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J Thorac Cardiovasc Surg 1996;112:1667-1669
© 1996 Mosby, Inc.
BRIEF COMMUNICATIONS |
Bern, Switzerland
Paul Mohacsi supported by a grant from the Swiss National Research Foundation (grant No. 31-39695.1).
Received for publication Feb. 13, 1996 Accepted for publication March 25, 1996.
Orthotopic cardiac transplantation is the treatment of choice for patients with end-stage heart failure. The operative technique used at most transplantation centers was developed in the early 1960s by Lower and Shumway
1 with a canine model. This original technique includes two atrial anastomoses and anastomosis of the aorta and pulmonary artery. Main advantages of this classical procedure are its simplicity, short operative time, and low prevalence of perioperative and postoperative technical complications.
Mild to moderate regurgitation of the atrioventricular valves (mainly of the tricuspid valve and to a lesser degree of the mitral valve), however, is a common postoperative clinical and echocardiographic finding. These morphologic and functional changes of the normal donor heart are thought to occur because of a postoperative modification in the atrial geometry. Moreover, the technique of biatrial anastomoses seems to increase the occurrence of sinus node dysfunction. 2
To prevent these potential complications, an alternative technique with bicaval anastomoses rather than the right atrial suture was recently reintroduced by several groups performing for transplantation. This technical refinement was originally described by Webb and colleagues 3 in 1959. The anatomic geometry and the sinus node function seem to be better preserved, but this technique can lead to significant stenosis of the venous anastomoses even when an interrupted suture technique is used. This report discusses the case of a patient with a severe stenosis of the superior vena cava (SVC) 2 weeks after heart transplantation. The condition was treated successfully with percutaneous balloon angioplasty.
Cardiac transplantation was performed in a 52-year-old white man because of end-stage dilated cardiomyopathy. Instead of biatrial anastomoses, separate SVC and inferior vena caval anastomoses were performed with interrupted 4.0 polypropylene sutures. A caliber mismatch between the donor and recipient SVCs was noted, with the recipient's SVC three times as large as the donor's SVC. After operation, immediate sinus rhythm was present and no significant atrioventricular regurgitation was demonstrated.
The postoperative course was uneventful, with the exception of cellular rejection (ISHLT 3 A) on postoperative day 14, which was successfully treated with corticosteroids. An endomyocardial biopsy sample was difficult to obtain, however, because it was nearly impossible to introduce a guide wire through the SVC into the right atrium. After several attempts, successful introduction of a 6F catheter revealed a pressure gradient of 10 mm Hg across the stenosis (Fig. 1). The tight stenosis was confirmed by SVC angiography, and it was decided to use percutaneous angioplasty to dilate the anastomosis at the SVC level.
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2,4-6 Despite some potential morphologic and functional advantages, the technique of bicaval anastomosis may lead to a stenosis of the vena cava at the level of the suture. This problem may be emphasized by a difference in caliber between the donor and recipient veins and also by the purse-string effect caused by use of a continuous suture technique. The interrupted suture technique (running suture of the posterior wall and interrupted stiches of the anterior wall) may partially reduce the prevalence of significant stenosis of the vena caval anastomosis. Because of the larger caliber of the inferior vena cava, this complication has not been described at that location.
Although our patient did not have clinical signs of upper venous congestion, the bicaval anastomosis was stenosed enough to cause a significant pressure gradient and difficulties in obtaining endomyocardial biopsy samples. Because of the favorable appearance of the stenosis, it was decided to perform percutaneous transvenous angioplasty even though the risk of a balloon intervention seemed higher early after heart transplantation.
This procedure avoided a second operation and allowed us to obtain an immediate decrease in the pressure gradient and an easier passage through the SVC to the right heart cavities. Furthermore, the excellent follow-up results after balloon angioplasty in this case demonstrate the feasibility and safety of this procedure, even early after transplantation. Angiographic assessment and pressure gradient measurements at 1 week and at 3 months revealed no recurrent stenosis, and endomyocardial biopsies are actually easy to perform. An alternative to angioplasty would have been the repair of the anastomosis with a temporary shunt between the cranial part of the SVC and the right atrium.
Orthotopic cardiac transplantation with bicaval anastomoses represents an attractive alternative to the conventional technique. Even when interrupted suture lines are used, however, the bicaval anastomotic technique may occasionally lead to stenoses of the vena cava, which may necessitate operative treatment. For these patients, percutaneous balloon angioplasty represents an attractive treatment alternative. In the case of a significant caliber mismatch between the donor and recipient SVCs, a classic biatrial anastomosis should be considered.
Footnotes
From the Department of Cardiologya and Clinic for Thoracic and Cardiovascular Surgery,b University Hospital, Bern, Switzerland. 
J THORAC CARDIOVASC SURG 1996;112:1667-9
References
This article has been cited by other articles:
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  G. Santise, G. D'Ancona, R. Baglini, and M. Pilato Hybrid treatment of inferior vena cava obstruction after orthotopic heart transplantation Interact CardioVasc Thorac Surg, December 1, 2010; 11(6): 817 - 819. [Abstract] [Full Text] [PDF]
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 N. B. Tsilimingas Modification of bicaval anastomosis: an alternative technique for orthotopic cardiac transplantation Ann. Thorac. Surg., April 1, 2003; 75(4): 1333 - 1334. [Abstract] [Full Text] [PDF]
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 D. Y. Sze, R. C. Robbins, C. P. Semba, M. K. Razavi, and M. D. Dake Superior vena cava syndrome after heart transplantation: percutaneous treatment of a complication of bicaval anastomoses J. Thorac. Cardiovasc. Surg., August 1, 1998; 116(2): 253 - 257. [Abstract] [Full Text] [PDF]
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V. Doring and P. Marcsek Atrial Flap Anastomosis: An Alternative Technique for Orthotopic Heart Transplantation Ann. Thorac. Surg., April 1, 1998; 65(4): 1163 - 1164. [Abstract] [Full Text] [PDF]
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