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A prospective randomized trial of complete atrioventricular transplantation versus ventricular transplantation with
A D Bainbridge1, M Cave, M Roberts
1Transplant Unit, Papworth Hospital NHS Trust, Papworth Everard, Cambridge, UK.
Insights
Complete atrioventricular anastomosis (CAVT) in heart transplantation preserves atrial geometry, reducing tricuspid regurgitation and ANP secretion compared to standard technique with atrioplasty (SOHT). This improves long-term outcomes for heart transplant recipients.
Area of Science:
- Cardiovascular Surgery
- Transplantation Medicine
- Cardiac Physiology
Background:
- Standard orthotopic heart transplantation with atrioplasty (SOHT) distorts atrial anatomy, potentially impairing ventricular function and valve competence.
- Complete atrioventricular anastomosis (CAVT) preserves atrial geometry, offering a potential alternative to SOHT.
Purpose of the Study:
- To compare the long-term outcomes of CAVT versus SOHT in heart transplant recipients.
- To evaluate the impact of surgical technique on exercise tolerance, atrioventricular valve function, and atrial natriuretic peptide (ANP) secretion.
Main Methods:
- A prospective randomized trial comparing CAVT and SOHT in 58 heart transplant recipients.
- Primary outcome measures included peak oxygen uptake, atrioventricular valve regurgitation via echocardiography, and ANP secretion.
- Follow-up assessments were conducted between 742 and 1825 days post-transplantation.
Main Results:
- No significant difference in peak oxygen consumption between CAVT and SOHT groups (53.5% vs. 63.8% predicted, p=0.14).
- CAVT significantly reduced tricuspid regurgitation compared to SOHT (13.6% vs. 52.6%, p=0.019).
- Resting ANP secretion was significantly lower in the CAVT group (283 pg/ml vs. 521.4 pg/ml, p=0.041).
Conclusions:
- Implantation technique did not influence peak oxygen consumption in heart transplant recipients.
- CAVT demonstrated a lower incidence of tricuspid regurgitation and attenuated elevation in resting ANP secretion compared to SOHT.
- CAVT may offer advantages in preserving atrioventricular valve function and reducing neurohormonal activation post-transplantation.
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.