title: Modified inferior vena caval anastomosis to reduce tricuspid valve regurgitation after heart transplantation.
abstract: Postoperative tricuspid valve regurgitation is moderate to severe in 15% to 20% of heart transplant recipients despite use of the bicaval surgical technique. We hypothesized that the regurgitation might be partly due to increased tension on the donor right atrium. To study the right atrial distortion, we modified the standard bicaval anastomosis. Our technique involves augmenting the donor right atrial anterior wall with a flap of the recipient's right atrium, which is left attached in continuity with the anterior aspect of the inferior vena cava along 65% of its circumference. We measured tricuspid regurgitation, right atrial area, and right atrioventricular diameter in 7 consecutive patients who underwent orthotopic heart transplantation with the modified anastomosis. Tricuspid regurgitation was graded as follows: 1 = trace, <10%; 2 = mild, 10%-24%; 3 = moderate, 25%-50%; and 4 = severe, >50%. All patients were weaned from inotropic support within 1 week after transplantation with excellent ventricular function, no heart block, and 100% survival at 30 days. The median follow-up time was 173 days (44-358 days). Other median measurements included tricuspid valve regurgitation jet area, 0.30 cm(2) (0-1.90 cm(2)); right atrial area, 15.90 cm(2) (14.47-18.00 cm(2)); atrioventricular diameter, 2.70 cm (2.63-3.09 cm); and tricuspid regurgitation, 1.67% (0-12.42%). Mild regurgitation occurred in 1 recipient; in all others, it was trace. The modified inferior vena caval anastomosis is simple and safe. It eliminates moderate and severe tricuspid valve regurgitation without routine annuloplasty after orthotopic heart transplantation via the bicaval technique.
authors.affiliation: Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Marelli
authors.forename: Scott C
authors.initials: SC
authors.lastname: Silvestry
authors.forename: Donna
authors.initials: D
authors.lastname: Zwas
authors.forename: Paul
authors.initials: P
authors.lastname: Mather
authors.forename: Sharon
authors.initials: S
authors.lastname: Rubin
authors.forename: Anthony F
authors.initials: AF
authors.lastname: Dempsey
authors.forename: Louis
authors.initials: L
authors.lastname: Stein
authors.forename: Evelio
authors.initials: E
authors.lastname: Rodriguez
authors.forename: James T
authors.initials: JT
authors.lastname: Diehl
authors.forename: Arthur M
authors.initials: AM
authors.lastname: Feldman
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D000714:Anastomosis, Surgical / Q000379:methods; D016275:Atrial Function; D001830:Body Surface Area; D018618:Echocardiography, Doppler, Color; D005500:Follow-Up Studies; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D016027:Heart Transplantation / Q000009:adverse effects*; D006801:Humans; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome; D014262:Tricuspid Valve Insufficiency / Q000000981:diagnostic imaging / Q000209:etiology* / Q000503:physiopathology / Q000517:prevention & control*; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging / Q000601:surgery*; D016276:Ventricular Function