[A comparative study of standard and total orthotopic cardiac transplantation]

The classical orthotopic heart transplant modifies size and geometry of the atria, may affect mitral and tricuspid function, and ventricular filling. A technical modification with subtotal excision of the recipient's heart, with anastomosis of a cuff of left atrium and of venae cavae has been used and compared with 2 consecutive series of transplantations : 70 classical (group I) 1986-1991, and 50 modified (group II) 1992-1994. The patients were similar for age, pretransplant characteristics, postoperative treatment. The aortic cross-clamping in the recipient (duration of cardiac excision and graft implantation) has been longer in group II (87 +/- 19 mm vs 65 +/- 15: p < 0.001). No surgical complication due to the technique was observed. Mortality was similar in the 2 groups (14% group I, 18% group II; NS). Five patients of group I has a systemic embolism (1 month to 5 years after transplant), none in group II. Two comparable groups of 30 patients were studied at least 6 months after transplantation with: surface EKG, Holter, transthoracic and esophageal echodoppler. A larger number of EKG anomalies, a significant increase in the size of atria, a significantly larger number of mitral and tricuspid insufficiencies, an increase in the variability of E/A ratio (left ventricular filling parameter) were noted after classical transplantation. Spontaneous contrast echo and thrombus in the left atrium were also noted after classical transplant. We conclude that these technical modifications result in a geometry and anatomy closer to normal. Less anomalies of the cardiac function were found. Due to the absence of left atrial thrombus and of systemic embolism we think that there is a definite advantage in this technically rather simple approach.