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Orthotopic Heart Transplant Using Bicaval Technique Part 2: Implantation of Donor Heart

Wednesday, March 8, 2023

Ohira S, Spielvogel D, Kai M. Orthotopic Heart Transplant Using Bicaval Technique Part 2: Implantation of Donor Heart. March 2023. doi:10.25373/ctsnet.22232908.v1



After the donor heart arrives (see Orthotopic Heart Transplant Using Bicaval Technique Part 1: Recipient Cardiectomy for that procedure), additional cardioplegia is given. The anatomy, such as the patent foramen ovale, is inspected before implantation.

Left atrial (LA) anastomosis using 3-0 MH needle starts at the level of the left upper pulmonary vein of the donor, outside-in. A second stich is passed through the level of the left atrial appendage of the recipient, inside-out. The third stich is placed in the recipient LA, outside-in, toward the caudal. After five stitches, three stitches on the recipient and two on the donor heart, the heart is parachuted down to the pericardial space. The posterior LA suture line is first completed to the inferior vena cava (IVC) level. The LV vent is advanced to the LV through the mitral valve. The other side of 3-0 suture is then used to complete the anterior LA suture line, including the atrial septum of the recipient.

Next, IVC anastomosis is performed after releasing the snare of the IVC. It is important to make sure the IVC cannula inserted from the femoral vein is placed right next to the IVC orifice of the recipient. In addition, reverse Trendelenburg position helps venous drainage through the IVC cannula. IVC anastomosis starts from the far side of the donor IVC, outside-in using 4-0 SH needle, and then to the recipient’s IVC, inside-out. The posterior wall of the IVC is then completed.

Next, both donor and recipient pulmonary artery (PA) are trimmed as short as possible to prevent kinking. A running 4-0 RB suture is used. Anastomosis is then completed in the same way as the IVC. After completion of a bottom half of PA anastomosis, attention is moved to the SVC of the donor, which is trimmed below the level of the azygos vein. A PA catheter is passed through the donor SVC to the opening of IVC anastomosis. A PA catheter is then guided to the right PA using a big C-shaped clamp, which is passed through the PA anastomosis, pulmonic valve, tricuspid valve, and IVC anastomosis. The anterior wall of PA anastomosis is completed.

The ascending aorta is then trimmed to adjust the length. Care is taken not to make it too short, which can cause bleeding from unexpected tension of anastomosis. Aortic anastomosis is performed using a running 4-0 RB suture using the same technique used in IVC and PA. After completion of aortic anastomosis, warm blood is administrated from the LV vent for de-airing (400 cc/min). After the aortic cross-clamp is removed, the suture is tied. 

The total ischemic time of the donor heart was 179 minutes, and warm ischemic time at the hospital was 32 minutes, respectively. Next, the rest of IVC anastomosis is completed while the donor heart is being perfused. When the heart starts beating, the LV vent is removed.

Finally, SVC anastomosis is performed using 4-0 RB suture. This is paramount to avoid kinking, and care is taken not to cause a purse string effect. Epicardial pacing wires are placed. Hemostasis and separating from cardiopulmonary bypass are performed in a routine fashion.

Make sure to complete your knowledge with Orthotopic Heart Transplant Using Bicaval Technique Part 1: Recipient Cardiectomy.


  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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