ORTHOTOPIC CARDIAC TRANSPLANTATION WITH C AVAL ANASTOMOSES - A COMPARATIVE RANDOMIZED STUDY WITH THE STANDARD PROCEDURE IN 81 CASES

Complete resection of the right atrium with conservation of a strip of left atrium around the 4 pulmonary veins followed by direct anastomos is on the vena cava has recently been proposed as an alternative to th e standard orthotopic cardiac transplantation described by Shumway and lower. In order to determine whether this ''anatomical'' transplantat ion should now be considered to be the procedure of choice, a prospect ive randomised study was undertaken in 1991 including 78 patients unde rgoing 81 cardiac transplantations by one of the two techniques: gr. I : classical transplantation (n = 40), gr. II: ''anatomical'' transplan tation (n = 41). The groups were comparable in age, sex, weight, natur e of the underlying cardiac disease and clinical status at the time of transplantation. Similarly, the parameters of the donors were compara ble with respect to age, sex, weight and dosage of inotropic drugs at the time of explantation. All patients came of cardiopulmonary bypass with comparable ischaemia time of the graft (gr. I : 136 +/- 46 min: g r. II : 138 +/- 51 min). Immediate return to sinus rhythm occurred in 20 cases in gr. I and 36 cases in gr. II. Atrial arrhythmia persisted in 3 cases in gr. I but in no cases of gr. II. These differences were very significant (p < 0.001). There were 13 early deaths in gr. I and 8 in gr. II. Doppler echocardiography was performed two to three month s after transplantation. The right atrial surface was significantly de creased in gr. II (18 +/- 4.7 cm(2)) compared with gr. I (24 +/- 7 cm( 2)): the same difference was observed for the left atrium (gr. 1 :24 /- 4.5 cm(2); gr. II : 20 +/- 5 cm(2)), p = 0.001. Tricuspid regurgita tion was observed in 82 % of patients in gr. I compared with 57 % in g r. II (p < 0.005). Exercise stress tests during the same period showed no difference in peak oxygen consumption between the groups. Holter E CG monitoring led to permanent pacing in 2 patients of gr. I (5 %). Th e technical simplicity and reduction of postoperative morbidity, espec ially with respect to arrhythmias, suggest an advantage with the ''ana tomical'' technique considering the lack of surgical complications.