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Background:For more than 35 years, the biatrial technique of performing orthotopic cardiac transplantation has been the gold standard, and involves anastomoses of donor and recipient atrial cuffs. More recently, however, bicaval and total techniques have been devised in an attempt to improve cardiac anatomy, physiology, and postoperative outcome. A bicaval approach preserves the donor atria and combines the standard left atrial anastomosis with a separate bicaval anastomosis. Total orthotopic heart transplantation involves complete excision of the recipient atria with separate bicaval end-to-end anastomoses, as well as pulmonary venous anastomoses. The aim of this study was to conduct a literature review of studies that compared the three surgical techniques (biatrial, bicaval, and total) for performing orthotopic cardiac transplantation. Numerous outcome variables were evaluated, and included post-transplant survival, atrial dimensions, atrioventricular valvular insufficiency, arrhythmias, pacing requirements, vasopressor requirements, and hospital stay.Methods:We conducted a Medline (Pubmed) search using the terms“biatrial and cardiac transplantation,”“bicaval and cardiac transplantation,” and“total technique and cardiac transplantation,” which yielded 192 entries: 39 of these were studies that compared surgical techniques and were included in the review.Results:There was overwhelming evidence that the bicaval technique provided anatomic and functional advantages, with improvements in post-transplant survival, atrial geometry, and hemodynamics, as well as decreased valvular insufficiency, arrhythmias, pacing requirements, vasopressor requirements, and hospital stay.Conclusions:The bicaval technique was superior to both biatrial and total techniques for numerous outcome variables. To further elucidate this issue, a prospective randomized trial comparing the three techniques, with long-term follow-up, is warranted.(J Card Surg 2005;20:102-106) [ABSTRACT FROM AUTHOR]

Abstract: Background: The increasing prevalence of obesity is a public health concern and perceived as a potential risk factor in open heart surgery. We critically appraised the literature available regarding postoperative complications in obese patients. Methods: A single-center retrospective evaluation of complication rates (1999–2004) in cardiac surgical patients categorized by body mass index (BMI) was conducted. The overall incidence of complications (CX), renal failure (RF), hemodialysis (HD), atrial fibrillation (AF), cardiac arrest (CA), infections (INF), stroke (CVA and TIA), prolonged ventilation (VENT), and pulmonary embolism (PE) were observed. Patients with normal BMI (20–30) served for comparison, obesity and extreme obesity (ExtOb) were defined as BMI 30–40 and ≥40, respectively. Results : In our institutional review of 1920 patients, 1780 met the inclusion criteria with BMI<20 (n =53), 20–30 (n =1056), 30–40 (n =592), and ≥40 (n =79) based on National Health and Nutrition Examination Survey (NHANES) criteria. Significant increase in complications (STS database guideline definitions) were observed with a BMI≥40, 58% versus 47% (p =0.04). Extremely obese patients (ExtOb) had increased length of stay (LOS) (11.4 days vs 9.6 days; p ≤0.01), rate of renal failure (14.3% vs 5%; p ≤0.01) and prolonged ventilation (39%; p =0.01) compared to non-obese patients. Extremely obese had no significant increase in hemodialysis (7.3% vs 3.2%; p =0.11) or stroke (5.2% vs 2.9%; p =0.29). Obese patients (Ob) had increased LOS (10 days vs 9.6 days; p =0.04) and prolonged ventilation (28.3% vs 23.5%; p =0.03). Conclusions: Cardiac surgery can be performed without significant increase in perioperative and 30-day mortality in obese and extremely obese patients. Overall complication rates and LOS in patients with BMI≥40 is increased and demands attention. We provide evidence that rates of few specific complications increase with extreme obesity. For risk stratification in the setting of an obesity epidemic, we advocate an interdisciplinary approach in obese patients undergoing elective cardiac surgery. [Copyright &y& Elsevier]

The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to ≈6000 to 8000 per year. Because the number of available donor hearts has not increased beyond ≈2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on “Maximizing Use of Organs Recovered From the Cadaver Donor” held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recovery and the impact of these data on donor yield. The rationale for and specific details of a donor-management pathway that uses pulmonary artery catheterization and hormonal resuscitation are provided. Administrative recommendations such as enhanced communication strategies among transplant centers and organ-procurement organizations, financial incentives for organ recovery, and expansion of donor database fields for research are also described. [ABSTRACT FROM AUTHOR]

We reviewed the impact of multiple donor characteristics on recipient mortality by univariate and multivariate analyses in a cohort of heart donors from 1995 to 1999. A sub-cohort of donors was also selected who met “marginal” criteria, and the early and late survival of these patients was then compared. Surrogates of donor size (donor weight, donor body mass index [BMI], BMI mismatch >20%), under-resuscitation (hematocrit, 24-hour fluid intake) and age >56 years were significantly associated with peri-operative mortality in the univariate analysis; in the multivariate analysis, only average donor heart rate at procurement (p = .001), donor hematocrit (p = .02) and donor weight (p = .05) were significantly associated. Few donor characteristics actually impact significantly on recipient outcome, and thus recipient characteristics may figure more prominently than those of the donor toward the risk of death after transplantation. [Copyright &y& Elsevier]

The shortage of available donor hearts continues to limit cardiac transplantation. For this reason, strict criteria have limited the number of patients placed on the US waiting list to approximately 6000 to 8000 per year. Because the number of available donor hearts has not increased beyond approximately 2500 per year, the transplant waiting list mortality rate remains substantial. Suboptimal and variable utilization of donor hearts has compounded the problem in the United States. In 1999, the average donor yield from 55 US regions was 39%, ranging from 19% to 62%. This report provides the detailed cardiac recommendations from the conference on "Maximizing Use of Organs Recovered From the Cadaver Donor" held March 28 to 29, 2001, in Crystal City, Va. The specific objective of the report is to provide recommendations to improve the evaluation and successful utilization of potential cardiac donors. The report describes the accuracy of current techniques such as echocardiography in the assessment of donor heart function before recovery and the impact of these data on donor yield. The rationale for and specific details of a donor-management pathway that uses pulmonary artery catheterization and hormonal resuscitation are provided. Administrative recommendations such as enhanced communication strategies among transplant centers and organ-procurement organizations, financial incentives for organ recovery, and expansion of donor database fields for research are also described.

Left ventricular assist device (LVAD) implantation is frequently complicated by intraoperative and postoperative bleeding, particularly at the aortic anastomosis site. Many modifications of the anastomosis have been attempted. We describe a simple method to anastomose the LVAD outflow tract to the ascending aorta with minimal bleeding and a short anastomosis time.