Heart failure module 6: surgical management

Released1 November 2017     Expires: 01 November 2019      Programme:

Donor organ selection and peri-operative management

Figure 7. HeartMate II® (Thoratec Corporation)
Figure 7. Key aspects of donor organ selection for cardiac transplantation

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;

  1. the bi-atrial technique: this left some recipient right atrium in situ and required long, sometimes fallible atrial anastomoses (figure 8a).11
  2. the total orthotopic technique: this involved separate anastomoses for each pulmonary vein and the great vessels. (not pictured)
  3. 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
Heart failure learning module 6 - Figure 8. Evolving surgical technique, with the donor organ in red, recipient structures in blue, and surgical instruments in grey. Panel A shows the biatrial technique where the recipient right atrium remains in situ necessitating a long atrial anastamosis but retaining more normal haemodynamics with native structures. Panel B shows the bicaval technique, where the recipient right atrium is removed and great veins anastamosed to the donor atrium
Figure 8. Evolving surgical technique, with the donor organ in red, recipient structures in blue, and surgical instruments in grey. Panel A shows the biatrial technique where the recipient right atrium remains in situ necessitating a long atrial anastamosis but retaining more normal haemodynamics with native structures. Panel B shows the bicaval technique, where the recipient right atrium is removed and great veins anastamosed to the donor atrium

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.

Table 2. Perioperative problems to anticipate following cardiac transplantation
Table 2. Problems to anticipate following cardiac transplantation
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