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Interact CardioVasc Thorac Surg 2009;9:333-342. doi:10.1510/icvts.2008.200121 © 2009 European Association of Cardio-Thoracic Surgery
Is bicaval orthotopic heart transplantation superior to the biatrial technique?
a Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK Received 3 December 2008; received in revised form 1 April 2009; accepted 21 April 2009
*Corresponding author. Tel.: +1 713 2569045.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the bicaval heart transplantation technique is superior to biatrial orthotopic heart transplantation (OHT). Altogether, 175 papers were found using the reported search, of which 20 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that many papers have documented the superiority of the bicaval technique over the biatrial technique for short-term outcomes. A meta-analysis of 41 papers on this topic found significant benefits for early atrial pressure, tricuspid valve regurgitation, return to sinus rhythm and even perioperative mortality. But for longer-term outcome, the largest series of 11,931 patients found no difference in survival between the two groups and the meta-analysis found no mortality differences at 1 or 3 years. The bicaval technique is also more demanding technically and has a slightly longer bypass and ischaemic time. The United Network for Organ Sharing (UNOS) database showed that in 2005 in the USA the bicaval technique has now become more popular than the biatrial technique (1083 procedures vs. 806).
Key Words: Evidence-based medicine; Orthotopic transplantation; Bicaval anastomosis; Biatrial anastomosis; Survival; Arrhythmia
A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
In [patients undergoing heart transplant] is [bicaval heart transplantation] superior to [biatrial heart transplant] in terms of [mortality and morbidity].
You are a transplant fellow performing your third heart transplant. The last two transplants were performed under the supervision of the director of your programme and he guided you through the biatrial technique. You were most impressed by how quick it was. You are now being supervised by the newest consultant who is recommending you perform the bicaval technique. You find it more difficult and slower, and after the procedure you resolve to look up the perceived benefits with this technique that he told you about including less tricuspid regurgitation and a higher incidence of sinus rhythm.
Medline 1966 to August 2008 using OVID interface [Cardiac surgery.mp OR exp Thoracic Surgery/OR exp Heart Transplantation/OR heart transplant.mp] AND [bicaval.mp OR biatrial.mp].
Using the reported search, 175 papers were identified. Twenty papers provided the best evidence to answer the clinical question (Table 1).
The biatrial technique introduced by Lower and Shumway for orthotopic heart transplantation (OHT) is very attractive in its simplicity and widely used as a standard technique. In the 1990s, the bicaval and total heart transplant techniques have been introduced and gained popularity, Weiss et al. [2] retrospectively reviewed patients undergoing first-time adult OHT in the United Network for Organ Sharing (UNOS) database to identify 11,931 patients undergoing OHT between the years 1999 and 2005. Although the biatrial group had a higher mortality at 24% vs. 18% at five years, this difference disappeared once confounding variables were taken into account. The bicaval technique was associated with shorter length of stay by two days and only 2% received pacemakers compared to 5.3% with biatrial transplant. Schnoor et al. [3] in 2007 performed a meta-analysis of 41 studies. The retrospective studies included 753 patients undergoing heart transplantation by means of the standard technique, 203 patients undergoing heart transplantation according to the method of Banner's technique (total), and 517 patients undergoing heart transplantation according to the method of Sevres's technique (bicaval). The prospective studies included 318 patients with the standard technique and 305 patients with the bicaval technique. The ischaemic times were slightly longer for the bicaval technique (WMD of 3.7 min for prospective studies and 15.8 min for retrospective studies), but there were several significant advantages for the bicaval technique, including reduced early atrial pressure (4.0 mmHg), a 59% relative mortality risk reduction when combining three prospective studies, and a 77% reduction in tricuspid valve regurgitation when summarizing seven prospective studies. The odds of sinus rhythm were also seven times higher in two prospective studies and three times higher in three retrospective studies. Kendall et al. [4] conducted one of the earliest randomized studies in 60 patients, but failed to find any advantages using a bicaval technique during functional evaluation at 4–6 months postoperatively. Tricuspid regurgitation was less common in the bicaval transplant group. Laske et al. [5] also showed that tricuspid valve regurgitation during the first two weeks improved in all recipients with bicaval anastomosis and in only 14% of the recipients with biatrial anastomoses. In addition, the biatrial group required more pacing (P<0.01). El-Gamel et al. [6] randomized patients to either their ‘Wythenshawe’ bicaval technique, previously described by Sarsam et al. [7], or the biatrial technique and found that bicaval orthotopic cardiac transplantation is associated with a lower right atrial pressure, a lower likelihood of atrial tachyarrhythmias, less need for pacing, less mitral incompetence, a lower diuretic dose, and a shorter hospital stay. Aziz et al. [8] showed in a comparative cohort study of 200 patients that there was a significant and persistent survival advantage with the bicaval technique, with a 5-year survival of 62% in the biatrial patients compared to 81% in the bicaval group (P=0.02). Milano et al. [9] found that mortality was similar for the two groups in this study, length of postoperative hospitalization was longer for the standard group relative to the bicaval group (12.1 days vs. 20.4 days, P<0.001). And cardiac index at 24 h after operation was increased for the bicaval group relative to the standard group (3.15±0.7 vs. 2.7±0.5 l/min/m2, P<0.05). Aleksic et al. [10] found that total OHT improved cardiac output in patients with high preoperative pulmonary vascular resistance. Koch et al. [11] showed that the significant reduction of left atrial size and atrio-ventricular valve regurgitation in the total transplant group might have an important impact on the long-term preservation of cardiac function. Solomon et al. [13] showed in a study of 75 patients a non-significant trend towards less pacing, less tricuspid regurgitation and lower central venous pressures with the bicaval technique. Grande et al. [14] concluded the same, in regard to conduction disturbances and major arrhythmias, however, the bicaval technique had a significantly lower blood loss, and required less isoproterenol use (5.9 vs. 3.4 days, P=0.005). Traversi et al. [15] used the echocardiographic automatic boundary detection technique to obtain on-line time/volume curves of the right and left atria and found that bicaval anastomosis technique results in smaller atrial volumes, yields better right and left atrial function than the standard technique. Meyer et al. [18] demonstrated a significant reduction in the need for permanent pacemaker insertion at 30 and 90 days with the bicaval technique. Grant et al. [19] found that a higher proportion of those who received biatrial technique required pacing than those who did not (P= 0.082). Bernardi et al. [20] showed that the proportion of patients showing evidence of parasympathetic re-innervation was significantly higher for the bicaval technique (P<0.001). Leyh et al. [21] provide some evidence that the bicaval technique improves cardiovascular dynamics as well as exercise capacity and duration (P<0.05). Furthermore, Sievers et al. [22] showed that bicaval technique preserves right atrial size and reduces tricuspid regurgitation during exercise. However, Pahl et al. [23] found that the bicaval anastomosis patients had similar endurance and peak heart rates compared to the standard biatrial group. Cui et al. [24] showed that the incidence of atrial flutter (Afl) was significantly higher in patients who underwent biatrial procedure (P<0.01). But atrial fibrillation (AF) was similar in both techniques.
Many papers have documented the superiority of the bicaval technique over the biatrial technique for short-term outcomes. A meta-analysis of 41 papers on this topic found significant benefits for early atrial pressure, tricuspid valve regurgitation, return to sinus rhythm and even peri- operative mortality. But for longer-term outcomes, the largest series of 11,931 patients found no difference in survival between the two groups and the meta-analysis found no mortality differences at 1 or 3 years. The UNOS database showed that in 2005 in the USA the bicaval technique has now become more popular than the biatrial technique (1083 procedures vs. 806).
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Abstract
1. Introduction