Recipient Cardiectomy: Bi-Caval Technique
This video demonstrates the technique associated with the recipient cardiectomy procedure using the bicaval technique originally described by Sievers et al. in 1991. Donor selection, donor cardiectomy, recipient preoperative preparation, and recipient preoperative timing are beyond the scope of this instructional video.
Cardiopulmonary bypass (CBP) was established through bicaval cannulation. In this case, metal angled venous cannulae are the preferred tools for the procedure. The aorta was preferentially cannulated high; this is often the preferred location in cases of prior aortic manipulation cannulation in the traverse arch. Examples include proximal coronary graft anastomosis or outflow graft insertion for left ventricular assist devices. Next, the superior vena cava (SVC) was cannulated high, below the left brachiocephalic vein insertion. This was done after mobilizing the pericardium from the anterior and medial aspect of the cava. Finally, the inferior vena cava (IVC) was cannulated low, near the diaphragm. The low cannulation of the cava allowed for the creation of a large venous cuff for implantation.
Preserving the maximum amount of usable recipient tissue in the creation of vascular cuffs was paramount to implantation. The tissue may be trimmed in length once the donor heart is available to measure. From there, the appropriate tissue length may be allocated appropriately. Sondergaard’s groove was routinely incised to facilitate ease in the creation of the left atrial cuff.
The recipient cardiectomy began with the application of the aortic cross-clamp at a point on the distal ascending aorta that increased the length of the aorta for implantation. Next, caval snares were secured to ensure total cardiopulmonary bypass. Cardioplegia was not required. A root vent could have been inserted at this time or prior to cross-clamp removal for the purpose of de-airing. In this case, the root vent was placed prior to removal of the aortic cross-clamp to allow for flexibility at the location of the aortic anastomosis.
The superior vena cava cuff was created by incising the SVC transversely as it joins the right atrium. Intravascular pacing and defibrillating lead may be encountered once the anterior half has been opened. This lead may be excised to aid in the cardiectomy procedure. However, care must be taken not to cut a Swan-Ganz catheter if it is present distal to the SVC cannulation site. Next, the SVC incision was completed posteriorly. Cautery may be used to mobilize the cuff from the left atrium and the right main pulmonary artery.
Afterward, the great vessels were separated from the recipient heart. A transverse aortotomy was made in the root below the fat stripe, at the level of the sinotubular junction for a virgin aorta. If the aorta has been manipulated, the aortotomy should be performed at the most proximal yet usable portion of the aorta. For patients with a prior left ventricular assist device (LVAD), this should be performed at the distal level of the outflow graft anastomosis. The pulmonary artery was incised transversely at its root, just above the valve. Following this incision, cautery was used to mobilize the adventitia posteriorly to separate both great vessels from the transverse sinus. The aorta was mobilized from the right main pulmonary artery as it crosses posteriorly.
The proceeding step was to create the IVC cuff. The process began with a transverse incision into the body of the right atrium directed inferiorly toward the coronary sinus. Directed posteriorly, the incision was carried through the coronary sinus ostia. Next, the incision was continued laterally with care to remain inferior to the right inferior pulmonary vein and the left atrium. The posterior incision may be guided by a finger in the oblique sinus posterior to the IVC, with the application of anterior tension. Finally, the posterior cuff may be incised sharply or with cautery. This leaves a nice, redundant IVC cuff.
Lastly, the left atrial cuff was created. The assistant retracted the heart inferiorly with a finger in the aortic root, exposing the dome of the left atrium. This was incised and directed toward the left atrial appendage. Afterward, the left atrial appendage was excised with the recipient heart. However, in this excision, care must be taken to separate the left atrial cuff between the left atrial appendage and the left pulmonary veins. This excision left several millimeters of atrial cuff behind. Once beyond the left inferior pulmonary vein, the procedure changed directions. The incisions from the dome—directed towards the IVC, progressing through the previously opened Sondergaard’s groove—left several millimeters of recipient left atrium above the right pulmonary veins. Subsequently, an assistant lifted the heart, exposing the inferior wall of the left atrium. The incision was then completed toward the left side, having taken precautions to keep the incision superior to the left inferior pulmonary vein. This action connected the resulting incision to the previous incision around the left pulmonary veins.
Prior to implantation of the donor, heart care was taken to ensure hemostasis. The posterior structures would be difficult to trace in their source of bleeding once the donor heart is implanted.
1. Sievers HH, Weyand M, Kraatz EG, Bernhard A. An alternative technique for orthotopic cardiac transplantation, with preservation of the normal anatomy of the right atrium. Thorac Cardiovasc Surg. 1991;39:70–2.
2. John, R and Liao, K. Orthotopic Heart Transplantation. Operative Techniques in Thoracic and Cardiovascular Surgery. 2010;15(2):138-146.