Ann Thorac Surg 2002;73:671-672
© 2002 The Society of Thoracic Surgeons
How to do it
Open inferior vena caval anastomosis during bicaval heart transplantation
Lishan Aklog, MD*a,
Jerome Sepic, MDa,
Farzan Filsoufi, MDa,
John G. Byrne, MDa,
David H. Adams, MDa
a Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Accepted for publication October 9, 2001.
* Address reprint requests to Dr Aklog, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
e-mail: laklog{at}partners.org
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Abstract
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Performing a precise inferior vena caval (IVC) anastomosis during bicaval orthotopic heart transplantation can sometimes be challenging because of crowding of the operative field by the venous cannula and tourniquet. We performed bicaval orthotopic heart transplantation in 10 patients using an open IVC anastomotic technique with vacuum-assisted venous drainage. A long venous cannula was passed into the IVC through the femoral vein. The IVC anastomosis was performed after removing the IVC tourniquet under vacuum-assisted venous drainage. A precise edge-to-edge IVC anastomosis was successfully performed in all patients. This technique may result in greater anastomotic precision and improved outcomes.
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Introduction
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Compared with the standard technique for orthotopic heart transplantation, the bicaval technique better preserves right atrial geometry [1] and eliminates the right atrial suture line. Possible additional advantages include a decreased incidence of tricuspid regurgitation [1, 2], fewer atrial arrhythmias [2], and improved atrial contractile function [3]. One technical challenge of the bicaval technique is performing the inferior vena caval (IVC) anastomosis with the IVC cannula and tourniquet crowding the surgical field. Redundant recipient right atrial tissue and Eustachian valves can further limit anastomotic precision.
Vacuum-assisted venous drainage (VAVD) is a cardiopulmonary bypass technique that uses active suction to augment venous return. Vacuum-assisted venous drainage permits the use of smaller caliber venous cannulas and allows the right heart chambers to be opened without the threat of venous air lock.
We describe the use of VAVD to allow the IVC anastomosis to be performed in an open fashion during bicaval orthotopic heart transplantation.
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Technique
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Median sternotomy, pericardiotomy, and heparinization were performed in the standard fashion. Cannulation for cardiopulmonary bypass was typically achieved with a 7-mm Soft-Flo arterial cannula (Terumo Cardiovascular Systems Corporation, Ann Arbor, MI) in the distal ascending aorta and a 24F right-angle venous cannula (Baxter Healthcare Corporation, Irvine, CA) in the superior vena cava. A 50-cm, 21F percutaneous venous cannula (Baxter Healthcare Corporation) was introduced using a modified Seldinger technique through the right femoral vein into the IVC just below the diaphragm, and its position was confirmed by transesophageal echocardiography. The vena cavae were occluded with vascular clamps or umbilical tape tourniquets. In redo sternotomy patients, open cannulation of the femoral artery and vein was typically performed.
Cardiopulmonary bypass with VAVD was initiated by applying up to -80 mm Hg of suction to the hard-shell venous reservoir. After cross-clamping the aorta, the heart was excised leaving separate superior vena cava and IVC cuffs. The left atrial, pulmonary artery, and aortic anastomoses were performed in standard fashion, using running polypropylene sutures. Although the aortic cross-clamp was typically removed after completion of the IVC anastomosis, to facilitate suturing and subsequent removal of air, it was occasionally removed first to minimize donor ischemia time. In such cases, a small sump vent was placed directly into the coronary sinus while completing the posterior portion of the IVC anastomosis.
At this point, the IVC anastomosis was performed in an open fashion with VAVD (Fig 1).
The IVC tourniquet or clamp was removed, and VAVD was initiated. If necessary, the IVC cannula was pulled back slightly from the open orifice to facilitate suturing and to reduce venous air entrainment. With the IVC open, all excess recipient right atrial tissue was excised, leaving a 3- to 4-mm cuff of recipient IVC. The IVC anastomosis was then completed using a running 4-0 Prolene suture (Ethicon, Somerville, NJ). If still in place, the aortic cross-clamp was removed after air was removed from the heart through a vent in the ascending aorta. Finally, the superior vena caval anastomosis was performed between vascular clamps using a running polypropylene suture.
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Fig 1. Open inferior vena caval anastomosis with vacuum-assisted venous drainage during bicaval orthotopic heart transplantation. A long femoral venous cannula connected to vacuum drainage sits in the inferior vena cava just below the diaphragm. A sump vent sits near the coronary sinus to maintain a bloodless field. A precise edge-to-edge anastomosis is performed between donor and recipient inferior vena cava after complete resection of the recipient right atrial tissue. The inset shows the standard bicaval approach with the direct inferior vena cava cannula and tourniquet crowding the field.
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Results
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Bicaval orthotopic heart transplantation using an open IVC anastomosis with VAVD was performed in 10 patients (6 women/4 men; mean age, 55.8 ± 6.4 years), 6 of whom had undergone previous sternotomy. Open femoral venous cannulation was performed in these 6 patients, and percutaneous femoral venous cannulation was performed in the remaining 4 patients.
The postoperative course in 9 of the 10 patients was unremarkable. One patient experienced acute graft failure at the time of transplantation requiring implantation of biventricular assist devices. She died before another donor heart became available. There were no neurologic deficits or groin complications (ie, hematoma, lymphocele). Follow-up echocardiography (2 to 8 weeks after transplantation) showed 1 patient with no tricuspid regurgitation and 8 patients with trace (1+/4+) tricuspid regurgitation.
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Comment
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An open IVC anastomosis with VAVD may offer potential benefits over the standard anastomotic technique during bicaval orthotopic heart transplantation. Visualization during performance of the IVC anastomosis was improved by (1) removing the cannula and tourniquet from the operative field, (2) eliminating puckering of the recipient IVC cuff, (3) permitting excision of the redundant recipient right atrial tissue, and (4) improving visualization of the Eustachian valves. In addition, any size discrepancy between the donor and recipient IVC was spread out precisely over the circumference of the anastomosis. This may decrease donor-recipient IVC misalignment and right atrial distortion, which may contribute to postoperative tricuspid regurgitation.
In this early experience, we found the open IVC technique to be relatively simple and reproducible. We experienced no technical problems with performance of the anastomosis or with anastomotic bleeding. One concern might be potential complications related to routine femoral venous cannulation. It is already our current practice to perform open femoral cannulation in all resternotomy transplant patients. In those undergoing primary sternotomy, the femoral vein is cannulated percutaneously, a technique we have found to be safe and effective in a large number of patients undergoing other cardiac procedures. In 170 patients over a four-year period, the only complication related to this technique was one groin hematoma requiring surgical exploration [4].
The possible risk of gaseous microemboli with VAVD, caused by air entrainment into the cardiopulmonary bypass circuit, has been raised [5]. Using the lowest effective amount of suction and proper positioning of the IVC cannula can minimize air entrainment during the open IVC anastomosis. Excess air entrainment during cardiopulmonary bypass was not a problem in any patient. None of our 10 patients showed any clinical evidence of neurologic injury or other postoperative complications attributable to VAVD. In addition, we have used VAVD in thousands of patients (up to a body surface area of 2.7 m2), undergoing various cardiac surgery procedures, with adequate venous return and no complications attributable to VAVD, such as air embolization or hemolysis. Subtle neurologic deficits cannot be excluded without formal neurocognitive testing.
In summary, performing the IVC anastomosis in an open fashion under VAVD may be a useful modification to the bicaval technique of orthotopic heart transplantation. Longer-term follow-up and a larger clinical experience will be necessary to determine whether or not this technique will lead to improved clinical outcomes.
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References
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Leyh R.G., Jahnke A.W., Kraatz E.G., Sievers H.H. Cardiovascular dynamics and dimensions after bicaval and standard cardiac transplantation. Ann Thorac Surg 1995;59:1495-1500.[Abstract/Free Full Text]
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Grande A.M., Rinaldi M., D’Armini A.M., et al. Orthotopic heart transplantation: standard versus bicaval technique. Am J Cardiol 2000;85:1329-1333.[Medline]
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Beniaminovitz A., Savoia M.T., Oz M., et al. Improved atrial function in bicaval versus standard orthotopic techniques in cardiac transplantation. Am J Cardiol 1997;80:1631-1635.[Medline]
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Adams DH, Aklog L, Filsoufi F, et al. Percutaneous femoral venous cannulation with vacuum-assistance is a versatile and safe technique [Abstract]. Fourth International Congress on Coronary Artery Disease, October 2001.
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Willcox T.W., Mitchell S.J., Gorman D.F. Venous air in the bypass circuit: a source of arterial line emboli exacerbated by vacuum-assisted drainage. Ann Thorac Surg 1999;68:1285-1289.[Abstract/Free Full Text]
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Abstract
Introduction
