inspected and palpated. Plaque in the coronary arteries may be identified by this method and valvular insufficiency or stenosis may be noted by thrills. The peri-cardial reflection is dissected free of the aorta and the pulmonary artery. The reflections at the SVC and IVC are similarly dissected free to allow adequate exposure. In freeing the superior vena cava the azygos vein may be isolated, ligated and divided. This is particularly helpful if a caval-to-caval anastomosis is planned in the recipient. A cardioplegia cannula is placed high in the ascending aorta, permitting room for a cross-clamping below the innominate artery. A 14-gauge angiocath is acceptable for cardioplegic delivery. The SVC is ligated, the aorta is cross-clamped, and a liter of cold (4°C) cardioplegic solution is administered. Once this has been commenced the IVC is clamped and partially transected to allow decompression of the right heart. The heart is elevated, and the left pulmonary vein is also partially transected to decompress the left heart. Iced slush is then placed in the pericardium for topical hypothermia. Hypothermia is the most important component of cardiac preservation, since it provides a profound reduction in myocardial oxygen consumption and demand. Once cardioplegic delivery is complete the IVC is completely transected and each of the pulmonary veins is transected at the peri-cardial reflection. The SVC is divided and the aorta is transected at or above the level of the innominate artery. The pulmonary artery is transected at its bifurcation. If concomitant lung procurement is not being done then the pulmonary artery division should include the bifurcation and portions of the main pulmonary arteries. Once excised the heart is inspected through the great vessels looking at the aortic and pulmonary valves. Similar inspection of the tricuspid and mitral valve is achieved via the cavae and pulmonary veins. The heart is then placed in a plastic bag with cold saline. An additional bag of cold saline is then wrapped around the first, and both bags are then placed in a bucket of cold saline, which is in turn placed in a cooler filled with ice.

Technical aspects of the recipient operation in an orthotopic transplantation are largely unchanged from the original description by Lower and Shumway as reported in 1960 (Figs. 11.3A and 11.3B). A median sternotomy is performed and the patient is placed on cardiopulmonary bypass. If the heart appears to be adherent to the underside of the sternum as a result of previous operations, cardiopulmonary bypass may be instituted by cannulation of the femoral artery and vein. Otherwise standard aortic cannulation at the level of the innominate artery and bicaval venous cannulation are used. The heart is excised at the level of the atrial ventricular groove and excess donor atrium is excised as well. The donor left atrial cuff is created by making an incision that connects all of the pulmonary veins. The right atrial cuff is reestablished by making an incision extending from the IVC up towards the right atrial appendage. If caval-to-caval anastomosis is to be completed, the IVC and SVC are trimmed and beveled to prevent stenosis of the anastomoses. Using a 3-0 monofilament suture, the left atrial anastomosis is performed first. Before closure of the septum, the left atrium is filled with saline to eliminate as much air as possible. The right atrial anastomosis is then completed. The aortic anastomosis is completed next using a 4-0 monofilament suture. A

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