Orthotopic Heart Transplant Using Bicaval Technique Part 1: Recipient Cardiectomy

To begin the cardiectomy, the sternum is opened in a standard full sternotomy. The ascending aorta, superior vena cava (SVC) and inferior vena cava (IVC) are isolated and umbilical tape snares are passed around them.

After heparin administration, the ascending aorta is cannulated using a 20 Fr cannula as distal as possible, as is SVC using a 22 Fr cannula. The femoral vein is percutaneously cannulated using a long 23/25 Fr venous cannula. Carbon dioxide is flowed continuously in the pericardial cavity to reduce the risk of air embolism. 

Next, the recipient’s aorta is cross-clamped. A pediatric left ventricular vent is inserted via the right upper pulmonary vein. Both SVC and IVC are snared and the right atrium is opened along the atrioventricular groove to the coronary sinus. A pulmonary artery catheter is pulled out through this incision for later insertion. The implantable cardioverter-defibrillator (ICD) or permanent pacing leads in the right side of the heart are cut as necessary. The ascending aorta is transected above the sinotubular junction. Similarly, the main pulmonary is transected at the commissure level. Next, a 10-blade with a long holder is used to incise the doom of the left atrium, which is extended to the atrial septum, and coronary sinus leaving the donor atrial septal wall.

The posterior left atrial incision, between the left atrial appendage and left pulmonary veins, is then competed by connecting the initial atrial incision to the orifice of the coronary sinus along the atrioventricular groove. The IVC cuff is created followed by the SVC cuff. Then, the lateral side of the right atrium is resected. The raw surface of the right atrial wall from excision is sutured by a running 3-0 MH polypropylene to secure hemostasis. The patent foramen ovale of the recipient is closed as necessary.

For the next stage of this transplantation, read  “Orthotopic Heart Transplant Using Bicaval Technique Part II: Implantation of Donor Heart.”
 

References

1. John, R and Liao, K. Orthotopic Heart Transplantation. Operative Techniques in Thoracic and Cardiovascular Surgery. 2010;15(2):138-146.

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