(Br HeartJ 1995;74:149-153) Keywords: bicaval atrial anastomosis; atrial arrhythmias; pacing; transplantation The standard surgical technique for implantation of the transplanted heart described by Lower et all involves excision of the recipient heart with division of the atrial septum, leaving cuffs of the right and left atrium and the great vessels to which the suitably trimmed donor heart is sutured. This technique is relatively simple and quick, and provides access to the anastomoses in cases of postoperative bleeding. It has the disadvantage that the atrial anatomy is distorted. Theoretical disadvantages of this distortion are that function of the tricuspid and mitral valves may be affected, as well as the atrial contribution to ventricular filling. Moreover the atrial surgery which involves substantial incision and suturing of the donor anterior right atrial wall has the potential to disturb the sinus node and produce an arrhythmogenic substrate. An alternative technique involving the use of a small left atrial cuff with anastomoses of the donor and recipient cavas has recently been described at this institution.2 We have compared our results using bicaval and standard anastomoses to determine the incidence of postoperative pacing and atrial arrhythmias. Patients and methods SURGICAL TECHNIQUE

Dopamine given at 'renal-dose' appears to offer no renal protection in patients with normal heart and kidney functions undergoing elective coronary surgery. On the contrary, it exacerbates the severity of renal tubular injury during the early postoperative period. Based on these findings we do not recommend the use of dopamine for routine renal prophylaxis in this group of patients.

No abstract

Exploring patients' narratives can lead to new understandings about perceived illness states. Intensive Care Unit delirium is when people experience transitory hallucinations, delusions or paranoia in the Intensive Care Unit and little is known about how this experience affects individuals who have had a heart or lung transplant. A total of 11 participants were recruited from two heart and lung transplant services and were invited to tell their story of transplant and Intensive Care Unit delirium. A narrative analysis was conducted and the findings were presented as a shared story. This shared story begins with death becoming prominent before the transplant: 'you live all the time with Mr Death on your shoulder'. Following the operation, death permeates all aspects of dream worlds, as dreams in intensive care 'tunes into the subconscious of your fears'. The next part of the shared story offers hope of restitution; however, this does not last as reality creeps in: 'I thought it was going to be like a miracle cure'. Finally, the restitution narrative is found to be insufficient and individuals differ in the extent to which they can achieve resolution. The societal discourse of a transplant being a 'gift', which gives life, leads to internalised responsibility for the 'success' or 'failure' of the transplant. Participants describe how their experiences impact their sense of self: 'a post-transplant person'. The clinical implications of these findings are discussed.