Asian Cardiovasc Thorac Ann 2005;13:251-254
© 2005 Asia Publishing EXchange Ltd
Bicaval Anastomosis Reduces Tricuspid Regurgitation after Heart Transplantation
Kook-Yang Park, MD,
Chul-Hyun Park, MD,
Yang-Bin Chun, MD,
Mi-Seung Shin, MD,
Kyung-Chun Lee, MD
Gil Heart Center, Gachon Medical School, Inchon, South Korea
For reprint information contact: Kook-Yang Park, MD Tel: 82 32 460 3675 Fax: 82 32 232 0439 Email: kkyypark{at}ghil.com, Gil Heart Center, 1198 Kuwol-dong, Namdong-ku, Inchon 405-760, South Korea.
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ABSTRACT
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The standard surgical technique utilizing two atrial cuff anastomoses has been used in the majority of transplant centers until recently when bicaval anastomoses was introduced. The purpose of this study was to compare the prevalence of tricuspid regurgitation after the bicaval and standard techniques of anastomosis. Heart transplantation was performed in 43 patients at our institution from April 1994 to December 2003: 15 by the standard technique (group A) and 28 by the bicaval technique (group B). No differences in pre-transplant diagnosis, donor age, immunosuppression, rejection treatment, or graft ischemic time were evident between the two groups. The prevalence of tricuspid regurgitation ( 
moderate) was higher after the standard technique (36.4% vs. 10.5%; p < 0.05). Survival rates at 1 and 3 years in group A were 87% and 55%, and 86% and 78% in group B, with a significant difference in the 3-year mortality. The bicaval anastomosis technique was found to be associated with a lower incidence of tricuspid regurgitation during the late postoperative period, and should be preferred for heart transplantation.
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INTRODUCTION
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The standard surgical technique of orthotopic heart transplantation (OHT) was that described by Lower and Shumway1 in 1960, until the method of separate caval anastomoses was introduced in the mid 1990s.2 The standard technique is reported to have a significant number of complications related to loss of atrial integrity, such as tricuspid regurgitation (TR) and right atrial enlargement.3 TR is the most common valvular abnormality after OHT. A variety of causes have been implicated, including asynchronous contraction of the donor and recipient atrial compartments, disturbed geometry of the right atrial anastomosis with subsequent impairment of the functional integrity of the valvular apparatus, and damage to the subvalvular apparatus during endomyocardial biopsy.4–6 The purpose of this study was to compare two consecutive series of heart transplant recipients who underwent surgery at our center, in relation to TR and the atrial anastomosis technique.
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PATIENTS AND METHODS
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From 1994 to 2003, 43 cardiac transplantations were performed at our center. The initial 15 patients underwent OHT using the standard technique originally described by Lower and Shumway.1 The bicaval technique was introduced in 1996 and has been used exclusively since. Preoperative characteristics were retrospectively acquired from hospital records and included donor age, recipient age, recipient sex, recipient weight, preoperative diagnosis, graft ischemic time, preoperative pulmonary pressure, rejection episodes, preoperative ejection fraction, and preoperative New York Heart Association functional class. Echocardiographic studies were performed in patients who survived more than one year, and the results of the two groups were compared: 13 had the standard technique, group A; and 25 had the bicaval technique, group B. All patients were free from rejection and in sinus rhythm when studied.
For the bicaval technique, cardiopulmonary bypass was initiated by means of cannulas placed in both venae cavae and the ascending aorta. The bypass circuit included a DeBakey roller pump (Sarns, Inc., Ann Arbor, MI, USA) and a Capiox SX 18 membrane oxygenator (Terumo Cardiovascular Systems, Ann Arbor, MI, USA). The prime consisted of 1 L of Plasma Solution A (CJ, Seoul, Korea) and 300 to 500 mL of 10% pentastarch. Core temperature was maintained between 26°C and 28°C. The right atrium of the recipient was excised, leaving a generous length of each cavae. Most of the left atrial wall was resected, leaving only the atrial roof in situ, contrary to the standard technique where the atrial septum, as well as a large remnant of the recipient atrial mass, is left behind. All donor hearts were arrested using cold University of Wisconsin solution (20 mL·kg–1) and stored in saline at 4°C for transportation. The donor heart was excised with an intact right atrium and long venae cavae. The donor left atrium was sutured to the recipient left atrium with a continuous 4/0 Prolene suture (Ethicon, Sommerville, NJ, USA) in the usual fashion. The posterior two thirds of the pulmonary artery anastomosis were completed with the same suture material, leaving the anterior one third open for de-airing. Aortic anastomosis was performed with a single over-and-over suture technique, followed by release of the crossclamp. While the heart was rewarming, the donor inferior vena cava was sutured to the recipient’s inferior vena cava with a continuous 5/0 Prolene suture. The superior vena caval anastomosis was completed in the same fashion. The anterior one third of the pulmonary artery was then sutured on de-airing of the right heart. Two atrial and 2 ventricular temporary myocardial pacemaker leads were placed in the usual manner.
Immunosuppression was based on cyclosporine, azathioprine, steroids, and a 3-day course of rabbit antithymocyte globulin therapy. The cyclosporine dose was adjusted to a target whole blood trough level between 200 and 300 ng·mL–1 (using the whole blood monoclonal fluorescence polarization immunoassay) for the first month, and then slowly reduced to a maintenance level of 100–150 ng·mL–1. Rejection was monitored by regular endomyocardial biopsies, and rejection episodes of grade 3A or higher (according to the classification of the International Society of Heart Lung Transplantation) were treated with pulsed doses of methylprednisolone or a variety of other agents (methotrexate, cytolytic therapy, or plasmapheresis), depending on the histologic grade and hemodynamic consequences.7 In patients with graft dysfunction without any evidence of cellular rejection, methotrexate was administered. Since the introduction of mycophenolate mofetil (CellCept; Roche, Nutley, NJ, USA) to Korea, azathioprine has been replaced by CellCept in all patients. Endomyocardial biopsies were performed routinely once a week for the first month, twice a month until 3 months, once a month until 6 months, and once a year thereafter. The jugular or femoral vein was used for catheter introduction. The number of biopsies was the same in both groups.
Patients routinely underwent echocardiographic studies on the same schedule as endomyocardial biopsy. The degree of TR was graded according to the ratio of the maximum area of the regurgitant jet to the right atrial area, as described previously.8 A regurgitation jet area/atrial area of < 10% was considered trivial TR, 10–24% was mild TR, 25–49% was moderate TR, and severe TR was 50%. The echocardiographic data obtained at the latest follow-up, at least 1 year after transplantation, were analyzed. An experienced echocardiographer performed each study as part of the routine evaluation. Transthoracic and transesophageal echocardiography were carried out using a VIVID 7 echocardiograph (General Electric Medical Systems, Horten, Norway) equipped with a Matrix 3 Sector probe with a range of 1.5 to 3.6 MHz. All patients underwent echocardiography while in the left lateral decubitus position in quiet respiration. The tricuspid valve was examined in the parasternal short-axis and apical 4-chamber views. Color-flow Doppler examinations were accomplished with the sector angle as narrow as possible to maximize the imaging frame rate. Assessment of TR was semiquantitative and relied on combined findings from continuous-wave and color-flow Doppler mapping. Transthoracic echocardiography enabled measurement of the right atrial diameter and grading of TR. If the echocardiography window was not adequate for evaluation, transesophageal echocardiography was used to confirm the measurements.
All statistical analyses were performed using SPSS software for Windows, version 11.5 (SPSS, Inc., Chicago, IL, USA). The Pearson chi-squared test was used for comparisons between the two groups. A p value < 0.05 was considered significant. A cumulative survival curve was computed according to the Kaplan-Meier method, and comparison between groups was performed using the log-rank test. All values are expressed as mean ± standard deviation. Fisher’s exact test was used to compare groups when appropriate. A p value 
0.05 was considered statistically significant.
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RESULTS
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No statistical differences were observed between the two groups in terms of donor age, recipient weight, graft ischemic time, preoperative pulmonary artery pressure, preoperative left ventricular ejection fraction, and number of rejection episodes, as shown in Table 1
. The most common etiology for heart failure in both groups was dilated cardiomyopathy. Recipient age was younger in group A ( p < 0.05). The grade of TR at the latest follow-up showed the prevalence of significant TR (moderate or severe) was higher in group A than group B (Table 1). Survival rates at 1 and 3 years in group A were 87% and 55% vs. 86% and 78% in group B, with a significant difference in the 3-year mortality. Survival at 5 years after OHT was 38% in group A and 72% in group B. Kaplan-Meier survival curves showed a significantly better result for group A than group B (Figure 1).
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DISCUSSION
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The original OHT technique involved anastomosis of the two atria, which resulted in enlargement and alteration of the atrial geometry. This may have contributed to the development of various postoperative complications such as arrhythmia, TR, and ventricular dysfunction.6,9 The incidence of TR after OHT varies. The introduction of color Doppler echocardiography increased the sensitivity of detection of TR, and can demonstrate trivial degrees of TR in normal individuals in the general population, with a quoted prevalence of 17%.10 Following OHT, TR has been reported to be highly prevalent, especially in patients treated by the standard Lower and Shumway technique.11–12 Trivial or mild TR usually has a benign clinical course. However, a considerable degree of TR may cause intractable right heart failure and may contribute to early and late morbidity and mortality after heart transplantation.13 Two of our group A patients showed severe TR with signs of right heart failure; they died during follow-up.
A number of different etiologies were proposed to explain TR, including endomyocardial biopsy, cellular rejection, and altered right ventricular geometry.5,14 Moreover, a report from England showed a positive correlation between the prevalence of TR and the number of cellular rejection episodes.11 However, in our study, no significant relationship was found between rejection episodes and the degree of TR. The other possible explanation includes disturbed geometry of the right atrial anastomosis with subsequent impairment of the functional integrity of the valvular apparatus. Many authors have suggested that the conventional technique using atrial cuff anastomosis alters atrial geometry and causes TR, which was frequently observed after the operation.4 To avoid these complications due to conventional atrial anastomoses, alternative surgical techniques have been proposed since the early 1990s by different groups.
In 1992, Kendall and colleagues15 described total OHT using bicaval and two pulmonary vein cuff anastomoses. This total OHT technique was reported to improve left heart function and reduce thromboembolism. Bouchart and colleagues16 showed a high incidence of left atrial spontaneous echo contrast and thrombi when using the standard technique, which was absent when the total OHT technique was used. el Gamel and colleagues2 devised a modified technique using a bicaval and single small recipient left atrial cuff technique. The basic idea was to retain normally shaped atria and reduce operation time. They also insisted that this technique retained normal atrial morphology, with the theoretical advantages of preserved synchronous atrial contractility, sinus node function, and improved atrioventricular valve competence. Several other reports have pointed out that the bicaval technique can reduce atrial complications with less atrial flutter and fibrillation.17 Other reported advantages include improved survival, maintenance of right atrial size, and improved cardiovascular dynamics and dimensions.4,18 A recent survey showed that this technique is currently the most frequently used.19 Others have defined the advantages of the bicaval technique over the conventional technique in terms of postoperative hemodynamic results.20
In our study, a statistically significant difference in TR and survival rate was found between the two groups. However, we believe that it is too early to determine whether survival is improved by the technique because the number of patients in our study was limited and they were not randomized. Moreover, all of the patients who received the standard technique underwent OHT during the initial learning period at our center. The recipient age was younger in group A. As experience accumulated, the age of the recipient naturally increased. However, we do not attribute this to the difference in TR rate and mortality. We believe that preservation of the integrity of the donor right atrium by bicaval anastomoses results in a significantly reduced incidence of tricuspid regurgitation after orthotopic heart transplantation, compared to the standard technique. The bicaval technique should be preferred for heart transplantation.
Presented at the 12th Annual Meeting of the Asian Society for Cardiovascular Surgery, April 21–23, 2004, Istanbul, Turkey.
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REFERENCES
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- el Gamel A, Yonan NA, Grant S, Deiraniya AK, Rahman AN, Sarsam MA, et al. Orthotopic cardiac transplantation: a comparison of standard and bicaval Wythenshawe techniques. J Thorac Cardiovasc Surg 1995;109:721–30.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
