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J Thorac Cardiovasc Surg 1995;109:1258-1259
© 1995 Mosby, Inc.

LETTERS TO THE EDITOR

The clinical benefit of the bicaval technique for cardiac transplantation

Klinik für Herzchirurgie
Medizinische Universität zu Lübeck
Lubeck, Germany

Reply to the Editor:

Dr. El Gamel and associates ¹ should be complimented for expanding the knowledge of the alternative bicaval technique for cardiac transplantation. Their results conform mostly with ours in that the shape of the atria is normal and the incidence of tricuspid valve regurgitation is lower in the bicaval group when compared with the standard method. ² Furthermore, they observed normal right atrial function in these patients and a lower mean right atrial pressure at rest, which was observed in our patients only during exercise. In addition, tricuspid valve regurgitation was significantly less in our patients during exercise, which probably contributed to an increased exercise performance. ² We also entirely confirm the findings of Dr. El Gamel and associates concerning the lower incidence of tachyarrhythmias and bradyarrhythmias, especially during the immediate postoperative period. However, despite normal right atrial size and pressure, we were surprised to find significantly elevated concentrations of plasma atrial natriuretic peptides in the bicaval group, as was also observed in patients with standard anastomoses. ³

We agree that the alternative technique is both simpler and probably safer than total cardiac transplantation ⁴ because of the technically demanding and inaccessible pulmonary venous anastomoses. To circumvent these difficulties, we introduced the alternative technique first in 1989. ⁵ Increasing surgical experience, reperfusion, or blood cardioplegia after completion of the left atrial anastomosis, as suggested by Dr. El Gamel and associates, decreases the ischemic time to levels also required for standard anastomoses. Furthermore an atrial cuff around the superior vena cava ¹ may be advantageous especially in cases of a considerable mismatch between donor and recipient right atrial size.

In comparison with the standard method of cardiac transplantation, results with this alternative technique provide increasing evidence ^1,2,5,6 for an improvement of hemodynamics, atrioventricular valve function, cardiac rhythm, and probably right ventricular function. Studies of longer duration, especially on potential problems like thrombosis and stenosis at the site of the caval anastomoses, are desirable for final judgement of this alternative, more physiologic approach to cardiac transplantation.

12/8/63205

References

1. Sarsam MAI, Campbell CS, Yonan NA, Deiraniya A, Rahman AN. An alternative surgical technique in orthotopic cardiac transplantation. J Card Surg 1993;8:344-9.[Medline]
   
2. Sievers HH, Leyh R, Jahnke A, et al. Bicaval versus atrial anastomoses in cardiac transplantation: right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation. J THORAC CARDIOVASC SURG 1994;108:780-4.[Abstract/Free Full Text]
   
3. Singer DRJ, Buckley MG, Mac Gregor GA, Khaghani A, Banner NR, Yacoub MH. Raised concentrations of plasma atrial natriuretic peptides in cardiac transplant recipients. Br Med J 1986;293:1391-2.
   
4. Banner NR, Khaghani A, Fitzgerald M, Mitchell AG, Radley-Smith R, Yacoub MH. The expanding role of cardiac transplantation. In: Unger F, ed. Assisted circulation, 3rd ed. Berlin: Springer, 1989:449-67.
   
5. Sievers HH, Weyand M, Kraatz EG, Bernhard A. An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium. Thorac Cardiovasc Surg 1991;39:70-2.[Medline]
   
6. Blanche C, Czer LSC, Valenza M, Trento A. Alternative technique for orthotopic heart transplantation. Ann Thorac Surg 1994;57:765-7.[Abstract]
   

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