2. Biatrial vs. bicaval technique: Best evidences

During the 1990s, many single center reports, with variable potency and sample size have been published, comparing both techniques from different points of view and outcomes, like postoperative mortality, length of operation in terms of ischemic organ time, length of hospital stay, need for permanent pace maker, echocardiographic findings, exercise capacity and long-term survival.

Remarkable is the paper of Sun et al. [21] with a total of 615 enrolled patients. Among them, 322 were transplanted using the BC technique and 293 using the BA technique. There was no statistically significant difference in terms of early mortality (within 30 post-operative days) between the two groups (3.4% in the BC group vs. 4.8% in the BA group, p 0.5). The average follow-up period was 4.0 3.0 years (ranging from 1 to 11 years). There was no significant difference between groups (3.8 3.5 years in Group 1, 3.8 3.8 years in Group 2). Survival rates at 1, 5 and 10 years were 93, 89 and 87% in the BC group and 89, 82 and 80% in the BA group, respectively. Long-term survival differed significantly between the two groups and the cumulative proportion of survival was significantly higher in the BC group than in the BA group (p 0.05). In the univariate regression analysis, several echocardiographic parameters, such as left atrial diameter, mitral regurgitation, tricuspid regurgitation, left ventricular ejection fraction, right ventricular ejection fraction and surgical techniques, were predictors of long-term survival. Both mitral and tricuspid regurgitation were weakly associated with mortality. There were significant correlations between left and right ventricular ejection fraction and surgical techniques with mortality outcome. Using a multivariate model of analysis, left and right ventricular ejection fraction remained significant risk factors for mortality. When adjusted for left and right ventricular ejection fraction, the surgical techniques (BC vs. BA) significantly influenced mortality outcome in the multivariate analysis. Any significant difference in the incidence of mitral regurgitation between BC and BA transplant patients was demonstrated. However, tricuspid valve regurgitation was much more common in the BA group than in the BC group. They concluded that the BC technique helps to decrease atrial size and tricuspid regurgitation, and better preserves right and left heart function, resulting in improved long-term survival after heart transplantation compared with the BA technique.

Other authors have demonstrated that the BC technique leads to an increased parasympathetic reinnervation compared with the standard technique, which might be of clinical relevance because an increase in blood pressure control, by larger reflex changes in heart rate, might improve adaptation to various stimuli and to physical exercise [22].

Davies et al. [23] recently reported from the UNOS data base an analysis of 20,999 transplantations performed on adult patients with no congenital heart disease between 1997 and 2007, including the type of anastomosis performed. Patients were stratified accordingly to the atrial anastomosis technique: standard BA (atrial group, n. 11,919 [59.3%]), BC (caval group, n. 7661 [38.1%]), or total orthotopic (total group, n. 519 [2.6%]). First of all, until 2003, the BA technique

Institution Study Type Patients TVR PM

BA: 221 BC: 226

BA: 11.919 (59.3%) BC: 7.661 (38.1%) Total: 519 (2.6%)

BA: 6.724 BC: 5.207

BC: 872

BC: 1.968

BA: biatrial; BC: bicaval; NA: not analyzed; PM: pace-maker; TVR: tricuspid valve repair; \*= p< .01.

Table 1. Overview and outcomes of Biatrial vs. Bicaval for orthotopic heart transplantation.

BA:

Mild: 103 (37%) Moderate/ Severe: 63 (61%)\* BC:

Mild: 169 (61%) Moderate/ Severe: 39 (38%)

NA BA: 576

NA BA: 343

BA: 310/685 (45.2%) BC: 184/593 (31%)

BA: 153/261 (58.6%) BC: 61/211 (28.9%)

(5.1%) BC: 146 (2.0%) Total: 11 (1.9%)

(5.3%) BC: 103 (2.0%)

Retrospective Cohort Study

Retrospective Review UNOS database

Retrospective Review UNOS database

Meta-analysis BA: 914

Meta-analysis BA: 1.803

Insertion

Orthotopic Heart Transplantation: Bicaval Versus Biatrial Surgical Technique

Mortality Survival

5 years: 73% 10 years: 58% 15 years: 43% 20 years: 27% 115

BA: 1 year: 85.6%\* 5 years: 72.2%\* 10 years: 51.1%\* BC: 1 year: 87.1% 5 years: 73.5% 10 years: 57.4%

BA: 30-days: 93% 1 year: 86% 3 years: 79% 5 years: 72% BC: 30-days: 94% 1 year: 87% 3 years: 81% 5 years: 75%

NA

NA

NA 48 (9.9%) 1 year: 84%\*

http://dx.doi.org/10.5772/intechopen.76803

BA: 8.9% BC: 7.6% Total: 9.5%

BA: 30-days: 6.6% 1 year: 13.4% BC: 30-days: 5.4% 1 year: 11.5%

NA BA: 102/547 (18.6%) BC: 64/585 (10.9%)

NA BA: 18/110 (16.4%) BC: 9/118 (7.6%)

Author/ year

Wartig et al. 2014 [30]

Davies et al. 2010 [23]

Weiss et al. 2008 [24]

Locali et al. 2008 [28]

Schnoor et al. 2007 [10] Sahlgrenska University Hospital, Gothenburg, Sweden

Columbia University, New York, USA

Johns Hopkins Medical Institution, Baltimore, USA

Universidade Federal São Paulo, Brazil

Medical University Schleswig-Holstein, Luebeck, Germany

However the best way to reach some conclusion is by analyzing papers with the strongest evidences. Relevant among these, two multicenter studies from the UNOS database and other two meta-analysis (see Table 1).


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.

During the 1990s, many single center reports, with variable potency and sample size have been published, comparing both techniques from different points of view and outcomes, like postoperative mortality, length of operation in terms of ischemic organ time, length of hospital stay, need for permanent pace maker, echocardiographic findings, exercise capacity and long-term

Remarkable is the paper of Sun et al. [21] with a total of 615 enrolled patients. Among them, 322 were transplanted using the BC technique and 293 using the BA technique. There was no statistically significant difference in terms of early mortality (within 30 post-operative days) between the two groups (3.4% in the BC group vs. 4.8% in the BA group, p 0.5). The average follow-up period was 4.0 3.0 years (ranging from 1 to 11 years). There was no significant difference between groups (3.8 3.5 years in Group 1, 3.8 3.8 years in Group 2). Survival rates at 1, 5 and 10 years were 93, 89 and 87% in the BC group and 89, 82 and 80% in the BA group, respectively. Long-term survival differed significantly between the two groups and the cumulative proportion of survival was significantly higher in the BC group than in the BA group (p 0.05). In the univariate regression analysis, several echocardiographic parameters, such as left atrial diameter, mitral regurgitation, tricuspid regurgitation, left ventricular ejection fraction, right ventricular ejection fraction and surgical techniques, were predictors of long-term survival. Both mitral and tricuspid regurgitation were weakly associated with mortality. There were significant correlations between left and right ventricular ejection fraction and surgical techniques with mortality outcome. Using a multivariate model of analysis, left and right ventricular ejection fraction remained significant risk factors for mortality. When adjusted for left and right ventricular ejection fraction, the surgical techniques (BC vs. BA) significantly influenced mortality outcome in the multivariate analysis. Any significant difference in the incidence of mitral regurgitation between BC and BA transplant patients was demonstrated. However, tricuspid valve regurgitation was much more common in the BA group than in the BC group. They concluded that the BC technique helps to decrease atrial size and tricuspid regurgitation, and better preserves right and left heart function, resulting in improved long-term survival after heart transplantation compared with the BA technique.

Other authors have demonstrated that the BC technique leads to an increased parasympathetic reinnervation compared with the standard technique, which might be of clinical relevance because an increase in blood pressure control, by larger reflex changes in heart rate, might

However the best way to reach some conclusion is by analyzing papers with the strongest evidences. Relevant among these, two multicenter studies from the UNOS database and other

improve adaptation to various stimuli and to physical exercise [22].

two meta-analysis (see Table 1).

2. Biatrial vs. bicaval technique: Best evidences

survival.

114 Heart Transplantation

BA: biatrial; BC: bicaval; NA: not analyzed; PM: pace-maker; TVR: tricuspid valve repair; \*= p< .01.

Table 1. Overview and outcomes of Biatrial vs. Bicaval for orthotopic heart transplantation.

Davies et al. [23] recently reported from the UNOS data base an analysis of 20,999 transplantations performed on adult patients with no congenital heart disease between 1997 and 2007, including the type of anastomosis performed. Patients were stratified accordingly to the atrial anastomosis technique: standard BA (atrial group, n. 11,919 [59.3%]), BC (caval group, n. 7661 [38.1%]), or total orthotopic (total group, n. 519 [2.6%]). First of all, until 2003, the BA technique was used more frequently than the BC one, while the number of total transplantation decreased. In 2006, more than 34% of the cases of cardiac transplantation were performed with the "standard" or BA technique. The percentage of transplantations performed with the BC technique was higher at higher-volume transplant centers.

less than 18 years (n. 1831) and more than 80 years (n. 2), orthotopic total transplants (n. 482), heterotopic transplants (n. 4) and those without data on transplant technique (n. 139), the final study population was 11,931. Of these, 5207 (43%) received the BC anastomotic technique, with follow-up through September 2006. Almost 10,000 patient less than the population analyzed by Davies et al. [23]. Weiss et al. concluded that there was no difference in survival between BC and BA techniques when modeled with long-term follow-up and adjusted for confounding variables. Although the mortality rates were higher for the BA group at 30 days and 1, 3 and 5 years, this represents unadjusted mortality, which disappears in both the logistic regression and proportional hazards model for all time-points. Comparing both studies, we can conclude that probably the results obtained by Davies et al., due to the sample size and the interval period, are complementary to those obtained in the previous Weiss' UNOS analysis, giving more conclusive information. Also the BC technique gives the advantage of decreasing both the need of PPM and the post-operative mortality, but also influences positively the long

Orthotopic Heart Transplantation: Bicaval Versus Biatrial Surgical Technique

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117

Regarding two relevant meta-analysis, the first one, published by Schnoor et al. [10] in 2007, provides evidences that the expected theoretic advantages of BC transplantation, in comparison with the standard technique, have come true in clinical practice. The meta-analysis included 23 retrospective and 16 prospective studies. In prospective trials, a reduction in right atrial pressure was found. The absolute difference in right atrial pressure is probably of no clinical relevance at rest but it probably could be on exertion. It has been suggested that the patients with BC heart transplant may have superior exercise performance in comparison with BA heart transplant. An attempt to solve this dilemma has been done in 2011 by Czer et al. [25]: he did not found any significant difference in the exercise capacity between patients with BA versus BC techniques for orthotopic heart transplantation. Other factors such as cardiac denervation and immunosuppressive drug effect, or physical deconditioning, may be more important determinants of subnormal exercise capacity after heart transplantation. Nevertheless, the reduction in morbidity and postoperative complications and the simplicity in the BC technique suggest that the BC heart transplantation offers advantages when compared to the

Another study by Aleksic et al. demonstrated that the BC technique improves resting hemodynamics in patients with high preoperative pulmonary vascular resistance as highlighted by higher cardiac output and index with lower right atrial pressures. Further studies by Aleksic et al. showed that the BC technique improved hemodynamics during episodes of cellular

Other conclusions from the Schnoor meta-analysis confirmed the outcomes of other single center results, like a higher rate of sinus rhythm after transplantation in the BC group, as well as the significantly reduced rate of tricuspid valve regurgitation, the prevention of contraction abnormalities by the acute atrial enlargement with the standard technique, and the asynchrony of recipient and donor atrial innervation, improving hemodynamic effects after BC transplantation. The enlargement and distension of the atria typical of the standard technique might not only induce an impairment of the electrical impulse initiation and conduction, triggering arrhythmias, but also promote atrial thrombus formation, most likely avoided using the BC technique.

rejection (grade 1B-1R or greater) and during antibody-mediated rejection [26, 27].

term survival.

standard BA technique.

Regarding the outcomes, the need for permanent pacemaker was increased in patients in the atrial group (n. 576, 5.1%) requiring a PPM before discharge more often (odds ratio [vs. the caval group], 2.6; 95% CI, 2.2–3.1) than the caval group (n. 146, 2.0%) or the total group (n. 11, 1.9%; odds ratio [vs. the caval group], 1.0, 95% CI, 0.6–1.7). Multivariate predictors of the need for PPM implantation included BA anastomosis (odds ratio, 3.1; 95% CI, 2.5–3.9), donor age of 60–69 years (odds ratio, 2.9; 95% CI, 1.5–5.3), donor age of 50–59 years (odds ratio, 2.0; 95% CI, 1.6–2.5), donor age of 40–49 years (odds ratio, 1.3; 95% CI, 1.0–1.6), recipient inotropic support at transplantation (odds ratio, 1.5; 95% CI, 1.2–1.7), donor history of hypertension (odds ratio, 1.2; 95% CI, 1.0–1.4), and transplantation year (odds ratio, 1.04; 95% CI 1.01–1.07 [per year]); use of T4 before organ retrieval (odds ratio, 0.8; 95% CI, 0.6–0.9) was protective.

In terms of hospital length of stay, patients in the atrial group had longer posttransplantation stay (21.1 days) than those in the caval group (19.3 days, P < 0.0001).

In univariate analysis atrial group patients had a higher incidence of postoperative death (8.9%; odds ratio, 1.17; 95% CI, 1.05–1.30) than those in the caval group (7.6%; odds ratio, 0.83; 95% CI, 0.75–0.93); postoperative mortality in the total group (9.5%; odds ratio, 1.14; 95% CI, 0.86–1.53) was not significantly different from the one seen in either of the other groups. However, the logistic regression model predicting postoperative death did not include the type of anastomosis.

Also in the long-term outcomes, the need for PPM implantation was significantly higher among patients in the atrial group, (P < 0.0001): at 2 years, 8.6% required a pacemaker versus only 5.4% in the BC group and 4.0% in the total group. Multivariate predictors of the interval time between transplantation and PPM insertion included other factors, like recipient age (odds ratio, 1.006; 95% CI, 1.001–1.012 [per year]), transfusions between listing and transplantation (odds ratio, 1.2; 95% CI, 1.0–1.4), donor age of 50 to 59 years (odds ratio, 1.6; 95% CI, 1.3–2.0), donor's age of 60 to 69 years (odds ratio, 2.2; 95% CI, 1.3–3.7), transplantation year (odds ratio, 1.25; 95% CI, 1.21–1.28 [per year]), and BA anastomosis (odds ratio, 2.5; 95% CI, 2.2–2.9); ventricular assistance device at transplantation was protective in this model (odds ratio, 0.7; 95% CI, 0.6–0.9). There was a small but significant difference in long-term survival between the atrial and caval groups in univariate analysis (survival at 1 year, 85.6 vs. 87.1%; at 5 years, 72.2 vs. 73.5%; at 10 years, 51.1 vs. 57.4%; P < 0.0168). Multivariate Cox proportional hazards regression analysis confirmed the decreased survival among patients in the atrial group (hazard ratio, 1.11; 95% CI, 1.04–1.19). There was no difference in graft survival, renal failure-free survival, and transplant coronary atherosclerosis–free survival, based on anastomotic technique.

Three years before the UNOS analysis from Davies et al. [23], Weiss et al. [24] conducted a retrospective review of the UNOS database from January 1999 to December 2005. A total of 14,418 patients underwent first-time OHT during this period. After exclusion of patients aged less than 18 years (n. 1831) and more than 80 years (n. 2), orthotopic total transplants (n. 482), heterotopic transplants (n. 4) and those without data on transplant technique (n. 139), the final study population was 11,931. Of these, 5207 (43%) received the BC anastomotic technique, with follow-up through September 2006. Almost 10,000 patient less than the population analyzed by Davies et al. [23]. Weiss et al. concluded that there was no difference in survival between BC and BA techniques when modeled with long-term follow-up and adjusted for confounding variables. Although the mortality rates were higher for the BA group at 30 days and 1, 3 and 5 years, this represents unadjusted mortality, which disappears in both the logistic regression and proportional hazards model for all time-points. Comparing both studies, we can conclude that probably the results obtained by Davies et al., due to the sample size and the interval period, are complementary to those obtained in the previous Weiss' UNOS analysis, giving more conclusive information. Also the BC technique gives the advantage of decreasing both the need of PPM and the post-operative mortality, but also influences positively the long term survival.

was used more frequently than the BC one, while the number of total transplantation decreased. In 2006, more than 34% of the cases of cardiac transplantation were performed with the "standard" or BA technique. The percentage of transplantations performed with the BC technique

Regarding the outcomes, the need for permanent pacemaker was increased in patients in the atrial group (n. 576, 5.1%) requiring a PPM before discharge more often (odds ratio [vs. the caval group], 2.6; 95% CI, 2.2–3.1) than the caval group (n. 146, 2.0%) or the total group (n. 11, 1.9%; odds ratio [vs. the caval group], 1.0, 95% CI, 0.6–1.7). Multivariate predictors of the need for PPM implantation included BA anastomosis (odds ratio, 3.1; 95% CI, 2.5–3.9), donor age of 60–69 years (odds ratio, 2.9; 95% CI, 1.5–5.3), donor age of 50–59 years (odds ratio, 2.0; 95% CI, 1.6–2.5), donor age of 40–49 years (odds ratio, 1.3; 95% CI, 1.0–1.6), recipient inotropic support at transplantation (odds ratio, 1.5; 95% CI, 1.2–1.7), donor history of hypertension (odds ratio, 1.2; 95% CI, 1.0–1.4), and transplantation year (odds ratio, 1.04; 95% CI 1.01–1.07 [per year]);

In terms of hospital length of stay, patients in the atrial group had longer posttransplantation

In univariate analysis atrial group patients had a higher incidence of postoperative death (8.9%; odds ratio, 1.17; 95% CI, 1.05–1.30) than those in the caval group (7.6%; odds ratio, 0.83; 95% CI, 0.75–0.93); postoperative mortality in the total group (9.5%; odds ratio, 1.14; 95% CI, 0.86–1.53) was not significantly different from the one seen in either of the other groups. However, the logistic regression model predicting postoperative death did not include the type

Also in the long-term outcomes, the need for PPM implantation was significantly higher among patients in the atrial group, (P < 0.0001): at 2 years, 8.6% required a pacemaker versus only 5.4% in the BC group and 4.0% in the total group. Multivariate predictors of the interval time between transplantation and PPM insertion included other factors, like recipient age (odds ratio, 1.006; 95% CI, 1.001–1.012 [per year]), transfusions between listing and transplantation (odds ratio, 1.2; 95% CI, 1.0–1.4), donor age of 50 to 59 years (odds ratio, 1.6; 95% CI, 1.3–2.0), donor's age of 60 to 69 years (odds ratio, 2.2; 95% CI, 1.3–3.7), transplantation year (odds ratio, 1.25; 95% CI, 1.21–1.28 [per year]), and BA anastomosis (odds ratio, 2.5; 95% CI, 2.2–2.9); ventricular assistance device at transplantation was protective in this model (odds ratio, 0.7; 95% CI, 0.6–0.9). There was a small but significant difference in long-term survival between the atrial and caval groups in univariate analysis (survival at 1 year, 85.6 vs. 87.1%; at 5 years, 72.2 vs. 73.5%; at 10 years, 51.1 vs. 57.4%; P < 0.0168). Multivariate Cox proportional hazards regression analysis confirmed the decreased survival among patients in the atrial group (hazard ratio, 1.11; 95% CI, 1.04–1.19). There was no difference in graft survival, renal failure-free survival, and transplant coronary atherosclerosis–free survival, based on anasto-

Three years before the UNOS analysis from Davies et al. [23], Weiss et al. [24] conducted a retrospective review of the UNOS database from January 1999 to December 2005. A total of 14,418 patients underwent first-time OHT during this period. After exclusion of patients aged

use of T4 before organ retrieval (odds ratio, 0.8; 95% CI, 0.6–0.9) was protective.

stay (21.1 days) than those in the caval group (19.3 days, P < 0.0001).

was higher at higher-volume transplant centers.

of anastomosis.

116 Heart Transplantation

motic technique.

Regarding two relevant meta-analysis, the first one, published by Schnoor et al. [10] in 2007, provides evidences that the expected theoretic advantages of BC transplantation, in comparison with the standard technique, have come true in clinical practice. The meta-analysis included 23 retrospective and 16 prospective studies. In prospective trials, a reduction in right atrial pressure was found. The absolute difference in right atrial pressure is probably of no clinical relevance at rest but it probably could be on exertion. It has been suggested that the patients with BC heart transplant may have superior exercise performance in comparison with BA heart transplant. An attempt to solve this dilemma has been done in 2011 by Czer et al. [25]: he did not found any significant difference in the exercise capacity between patients with BA versus BC techniques for orthotopic heart transplantation. Other factors such as cardiac denervation and immunosuppressive drug effect, or physical deconditioning, may be more important determinants of subnormal exercise capacity after heart transplantation. Nevertheless, the reduction in morbidity and postoperative complications and the simplicity in the BC technique suggest that the BC heart transplantation offers advantages when compared to the standard BA technique.

Another study by Aleksic et al. demonstrated that the BC technique improves resting hemodynamics in patients with high preoperative pulmonary vascular resistance as highlighted by higher cardiac output and index with lower right atrial pressures. Further studies by Aleksic et al. showed that the BC technique improved hemodynamics during episodes of cellular rejection (grade 1B-1R or greater) and during antibody-mediated rejection [26, 27].

Other conclusions from the Schnoor meta-analysis confirmed the outcomes of other single center results, like a higher rate of sinus rhythm after transplantation in the BC group, as well as the significantly reduced rate of tricuspid valve regurgitation, the prevention of contraction abnormalities by the acute atrial enlargement with the standard technique, and the asynchrony of recipient and donor atrial innervation, improving hemodynamic effects after BC transplantation. The enlargement and distension of the atria typical of the standard technique might not only induce an impairment of the electrical impulse initiation and conduction, triggering arrhythmias, but also promote atrial thrombus formation, most likely avoided using the BC technique.

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

A good option to palliate the high incidence of tricuspid regurgitation is that patients undergoing HTx should have a prophylactic tricuspid valve annuloplasty [31, 32]. This may be a good option using the BA technique is used, but when the BC technique is used, prophylactic tricuspid annuloplasty not only becomes cumbersome intraoperatively, but also unnecessary

In light of these facts, the superiority of the BC technique demonstrated in many scientific relevant papers is undebatable. For this reason, some Authors postulated that the BA transplantation technique should no longer be considered the gold standard for transplantation, and should only be used in selected cases. Thus, today there is no more room for questioning whether there are advantages of the BC or total techniques over the BA technique, but it is legitimate to research possible advantages of one technique over the other, providing the

, Daniela Votano<sup>1</sup>

, Antonio Loforte<sup>1</sup>

Orthotopic Heart Transplantation: Bicaval Versus Biatrial Surgical Technique

http://dx.doi.org/10.5772/intechopen.76803

119

,

because none or mild TR appears to be the case in approximately 80% of patients.

, Luciano Potena<sup>2</sup> and Francesco Grigioni<sup>2</sup>

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

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

[1] Carrel A, Guthrie CC. The transplantation of vein and organs. AmMed. 1905;10:1101-1102

[2] Mann FC, Priestley JT, Markowitz J, Yater WM. Transplantation of the intact mammalian

[3] Marcus E, Wong SN, Luisada AA. Homologous heart grafts: Transplantation of the heart

[4] Cooper DK. Experimental development of cardiac transplantation. British Medical Jour-

[5] Lower RR, Shumway NE. Studies on orthotopic homotransplantation of the canine heart.

[6] DiBardino DJ. The history and development of cardiac transplantation. Texas Heart Insti-

\*, Marianna Berardi<sup>1</sup>

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

heart. Archives of Surgery. 1933;26:219-224

in dogs. Surgical Forum. 1951;2:212-217

nal. 1968;4:174-181

tute. 1999;26:198-205

Surgical Forum. 1960;11:18-19

patients with the best treatment.

Author details

Sofia Martin-Suarez<sup>1</sup>

Giuseppe Marinelli<sup>1</sup>

Italy

References

A good option to palliate the high incidence of tricuspid regurgitation is that patients undergoing HTx should have a prophylactic tricuspid valve annuloplasty [31, 32]. This may be a good option using the BA technique is used, but when the BC technique is used, prophylactic tricuspid annuloplasty not only becomes cumbersome intraoperatively, but also unnecessary because none or mild TR appears to be the case in approximately 80% of patients.

In light of these facts, the superiority of the BC technique demonstrated in many scientific relevant papers is undebatable. For this reason, some Authors postulated that the BA transplantation technique should no longer be considered the gold standard for transplantation, and should only be used in selected cases. Thus, today there is no more room for questioning whether there are advantages of the BC or total techniques over the BA technique, but it is legitimate to research possible advantages of one technique over the other, providing the patients with the best treatment.
