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Ann Thorac Surg 1995;59:1495-1500
© 1995 The Society of Thoracic Surgeons

Cardiovascular Dynamics and Dimensions After Bicaval and Standard Cardiac Transplantation

Department of Cardiovascular Surgery, University of Kiel, Kiel, Germany

Accepted for publication February 22, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Bicaval orthotopic cardiac transplantation leaving the right atrium intact has been introduced recently into clinical practice as an alternative to the standard method. To determine the effect of the surgical technique, 27 patients were studied at rest and supine exercise 19 ± 5 months after bicaval orthotopic cardiac transplantation (group A, n = 15) and 22 ± 7 months after standard orthotopic cardiac transplantation (group B, n = 12). Resting hemodynamics showed no difference between groups. With exercise, a significantly higher right atrial pressure was noted in group B. Echocardiographic analysis showed asynchronous right atrial contraction in 83% of group B patients versus none in group A. Resting right ventricular dimensions were significantly greater in group B (right ventricular end-diastolic diameter, 3.27 ± 0.44 cm versus 2.88 ± 0.35 cm [p < 0.05]; right ventricular end-diastolic area, 21.3 ± 2.85 cm² versus 17.1 ± 2.01 cm² [p < 0.005]). A higher incidence and significantly higher grade of tricuspid regurgitation were found throughout exercise in group B. The exercise duration (17.34 ± 3.53 minutes versus 14.04 ± 4.11 minutes [p < 0.05]) and the exercise capacity (1.17 ± 0.25 W/kg versus 0.93 ± 0.34 W/kg [p < 0.05]) were increased in group A. These data provide some evidence that the bicaval technique of cardiac transplantation improves cardiovascular dynamics and dimensions as well as exercise capacity.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Orthotopic cardiac transplantation is a well-established method for treatment of end-stage heart disease. Abnormal hemodynamic response during supine and upright exercise has been well documented in patients who have had cardiac transplantation [1–4]. Most orthotopic cardiac transplantations are performed according to the technique of Lower and Shumway [5]. Recently, two alternative techniques have been introduced into clinical practice, the total orthotopic transplantation using separate pulmonary and systemic venous anastomoses as first described by Banner and associates [6] and the bicaval technique with standard left atrial and separate bicaval anastomoses leaving the right atrial anatomy intact and thus theoretically resulting in improved cardiac function as first described in 1991 [7].

The influence of the surgical technique on hemodynamics, right atrial contraction pattern, right ventricular dimensions, tricuspid regurgitation at rest and exercise, and exercise capacity has not been evaluated in detail. Therefore, we studied 15 cardiac transplant recipients who received the donor organ by the bicaval technique and 12 cardiac recipients receiving the donor organ by the standard technique. The results in the two groups were compared.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patient Demographics
Hemodynamic data from 15 patients (group A: 14 male and 1 female with a mean age of 52.2 ± 10.3 years) who underwent orthothopic cardiac transplantation by the bicaval technique 19 ± 5 months prior to supine exercise studies were compared with those from 12 patients (group B: 10 male and 2 female with a mean age of 50.3 ± 10.4 years) recorded 22 ± 7 months after standard orthotopic cardiac transplantation. These were not select patients, and all survivors during the study period were included.

All patients in this study showed preserved left ventricular function at annual cardiac angiography and routine echocardiographic follow-up with no difference in resting left ventricular ejection fraction between the groups. No patient in either group had evidence of graft rejection that required modification of immunosuppressive therapy at the time of the study. Patients in group A experienced 1.0 ± 0.8 episode of rejection until the time of the study and those in group B, 1.2 ± 0.7 episodes (p > 0.05). Preoperative pulmonary vascular resistance index revealed no differences between the groups: 2.8 ± 0.9 Wood units in group A and 2.6 ± 1.1 Wood units in group B.

Total time of graft ischemia was significantly longer in group A (204.5 ± 40.1 minutes versus 159 ± 68.3 minutes [p < 0.05]). Donor age was similar in both groups: 35.8 ± 14.3 years in group A and 38.1 ± 10.6 years in group B.

Twelve patients in group A were treated for hypertension; 9 patients were on a regimen that combined diltiazem hydrochloride and diuretics, and the other 3 were on a regimen of diuretics only. Similarly, in group B, 9 patients were receiving antihypertensive treatment at the time of study; 6 were treated with diltiazem and diuretics, 1 patient received diltiazem, diuretics, and clonidine, and 2 patients were treated with diuretics only. All patients gave informed consent for routine myocardial biopsy and hemodynamic evaluation.

Surgical Technique
Standard cardiopulmonary bypass with a membrane oxygenator and a nasopharyngeal temperature of 24°C was used. The surgical technique has been described in detail elsewhere [7]. In brief, the inferior and superior venae cavae were cannulated as distally as possible. In the bicaval surgical technique, the recipient right atrium was excised so as to maintain the origin of the superior vena cava. The inferior vena cava was left with a 5-mm cuff of right atrial tissue. The left atrium was resected leaving a small posterior cuff of tissue including the ostia of the pulmonary veins. Implantation was started with the left atrial anastomosis, which was performed in a conventional fashion. The superior vena cava and the inferior vena cava as well as the great arteries were anastomosed in an end-to-end technique. Special surgical techniques to overcome size mismatches of the superior vena cava were not applied. In some cases, a small incision (up to 1 cm) in the right atrium of the donor provided a larger circumference for the inferior caval anastomosis.

The standard technique was performed as described by Lower and Shumway [5].

Immunosuppression
Perioperative immunosuppression consisted of methylprednisolone (single dose of 1,000 mg) after the declamping of the aorta. The immediate postoperative immunosuppression comprised (rabbit anti-hymocyte globulin) (100 mg/d) for the first 4 postoperative days, azathioprine (2 mg • kg^-1 • d^-1 according to the patient's white cell count), cyclosporine (maintenance level of 300 to 400 ng/mL by whole-blood monoclonal radioimmunoassay), and steroids, which were tapered after 6 weeks according to the biopsy results. At the time of the study, no patient was receiving steroids. Long-term immunosuppression was accomplished with a combination of cyclosporine and azathioprine. The cyclosporine dose was maintained at a plasma level of 150 to 200 ng/mL by whole-blood monoclonal radioimmunoassay. The dosage of azathioprine was 2 mg • kg^-1 • d^-1 and was adjusted to the patient's white cell count.

Hemodynamic Measurements
As part of the routine assessment after cardiac transplantation, right ventricular biopsy through the right internal jugular vein and right heart catheterization at rest and during supine exercise were performed. A right ventricular flow–directed pulmonary artery catheter (model 93A431H; American Edwards, Santa Ana, CA) with a fast-response thermostat and electrocardiographic sensor was inserted and advanced into the pulmonary artery until a wedge pressure tracing was noted. Pressure measurements were made using a Siemens monitoring system (Sirecust 1281; Siemens, Erlangen, Germany). The pressure transducer was positioned at the midaxillary line with the patient in the supine position.

Cardiac index, mean right atrial pressure, mean right ventricular pressure, mean pulmonary artery pressure, mean pulmonary capillary wedge pressure, systemic vascular resistance index, pulmonary vascular resistance index, and right and left ventricular stroke work indices were recorded. The cardiac index was measured by the thermodilution technique using a cardiac output computer (model REF 1; American Edwards); these measurements were performed three times and averaged. Arterial blood pressure was monitored using a sphygmomanometer. Mean arterial pressure was calculated according to the standard formula.

Echocardiographic Assessment
Transthoracic echocardiography was performed with a mechanical sector scanner (Aloka 870 SSD; Aloka Co Ltd, Tokyo, Japan) using a 3.5-MHz transducer. Two-dimensional, color-flow, and Doppler echocardiograms in the apical and subcostal four-chamber view were obtained at rest, during each exercise stage, and in the recovery period to assess tricuspid valve function. The degree of tricuspid insufficiency was estimated semiquantitatively and graded 1 to 3 by color-flow mapping [8]; grade 1 = regurgitant flow reaches the halfway point of the long axis of the right atrium; grade 2 = regurgitant flow extends beyond the halfway point of the long axis of the right atrium; and grade 3 = regurgitant flow extends beyond the halfway point of the long axis of the right atrium with major regurgitation in the hepatic veins. Right atrial contraction was analyzed at rest in the apical four-chamber view to detect asynchronous contraction between donor and recipient right atria. To assess right ventricular size at rest, two-dimensional images in the apical four-chamber view were analyzed to obtain right ventricular end-diastolic dimensions (in cm) and right ventricular end-diastolic areas (in cm²).

Exercise Protocol
After routine myocardial biopsy, baseline echocardiographic and hemodynamic measurements were obtained in the supine position with the legs passively elevated on the ergometer foot pedals. The exercise test was performed on a supine exercise unit (Siemens 870 L), starting with a 25-W work load. The work load was increased every 5 minutes by 25 W. The exercise test was terminated when the patient became fatigued or reached a work load of 100 W. After 4 minutes, echocardiographic evaluation and hemodynamic measurements were performed in each work load stage. Recovery evaluations were performed 20 minutes after completion of the exercise test. The heart rate was determined at the time of cardiac index measurements. Patients were monitored with a three-lead electrocardiogram throughout the exercise test.

Data Analyses
Data are expressed as the mean ± one standard deviation. Data between the two groups were compared with the unpaired t test. For comparison of two relative frequencies, the Fisher exact test of independence was applied. A p value of less than 0.05 was defined as significant.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Echocardiography
Assessment of atrial wall contraction pattern revealed asynchronous contraction of donor and recipient right atria in 83% of group B patients, but this finding could not be validated in group A. Echocardiographic dimensions are depicted in Figure 1. The right ventricular dimensions were significantly greater in group B (conventional transplantation technique): right ventricular end-diastolic dimension, 3.27 ± 0.44 cm versus 2.88 ± 0.35 cm (p < 0.05), and right-ventricular end-diastolic area, 21.3 ± 2.85 cm² versus 17.1 ± 2.01 cm² (p < 0.005). The data for echocardiographic assessment of tricuspid valve function are shown in Table 1. The incidence of tricuspid regurgitation was greater in group B at rest, during exercise, and in the recovery period. The grade of tricuspid regurgitation was significantly higher throughout the study for patients with atrial anastomoses (group B).

View larger version (14K): [in this window] [in a new window]   Fig 1. . Right ventricular echocardiographic dimensions (mean ± 1 standard deviation) in 27 patients after orthotopic heart transplantation. Right ventricular end-diastolic dimension (RVEDD) and right ventricular end-diastolic area (RVEDA) were significantly greater in the group having standard transplantation (group B, n = 12) compared with the group having bicaval transplantation (group A, n = 15).

View larger version (14K): [in this window] [in a new window]   Fig 2. . Exercise capacity (mean ± 1 standard deviation) of 27 patients after orthotopic heart transplantation. Exercise capacity was significantly greater in the bicaval transplantation group (group A, n = 15), (1.17 ± 0.25 W/kg body weight) compared with the standard transplantation group (group B, n = 12) (0.93 ± 0.34 W/kg body weight).

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

Immediately after cardiac transplantation in the majority of patients, the right ventricle is exposed to elevated pulmonary pressure with the risk of acute right ventricular failure developing because of afterload mismatch. Thus, a surgical technique leaving the right atrium intact with subsequent preservation of the right atrial booster function to net stroke volume may have a positive effect on right ventricular function. Normal atrial pump function contributes up to 20% of the stroke volume [9, 13, 14]. As asynchronous contraction of recipient and donor atria as well as abnormal atrial size is a common finding after standard transplantation, atrial contribution to stroke volume might be diminished [10, 13]. Furthermore, Hosenpud and Morton [4] found a reduction in or absence of the A wave (representing ventricular filling by the atrium) after conventional transplantation. In contrast to the standard technique, the bicaval technique offers a more physiologic right atrial size [15] and contraction pattern throughout the cardiac cycle [16]. In our study, asynchronous right atrial contraction was found in 83% (10/12) of the patients in group B versus none in group A by transthoracic echocardiography. Thus, physiologic atrial contraction might be preserved by the bicaval transplantation technique and may contribute to the stroke volume.

Exercise hemodynamic studies revealed abnormal right ventricular hemodynamics with increased right ventricular filling pressures in patients undergoing conventional transplantation [2, 3, 17]. In our study, right ventricular filling pressure increased gradually during exercise in all recipients but was significantly higher in those having conventional transplantation (group B). Stinson and co-workers [18] found that after standard transplantation, contraction of the recipient atrium is maintained and may augment atrial pressure up to 4 mm Hg. Further, during exercise the recipient atrial remnant heart rate may exceed the donor heart rate, and contraction of the recipient atrium against a closed atrioventricular valve may occur with subsequent increase in right atrial pressure [19]. These factors could partly explain the higher mean right atrial pressure in the group undergoing the standard procedure.

The right ventricle responds to transplantation by increasing in size [20]. Bizouarn and co-workers [16] determined the right ventricular size after standard and total orthotopic cardiac transplantation and reported no difference between the groups within 2 days after transplantation. However, our study showed that the right ventricular end-diastolic dimension as well as the right ventricular end-diastolic area was significantly higher in group B (see Fig 1). Bhatia and colleagues [20] reported that exposure of the right ventricle to the abnormal recipient pulmonary pressure resulted in early and late right ventricular dilatation as well as tricuspid regurgitation despite resolution of moderately elevated pulmonary pressure within 1 month after cardiac transplantation. The pulmonary vascular resistance and mean pulmonary artery pressure were equally elevated in both our groups. Therefore, the significantly elevated right ventricular dimensions in group B indicate that hearts with bicaval anastomoses work more effectively against the increased pulmonary vascular resistance, a finding probably resulting from the preserved right atrial function and the lower incidence of tricuspid insufficiency (see Table 1).

Tricuspid regurgitation, a common finding after transplantation [10, 12, 20, 21], may be responsible for right ventricular enlargement [20]. Echocardiographic studies revealed a higher incidence and grade of tricuspid insufficiency in group B at rest, exercise, and during the recovery period (see Table 1). Several causes may be responsible for tricuspid regurgitation, such as donor ventricle ischemic time [22, 23], right ventricular afterload mismatch [20, 24], severance of the subvalvular apparatus caused by endomyocardial biopsy [25], and number of rejection episodes [23]. Apart from a significantly longer ischemic time in the bicaval group, all factors were equally distributed between the two groups. Thus, the only consistent difference between them was the surgical technique, which suggests the technique itself could be responsible for our findings.

Lewen and associates [22] and Bhatia and colleagues [20] found that tricuspid insufficiency is well tolerated after cardiac transplantation and of no clinical significance. However, they did not include exercise studies. Long-standing right ventricular volume overload resulting from tricuspid insufficiency may impair right ventricular function and exercise capacity. In our study, exercise capacity was significantly higher (p < 0.05) in group A patients (1.17 ± 0.25 W/kg versus 0.93 ± 0.34 W/kg).

Frist and coauthors [2] demonstrated that left ventricular systolic function as an important factor for exercise capacity is stable over time in recipients who survive the first year. All our patients studied showed preserved left ventricular function at annual cardiac angiography and on routine echocardiographic follow-up. Moreover, the results of left ventricular hemodynamic evaluation revealed no significant differences between the groups (see Table 2), which leads us to assume that left ventricular function is equally preserved in all patients regardless of the surgical technique.

Potential complications related to the morbidity from caval anastomoses, i.e., caval stenosis or caval thrombosis, were not observed in our patients during the maximum follow-up of 36 months. Another problem could be the time of ischemia. In patients with bicaval anastomoses, the total ischemic time was significantly longer (204.5 ± 40.1 minutes versus 159 ± 68.3 minutes [p < 0.05]), which is partly explained by the longer cold storage time and by the surgical technique itself. However, the total ischemic time in the majority of the most recent patients was comparable to that of the standard technique because reperfusion was started after completion of the left atrial and aortic anastomoses, which were performed in the same fashion in both groups.

The data have to be interpreted with the awareness that right and left ventricular function and right ventricular size were not assessed exactly by our echocardiographic or angiographic technique. Radionuclide ventriculography or pressure–volume relations would be advantageous to more precisely define ventricular function. Nevertheless, our data provide some evidence that the bicaval technique may be superior to the standard technique inasmuch as improved hemodynamics, a better right atrial contraction pattern, better right ventricular dimensions, and improved exercise capacity are found after bicaval cardiac transplantation.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Leyh, Klinik für Herzchirurgie der Universitätsklinik Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Leyh, R. G. Articles by Sievers, H.-H. Search for Related Content PubMed PubMed Citation Articles by Leyh, R. G. Articles by Sievers, H.-H.