Donor organ selection and peri-operative management
Specialised teams based at cardiac transplant centres carry out organ retrieval. Techniques for selecting suitable organs are complex and usually involve clinical examination, electrocardiography (ECG), haemodynamic studies using a pulmonary artery catheter, and direct visual inspection (figure 7). This is complemented by data from echocardiography or cardiac catheterisation if available. The organ is transferred to the centre in cold storage or in an organ care system that maintains a warm perfused state, where available.
The surgical transplant operation has evolved over time;
- the bi-atrial technique: this left some recipient right atrium in situ and required long, sometimes fallible atrial anastomoses (figure 8a).11
- the total orthotopic technique: this involved separate anastomoses for each pulmonary vein and the great vessels. (not pictured)
- the bicaval technique. Here the recipient pulmonary veins’ insertion to the left atrium remains in situ, with the donor left atrium anastamosed to this remnant and the donor right atrium anastamosed to the great veins (figure 8b).11
The operation and post-operative recovery can vary from the routine (such as in the first sternotomy, stable patient) to extremely high-risk (such as in the patient with several previous sternotomies, a VAD in situ, or in the critically ill). Specific early problems that should be anticipated are summarised in table 2.