Benefits of the Modified Bicaval Anastomosis Technique for Orthotopic Heart Transplantation From a Size-Mismatched Marginal Donor

Surgical Results of the Superior Vena Cava Intimal Layer-Only Suture Technique in Heart Transplantation

Background

Superior vena cava (SVC) stenosis during follow-up is a major concern after heart transplantation, and many technical modifications have been introduced. We analyzed the surgical results of the SVC intima layer-only suture technique in heart transplantation.

Methods

We performed SVC anastomosis with sutures placed only in the intima during heart transplantation. We measured the area of the SVC at 3 different points (above the anastomosis, at the anastomosis, and below the anastomosis) in an axial view by freely drawing regions of interest, and then evaluated the degree of stenosis. Patients who underwent cardiac computed tomography (CT) at 2 years postoperatively between June 2017 and May 2020 were included in this study.

Results

We performed heart transplantation in 41 patients. Among them, 24 patients (16 males and 8 females) underwent follow-up cardiac CT at 2 years postoperatively. The mean age at operation was 49.4±4.9 years. The diagnoses at time of operation were dilated cardiomyopathy (n=12), ischemic heart disease (n=8), valvular heart disease (n=2), hypertrophic cardiomyopathy (n=1), and congenital heart disease (n=1). No cases of postoperative bleeding requiring intervention occurred. The mean CT follow-up duration was 1.9±0.7 years. At follow-up, the mean areas at the 3 key points were 2.7±0.8 cm2, 2.7±0.8 cm2, and 2.7±1.0 cm2 (p=0.996). There were no SVC stenosis-related symptoms during follow-up.

Conclusion

The suture technique using only the SVC intimal layer is a safe and effective method for use in heart transplantation.

Extended criteria donor organ use for heart-lung transplantation in the modern era

BACKGROUND

Demand for donor hearts and lungs exceeds their supply. Extended Criteria Donor (ECD) organs are used to help meet this demand, but their impact on heart-lung transplantation outcomes is poorly characterized.

METHODS AND RESULTS

The United Network for Organ Sharing was queried for data on adult heart-lung transplantation recipients (n = 447) from 2005‒2021. Recipients were stratified based on whether they received ECD hearts and/or lungs. Morbidity was analyzed using Kruskal-Wallis, chi-square, and Fisher's exact tests. Mortality was analyzed using Kaplan-Meier estimation, log-rank tests and Cox regression. Sixty-five (14.5%) patients received two ECD organs, 134 (30.0%) received only an ECD lung, and 65 (14.5%) only an ECD heart. Recipients of two ECD organs were older, more likely to have diabetes, and more likely transplanted from 2015‒2021 (p < 0.05). Groups did not differ by pre-transplant diagnosis, intensive care unit disposition, life support use, or hemodynamics. Group five-year survival rates ranged from 54.5% to 63.2% (p = 0.428). Groups did not differ by 30-day mortality, strokes, graft rejection, or hospital length of stay.

CONCLUSIONS

Using ECD hearts and/or lungs for heart-lung transplantation is not associated with increased mortality and is a safe strategy for increasing donor organ supply in this complex patient population.

Oversized donor heart transplantation-clinical experience with an underestimated problem

PURPOSE

Heart transplantation is the definitive treatment for end-stage heart failure. With respect to donor-recipient size matching, the problems with undersized heart transplantation have been widely discussed, but there is a paucity of information on oversized transplants due to the presumed advantage of large hearts. We intend to share our center's experience with oversized heart transplantation and its associated problems which would help to expand the knowledge on oversized cardiac allografts.

METHODS

Patients who underwent isolated heart transplantation at our hospital between March 1, 2008, and March 1, 2020, were included. For adults, a donor-recipient predicted heart mass percentage difference exceeding 30% and for children, a donor-recipient weight ratio < 0.8 and > 2.0 was considered a mismatch. We collected data from the in-patient medical records and analyzed the in-hospital outcomes and survival post-transplant among various other parameters.

RESULTS

Out of the 43 patients included in this study, 32 (74.4%) patients received a matched heart and 11 (25.6%) patients received oversized hearts. None of the patients received an undersized heart. The in-hospital mortality rate of oversized transplants was 18.2% whereas that of matched transplants was 9.4% (p = 0.432). The post-operative characteristics and 1-year survival were comparable between the groups. We encountered problems specific to oversizing in 5 of the 11 patients (45.4%) which are discussed.

CONCLUSION

With the liberalization of donor criteria to overcome organ shortage, oversized heart transplantation poses certain unique challenges, which when efficiently managed offers acceptable outcomes.