Systemic embolism: a serious complication after cardiac transplantation avoidable by bicaval technique

Objective: Systemic embolism is a serious complication after classical orth otopic transplantation, presumably originating from enlarged left atrium. W e specifically studied this problem after classical and modified bicaval tr ansplantation. Methods: Between December 1985 and March 1999 we consecutive ly performed 72 classical and 106 modified heart transplantation. Modificat ion included bicaval anastomosis and recipient left atrium maximal reductio n. Mean age was 47 years. All the patients received an antiplatelet therapy and were routinely followed. When clinical signs of systemic embolism were present, a neurological evaluation and transesophageal echocardiography we re done. Sixty matched patients (30 of each group) had comparative transeso phageal echocardiography study, at least 6 months after transplantation. Re sults: Perioperative mortality was 17.4%. Mean follow-up was 6.82 + /47 yea rs. All patients were in sinus rhythm. Among 147 survivors, 11 patients who underwent classical transplantation had a systemic embolism, 1 month to 12 years after transplantation, 15.3%, (11/72). Two limb ischemia and one mes enteric ischemia (needing surgery), seven strokes (one death, two permanent neurological deficit). There was no systemic embolism in the modified tech nique group (P = 0.013). Left atrial comparative transesophageal echocardio graphy study showed a larger left atrial surface in classical transplantati on. 33 +/- 4 cm(2) versus 20 +/- 3 cm(2) in a modified technique, P = 0.01. Spontaneous echo contrast was present in 56% of classical technique group associated with atrial thrombosis in nine patients, there were no atrial th rombosis in modified technique group and spontaneous echocontrast was prese nt in 0.5% (P = <0.001). Conclusion: The occurrence of systemic embolism, l eft atrial spontaneous echocontrast and thrombosis when using classical tec hnique, and the absence of these complications with the bicaval technique j ustified the use of this method. Our experience with atrial thrombosis and spontaneous echocontrast rises the question of anticoagulation in classical transplantation. <(c)> 2001 Elsevier Science B.V. All rights reserved.