Heart Transplant Surgical Technique

Orthotopic heart transplantation removes the diseased native heart and implants a donor heart in its place, on cardiopulmonary bypass, by anastomosing the donor and recipient atria (or venae cavae), pulmonary artery, and aorta. The choice between the original biatrial method and the later bicaval method is the principal technical distinction.

Definition

Heart transplant surgical technique is the orthotopic implantation of a donor heart, performed on cardiopulmonary bypass after recipient cardiectomy, by anastomosing the left atrium, the right atrium or the superior and inferior venae cavae, the pulmonary artery, and the aorta of donor and recipient.

Scope

The topic covers the orthotopic recipient operation and the biatrial versus bicaval anastomotic techniques. Donor heart procurement, mechanical circulatory support, recipient selection, and rejection are covered in neighbouring entries; combined heart-lung transplantation is noted only for historical context.

Core questions

• How is the donor heart implanted in the orthotopic position?
• What distinguishes the biatrial from the bicaval anastomotic technique?
• Which great-vessel and atrial or caval anastomoses are required?
• Why is cardiopulmonary bypass used during the procedure?

Key concepts

• Orthotopic implantation
• Cardiopulmonary bypass
• Recipient cardiectomy
• Biatrial (Shumway-Lower) technique
• Bicaval technique
• Left atrial cuff anastomosis
• Aortic and pulmonary artery anastomoses

Mechanisms

With the recipient supported on cardiopulmonary bypass, the native heart is excised, leaving cuffs of recipient tissue. In the original biatrial (Shumway-Lower) technique the donor and recipient atria are joined along atrial cuffs; in the bicaval technique the right atrium is reconstituted by separate superior and inferior vena cava anastomoses while a left atrial cuff is retained, which better preserves right atrial geometry. The great vessels are then anastomosed end-to-end (pulmonary artery and aorta) and the heart is reperfused and weaned from bypass. Comparative analyses suggest the bicaval technique is associated with less tricuspid regurgitation and fewer atrial arrhythmias and pacemaker requirements than the biatrial method (jacob-2009, immohr-2022).

Clinical relevance

Heart transplantation is a treatment for selected patients with end-stage heart failure, and the anastomotic technique influences postoperative atrial function, valve competence, and rhythm. This entry describes the operation for educational reference and does not provide operative instruction or individualized clinical guidance.

Evidence & guidelines

The orthotopic operation derives from the biatrial method developed by Lower and Shumway and used in the first clinical transplants. Comparative evidence, including a systematic review by Jacob and Sellke (jacob-2009) and a single-centre comparison by Immohr and colleagues (immohr-2022), supports the bicaval and modified-bicaval techniques for reducing tricuspid regurgitation and atrial arrhythmia. Combined heart-lung transplantation, reported by Reitz and colleagues, extended cardiac transplant techniques to patients with pulmonary vascular disease (reitz-1982).

History

Lower and Shumway developed the biatrial orthotopic technique in canine models, and Christiaan Barnard performed the first human-to-human heart transplant in 1967 using that approach. The bicaval modification, introduced to better preserve atrial anatomy, became widely adopted as comparative data accumulated (jacob-2009). Reitz and colleagues subsequently demonstrated successful combined heart-lung transplantation (reitz-1982).

Debates

Biatrial versus bicaval anastomotic technique

Bicaval anastomosis better preserves right atrial geometry and is associated with less tricuspid regurgitation and fewer atrial arrhythmias and pacemaker needs, though it is technically more demanding; comparative reviews favour the bicaval approach.

Key figures

• Norman Shumway
• Richard Lower
• Christiaan Barnard
• Bruce A. Reitz

Seminal works

• reitz-1982

Frequently asked questions

What is the difference between the biatrial and bicaval techniques?

In the biatrial technique the donor and recipient atria are joined along atrial cuffs, whereas in the bicaval technique the right side is reconstructed by separate superior and inferior vena cava anastomoses. The bicaval method better preserves atrial geometry and is associated with fewer rhythm and tricuspid valve problems.

Why is cardiopulmonary bypass needed for a heart transplant?

Because the native heart is removed during the operation, a heart-lung (cardiopulmonary bypass) machine maintains the recipient's circulation and oxygenation until the donor heart is implanted, reperfused, and able to support the circulation.