Conventional and total orthotopic cardiac transplantation: a comparative clinical and echocardiographical study.

OBJECTIVE: Clinical interest has recently emerged in a new technique of heart transplantation with bicaval and pulmonary venous anastomosis. This technique is thought to improve left heart function and reduce thromboembolism. We have used this technique systematically since 1993. We compared the patients transplanted before September 1993 with the standard technique and the patients transplanted with the new technique.

METHODS: A total of 135 patients were transplanted at our institution from 1987 to 1995, 100 with the standard technique and 35 with the new technique. of these, 95 survivors were studied by transthoracic and transesophageal echocardiography; 65 were transplanted with the standard technique ('standard' group) and 30 with the new technique ('total heart' group). All patients were free from rejection and in sinus rhythm when studied.

RESULTS: Boths groups were similar in pretransplant characteristics. Operative data were similar with a limited increase in the ischemic time with the total heart technique (210 +/- 73 min for 'total heart' vs. 196 +/- 84 min for 'standard'). Right heart catheterization showed comparable cardiac output and pulmonary pressures. Peripheral embolic events occured in 9 patients in the 'standard' group and none in the 'total heart' group. The left atrium was larger in the 'standard' group (58 +/- 6 vs. 42 +/- 4 mm, P = 0.0006). Left atrial spontaneous echo contrast was present in 32 patients in group 'standard' and none in 'total heart' group (P < 0.0001), and left atrial thrombi were detected in 17 patients in group 'standard' vs. none in group 'total heart' (P = 0.01). All patients with a history of embolism had left atrial thrombus and spontaneous echo contrast.

CONCLUSION: This study showed a high incidence of left atrial spontaneous echo contrast and thrombi when using the standard technique, which was absent when using the total heart technique. Total heart transplantation with bicaval and pulmonary venous anastomosis should be preferred for heart transplantation.