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Heart transplant

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"heart transplantation"[MeSH Terms] AND outcomes

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This is a complete exam-ready review of heart transplantation covering all major topics. Here is a summary of what's included:
Covered topics:
  1. Background - epidemiology, common etiologies (ischemic CM most common)
  2. Indications & Contraindications - ISHLT criteria, peak VO2 thresholds, absolute vs. relative contraindications (PVR >6 Wood units = absolute)
  3. Candidate evaluation - full multidisciplinary workup including hemodynamics and CPET
  4. Donor selection & UNOS allocation - ABO compatibility, size matching, the 2018 6-tier status system, DCD vs. DBD
  5. Allograft preservation - cold static storage, normothermic machine perfusion (OCS Heart)
  6. Surgical technique - biatrial (classic) vs. bicaval (preferred) orthotopic transplantation; anastomosis sequence
  7. Immunosuppression - triple therapy (tacrolimus + MMF + prednisone), mechanism and side effects of each drug class, induction agents
  8. Rejection - all 3 types (hyperacute, ACR, AMR), ISHLT grading, diagnosis by endomyocardial biopsy, treatment protocols
  9. Complications - early (primary graft dysfunction, RV failure) and late (CAV, malignancy, CKD, PTLD)
  10. Outcomes - ~85% 1-year survival, ~12-13 year median survival; leading causes of death by time period
  11. Bridging strategies - LVAD, IABP, ECMO

Simplifiy and explain Orthotopic Heart Transplantation - Two Techniques

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Here is a simplified, visual explanation of both techniques.

Orthotopic Heart Transplantation: Two Techniques, Simply Explained

"Orthotopic" just means the donor heart is placed in the same position as the original heart - in the chest, in the normal anatomical location. (The alternative, heterotopic, would mean placing the donor heart elsewhere as a "piggyback" heart, which is rarely done.)
The recipient's diseased heart is removed completely. Then the donor heart is sewn in place by connecting it to the remaining blood vessels - these connections are called anastomoses (joins).
The two techniques differ in how many joins are made and where.

Technique 1: Biatrial (Classic / Lower-Shumway)

Developed by Norman Shumway at Stanford in the 1960s. Used for the first human heart transplant.

The Big Idea

Instead of cutting the recipient's heart all the way out, the surgeon leaves a large cuff (rim) of both the left and right atria still attached to the body. The donor heart is then sewn onto these two atrial cuffs.

Joins Made (4 total)

  1. Left atrium - donor LA sewn to recipient LA cuff (which includes the pulmonary vein openings)
  2. Right atrium - donor RA sewn to recipient RA cuff (which includes the SVC and IVC openings)
  3. Pulmonary artery - end to end
  4. Aorta - end to end

Think of it as:

Two big atrial "sockets" left in the body → you plug the donor heart's atria into both sockets.

The Problem

  • The right atrial cuff contains the recipient's sinus node (the heart's natural pacemaker)
  • Now there are two sinus nodes - one from the donor, one from the recipient
  • This can cause sinus node dysfunction, irregular rhythms, and the need for a pacemaker
  • The large atrial remnant can also cause tricuspid valve regurgitation (leaky valve)

Technique 2: Bicaval (Modern / Preferred Today)

Developed in the 1990s. Now the standard technique at most centers.

The Big Idea

The surgeon removes almost the entire heart, including the right atrium. Instead of one big right atrial cuff, each large vein is joined individually - the SVC and IVC are sewn directly to the donor's SVC and IVC.

Joins Made (5 total)

  1. Left atrium - same as biatrial (recipient LA cuff sewn to donor LA)
  2. Inferior vena cava (IVC) - sewn directly, end to end
  3. Superior vena cava (SVC) - sewn directly, end to end
  4. Pulmonary artery - end to end
  5. Aorta - end to end

Order of anastomoses in the OR:

Left atrium → IVC → Pulmonary artery → Aorta → SVC

Why it's better

  • The entire donor right atrium is preserved intact, including the donor's own sinus node
  • Only one sinus node = much better heart rhythm
  • Less tricuspid regurgitation
  • More physiological blood flow through the right side

Side-by-Side Comparison

FeatureBiatrial (Classic)Bicaval (Modern)
Year introduced1960s1990s
Right atriumPartial recipient cuff keptDonor RA fully preserved
Number of joins45
Sinus nodes present2 (recipient + donor)1 (donor only)
Pacemaker needHigherLower
Tricuspid regurgitationMore commonLess common
Used today?RarelyYes - standard

Visual Summary (The Surgical Image Above)

The figure from Sabiston's Surgery shows the bicaval technique in 3 steps:
  • (A) Left atrial anastomosis - the back wall of the left atrium is sewn first
  • (B) IVC and SVC joined individually - the two big veins are connected one at a time
  • (C) Pulmonary artery and aorta joined - the final two tubes are connected, then the clamp is released and the heart is reperfused

One-Line Memory Aid

Biatrial = 2 atrial "sleeves" kept → 2 pacemakers → problems Bicaval = each vein sewn separately → 1 pacemaker → better rhythm → preferred
Source: Sabiston Textbook of Surgery (2024), Chapter 57
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