Impact of Modified Anastomosis Sequence on Warm Ischemic Time and Clinical Outcomes in Orthotopic Heart...

Prolonged ischemic time adversely affects outcomes after orthotopic heart transplantation (OHT). We implemented a modified anastomosis sequence to reduce warm ischemic time (WIT) and evaluated its impact on myocardial preservation and clinical outcomes.

We retrospectively analyzed 273 OHT recipients who underwent either a conventional (n=101) or modified (n=172) sequence between March 2009 and December 2020. In the modified group, the left atrial and aortic anastomoses were completed under aortic cross-clamping (ACC), followed by reperfusion and completion of the remaining anastomoses on a beating heart. Baseline imbalances were addressed using inverse probability of treatment weighting based on propensity scores, with additional adjustment for covariates that remained imbalanced after weighting.

After adjustment, the modified anastomosis sequence was associated with shorter WIT (43.3±2.8 vs. 61.1±3.2 minutes; p<0.001) and lower postoperative myocardial injury markers, including creatine kinase-myocardial band and troponin-I. The modified sequence was also associated with lower odds of low cardiac output syndrome requiring extracorporeal membrane oxygenation support (odds ratio [OR], 0.07; 95% confidence interval [CI], 0.01-0.59; p=0.016) and left ventricular primary graft dysfunction (OR, 0.05; 95% CI, 0.00-0.53; p=0.014). Early mortality showed no statistically significant association with the anastomosis sequence. Findings were consistent in prespecified sensitivity analyses addressing transplant era.

The modified anastomosis sequence was associated with shorter WIT, lower myocardial injury markers, and a lower risk of early graft dysfunction. As a structured approach intended to reduce WIT through earlier ACC release, the modified sequence may be associated with more favorable early myocardial preservation and graft function after transplantation.