Operative Techniques Of Implant

In pediatric patients, the original transplants were performed using the "right atrial" technique first described by Lower and Shumway.9 For transplant of the infant with HLHS, the technique requires reconstruction of the hypoplastic aortic arch, which necessitates a period of circulatory arrest. For older children we and others have changed from the right atrial technique to using a "bicaval" anastomosis. The bicaval technique preserves the donor right atrial anatomy, which leads to significantly less tricuspid valve insufficiency and better preservation of sino-atrial node function. We have had to replace the tricuspid valve in 2 patients that had the right atrial technique of implant. Our technique of transplant for patients with HLHS is illustrated in Figure 13A.1 and 13A.2, and emphasizes mini-

Fig. 13A.2. Cardiac Transplantation for HLHS: Donor Heart and Implant. The donor heart has been procured along with the aortic arch. The right atrium (RA) has been opened with an incision toward the SVC. Also shown are the left atrium (LA) and pulmonary artery (PA). The second panel shows the left atrial and aortic (Ao) anastomosis completed. Note the aortic cannulation is now in the donor aorta, and the heart and body are being perfused. The pulmonary artery (PA) anastomosis is being performed and the right atrial (RA) anastomosis will be done last.

Fig. 13A.2. Cardiac Transplantation for HLHS: Donor Heart and Implant. The donor heart has been procured along with the aortic arch. The right atrium (RA) has been opened with an incision toward the SVC. Also shown are the left atrium (LA) and pulmonary artery (PA). The second panel shows the left atrial and aortic (Ao) anastomosis completed. Note the aortic cannulation is now in the donor aorta, and the heart and body are being perfused. The pulmonary artery (PA) anastomosis is being performed and the right atrial (RA) anastomosis will be done last.

mizing circulatory arrest time.10 The recipient heart is excised and the left atrial anastomoses performed while systemic perfusion is maintained. Circulatory arrest is only used for the arch reconstruction. Systemic and cardiac perfusion are resumed for the right atrial and pulmonary artery anastomosis. Using this technique, the mean length of circulatory arrest was 26 minutes. The technique of OCT with a "right atrial" anastomosis is shown in Figure 13A.3, and OCT with "bicaval" anastomosis is shown in Figure 13A.4. With both techniques the aortic cross clamp is removed after the left atrial and aortic anastomosis to minimize ischemia time of the donor heart. The mean ischemia time in our series is 2.4 hours. The right atrial (or bicaval) and pulmonary artery anastomoses are performed with the donor heart perfused. The bicaval technique lends itself particularly well for patients that have had a previous Fontan operation, a previous Glenn shunt, or a prior atrial repair of transposition of the great arteries. Innovative use of donor vessels is required for patients with situs inversus or other complex anatomic anomalies.11 For the SVC anastomosis we have used interrupted PDS (absorbable) suture to allow for growth.

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