Over Ten Years of Experience with a Modified Right Atrial Anastomosis in Orthotopic Heart Transplantation: Follow-up and Comparison with the Biatrial and Bicaval Technique.

BACKGROUND: In 1997, a modified right atrial anastomosis (cavoatrial technique) for orthotopic heart transplantation (oHTx) was first developed in our institution. The purpose of this study is to report our long-term experience with this technique compared with biatrial and bicaval technique. METHODS: Retrospectively, 202 consecutive oHTx between 1997 and 2013 were analyzed. The applied transplantation techniques were biatrial (n = 108), bicaval (n = 22), and cavoatrial (n = 72). RESULTS: Demographic data were similar in all groups. The cardiopulmonary bypass and cross-clamp time were significantly shorter in the biatrial group. Follow-up echocardiographic examination showed excellent results in all groups with no relevant differences. After 1 year, occurrence of severe tricuspid regurgitation (biatrial 1.9% vs bicaval 0.0% vs cavoatrial 1.4%) was low in all groups. Rate of permanent pacemaker implantations was also low (12.0% vs 5.0% vs 11.1%). There were no significant differences in survival between the groups. CONCLUSION: The cavoatrial technique can be a safe and simple alternative for heart transplantation. Easy handling and similar reduced postoperative complications encourage the use of this technique.

Atrial function in heart transplant recipients operated with the bicaval technique.

OBJECTIVES: In heart transplantation (HTx) with the bicaval technique the whole right atrium (RA) is donor tissue while the left atrium (LA) consists of both donor and recipient tissue. The aims of the study were to describe atrial function in comparison with healthy controls and to identify determinants of dysfunction. DESIGN: Forty-three patients and 30 controls were retrospectively included. Echocardiography was performed within 24 h of right heart catheterization (RHC) (HTx recipients). RESULTS: The peak longitudinal atrial systolic strain (ɛ) described the atrial reservoir function. The LA and RA reservoir function were reduced versus controls (LA-ɛ 18 ± 8 versus 44 ± 10%; RA-ɛ 22 ± 10 versus 69 ± 17%, p < 0.001). There were moderate relationships between atrial-ɛ and ventricular filling pressure (r = -0.64 for LA-ɛ; r = -0.57 for RA-ɛ). In a multiple regression analysis the LA-ɛ was determined by pulmonary capillary wedge pressure (PCWP) and LA minimum volume index (r = -0.71) while RA-ɛ was dependent on the right ventricular ɛ (r = -0.77). CONCLUSIONS: Atrial reservoir function is markedly reduced in HTx recipients related to elevated PCWP and LA-enlargement in the LA and in the RA impaired longitudinal right ventricular function.

Total venous inflow occlusion and pericardial auto-graft reconstruction for right atrial hemangiosarcoma resection in a dog.

A sizeable right atrial hemangiosarcoma in a 6-year-old Bordeaux dog, World Health Organization (WHO) stage 2, was excised using total venous inflow occlusion. The defect was restored with a non-vascularized pericardial auto-graft. The dog had a disease-free interval of 7 mo. The dog was euthanized 9 months later, at which time there were distant metastases but no indication of local recurrence.

Occlusion totale du remplissage veineux et reconstruction par autogreffe péricardique pour une résection d'un hémangiosarcome atrial droit chez un chien. Un hémangiosarcome atrial droit considérable chez un chien Dogue de Bordeaux âgé de 6 ans, stade 2 de l'Organisation mondiale de la santé (OMS), a été excisé en utilisant l'occlusion totale du remplissage veineux. Le défaut a été rétabli par une autogreffe péricardique non vascularisée. Le chien a connu une période de sept mois sans maladie. Le chien a été euthanasié 9 mois plus tard, lorsque des métastases distantes ont été décelées, mais sans indication d'une récurrence locale.(Traduit par Isabelle Vallières).

Assessment of biatrial function in clinically well pediatric bicaval heart transplantation patients by three-dimensional echocardiography.

Atrial size and function are closely correlated with atrial contributions to cardiovascular performance. Therefore, in this study, we aimed to assess atrial size and function in pediatric heart transplantation (HTx) patients using three-dimensional echocardiography (3DE). We enrolled 33 clinically well pediatric HTx patients and 33 healthy controls with a similar distribution of sex and age to the HTx patients. All patients underwent two-dimensional echocardiography (2DE) and 3DE. 2DE- and 3DE-derived biatrial maximal volume (Vmax), minimal volume (Vmin), ejection volume (EV), ejection fraction (EF), volume before atrial contraciton (VpreA), passive EV, passive EF, active EV and active EF were obtained in all patients. The 3D left atrail (LA) Vmax, Vmin and VpreA increased significantly in HTx patients after being indexed by BSA, while 3D LAEV and passive EV decreased significantly (P < 0.05). Moreover, the 3D LAEF, LA passive EF, and LA active EF all decreased significantly in HTx patients (P < 0.05). The 3D right atrial (RA) Vmax, Vmin, and VpreA increased significantly in HTx patients (P < 0.05), while the 3D RAEF and RA passive EF decreased significantly in HTx patients (P < 0.05). 3DE-derived LAVmax, LAVpreA, LA passive EV, LAEF, and LA passive EF were all lower than the corresponding 2D parameters. 3DE-derived RAVpreA, RA passive EV and RAEF were all lower than the corresponding 2D parameters. Atrial sizes and function assessed by 3DE- and 2DE-derived parameters, yield significantly discordant results in pediatric HTx patients. 3DE confirms significantly enlarged atrial sizes and decreased atrial functions in pediatric HTx patients.

Mechanophysiologically active patch for closure of atrial septal defect.

Closure of atrial septal defects (ASDs) can be achieved by various methods right from direct closure to patch closure using various materials viz. pericardium, Dacron and Teflon, to device closure using percutaneous techniques. Although percutaneous techniques are the most commonly practised method in developed countries, a subset of patients will require surgical closure. Various patch materials have been used for long, but all of them have some complications and risks associated with them. We report a case of novel technique of ASD closure done using a pedicled, vascularised and contractile right atrial wall flap.

Closure of secundum atrial septal defect with autologous right atrial patch: case report.

BACKGROUND: Although various synthetic materials and pericardium have been used for atrial septal defect (ASD) closure, investigators are continuing to search for an ideal material for this procedure. We report and evaluate a case in which autologous right atrial wall tissue was used for ASD closure. CASE: In this case, we closed a secundum ASD of a 22-year-old woman who also had right atrial enlargement due to the defect. After establishing standard bicaval cannulation and total cardiopulmonary bypass, we opened the right atrium with an oblique incision in a superior position to a standard incision. After examining the secundum ASD, we created a flap on the inferior rim of the atrial wall. A stay suture was stitched between the tip of the flap and the superior rim of the defect, and suturing was continued in a clockwise direction thereafter. Considering the size and shape of the defect, we incised the inferior attachment of the flap, and suturing was completed. Remnants of the flap on the inferior rim were resected, and the right atrium was closed in a similar fashion. RESULTS: During an echocardiographic examination, neither a residual shunt nor perigraft thrombosis was seen on the interatrial septum. The patient was discharged with complete recovery. CONCLUSION: Autologous right atrial patch is an ideal material for ASD closure, especially in patients having a large right atrium. A complete coaptation was achieved because of the muscular nature of the right atrial tissue and its thickness, which is a closer match to the atrial septum than other materials.

Genetic, neurohumoral, and hemodynamic influences on spontaneously hypertensive rat heart development in oculo.

To distinguish among genetic, neurohumoral, and hemodynamic explanations for structural and functional differences in the hearts of young spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY) control rats, embryonic SHR and WKY rat heart tissue was cultured in the anterior eye chamber of adult SHR and WKY rats. In study 1, atria from E-12 WKY rat embryos grafted into anterior eye chambers of either SHR or WKY host rats achieved a larger size than did SHR grafts by 8 weeks in oculo (2.98 +/- 0.75 and 2.55 +/- 0.32 mm2 vs. 1.80 +/- 0.20 and 2.04 +/- 0.44 mm2). Beating rates did not differ between SHR and WKY rat atria implanted into SHR or WKY host rats. In study 2, ventricles from E-13 embryonic SHR and WKY rat hearts grew to similar size and weight when implanted into SHR or WKY host rats (e.g., SHR hearts, 1.81 +/- 0.32 vs. 1.74 +/- 0.33 mm2; WKY rat hearts, 1.75 +/- 0.29 vs. 2.29 +/- 0.32 mm2). Ventricle grafts from SHR embryos into SHR host rats beat more rapidly (165 +/- 19 beats/min) during weekly measurements than either WKY rat ventricles (92 +/- 9 beats/min in SHR hosts and 99 +/- 9 beats/min in WKY host rats) or SHR ventricles grafted into WKY host rats (109 +/- 7 beats/min, p less than 0.001). In study 3, atria from E-13 SHR and WKY rat embryos were grafted into sympathectomized and intact eye chambers of SHR or WKY host rats. Sympathectomy of the eye chamber compromised growth of grafts into WKY host rats (1.54 +/- 0.24 vs. 0.90 +/- 0.14 mm2) but not SHR hosts (1.54 +/- 0.25 vs. 1.73 +/- 0.24 mm2). Grafts into sympathectomized eye chambers of WKY host rats beat more slowly than grafts into eye chambers with sympathetic innervation intact (282 +/- 14 vs. 202 +/- 14 beats/min); sympathectomy did not alter beating rate of grafts in SHR hosts (266 +/- 14 vs. 255 +/- 18 beats/min). These results suggest that the growth and beating rate of SHR atrial grafts may be less sensitive to sympathetic innervation than WKY rat atrial grafts. In these studies, SHR grafts did not grow larger than WKY heart grafts and did not show an increased intrinsic beating rate, suggesting that the cardiac hypertrophy and increased intrinsic beating rate observed in intact SHR are unlikely to result from direct genetic programming.

Repair of congenital pulmonary venous stenosis with living autologous atrial tissue.

Repair of localized bilateral congenital pulmonary venous stenosis with living autologous atrial tissue was accomplished in two patients, 3 and 4 months of age. The tip of the left atrial appendage was opened and used as an onlay patch to widen the stenotic area of the left pulmonary veins, leaving a double pathway for venous return. A flap of interatrial septum was evaginated through an incision in the right side of the left atrium and used as an onlay patch to widen the stenotic area of the right pulmonary veins. Effective relief of obstruction was demonstrated by nearly normal postrepair pulmonary artery pressure in each and early postoperative angiography in one. Although we believe this method of repair will increase the probability of a lasting result, further experience and subsequent late reevaluation are needed to demonstrate its long-term effectiveness.

A comparison of intracellular solutions for donor heart preservation.

Numerous solutions have been advocated for the preservation of donor hearts, and there has been much interest in universal and intracellular preservation solutions. This study compared the effects of Euro-Collins, University of Wisconsin, and Bretschneider's solutions with the use of an in vitro human right atrial muscle preparation to assess recovery of function after a 24-hour period of simulated cardiac arrest. There were no statistically significant differences among groups in length, weight, cross-sectional area, initial developed force, or resting force of muscles, including those muscles that were contracted in Krebs-Henseleit solution and served as a control. After the 24-hour arrest period at either 4 degrees or 12 degrees C, the solution was changed back to Krebs-henseleit at 34 degrees C and recovery was assessed over 30 minutes. At 30 minutes, developed forces for muscles that were cooled to 4 degree C were 58.9%, 76.6%, and 60.7% of the control for Euro-Collins, University of Wisconsin, and Bretschneider's solutions, respectively (p = not significant). For those cooled to 12 degrees C, developed forces were 9.5%, 30.5%, and 95.6% of the control for Euro-Collins, University of Wisconsin, and Bretschneider's solutions (p = 0.0001). Bretscheider's solution resulted in greatly improved recovery compared with both Euro-Collins and University of Wisconsin solutions (p = 0.005), and University of Wisconsin solution was better than Euro-Collins solution (p = 0.02). Recovery of developed force was affected by temperature for Euro-Collins and University of Wisconsin solutions (p = 0.005 and p = 0.001, respectively) but not for Bretschneider's solution. Resting force was elevated in muscles that were cooled in both Euro-Collins and University of Wisconsin solutions at 12 degrees C compared with almost normal values for Bretschneider's solution at either temperature (p = 0.07). Bretschneider's solution has a very high buffering capacity, which may be beneficial for long-term preservation. In conclusion, Bretschneider's solution resulted in the best recovery of human atrial myocardial function after a 24-hour preservation period compared with Euro-Collins and University of Wisconsin solutions and should be considered for use in donor heart transportation. The variability in quality of preservation at different temperatures with either Euro-Collins or University of Wisconsin solution make them less desirable as preservation solutions because uniform temperatures are seldom obtained during donor heart transplantation.

The Cox maze iii procedure: parallel normalization of sinus node dysfunction, improvement of atrial function, and recovery of the cardiac autonomic nervous system.

OBJECTIVE: The Cox maze III procedure includes isolation of the pulmonary veins and multiple incisions in both atria in what corresponds to partial autotransplantation and partial denervation of the heart. The aim of this prospective longitudinal study was to identify physiologic effects of reinnervation on changes in heart rate at rest and in response to various stimulations and on atrial function after the Cox maze III procedure. PATIENTS AND METHODS: Power spectral analysis of heart rate variability, exercise testing, 24-hour Holter monitoring, electrocardiography, and transthoracic and transesophageal echocardiography were performed in 30 adult patients after the combined Cox maze III procedure and mitral valve surgery (maze group). They were prospectively followed up at 1, 3, 6, and 12 months after the operation. The results were compared with those of 15 heart transplant recipients (transplant group) and normal probands (healthy adults, n = 12). RESULTS: The physiologic effects of denervation with no differences in cardiac autonomic activity between the groups were seen early after the operation. Later, evidence of autonomic reinnervation was observed only in the maze group but not in the transplant group. Inappropriate heart rate responses during physical exercise were clearly evident in both groups after 1 and 3 months, with progressive improvement seen between 6 and 12 months only in the maze group. Left atrial function after the Cox maze procedure improved parallel to the recovery of sinus node function. CONCLUSION: Progressive improvement of sinus node function and atrial contractions with significant functional normalization 1 year after the Cox maze procedure corresponded to functional reinnervation and recovery of the autonomic nervous system.

A new approach to total repair of transposition of the great vessels: a technique for atrial autotransplantation.

We have devised a new operative procedure called atrial autotransplantation for transposition of the great vessels and applied it in 7 cases. Results were satisfactory except for one death. The bais of this technique was the experiment, using 70 dogs, in which the relationship of separation of the atrial wall and atrial septum to the development of arrhythmia was studied. It was found that reservation of the upper one sixth of the right atrial wall and the upper one third of the left atrial wall developed almost no significant arrhythmia with slow rate. By this concept and method, the left and right atria are almost completely separated, and a complete intraventricular and intra-atrial repair is made in a satisfactory operative field. Since there is no surgical intervention in the ventricular wall, postoperative cardiac function can be satisfactorily maintained. With this procedure intr-atrial conversion was performed in four cases and intraventricular conversion in three cases-the former for type I of uncomplicated transposition and type III of combined pulmonary stenosis, with or without VSD, and the latter for type II of combined large VSD. Only one patient with intraventricular conversion died of low cardiac output syndrome, probably due to incomplete relief of combined pulmonary stenosis.

Atrial transplantation for recurrent cardiac sarcoma.

Cardiac transplantation for sarcomas has met with little success and the surgical treatment remains controversial. We describe the case of a 56-year-old woman who was referred for transplantation after two procedures in which undifferentiated atrial sarcoma was locally excised successfully. The patient underwent atrial homograft transplantation, the first reported to date. Advantages of the procedure include wide atrial resection and no need for immune suppression.

A prospective randomized trial of complete atrioventricular transplantation versus ventricular transplantation with atrioplasty.

BACKGROUND: The standard technique of ventricular transplantation with atrioplasty (SOHT) distorts atrial anatomy. This may compromise diastolic ventricular function, impair atrioventricular valve competence and elevate resting ANP secretion. In contrast, complete atrioventricular anastomosis (CAVT) preserves atrial geometry. METHODS: We evaluated long term outcome in a prospective randomized trial of CAVT vs. SOHT. The primary outcome measures were peak oxygen uptake, atrioventricular valve regurgitation and ANP secretion. RESULTS: 58 recipients (median age 49 years; range 21-64) were consecutively randomized (29 CAVT; 29 SOHT). There were no differences in total ischaemic time, cardiopulmonary bypass time, postoperative bleeding or immunosuppression. Cardiopulmonary exercise tolerance testing was performed by 29 recipients at 742 to 1825 days. Pulmonary function was equivalent. Peak oxygen consumption expressed as a percentage of predicted maximum was 53.5% with CAVT and 63.8% with SOHT (p = 0.14). Echocardiography was performed on 41 recipients at 944 to 1665 days. There was less tricuspid regurgitation with CAVT (3/22 [13.6%] CAVT vs. 10/19 [52.6%] SOHT; p = 0.019). The incidence of mitral regurgitation was similar (5/22 [22.7%] CAVT vs. 4/19 [21.1%] SOHT; p = 0.803). Resting ANP secretion was assessed in 17 recipients at 1013 to 1812 days. All were hemodynamically stable and none had concurrent rejection. Resting ANP secretion was less with CAVT (CAVT: 283 pg/ml; SOHT: 521.4; p = 0.041). CONCLUSIONS: Peak oxygen consumption was not influenced by implantation technique. However, CAVT reduced the incidence of tricuspid regurgitation and attenuated the elevation in resting ANP secretion.

Intraatrial rerouting by atrial flaps for partial anomalous pulmonary venous return.

We report a new surgical correction technique using an autologous atrial septal flap and anterolateral right atrial wall in a 3-year-old girl with partial anomalous pulmonary venous return and lower margin atrial septal defect. The patient recovered smoothly and is doing well 3 years after the operation.

Myocardium and cortex cerebri xenografts transplanted into the anterior chamber of the eye of athymic rats: a morphologic and electrophysiologic profile.

Heart atria and cortex cerebri from fetal rabbits (E14 and E18, respectively) were grafted into the anterior eye chamber of anesthetized athymic nude rats and allowed to mature for 2-11 weeks. All grafts received a rich vascular supply from the host iris. Atrial transplants survived well but showed no significant growth while cortex grafts increased in size an average of 320%. Spontaneous action potentials were recorded from cellular elements in both tissues and, in the case of the atria, were accompanied by observable contractions. Functional cholinergic innervation from the autonomic ground plexus of the iris was elicited in both types of grafts by phasic retinal illumination. No evidence of immunologic rejection was found by histological analysis. Taken together, these data suggest that athymic rats may provide an appropriate host environment to study transplants of the central nervous and peripheral tissue from immunologically otherwise incompatible mammalian species.

Growth potential after root replacement of the right and left ventricular outflow tracts.

A successful operation for acute and severe aortic regurgitation after balloon valvuloplasty together with mitral regurgitation is described in a 9-month-old infant. Aortic root replacement was performed using a pulmonary autograft, while the right ventricular outflow tract was reconstructed with an interposed left atrial appendage posteriorly and a heterologous pericardial patch anteriorly. Mitral valve reconstruction was also effectively accomplished. This combination of right and left ventricular outflow tract reconstruction has a good potential for growth and may provide a solution for the future in infants.

Modification of the Senning repair in a case of transposition of the great arteries with juxtaposition of the atrial appendages.

A further modification of the Senning operation is described in a case of transposition of the great vessels with juxtaposition of the atrial appendages in which the right atrial appendage was excised and used as a free graft in the construction of the venous pathways.

Avoiding potential complications in left atrial reduction: partial heart autotransplantation.

Left atrial reduction is a surgical procedure designed in order to eliminate the chronic atrial fibrillation caused by mitral valve disease. However, this surgical technique is not high-risk free. Since a mount of tissue is excised from the left atrium, misalignment of the left atrium can be present. Bleeding of the posterior suture line in this chamber, as well as injury of the circumflex coronary artery may be fatal complications of this technique. Partial heart autotransplantation offers a good solution allowing an excellent visual operative field. The circumflex coronary artery is under direct vision while performing the anastomosis of the left atrium, and the suture line becomes safer and easier.

[The ultrastructural characteristics of the reactive changes in the cardiomyocytes of adult rats when cultured in vivo]. / Ul'trastrukturnye osobennosti reaktivnykh izmenenii kardiomiotsitov vzroslykh krys pri kul'tivirovanii in vivo.

60 implantes of the left atrium myocardium were studied on the 1st, 3rd and 6th days of in vivo culture according to F. M. Lazarenko method (outbred laboratory male rats of 200-250g. body weight were used both as donors and recipients). Reactive changes of the cultured cardiomyocytes were assessed by methods of light and electron microscopy. Polymorphic nature of the cardiomyocyte reactive changes with the preservation of its tissue pecific determination was established. Myocardium implant did not form myosymplastic elements, cellular characteristics of organization remained in its implanted pieces. Data concerning degenerating and surviving cardiomyocytes are presented as well as those on cellular forms, identification of which is difficult on the ultrastructural level.