercise performance comparison of bicaval and biatrial orthotopic heart transplant recipients

BACKGROUND

The standard biatrial technique for orthotopic heart transplantation uses a large atrial anastomosis to connect the donor and recipient atria. A modified technique involves bicaval and pulmonary venous anastomoses and is believed to preserve the anatomic configuration and physiological function of the atria. Bicaval heart transplantation reduces postoperative valvular regurgitation and is associated with a lower incidence of pacemaker insertion.

OBJECTIVE

The aim of this study was to compare postoperative functional capacity and exercise performance in patients with bicaval and biatrial orthotopic heart transplantation.

METHODS

Patients were selected for the study if they did not have any of the following: obstructive coronary artery disease (>50% stenosis), severe mitral or tricuspid regurgitation, signs of rejection (grade≥1B-1R) on endomyocardial biopsy during the prior year, respiratory impairment, a permanent pacemaker, orthopedic or muscular impediments, or lived more than 150 miles from the medical center. A total of 27 patients qualified. In 15 patients who received a biatrial heart transplant and 12 patients with a bicaval heart transplant, a stationary bicycle exercise test was performed. Ventilatory gas exchange and maximum oxygen consumption measurements were measured.

RESULTS

Recipient and donor characteristics, including body surface area, donor/recipient weight mismatch, immunosuppressive regimen, and self-reported weekly exercise activity, did not differ between the biatrial and bicaval groups (P=not significant [NS]). At peak exercise, similar heart rate, workload, oxygen consumption, carbon dioxide production, ventilation, functional capacity, and exercise duration were found between the 2 groups (P=NS). Patients in the biatrial group were studied later than patients in the bicaval group (6.54±0.71 vs 4.68±0.28 years; P<.001).

CONCLUSION

There were no significant differences in the exercise capacity between patients with biatrial versus bicaval techniques for orthotopic heart transplantation. Factors other than the atrial connection (such as cardiac denervation, immunosuppressive drug effect, or physical deconditioning) may be more important determinants of subnormal exercise capacity after heart transplantation. Nevertheless, the reduction in morbidity and postoperative complications and the simplicity in the bicaval technique suggest that bicaval heart transplantation offers advantages when compared with the standard biatrial technique.

Long-term pulmonary vascular reactivity after orthotopic heart transplantation by the biatrial versus the bicaval technique

INTRODUCTION

Advantages of the bicaval versus the biatrial technique have been reported, emphasizing atrial electrical stability and less tricuspid regurgitation.

OBJECTIVE

To analyze the impact of the surgical technique on long-term pulmonary pressures, contractility, and graft valvular behavior after heart transplantation.

METHODS

Among 400 orthotopic heart transplantation recipients from 1985 to 2010, we selected 30 consecutive patients who had survived beyond 3 years. The biatrial versus bicaval surgical technique groups included 15 patients each. Their preoperative clinical characteristics were similar. None of the patients displayed a pulmonary vascular resistance or pulmonary artery pressure over 6U Wood or 60 mm Hg, respectively. We evaluated invasive hemodynamic parameters during routine endomyocardial biopsies. Two-dimensional echocardiographic parameters were obtained from routine examinations.

RESULTS

There were no significant differences regarding right atrial pressure, systolic pulmonary artery pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance, cardiac index, systolic blood pressure, left ventricular ejection fraction, and mitral regurgitation (P > .05). Tricuspid regurgitation increased significantly over the 3 years of observation only among the biatrial group (P = .0212). In both groups, the right atrial pressure, pulmonary wedge capillary pressure, transpulmonary gradient, and pulmonary vascular resistance decreased significantly (P < .05) from the pre- to the postoperative examination. In both groups cardiac index and systemic blood pressure increased significantly after transplantation (P < .05). Comparative analysis of the groups only showed significant differences regarding right atrial pressure and degree of tricuspid regurgitation; the bicaval group showing the best performance.

CONCLUSIONS

Both surgical techniques ensure adequate left ventricular function in the long term; however, the bicaval technique provided better trends in hemodynamic performance, as well as a lower incidence and severity of tricuspid valve dysfunction.

Surgery-related complications in cardiac transplantation patients

OBJECTIVE

The surgical techniques was first described by Lower and Shumway for cardiac transplantation have not changed for many years; they are still being commonly used worldwide despite recently presented alternatives. We sought to evaluate the surgical complications among our cardiac transplantation patients in whom we performed the standard technique.

PATIENTS AND METHODS

The standard biatrial anastomosis technique was used in 13 patients who have a mean follow-up of 18.6 (1 to 38) months. During the follow-up, echocardiographic assessment was performed to evaluate left and right atrial diameters, tricuspid and mitral valve regurgitation, interatrial septum, and suture lines. Elecotrocardiograms were evaluated for arryhthmia and pacemaker requirements in the midterm.

RESULTS

The mean left and right atrial diameters were measured as 40.5 (32 to 57) x 66.6 (48 to 78) and 37.9 (32 to 43) x 56.3 (48 to 69) mm, respectively. The jet area was calculated at less than 5 cm(2) for mitral and tricuspid valve regurgitation, which can be defined as "mild" regurgitation. There was no increase in the degree of regurgitation of both atrioventricular valves during the follow-up period. In one patient, a thrombus was detected in the suture line; there was a nonsignificant left to right shunt in another patient. A temporary pacemaker was indicated in two patients. Atrial fibrillation was detected in three patients, who responded to medical therapy. During the follow-up atrial fibrillation developed in one patient.

CONCLUSION

The cardiac transplantation operation using the standard technique may result in atrial dysfuntion due to deformation of atrial integrity and geometry. However, when we evaluated our results, we concluded that the standard surgical technique was a safe, simple, effective, and feasible method.

Influence of different implantation techniques on long-term survival after orthotopic heart transplantation: an echocardiographic study

BACKGROUND

Orthotopic heart transplantation (OHT) was initially done by the biatrial technique, although the bicaval technique has recently become more popular. The aim of this study was to compare OHT outcomes when using the bicaval technique vs the biatrial technique.

METHODS

A total of 615 patients were transplanted at the Cleveland Clinic Foundation from January 1993 and October 2003 (biatrial technique: n = 293; bicaval technique: n = 322). The average follow-up period was 4.2 +/- 2.9 years (range 1 to 11 years). Patients who were supported with a left ventricular assist device (prior to transplant) and who could not be weaned off respiratory support were excluded.

RESULTS

Patients in both groups were similar with regard to pre-operative characteristics. The peri-operative mortality showed no statistical significant differences between the two groups. The left atrium was significantly more enlarged in the biatrial group. The bicaval group showed a significantly reduced incidence of tricuspid regurgitation. Survival at 10-year follow-up was 87.3% in the bicaval group and 79.9% in the biatrial group (p < 0.05). Left ventricular ejection fraction (LVEF), right ventricular ejection fraction (RVEF) and moderate to severe tricuspid regurgitation were significant risk factors for death in both groups. The bicaval technique showed a significantly better mortality outcome.

CONCLUSIONS

This study showed that the bicaval technique for OHT offers a better outcome than the biatrial technique. The significant reduction of left atrial size and atrioventricular valve regurgitation in the bicaval group may have a major impact on the long-term preservation of cardiac function and survival.

Donor Tricuspid Annuloplasty During Orthotopic Heart Transplantation: Long-Term Results of a Prospective Controlled Study

BACKGROUND

Development of tricuspid regurgitation after orthotopic heart transplantation can cause heart failure along with renal and hepatic impairment and portends a poor prognosis. If tricuspid regurgitation causes significant symptoms, tricuspid valve repair or replacement is often required. This study was designed to study the effects of prophylactic tricuspid valve annuloplasty (TVA) during orthotopic heart transplantation on long-term survival, renal function, and amount of tricuspid regurgitation.

METHODS

Between April 1997 and March 1998, 60 patients (aged 18 to 70 years; 22 female) randomly received either standard bicaval orthotopic heart transplantation (group STD; n = 30) or bicaval orthotopic heart transplantation with DeVega TVA (group TVA; n = 30). Tricuspid valve annuloplasty was performed on the donor heart before implantation using pledgeted 2-0 polypropylene and sized to an annulus of 29 mm. Echocardiographic measurements, laboratory values, and hemodynamics were obtained prospectively and reviewed by an independent data analyst.

RESULTS

Follow-up of patients as of December 2003 was complete. Although there was a perioperative mortality advantage in group TVA, there was no difference between groups in long-term survival. At the end of the study, however, there was a statistical difference (group STD versus group TVA, p < 0.05) with regard to cardiac mortality (7 of 30 versus 3 of 30), average amount of tricuspid regurgitation (1.5 +/- 1.3 versus 0.5 +/- 0.4), percentage of patients with 2+ or greater tricuspid regurgitation (34% versus 0%), serum creatinine (2.9 +/- 2.0 versus 1.8 +/- 0.7), and difference in serum creatinine over baseline (2.0 +/- 2.1 versus 0.7 +/- 0.8).

CONCLUSIONS

Prophylactic DeVega TVA of the donor heart is durable and decreases the incidence of cardiac-related mortality and tricuspid regurgitation after orthotopic heart transplantation. In addition, there is improved protection of renal function. Considering the ease and safety of TVA and its advantages, it should be performed as a routine adjunct to orthotopic heart transplantation.

Incidence of Atrial Fibrillation in Heart Transplant Patients: Long-Term Follow-Up

BACKGROUND

The incidence of atrial fibrillation (AF) in heart transplant patients has not been well documented.

METHODS

To determine the incidence of AF in a cohort of patients undergoing cardiac transplantation, clinical data were obtained from a prospectively collected database for all consecutive orthotopic heart transplantation (OHT) patients and for all consecutive coronary artery bypass graft (CABG) surgery patients between January 1984 and March 2004 at our institution. A cohort of 1,714 OHT patients and low-risk CABG (normal ejection fraction [EF] and no left ventricular hypertrophy [LVH]) patients were age- and sex-matched.

RESULTS

The average age in the two groups was 56 +/- 7 years with 87% male and 81% white race and body mass index (BMI) of 26 +/- 4. There were 3 cases of AF (0.3%) in the OHT group and 757 cases of AF (21%) in the low-risk CABG group. The strongest independent predictor of freedom from postoperative AF was having had a transplant (odds ratio [OR] 96, 95% confidence interval [CI] 13-720). The incidence of AF, atrial flutter (AFL), and supraventricular tachycardia (SVT) in OHT was 0.33, 2.8%, and 1.3%, respectively. Given that incidence of AF, AFL, and SVT in historical post-CABG population is 25%, 17%, and 4.3%, transplanted patients appear to have lower incidence of AF, AFL, and SVT than the reference population. Consistent with this, transplanted patients underwent few ablation procedures for atrial arrhythmias. Additionally, the three patients with AF had bicaval anastomoses suggesting the possibility of PACs originating in the donor superior vena cava (SVC) or IVC (inferior vena cava) initiating AF in these patients.

CONCLUSIONS

In a cohort study of transplant and low-risk CABG patients, the strongest independent predictor of freedom from AF is having undergone transplant surgery. One potential explanation for the markedly lower incidence of AF may be effective isolation of thoracic veins with documented cases retaining the native SVC.

Outcomes and Complications After Heart Transplantation

In more than 35 years of experience with heart transplantation, improvements in patient selection, surgical techniques, organ preservation, and postoperative management have increased survival rates and reduced complications. However, a number of significant complications continue, limiting the benefit of heart transplantation as the long-term solution for patients. Current survival rates are 83% at 1 year and 72% at 5 years, with 50% of patients surviving 9.4 years or more. Recipient and donor characteristics influence survival outcome. Primary graft dysfunction is the most frequent cause of death during the first 30 days. The function of the transplanted heart allows return to pre-illness activities, though denervation limits peak exercise capacity. Advances in immunosuppressive medications have decreased the incidence and severity of rejection, though only recently have shown promise in attenuating the incidence of cardiac graft vasculopathy, the major complication limiting long-term graft function. This review addresses current outcomes and the short- and long-term complications of heart transplantation.

Orthotopic cardiac transplantation: comparison of outcome using biatrial, bicaval, and total techniques

BACKGROUND

For more than 35 years, the biatrial technique of performing orthotopic cardiac transplantation has been the gold standard, and involves anastomoses of donor and recipient atrial cuffs. More recently, however, bicaval and total techniques have been devised in an attempt to improve cardiac anatomy, physiology, and postoperative outcome. A bicaval approach preserves the donor atria and combines the standard left atrial anastomosis with a separate bicaval anastomosis. Total orthotopic heart transplantation involves complete excision of the recipient atria with separate bicaval end-to-end anastomoses, as well as pulmonary venous anastomoses. The aim of this study was to conduct a literature review of studies that compared the three surgical techniques (biatrial, bicaval, and total) for performing orthotopic cardiac transplantation. Numerous outcome variables were evaluated, and included post-transplant survival, atrial dimensions, atrioventricular valvular insufficiency, arrhythmias, pacing requirements, vasopressor requirements, and hospital stay.

METHODS

We conducted a Medline (Pubmed) search using the terms "biatrial and cardiac transplantation,""bicaval and cardiac transplantation," and "total technique and cardiac transplantation," which yielded 192 entries: 39 of these were studies that compared surgical techniques and were included in the review.

RESULTS

There was overwhelming evidence that the bicaval technique provided anatomic and functional advantages, with improvements in post-transplant survival, atrial geometry, and hemodynamics, as well as decreased valvular insufficiency, arrhythmias, pacing requirements, vasopressor requirements, and hospital stay.

CONCLUSIONS

The bicaval technique was superior to both biatrial and total techniques for numerous outcome variables. To further elucidate this issue, a prospective randomized trial comparing the three techniques, with long-term follow-up, is warranted.

Successful outcome with extended allograft ischemic time in pediatric heart transplantation

BACKGROUND

Many cardiac transplant programs have liberalized donor eligibility criteria in an attempt to maximize donor supply and to accommodate increasing demand. Although many studies have evaluated the potential adverse effects of prolonged donor ischemic time (DIT) in adults undergoing cardiac transplantation, relatively few have focused specifically on pediatric recipients that include a substantial number of patients and long-term follow-up. The focus of this study was to examine the effect of extended DIT on mortality after pediatric heart transplantation.

METHODS

We conducted a retrospective review of our pediatric cardiac transplant experience in the past 11 years, comparing patients who received allografts and had ischemic times >240 minutes with those who had ischemic times <240 minutes.

RESULTS

A total of 129 pediatric patients (<19 years) underwent orthotopic heart transplantation, of whom 78 (60.5%) had DIT <240 minutes and 51 (39.5%) had DIT >240 minutes. We found no statistically significant difference in age, sex, race, height, weight, or donor age between the groups (p = not significant). Post-transplant survival at 1, 5, and 10 years was similar for both groups: 91.2%, 88.0%, and 85.2%, respectively, for patients with DIT <240 minutes vs 89.6%, 87.2%, and 79.8%, respectively, for patients with DIT >240 minutes (p = 0.433). Additionally, using Cox proportional hazard models, extended DIT >240 minutes was not a statistically significant independent predictor of post-transplant mortality (odds ratio, 0.655; 95% confidence interval, 0.518-0.972; p = 0.684; standard error = 0.468).

CONCLUSION

Procurement of hearts from distant locations with associated extended DIT is justified in the setting of increased demand and a fixed donor population.

Surgical advances in heart and lung transplantation

The successes of thoracic transplantation have led to the expansion of indications and a subsequent growth in demand for a short supply of organs. In response to this disparity, the criteria for organ donation have been liberalized. Despite these difficult challenges, with advances in surgical techniques and perioperative care of both the donor and recipient, outcomes have continued to improve over time. This article focuses on the more recent surgical advances in donor selection and management, procurement and implantation, and the impact of these advances on patient outcome.

A one-year comparison of prophylactic donor tricuspid annuloplasty in heart transplantation

BACKGROUND

The bicaval technique for orthotopic heart transplantation decreases the incidence of tricuspid valve regurgitation when compared with the standard biatrial technique. This study was designed to study the effects of prophylactic tricuspid valve annuloplasty during bicaval orthotopic heart transplantation on survival, renal function, and amount of tricuspid valve regurgitation.

METHODS

Between April 1997 and March 1998, 60 patients (age 18 to 70 years, 22 women) randomly received either bicaval orthotopic heart transplantation (n = 30) or bicaval orthotopic heart transplantation with DeVega tricuspid valve annuloplasty (n = 30). Tricuspid valve annuloplasty was performed on the donor heart before implantation using pledgeted 2-0 polypropylene suture and sized to an annulus of 29 mm. Echocardiographic variables, laboratory values, and hemodynamics were obtained prospectively and reviewed by an independent data analyst.

RESULTS

Intraoperatively, the group undergoing tricuspid valve annuloplasty had a shorter reperfusion time (46 +/- 29 minutes versus 65 +/- 48 minutes; p < 0.05) and higher mean pulmonary artery to central venous pressure difference (11.8 +/- 3.7 mm Hg versus 15.3 +/- 4.1 mm Hg; p = 0.001). Additional differences between the two groups included early mortality from donor dysfunction (4 of 30 patients versus 0 of 30 patients; p < 0.05), amount of tricuspid valve regurgitation at 1 year (1.3 +/- 1.0 versus 0.2 +/- 0.3; p < 0.05), and percentage of patients with 2+ or greater tricuspid valve regurgitation (34% versus 0%; p < 0.05).

CONCLUSIONS

Tricuspid valve annuloplasty of the donor heart before bicaval orthotopic heart transplantation improves immediate donor heart function as demonstrated by better right ventricular performance, lower perioperative mortality, and shorter reperfusion times. At 1 year, there is less tricuspid valve regurgitation but no difference in renal function. Considering the ease and safety of tricuspid valve annuloplasty and its advantages, it should be performed as a routine adjunct with bicaval orthotopic heart transplantation.

Vasomotor responses to decreased venous return: effects of cardiac deafferentation in humans

We compared haemodynamic and peripheral vasomotor responses to lower body negative pressure (LBNP) in cardiac transplant recipients who had undergone bicaval anastomoses, involving right atrial deafferentation (-RA), and the conventional procedure in which some atrial baroreceptor afferents remain intact (+RA). We measured mean forearm blood flow (FBF) responses using Doppler/ultrasound during three randomised trials involving 0 (baseline), -20 and -40 mmHg LBNP in 15 transplant recipients (9 -RA, 6 +RA) and in eight healthy matched controls. A significant effect of LBNP on FBF existed between control and transplant groups (P < 0.05; two-way ANOVA). Mild LBNP (-20 mmHg), significantly decreased FBF by 29.7 +/- 10.0% relative to baseline in +RA subjects (P < 0.05), whereas the 17.7 +/- 10.3% decrease in -RA subjects was not significant. In response to -40 mmHg LBNP, FBF significantly decreased in control (42.4 +/- 4.6%, P < 0.05) and +RA subjects (33.3 +/- 11.4%, P < 0.05) with no significant change in the -RA group. The response of systolic blood pressure (SBP) to -40 mmHg significantly differed between groups (P < 0.05): -RA subjects decreased significantly (P < 0.05) whilst the decrease in SBP in +RA subjects did not achieve significance and control subjects exhibited an increase. The heart rate increase from baseline to -40 mmHg was significantly attenuated in -RA relative to controls and the +RA group (P < 0.05). The present study demonstrates that atrial deafferentation impairs reflex vasomotor control of the circulation in response to low- and high-level LBNP, indicating that atrial deafferentation may contribute to abnormal arterial pressure regulation.

Long-term results of cardiac transplantation in patients 65 years of age and older: a comparative analysis

BACKGROUND

Advanced age is viewed by some transplant centers as a contraindication for heart transplantation secondary to concerns regarding decreased survival.

METHODS

Between January 1992 and June 2002, 63 of 881 (7.2%) orthotopic heart transplants were performed in patients above 65 years. These patients were compared to 63 recipients below age 65 who were matched for sex, etiology of heart failure, United Network for Organ Sharing status, and immunosuppression therapy era.

RESULTS

Mean age was 67.1 +/- 2.3 years (range, 65.0 to 74.8) for the older group and 48.1 +/- 14.5 years (range, 18.3 to 64.4) for the younger group (p < 0.001). There was no significant difference in the incidence of diabetes, hypertension, chronic obstructive pulmonary disease, or peripheral vascular disease between the groups (p = not significant) although there were more patients with prior myocardial infarctions in the older group (p < 0.001). There was no significant difference in overall survival between the groups, with 1-, 3-, 5-, and 10-year actuarial survival of 85.8%, 80.3%, 73.1%, and 49.9% for the older group; and 86.9%, 83.4%, 75.0%, and 57.0% for the younger group (p = 0.597). Postoperative intensive care unit stay and overall hospital stay were similar for the two groups (p = not significant). There was no significant difference between the groups in freedom from infection or rejection at 1, 3, or 5 years after transplant (p = not significant) although the incidence of transplant coronary artery disease was higher in the older group (p = 0.025).

CONCLUSIONS

These data demonstrate similar short-term and long-term results for elderly and young recipients undergoing cardiac transplantation. This supports proceeding with transplantation in carefully selected elderly patients.

Prolonged donor ischemic time does not adversely affect long-term survival in adult patients undergoing cardiac transplantation

OBJECTIVE

With liberalization of donor eligibility criteria, organs are being harvested from remote locations, increasing donor ischemic times. Although several studies have evaluated the effects of prolonged donor ischemic times on short-term survival and graft function, few have addressed concerns regarding long-term survival.

METHODS

Over the last 11 years, 819 consecutive adults underwent cardiac transplantation at Columbia Presbyterian Medical Center. Recipients were separated into the following 4 groups based on donor ischemic time: <150 minutes, 150 to 200 minutes, 200 to 250 minutes, and >250 minutes. Statistical analysis included Kaplan-Meier survival and Cox proportional hazard models to identify predictors of long-term survival.

RESULTS

Donor ischemic time was 120.1 +/- 21.1 minutes for group 1 (n = 321), 174.1 +/- 14.7 minutes for group 2 (n = 264), 221.7 +/- 14.6 minutes for group 3 (n = 154), and 295.5 +/- 37.1 minutes for group 4 (n = 80) (P <.001). There were no significant differences in recipient age, donor age, etiology of heart failure, United Network for Organ Sharing status, or history of previous cardiac surgery among the groups (P = NS). Prolonged donor ischemic time did not adversely affect long-term survival, with actuarial survival at 1, 5, and 10 years of 86.9%, 75.2%, and 56.4% for group 1; 86.2%, 76.9%, and 50.9% for group 2; 86.4%, 71.0%, and 43.7% for group 3; and 86.7%, 70.1%, and 50.9% for group 4 (P =.867). There was no significant difference in freedom from transplant coronary artery disease among the 4 groups (P =.474).

CONCLUSIONS

Prolonged donor ischemic time is not a risk factor for decreased long-term survival. Procurement of hearts with prolonged donor ischemic time is justified in the setting of an increasing recipient pool with a fixed donor population.

[Incidence and dynamic behavior of spontaneous echocardiographic contrast and atrial thrombi in the transplanted heart]

BACKGROUND

Standard orthotopic heart transplantation produces important anatomic and functional atrial alterations with subsequent thrombotic risk. Therefore the aim of this study was to analyze the prevalence and evolution of spontaneous echocardiography, atrial thrombi and embolic events.

PATIENTS AND METHOD

52 consecutive transplanted patients were analyzed with transesophageal echocardiography and hemodynamic studies performed at 15 days and one year after transplantation.

RESULTS

Spontaneous echocardiography contrast was present in 27 patients (52%). Ten atrial thrombi were observed (19.2%), 9 with spontaneous echocardiography contrast. Six atrial thrombi appeared on day 15 and 4 after one year (with spontaneous echocardiography contrast on the previous study). Using multiple logistic regression analysis left atrial size was the only independent predictor factor for spontaneous echocardiography contrast (OR = 1.27; 95% CI, 1.09-1.54) and was an important predictor factor of atrial thrombi formation (OR = 1.19; 95% CI, 1.04-1.42). Likewise, the main predictor of atrial thrombi was the presence of spontaneous echocardiography contrast (OR = 116; 95% CI, 8.4-999). The hemodynamic pattern did not predict either the presence of spontaneous echocardiography contrast or atrial thrombi. The global incidence of embolic events was 4% less than previously described.

CONCLUSIONS

The incidence of atrial thrombi and spontaneous echocardiographic contrast after standard orthotopic heart transplantation was 19.2% and 52%, respectively. An enlarged atrium and/or spontaneous echocardiography contrast was found to increase the risk of atrial thrombi. Considering the dynamic nature of atrial thrombi formation, periodical transesophageal echocardiography studies are recommended after heart transplantation.

Heart transplantation--surgical results

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, the surgical technique has undergone several revisions. These revisions have addressed certain anatomic and geometric distortions that occurred with the original biatrial technique of Lower and Shumway. Early revisions have included the use of a bicaval technique for implanting the right atrium. Subsequently, the additional use of a direct pulmonary venous anastomosis has lead to the surgical concept of the total orthotopic heart transplant. These revisions of the original bi-atrial technique have led to a decrease in atrial size and distortion, conduction abnormalities and tricuspid and mitral valve regurgitation. This has also resulted in less atrial thromboembolic events, less need for permanent postoperative pacemaker placement, and in an overall increase in right and left heart performance in the early postoperative period. Overall, this has contributed to better clinical results with patients returning sooner to their normal exercise capacity. Ninety percent of heart transplant patients lead a relatively normal lifestyle having no limitations in their activity and 40 % return to work. We believe that the technique of total orthotopic heart transplantation has improved surgical results and clinical outcomes.

Severe tricuspid regurgitation after heart transplantation

BACKGROUND

Tricuspid regurgitation (TR) is common after heart transplantation. However, the incidence of severe TR and the incidence of symptoms after echocardiographic diagnosis of severe TR have not been documented. The purpose of this study is to determine the incidence of severe TR and its clinical significance in the heart transplant population.

METHODS

We reviewed echocardiograms (echo) of all heart transplant patients coming for regular echocardiographic follow-up between 1990 and 1995. We reviewed the charts of all patients who had echo diagnosis of severe TR.

RESULTS

A total of 336 patients had echo follow-up during this time period. The number of months post-heart transplant to last echo was 54 +/- 50 (range, 1 to 265 months). Ninety patients had moderate TR and 23 patients had severe TR. Mean time from heart transplantation to diagnosis of severe TR was 43 +/- 38 months (range, 1 to 132). Using Cutler-Ederer analysis, at 5 years, 92.2% of surviving patients were free from severe TR. At 10 years, 85.8% of surviving patients were free from severe TR. Of the 23 patients with severe TR, 17 had charts available for review. The mean number of prior endomyocardial biopsies was 28 +/- 21 (range, 3 to 88). These patients were followed for 35 +/- 18 months after diagnosis. During this period, they developed significant heart failure and peripheral edema. Six patients eventually underwent tricuspid valve replacement.

CONCLUSIONS

Moderate to severe TR commonly occurs following heart transplantation. Severe TR is associated with significant morbidity.

The paradox of survival results after heart transplantation for cardiomyopathy caused by Trypanosoma cruzi. First Guidelines Group for Heart Transplantation of the Brazilian Society of Cardiology

BACKGROUND

Donor supply limits heart transplantation (HT) and relative priority should be given to cases with greater chances of success. The objectives of this multicenter study were (1) to determine the survival rate after heart transplantation for patients with Chagas' heart disease (ChHD) in comparison with other causes; and (2) to identify the causes of death specifically due to reactivation of the Trypanosoma cruzi infection.

METHODS

We studied 720 patients who had undergone orthotopic heart transplantation and were followed in 16 heart transplantation centers. The etiology was idiopathic dilated cardiomyopathy in 407 patients, ischemic cardiomyopathy in 196 patients, and ChHD in 117 patients.

RESULTS

Follow-up was 2.87 +/- 3.05 years (from 1 month to 13.85 years). Survival of ischemic recipients at 1, 4, 8, and 12 years was 59%, 44%, 34%, and 22%, respectively; for idiopathic dilated cardiomyopathy it was 69%, 57%, 40%, and 32%; and for ChHD it was 71%, 57%, 55%, and 46% (p < 0.027). In ischemic recipients the most frequent causes of death were infection (15.3%), acute graft failure (13.3%), and graft coronary artery disease/sudden death (7.7%). In idiopathic dilated cardiomyopathy the causes were infection (11.1%), rejection (9.6%), and acute graft failure (9.1%). In ChHD the causes were infection (10.3%), rejection (10.3%), and neoplasm (4.3%). In ChHD, reactivation of the cruzi infection was the cause of death in 2 patients.

CONCLUSIONS

The survival results after heart transplantation are paradoxical according to the usually high expected death rates for Chagas' disease. Heart transplantation for ChHD should be regarded as a valuable treatment option.

The Brazilian experience with heart transplantation: a multicenter report

BACKGROUND

The results of heart transplantation in developing countries are influenced by the high incidence of marginal donors and the large number of recipients with characteristics of alternative list. The purpose of this multicenter report was to determine the rate of survival after heart transplantation in a developing country. Also we studied the causes of death, the results based on the year of transplant, the influence of gender and age, the numbers of transplants per year, and the etiology of the cardiomyopathy causing the heart failure.

METHODS

We studied 792 (632 male) patients who underwent orthotopic heart transplantation at 16 centers. The mean age of the patients was 42 +/- 16 years. Etiology included idiopathic dilated cardiomyopathy in 407 patients, ischemia in 196 patients, Chagas disease in 117 patients, and various other in 72 patients. Cyclosporine was the cornerstone of the immunosuppression administered.

RESULTS

Survival for the entire population at 3 months and 1, 4, 8, and 12 years was 72%, 66%, 54%, 40%, and 27%, respectively. There was an improvement in survival from 1991 to 1995 compared with before 1991. Age and gender did not influence the results. Unexpected early mortality was observed, but the late results were satisfactory. The most prevalent causes of death were infection in 23%, acute graft failure in 19%, and rejection in 18%.

CONCLUSIONS

Heart transplantation has become feasible in developing countries and the survival rate has improved without the influence of gender and age recipients. A chagasic etiology was found to be the third-leading indication for heart transplantation. The impact of increment of donors with appropriate care for reduction of marginal donors, perhaps associated with better recipient selection and postoperative care, should be investigated for improving early results.

Techniques in orthotopic cardiac transplantation: a review

Cardiac transplantation currently is the most effective therapy for end-stage heart failure. Since the origination of the standard biatrial technique, alternative methods such as the bicaval and "total" techniques have been devised with the hope of improving postoperative physiologic and clinical parameters. In general, the newer techniques are at least as effective as the original technique with respect to arrhythmia, valvular function, hemodynamics, exercise capacity, and survival, but whether any one technique offers clear benefits over another has been controversial. The bicaval technique is most commonly used today, and the general consensus is that this technique ultimately will demonstrate clinical superiority.

Evaluation of early postoperative results after bicaval versus standard cardiac transplantation and review of the literature

OBJECTIVE

Previous studies have been inconsistent in defining a clinical benefit to the bicaval cardiac transplantation technique relative to the standard technique, and many major centers have not adopted this newer approach. The purpose of this study was to determine whether clinically significant benefits support utilization of the bicaval technique.

METHODS

Sixty-eight consecutive adult patients undergoing a standard cardiac transplant were compared with 75 consecutive patients who underwent the bicaval technique during the period from 1991 to 1999. Etiology, recipient sex, recipient age, donor age, and pulmonary vascular resistance were similar between the two groups.

RESULTS

Cardiac index at 24 hours after operation was increased for the bicaval group relative to the standard group (3.15 +/- 0.7 vs 2.7 +/- 0.5 L/min/m(2), P <. 05). Inotropic requirements were significantly less, and there was significantly less tricuspid regurgitation in the bicaval group relative to the standard group. In addition, the bicaval group more frequently had a nonpaced normal sinus rhythm at 24 hours after operation (73.9% vs 50.7% [standard group], P =.025) and had fewer postoperative arrhythmias (29.3% vs 47.7% [standard group], P <.01). Finally, although mortality was similar for the two groups, length of postoperative hospitalization was longer for the standard group relative to the bicaval group (12.1 +/- 11 vs 20.4 +/- 12 days, P <. 001). Review of the literature identified reduced tricuspid regurgitation and improved rhythm as consistent benefits of the bicaval technique.

CONCLUSION

This review demonstrates a clinical benefit during the early postoperative period with bicaval cardiac transplantation (relative to standard) and encourages further utilization of this technique.

Orthotopic heart transplantation: standard versus bicaval technique

We compared orthotopic heart transplantation (HT) by bicaval technique with the standard technique. Between January 1995 and December 1997, 117 patients underwent 118 HTs; 71 patients (15 women and 56 men) had 72 HTs by standard technique and 46 patients (9 women, 37 men) underwent HT using bicaval procedures. Preoperative parameters were similar in both groups; 5 patients who underwent the standard technique and no patients who underwent bicaval procedures required permanent pacemakers (p = NS). Isoproterenol infusion was significantly longer in the standard technique. Major perioperative arrhythmias (ventricular tachycardia and fibrillation, asystole) appeared in 8.2% and 7.0% of standard and bicaval HTs, respectively; atrial fibrillation appeared in 13.1% and 4.6%, respectively (p = NS). At 1 month, mitral and tricuspid regurgitation rates were higher in the standard group (p = NS); at 1 year only tricuspid regurgitation was still higher (p = NS). Right atrial pressure, Wood units, cardiac output, and cardiac index were examined (p = NS). At multivariate analysis, interaction between preoperative Wood units and transplant type was elicited for Wood units at 1 month and for right atrial pressure at 1, 3, and 6 months. In the high resistance subgroup, the patients who underwent bicaval procedures had higher resistances at 1 month. In the low resistance subgroup, right atrial pressure was higher in patients who underwent standard techniques at 1, 3, and 6 months follow-up. Thus, bicaval HT was found to be safe, without surgically related complications, it provoked significantly less blood loss, and required less isoproterenol use. No significant advantages were observed in conduction disturbances and major arrhythmias or regarding the need for temporary or permanent pacemakers.

Cardiac pacemakers in the transplanted heart: short term with the biatrial anastomosis and unnecessary with the bicaval anastomosis

Sinus node dysfunction occurs commonly after orthotopic heart transplantation and may be caused by surgical trauma, ischemia to the sinus node, rejection, drug therapy and increasing donor age. In the past, using the standard biatrial technique described originally by Lower and Shumway, many series have reported permanent pacing in more than 10% of patients. Unlike sinus node dysfunction in nontransplanted patients, which typically worsens with time, sinus node dysfunction in the transplanted heart usually improves over a period of weeks to months. Delaying the implantation of a permanent pacemaker may render it unnecessary. The development of the bicaval technique for implantation of the donor heart appears to have decreased even further or even eliminated the need for early permanent pacing. Because sinus node dysfunction in the transplanted heart does not predict subsequent development of atrioventricular (AV) node dysfunction, rate-responsive atrial pacing should be used in the majority of cases. Even after appropriate pacing for sinus node dysfunction, the sinus node may recover and permanent pacing may be discontinued. AV conduction abnormalities are far less common and generally occur late after transplantation. Dual-chamber pacing is required and permanent pacing should be continued indefinitely.

Surgical approaches to dilated cardiomyopathy

Heart failure is one of the leading causes of hospitalization in the United States today. Congestive heart failure is a chronic progressive disease with the common central element being the remodeling of the cardiac chamber associated with ventricular dilation. Secondary mitral regurgitation is a complication of end-stage cardiomyopathy and is associated with a poor prognosis. Historically, these patients were not considered operative candidates due to the high morbidity and mortality in this patient population. Heart transplantation is now considered the standard of treatment for select patients with end-stage heart disease, however, it is only applicable to a small number of patients. In an effort to address this problem, newer and alternative surgical approaches are evolving, including mitral valve annuloplasty, the Batista myoplasty, and cardiomyoplasty. When these operative techniques that alter the shape of the left ventricle are utilized, in combination with optimal medical management for heart failure, survival is improved and patients can avoid or postpone transplantation.