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Outcomes in bicaval versus biatrial techniques in heart transplantation: an analysis of the UNOS database
Eric S Weiss1, Lois U Nwakanma, Stuart B Russell
1Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
Insights
Heart transplant atrial anastomotic techniques, bicaval and biatrial, show similar survival rates. The bicaval technique, however, is linked to shorter hospital stays and fewer pacemaker needs.
Area of Science:
- Cardiology
- Transplantation Surgery
- Medical Databases
Background:
- Optimal atrial anastomotic technique in heart transplantation remains debated.
- The United Network for Organ Sharing (UNOS) database offers a large cohort for analysis.
- Previous studies have not definitively established the superiority of one technique over another.
Purpose of the Study:
- To compare patient survival rates between bicaval and biatrial anastomotic techniques in orthotopic heart transplantation (OHT).
- To evaluate secondary outcomes including length of hospital stay and pacemaker placement.
- To leverage the UNOS database for a large-scale analysis of OHT outcomes.
Main Methods:
- Retrospective review of 14,418 adult OHT cases from the UNOS database (1999-2005).
- Stratification into bicaval versus biatrial anastomotic techniques.
- Cox proportional hazard regression analysis to compare survival, with secondary analysis of hospital stay and pacemaker needs.
Main Results:
- Of 11,931 eligible patients, 44% received the bicaval technique.
- No significant difference in overall survival was observed between bicaval and biatrial techniques (HR 1.06, p=0.31).
- The bicaval technique was associated with shorter hospital stays (19 vs. 21 days, p<0.001) and reduced pacemaker placement (2.0% vs. 5.3%, p<0.001).
Conclusions:
- This large series confirms no survival difference between bicaval and biatrial anastomotic techniques in OHT.
- The bicaval technique offers advantages in reduced hospital length of stay and lower rates of permanent pacemaker implantation.
- Both techniques achieve equivalent long-term survival in orthotopic heart transplantation.
Background:
Despite 40 years of heart transplantation, the optimal atrial anastomotic technique remains unclear. The United Network for Organ Sharing (UNOS) database provides a unique and novel opportunity to address this question by examining survival in a large cohort of patients undergoing orthotopic heart transplantation (OHT). We hypothesized that, when examining the issue on a large scale, no difference in survival would exist between techniques.
Methods:
We retrospectively reviewed first-time adult OHT in the UNOS database to identify 14,418 patients undergoing OHT between the years 1999 and 2005. Primary stratification was between those who underwent bicaval vs biatrial techniques. Baseline demographic and clinical factors were also recorded. The primary end-point was mortality from all causes during the study period. Secondary outcomes included length of hospital stay (LOS), and need for permanent pacemaker placement (PP). Post-transplant survival was compared between groups using a Cox proportional hazard regression model.
Results:
Of the 11,931 patients who met inclusion criteria between 1999 and 2005, 5,207 (44%) underwent the bicaval anastomotic technique. Bicaval and biatrial groups were well matched for gender, donor age, ischemic time, pulmonary vascular resistance, transpulmonary gradient, cardiac index, body mass index and pre-operative creatinine. Technique was not associated with survival during the study period (hazard ratio 1.06, p = 0.31). On multivariate analysis, age, gender, donor age and ischemic time were independent predictors of mortality. The bicaval technique was associated with less need for post-operative PP (2.0% vs 5.3%, p < 0.001) and shorter LOS (19 vs 21 days, p < 0.001).
Conclusions:
This study is the single largest series examining bicaval vs biatrial anastamotic techniques for OHT. We found no difference in survival between the two groups, although the bicaval technique was associated with shorter LOS and pacemaker placement. Both techniques lead to equivalent survival in OHT.
