ORTHOTOPIC CARDIAC TRANSPLANTATION WITH DIRECT CAVAL ANASTOMOSIS - ISIT THE OPTIMAL PROCEDURE

Total excision of the right atrium,vith a minimal cuff of left atrium remaining around the four pulmonary veins, followed by direct anastomo ses on venae cavae, has been proposed as an alternative to the standar d procedure described by Shumway and Lower for orthotopic cardiac tran splantation. To investigate whether this ''anatomic'' transplantation should be proposed as the optimal procedure, we prospectively randomiz ed 78 patients having 81 procedures since 1991 into two groups: group I, standard transplantation (n = 40), and group II, ''anatomic'' trans plantation (n = 41), The two groups were statistically similar in reci pient age, sex, weight, disease, and status at the time of transplanta tion. Also similar were donor age, sex, weight, and drug dependency at the time of harvesting, All patients could be weaned from cardiopulmo nary bypass with comparable graft ischemic times (group I, 136 +/- 46 minutes; group II, 138 +/- 51 minutes), Immediate recovery of sinus rh ythm occurred in 20 cases of group I and 36 cases of group LT, Delayed recovery of sinus rhythm in the first postoperative week occurred in 15 cases of group I and 5 eases of group If, Persistence of atrial arr hythmia occurred in 5 cases of group I and never in group II, These di fferences were highly significant (p < 0.001), Postoperative hemodynam ics showed a higher cardiac index at day 1 in group II (4.12 + 0.85 L/ min per square meter) than in group I (3.77 +/- 0.65 L/min per square meter) (p = 0.04), There were 13 early deaths in group I and 8 early d eaths' in group II, One death in group I was related to an acute atrio ventricular block at 3 weeks with no evidence of cardiac rejection at histologic examination. Two patients in group I (5%) required definiti ve pacemaker implantation for prolonged sinus node dysfunction, Echoca rdiographic and Doppler studies of survivors have been performed 2 to 3 months after transplantation, Right atrial area was significantly re duced (p < 0.01) in group II (18 +/- 4.7 cm(2)) versus group I (24 +/- 7 cm(2)), as was left atrial area (group I, 24 +/- 4.5 cm(2); group I I, 20 +/- 5 cm(2)) (p = 0.01), Mild tricuspid regurgitation was observ ed in 82% of group I patients versus 57% of group II patients (p < 0.0 5), inasmuch as mitral regurgitation was comparable (71% in group I, 6 7% in group II), Exercise performance realized in the same period show ed no difference in peak oxygen consumption between the two groups, Ev en the slight improvement in morbidity should lead surgeons to conside r this alternative technique as the optimal procedure, because the tec hnique appears simple and safe,