Surgical technique for heart transplantation: a strategy for congenital heart disease

Abstract

The standard techniques for orthotopic heart transplantation often require certain adjustments when the procedure is carried out for complex congenital heart disease. This is because of both the unusual anatomy and possible distortions caused by previous surgery. Such technical adjustments have been described in various published reports over the years. Those reports, when combined, do cover the full spectrum of the technical difficulties that may be encountered, whether the defects are in their original form or altered by surgery, such that no cardiac malformation or distortion would prohibit transplantation. However, those reports are comprehensive only when combined. None of the individual reports addresses all the possible technical challenges. Consequently, the available information is somewhat fragmented. In addition, the generic aspect of the described technical strategies is not always given the emphasis that it deserves. Indeed, occasionally a technique may be presented as a specific solution for a specific malformation, without necessarily pointing out that the same technique may be applied to other hearts with different overall pathologies but which share that specific malformation. The aim of this review article was to combine all the available published information in one article in a manner that constructs a simple but comprehensive and generic system of decision-making that may be applied to any heart in order to determine the exact technical adjustments needed for transplantation in each case. Such a strategy is possible for two reasons. First, only a few anatomical sites are technically significant, namely the points of anastomosis between the donor's organ and the recipient. The rest of the intracardiac morphology does not affect the operation and may be ignored. Second, each of those anatomical sites can present difficulties in only a few ways, and each of those few difficulties has a well-described and published solution already. Therefore, the exact technical adjustments required in each case may be worked out by the sequential assessment of the anastomotic sites alone.

Superior vena cava obstruction after heart transplantation

“…1 In the early 1960s, the classic technique for heart transplantation was developed, but another technique (bicaval anastomosis) was developed at nearly the same time. 2 Currently, bicaval anastomosis is frequently used because of its hemodynamic benefits due to the fact that sinus node function seems to be better preserved. 3 However, it can have some complications such as vena caval anastomotic stenosis or strictures, which may lead to superior vena cava (SVC) syndrome.…”

Two hearts beating out of time: Mapping and ablation of concurrent atrial fibrillation and macroreentrant left atrial flutter in a transplanted heart

“…3 More classically, an anastomosis may be made within the RA rather than at the vena cavae, whilst other adjustments may need to be made to account for distortions present as a result of previous cardiac surgery or congenital abnormalities. 4 It can therefore be a challenge to interpret the initial information being gained during mapping if the full details of the surgical technique previously used are not known.…”

Orthotopic heart transplantation with persistent left superior vena cava draining into coronary sinus: the anterior rerouting technique

“…A number of investigators have reported several surgical techniques for reconstructions of PLSVCs in patients undergoing OHT (Table 2) (Fig. 4) [3][4][5][6][7][8][9][10][11][12][13]. The interposition technique uses a synthetic graft to repair the PLSVC (Fig.…”

“…Also, donor's en-bloc innominate veins can be used for a reconstruction of the PLSVC to avoid the use of a synthetic graft (Fig. 4c) [5,6]. Using donor's innominate veins is a simple technique because the technique does not require dissection of PLSVC from the atrioventricular groove.…”