This video outlines the surgical technique of beating heart transplantation using the Organ Care System (OCS). It details the preparation of the donor heart, cannulation, and the steps involved in transferring the heart from the OCS to the recipient. 

Traditionally, donor hearts require two cardioplegic arrests: once during removal from the deceased donor and again when disconnected from the OCS. This technique allows the heart to remain beating after removal from the OCS, eliminating the need for a second stoppage. By maintaining continuous coronary perfusion, this method reduces ischemic injury and improves graft function, which, in turn, decreases the likelihood of requiring mechanical circulatory support postoperatively (1).  

Initial steps, including median sternotomy and cardiectomy of the recipient heart, were performed in the typical fashion, as in traditional heart transplantation. This patient also had a left ventricular assist device (LVAD) in place, which was removed during the procedure. 

The team then proceeded to prepare the donor heart for removal from the OCS. The donor heart was placed backward in the OCS, with the posterior aspect of the sternum facing the surgeon. The heart was rotated 180 degrees to facilitate aortic root cannulation. A 4-0 Prolene purse-string suture was placed as low as possible while avoiding the aortic root to ensure sufficient length for the anastomosis after cross-clamping. 

A standard cardioplegic cannula provided more than adequate flow to the coronaries during the beating-heart implantation. Once inserted, the cannula was secured with a silk tie and connected to the cardioplegia line of the circuit, using warm blood for this purpose. 

In preparation for cross-clamping, flow on the OCS was slowly titrated down while flow from the root cannula was titrated up. Once a flow rate of approximately 200 cc/min via the root cannula was reached, the aorta was cross-clamped, and the OCS was shut off. 

The heart was then quickly moved from the box to a basin so that any blood from the coronary sinus can be salvaged by cardiotomy suction. Once the heart was in the basin and on the field, all sutures and securing devices from the OCS were removed, and any additional blood from the coronary sinus was also salvaged. 

In this case, the aorta was a little short, so the clamp was placed more proximally to ensure an adequate cuff for sewing. This highlights the importance of placing the root cannula as proximally as possible on the native aorta. 

A sling made from a moistened laparotomy sponge was then placed over the inferior portion of the sternotomy incision. Resting the heart on this sling facilitated the left atrial anastomosis. 

Left atrial anastomosis proceeded in standard fashion, similar to an arrested heart transplant. The surgeons found it helpful to place as many sutures as possible with the heart suspended in the sling outside the chest, as it is easier to work this way than inside the thoracic cavity. The sling was then removed, and the heart was gently lowered into the pericardial well. Care was taken to avoid kinking the aorta, which could lead to aortic insufficiency. The anastomosis continued in standard fashion. 

It is vitally important to keep a cardiotomy sucker in the left atrium after completing this anastomosis, since there is no other way to vent the left side of the heart. Any aortic insufficiency (AI) will lead to left ventricular (LV) distension. 

Next, the aortic anastomosis was completed using a running 4-0 Prolene suture. The proximal cross-clamp was then removed, and the aorta was pressurized. At this point, the root vent was added, the aorta was deaired, and the cross-clamp was removed. The surgeons converted from retrograde cardioplegia to root vent, and the heart was thenfully reperfused. 

The remainder of the transplant proceeded in identical fashion to an arrested heart implantation. The pulmonary artery anastomosis was performed with running 5-0 Prolene, followed by the inferior vena cava (IVC) and superior vena cava (SVC) anastomoses. 

No additional reperfusion period is required when using the beating heart technique, as the heart is already contracting vigorously. Once the final anastomosis was complete, the team proceeded directly to weaning from cardiopulmonary bypass and ensuring hemostasis. 

References

1. Krishnan A, Ruaengsri C, Guenthart BA, Shudo Y, Wang H, Ma MR, MacArthur JW, Hiesinger W, Woo YJ. Beating Heart Transplant Procedures Using Organs From Donors With Circulatory Death. JAMA Netw Open. 2024 Mar 4;7(3):e241828. doi: 10.1001/jamanetworkopen.2024.1828. PMID: 38466306; PMCID: PMC10928498.

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