Author details

Another relevant meta-analysis is the one conducted by the Brazilian group from San Paolo. Fagionato et al. [28] aimed at increasing the statistical power of the evidences supporting the new techniques against the BA transplantation, thus adding significance to the results of Schnoor et al. They demonstrated many advantages of the BC technique on the BA one: first of all, the ischemia time in the BC group, even when longer, as found in some studies, is compensated by a better cardiac performance with the new techniques, since adequate ventricular filling is dependent on a satisfactory atrial function. Furthermore, the incidence of atrial arrhythmias was lower in the group undergoing BC transplantation, like in Schnoor's study. This can be explained by the preservation of the sino-atrial node integrity. Modifications in the atrial geometry predispose to atrial arrhythmias, as well as increased internal pressure, since these events prolong the electrical conduction time. The severity of the newly developed arrhythmias is known to be also related and proportional to the severity of the rejection. Fagionato's results show no differences between the transplantation techniques in terms of rejection, concluding that the episodes of atrial arrhythmias are mainly due to greater deformity and atrial pressure. In this context, the rejection episodes can also be related to the degree of tricuspid valve regurgitation. In 2002, Aziz et al. [29] showed that individuals with moderate or severe tricuspid regurgitation have a higher number and intensity of rejection events. On the other hand, the progression of cardiac cellular rejection may be accompanied by oedema and papillary muscle dysfunction, or trigger asymmetrical right ventricular contractility, thus leading to tricuspid valve regurgitation. Additionally, the high hydrophilic property of the valve leaflets glycosaminoglycans leads to increased oncotic pressure in the extracellular matrix during cellular rejection, thus causing oedema and precluding adequate function. In this regard, there is another outstanding study conducted from the Swedish group of Wartig et al. [30] that demonstrated in a pretty huge population the impact of the transplantation techniques on the tricuspid function, as well as its impact on survival. Tricuspid valve regurgitation after cardiac transplantation has been argued to be related to the number of biopsies (although this has been found to be contradictory), to the altered geometry of the right atrial anastomosis in the BA technique, to the preoperative recipient's pulmonary vascular resistance, to the ischemic time of the donor's heart, to the donor-recipient size mismatch, to the mismatch between the donor's heart and a large pericardial cavity of the recipient, or to the presence of TR already in the donor. Wartig et al. revised retrospectively their population of transplanted patient since 1984, comparing both cohorts of 221 patients receiving BA technique and 226 receiving BC technique. They observed first that the incidence of early significant TR after HTx was more common after the BA technique than after the BC technique. Furthermore, they demonstrated with a multivariate logistic regression analysis that the BA technique was the only significant predictor of early moderate to severe TR (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.68–4.32; p 0.001). More interestingly, they found that moderate and severe TR at discharge was associated with impaired long-term survival. Moreover, it has been previously shown that the degree of TR is related not only to degree of symptoms and right-sided heart pressures but also to progressive renal dysfunction. When stratifying for technique, we found more patients with significant TR in the BA group at early and also 5-year follow-up, compared to the BC group; however, there was no difference at 10 year of follow-up between groups. The explanation might be that patients in the BA group

118 Heart Transplantation

with significant TR died before 10-year follow-up.

Sofia Martin-Suarez<sup>1</sup> \*, Marianna Berardi<sup>1</sup> , Daniela Votano<sup>1</sup> , Antonio Loforte<sup>1</sup> , Giuseppe Marinelli<sup>1</sup> , Luciano Potena<sup>2</sup> and Francesco Grigioni<sup>2</sup>

\*Address all correspondence to: docsofi74@hotmail.com

1 Cardiac Surgery Department, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy

2 Cardiology Department, S. Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
