1. Historic background of cardiac transplantation surgical techniques

On December 3, 1967 in Cape Town, Christiaan Barnard performed the first human heart transplant. This was one of the most significant accomplishments in history, allowing to save the life of several patients with end-stage heart disease in the last 50 years. This remarkable

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

surgical innovation was the result of constant work, diligent research, creativity and innovative perception. During the early 1900s, Alexis Carrel, the father of vascular and transplant surgery who was awarded the Nobel Prize in Physiology or Medicine in 1912, and Charles Guthrie, professor of Physiology and Pharmacology at Washington University, performed the first heterotopic heart transplant [1]. Subsequently, other American surgeons, including Mann [2] at Mayo Clinic in 1933 and Marcus [3] at Chicago Medical School two decades later, pursued the experimentation and proposed new techniques for heterotopic heart transplantation. At the same time, on the other side of the world, Vladimir Demikhov at M.V. Lomonosov Moscow State University gave a considerable contribution to this experimental specialty, performing the first combined heart-lung transplant and also the first orthotopic transplant in dogs without the use of hypothermia and pump-oxygenator support. His technique consisted of end-toside anastomoses between the corresponding thoracic aortae, superior venae cavae, inferior venae cavae, and pulmonary arteries. The donor's inferior pulmonary veins were joined together and connected to the recipient's left atrial appendage. Then, the portion of recipient's heart excluded from circulation was ligated and excised [4]. Unfortunately, Demikhov's research remained unknown for a long time and it was published in English only in 1962.

One month later, on January 6, 1968, Shumway and his team performed the first human heart transplant in the United States. The patient died of gastrointestinal bleeding on the 15th

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During the next year, 102 heart transplants were performed around the world, with only 40% survival at 1 year [7]. These poor results were the reason why the most important cardiovas-

After these first attempts, heart surgeons realized that specific suppression of the recipient's immune system was required for long-term graft survival. After the introduction of percutaneous transvenous endomyocardial biopsy in 1973, that improved the diagnosis of acute and chronic rejection, and the discovery of cyclosporine A in 1976, a powerful immunosuppressor, better results in terms of survival were achieved, therefore a greater number of procedures was

While the "Shumway technique" remained the standard for more than 20 years worldwide, in the early 1990s, some surgeons proposed new effective surgical techniques trying to improve hemodynamic results and late survival [10]. Despite the technical evolution, in the last 50 years, despite the improvement in pharmacological treatment of end-stage heart failure, cardiac transplantation has remained the only treatment (along with left ventricle assistance devices (LVAD) implantation as destination therapy) capable of improving the long-term survival [11, 12]. The standard BA technique, based on the description of Cass and Brock [13] and Lower and Shumway [5] for orthotopic heart transplantation (OHT), was adopted worldwide for many years due to its simplicity and reproducibility. This technique requires, to some extent, the excision of the posterior part of the donor's left atrium and the incision of the right atrium from the inferior vena cava toward the right atrial appendage to avoid injuries to the sino-atrial node. The atrial anastomoses can be performed easily, reducing from 8 possible

However, several studies have demonstrated that the drawback of this technique consists in enlarged, figure-of-eight configured right and left atria without a physiological geometry between the donor and the recipient's atria [14]. This non physiological geometry can lead to (i) higher incidence of mitral and tricuspid valve incompetence, (ii) rhythm disturbances [14] and (iii) tendency of thrombus formation and septal aneurysm [15]. Because of these problems, some authors, as Sir Magdi Yacoub, Banner and Dreyfus some time later [16–18] proposed a more anatomical surgical technique with complete excision of the recipient's atria and direct anastomoses to the left pulmonary veins, right pulmonary veins, inferior venae cavae (IVC), and superior venae cavae (SVC). No technical complications occurred, but the benefit of this

Sievers and co-workers [19] in 1991, and the Wythenshawe group [20] in 1993, introduced into clinical practice the bicaval transplantation technique (BC), characterized by two arterial, one left atrial, and two caval anastomoses, leaving the right atrium intact and leaving only a small posterior part of recipient's left atrial tissue between the pulmonary veins (Figure 2). Potential

single-vessel anastomoses for complete transplantation to 4 (Figure 1).

procedure on clinical outcome had to be demonstrated, at least in the 1990s.

postoperative day.

performed [6].

cular surgery centers abandoned the procedure.

The introduction of hypothermia and cardiopulmonary bypass in the early 1950s had a decisive impact on heart transplantation research.

In the late 1950s, Shumway and Lower at Stanford University achieved brilliant results experimenting on dogs [5]. They used a simple and effective surgical technique, called "Shumway" or biatrial technique (BA), where the anterior part of donor's left and right atria was incised and anastomosed to the posterior wall of the recipient's atria. This became the standard heart transplant surgical technique until the 1990s. These two pioneers also introduced two innovative methods that allowed to prolong survival times: the use of isotonic saline solution at 4C to preserve the donor's heart and the use of cardiopulmonary bypass to support the transplanted heart [6].

Based on these promising premises, Shumway begun to think about human heart transplant.

This research recalled the attention of the international scientific community, in particular of Christiaan Barnard, a young South African surgeon with a good reputation in open heart surgery who developed almost an obsession for heart transplantation. In August 1966, he spent 4 months in Lower's laboratory learning the principles of Shumway's research.

At his return to South Africa, on December 3, 1967, he performed the first heart transplant [7]. The donor was Denise Darvall, a 25-year-old woman who had a severe brain injury and was certified brain dead by the neurosurgeons. The recipient was Luois Washkansky, a 53-year-old man with severe heart failure; he died 17 days later due to pneumonia [8].

On December 6, 1967, Adrian Kantrowitz, another pioneer in this field, performed the first pediatric heart transplantation at Maimonides Hospital of New York. The donor was an anencephalic baby and the recipient was an 18-day-old child with Ebstein anomaly. Unfortunately, the young patient died after 6 hours [9].

One month later, on January 6, 1968, Shumway and his team performed the first human heart transplant in the United States. The patient died of gastrointestinal bleeding on the 15th postoperative day.

surgical innovation was the result of constant work, diligent research, creativity and innovative perception. During the early 1900s, Alexis Carrel, the father of vascular and transplant surgery who was awarded the Nobel Prize in Physiology or Medicine in 1912, and Charles Guthrie, professor of Physiology and Pharmacology at Washington University, performed the first heterotopic heart transplant [1]. Subsequently, other American surgeons, including Mann [2] at Mayo Clinic in 1933 and Marcus [3] at Chicago Medical School two decades later, pursued the experimentation and proposed new techniques for heterotopic heart transplantation. At the same time, on the other side of the world, Vladimir Demikhov at M.V. Lomonosov Moscow State University gave a considerable contribution to this experimental specialty, performing the first combined heart-lung transplant and also the first orthotopic transplant in dogs without the use of hypothermia and pump-oxygenator support. His technique consisted of end-toside anastomoses between the corresponding thoracic aortae, superior venae cavae, inferior venae cavae, and pulmonary arteries. The donor's inferior pulmonary veins were joined together and connected to the recipient's left atrial appendage. Then, the portion of recipient's heart excluded from circulation was ligated and excised [4]. Unfortunately, Demikhov's research remained unknown for a long time and it was published in English only in 1962.

The introduction of hypothermia and cardiopulmonary bypass in the early 1950s had a deci-

In the late 1950s, Shumway and Lower at Stanford University achieved brilliant results experimenting on dogs [5]. They used a simple and effective surgical technique, called "Shumway" or biatrial technique (BA), where the anterior part of donor's left and right atria was incised and anastomosed to the posterior wall of the recipient's atria. This became the standard heart transplant surgical technique until the 1990s. These two pioneers also introduced two innovative methods that allowed to prolong survival times: the use of isotonic saline solution at 4C to preserve the donor's heart and the use of cardiopulmonary bypass to

Based on these promising premises, Shumway begun to think about human heart transplant. This research recalled the attention of the international scientific community, in particular of Christiaan Barnard, a young South African surgeon with a good reputation in open heart surgery who developed almost an obsession for heart transplantation. In August 1966, he

At his return to South Africa, on December 3, 1967, he performed the first heart transplant [7]. The donor was Denise Darvall, a 25-year-old woman who had a severe brain injury and was certified brain dead by the neurosurgeons. The recipient was Luois Washkansky, a 53-year-old

On December 6, 1967, Adrian Kantrowitz, another pioneer in this field, performed the first pediatric heart transplantation at Maimonides Hospital of New York. The donor was an anencephalic baby and the recipient was an 18-day-old child with Ebstein anomaly. Unfortu-

spent 4 months in Lower's laboratory learning the principles of Shumway's research.

man with severe heart failure; he died 17 days later due to pneumonia [8].

sive impact on heart transplantation research.

nately, the young patient died after 6 hours [9].

support the transplanted heart [6].

110 Heart Transplantation

During the next year, 102 heart transplants were performed around the world, with only 40% survival at 1 year [7]. These poor results were the reason why the most important cardiovascular surgery centers abandoned the procedure.

After these first attempts, heart surgeons realized that specific suppression of the recipient's immune system was required for long-term graft survival. After the introduction of percutaneous transvenous endomyocardial biopsy in 1973, that improved the diagnosis of acute and chronic rejection, and the discovery of cyclosporine A in 1976, a powerful immunosuppressor, better results in terms of survival were achieved, therefore a greater number of procedures was performed [6].

While the "Shumway technique" remained the standard for more than 20 years worldwide, in the early 1990s, some surgeons proposed new effective surgical techniques trying to improve hemodynamic results and late survival [10]. Despite the technical evolution, in the last 50 years, despite the improvement in pharmacological treatment of end-stage heart failure, cardiac transplantation has remained the only treatment (along with left ventricle assistance devices (LVAD) implantation as destination therapy) capable of improving the long-term survival [11, 12]. The standard BA technique, based on the description of Cass and Brock [13] and Lower and Shumway [5] for orthotopic heart transplantation (OHT), was adopted worldwide for many years due to its simplicity and reproducibility. This technique requires, to some extent, the excision of the posterior part of the donor's left atrium and the incision of the right atrium from the inferior vena cava toward the right atrial appendage to avoid injuries to the sino-atrial node. The atrial anastomoses can be performed easily, reducing from 8 possible single-vessel anastomoses for complete transplantation to 4 (Figure 1).

However, several studies have demonstrated that the drawback of this technique consists in enlarged, figure-of-eight configured right and left atria without a physiological geometry between the donor and the recipient's atria [14]. This non physiological geometry can lead to (i) higher incidence of mitral and tricuspid valve incompetence, (ii) rhythm disturbances [14] and (iii) tendency of thrombus formation and septal aneurysm [15]. Because of these problems, some authors, as Sir Magdi Yacoub, Banner and Dreyfus some time later [16–18] proposed a more anatomical surgical technique with complete excision of the recipient's atria and direct anastomoses to the left pulmonary veins, right pulmonary veins, inferior venae cavae (IVC), and superior venae cavae (SVC). No technical complications occurred, but the benefit of this procedure on clinical outcome had to be demonstrated, at least in the 1990s.

Sievers and co-workers [19] in 1991, and the Wythenshawe group [20] in 1993, introduced into clinical practice the bicaval transplantation technique (BC), characterized by two arterial, one left atrial, and two caval anastomoses, leaving the right atrium intact and leaving only a small posterior part of recipient's left atrial tissue between the pulmonary veins (Figure 2). Potential

Figure 1. A schema of the Biatrial technique for orthotopic cardiac transplantation is shown. In the left (A), after cardiectomy, the double atrial cuff is distinguishable, with the interatrial septum with the foramen. In the right, (B) the right atrial cuff suture is represented.

Figure 2. The schema of the Bicaval technique has been designed. In the left side (A), both cavas and the left atrial cuff are prepared after cardiectomy, while in the right side (B) the final result with both superior and inferior vena cava sutures.

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Figure 2. The schema of the Bicaval technique has been designed. In the left side (A), both cavas and the left atrial cuff are prepared after cardiectomy, while in the right side (B) the final result with both superior and inferior vena cava sutures.

Figure 1. A schema of the Biatrial technique for orthotopic cardiac transplantation is shown. In the left (A), after cardiectomy, the double atrial cuff is distinguishable, with the interatrial septum with the foramen. In the right, (B) the

right atrial cuff suture is represented.

112 Heart Transplantation

shortcomings of the BC technique include the marginally prolonged ischemic transplantation time, which is likely of no clinical relevance, as well as some sort of stenosis at the level of the venous anastomoses. Both problems, however, can be neutralized by refined surgical techniques.
