Orthotopic cardiac transplantation: A comparison of standard and bicaval Wythenshawe techniques

AbstractWe describe an alternative technique for orthotopic cardiac transplantation (bicaval Wythenshawe technique), which maintains the right and left atrial anatomy. We compared the new bicaval technique with the conventional (Lower and Shumway) technique of orthotopic cardiac transplantation to identify any beneficial physiologic and clinical outcomes resulting from maintaining the normal anatomy. Seventy-five patients were randomized on an alternate basis to two groups: group A ( n = 40) had orthotopic cardiac transplantation with the bicaval technique and group B ( n = 35) had conventional orthotopic heart transplantation. All patients were studied with transthoracic echocardiogram, endomyocardial biopsies, and measurement of intracardiac pressures 1, 4, and 12 weeks after transplantation. There were no statistically significant differences in the demographic profile, ischemic time, bypass time, implantation time, transpulmonary gradient, or pulmonary vascular resistance between the two groups. The hemodynamic data were collected in the absence of histologic signs of rejection. In group A right atrial pressure (mean 3.6 mm Hg) was significantly lower ( p < 0.03) than in group B (mean 8.8 mm Hg). The right atrial a wave was recorded in 38 patients in group A compared with seven patients in group B ( p = 0.041). Atrial tachyarrhythmias occurred in two patients in group A compared with 11 in group B ( p < 0.016). Temporary pacing was required in 10 patients in group A and 16 patients in group B ( p = 0.034). Four cases of mitral regurgitation (all mild) were detected in group A in comparison with 12 cases (10 mild, 2 severe) in group B ( p = 0.008). The mean ejection fraction in the first week after transplantation was 58% in group A and 46% in group B ( p = 0.5). In the first 3 months the need for diuretics was less in group A (mean dose 80.8 mg furosemide daily) than in group B (mean dose 134 mg furosemide daily in the first week increasing to 160 mg furosemide daily). Hospital stay was shorter in group A (mean 23 days) than in group B (mean 27 days) ( p < 0.015). There were no early deaths as a result of right ventricular failure in group A ( n = 0/40) compared with four ( n = 4/35; 9%) in group B ( p < 0.034). This difference suggests that bicaval orthotopic cardiac implantation is associated with a lower right atrial pressure, a lower likelihood of atrial tachyarrhythmias, less need for pacing, less mitral incompetence, a lower diuretic dose, and a shorter hospital stay. Early mortality from right ventricular failure is significantly lower in this group, which may be the result of improved right ventricular function owing to effective atrial function. (J THORAC CARDIOVASC SURG 1995;109:721-30