Mohamed T. Hassanein, MD, PhD and Dominic Emerson, MD
Cedars-Sinai Medical Center, Los Angeles, CA, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Jose P. Garcia, MD and Tae H. Song, MD.
Essential Operative Steps
- Communication with procurement team throughout the procedure
- Lines and monitoring including Swan-Ganz Catheter after general endotracheal anesthesia
- Intraoperative TEE
- Median sternotomy after confirmation and communication with procurement team
- For redo sternotomy, obtain femoral vessel access in the event of groin cannulation
- Dissection to free up heart/ventricular assist devices
- Creation of pericardial well
- Proceed with cardiopulmonary bypass once donor heart is close to arrival
- Systemic heparinization 350-400 u/kg
- Arterial cannulation
- Bicaval venous cannulation – in the setting of a redo sternotomy, a long IVC cannula may be placed through the femoral
vein - Check ACT >400-450 secs
- Initiate cardiopulmonary bypass
- Crossclamp aorta and tighten caval snares
- Recipient cardiectomy
- Backtable preparation of donor organs including inspection of all valves, evaluation for possible PFO, closure of the LAA
vent site (when required), and trimming of cuffs - Left atrial anastomosis
- IVC anastomosis (may be partially completed)
- PA anastomosis (may be partially completed), and start rewarming
- Aortic anastomosis to completion – at this point, you may remove the aortic crossclamp once warm
- Completion of PA and IVC anastomoses
- SVC anastomosis
- Remove aortic crossclamp if not done after completion of the aortic anastomosis
- Allow for reperfusion of transplanted organ
- Check for hemostasis, inspect suture lines
- Wean from CPB
- Venous decannulation
- Atrial and ventricular epicardial pacing wire placement
- Protamine administration for heparin reversal
- Aortic decannulation
- Chest tube placement
- Sternotomy closure
Potential Complications and Pitfalls
Difficult redo sternotomies may require early femoral cannulation and initiation of cardiopulmonary bypass to ensure the heart
is decompressed during reentry into the chest. Proper planning with CT guidance may facilitate decision making. Dissection
and subsequent recipient native cardiectomy may be difficult, but often a “measure twice, cut once” approach is used. Once all
anastomoses are complete and coagulopathy is addressed, it is important to be in a good hemodynamic profile with a robust CI 2.2 and tolerable right ventricular function (this may differ from center to center). Concern for primary graft dysfunction
necessitating VA-ECMO support may be considered in select situations.
- Difficult redo sternotomy, cardiectomy
- Inadequate communication with procurement team
- Prolonged donor heart ischemic time due to the above issues
- Cannulation issues (aortic dissection/bleeding, caval injury)
- Inadequate cuffs for anastomosis
- Kinking of anastomoses and/or insufficient length resulting in tension
- Sinoatrial node injury
- Improper deairing
- Bleeding from anastomoses
- Inadequate control of hemostasis prior to sternal closure/bleeding from cannulation sites
- Coagulopathy
- Primary graft dysfunction
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g. End-stage heart failure due to non-ischemic cardiomyopathy]
Postoperative Diagnosis: Same (with appropriate adjustments)
General Indications:
- Cardiogenic shock requiring continuous intravenous inotropic support or circulatory support with an IABP or
mechanical circulatory support (such as temporary left ventricular assist device) to maintain adequate organ perfusion - NYHA functional class IV heart failure symptoms refractory to optimal medical and surgical therapy (including the use
of devices) - Peak VO2 (VO2max) less than 10mL/kg/ min
- Intractable or severe anginal symptoms in patients with coronary artery disease not amenable to percutaneous or
surgical revascularization, including cardiac allograft vasculopathy - End-stage congenital HF with no evidence of pulmonary hypertension
- Intractable life-threatening arrhythmias unresponsive to medical therapy, catheter ablation, surgery, or an implantable
cardioverter-defibrillator - Selected patients with restrictive and hypertrophic cardiomyopathies and NYHA Class III to IV HF
Procedure(s) Performed: Orthotopic heart transplantation with backtable preparation of donor organ (and PFO closure, when
performed)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: The patient is a [AGE]-year-old [SEX] with a [DURATION] history of [COMPLAINT: e.g.
ischemic cardiomyopathy, idiopathic dilated cardiomyopathy, end-stage heart failure secondary to amyloid deposition]. The
patient had previously undergone placement of a left ventricular assist device (LVAD) as a bridge to transplant, and an organ
appropriate for implantation became available.
Description of the Procedure: The patient was taken to the operating room on [DATE]. After identification of the patient and
verification of informed consent, the patient was placed on the operating room table in supine position. General anesthesia was
administered after endotracheal intubation. A right internal jugular central venous line and a PA catheter was placed. A right
radial arterial line was inserted. The chest, abdomen, and groins were prepped and draped in sterile fashion. A timeout was
performed, including confirmation that preoperative antibiotics had been given.
After confirming with the procurement team that the donor organ was suitable for implantation, median sternotomy was
performed. [For redo cases, as needed: “The right femoral vessels were then exposed. A cutdown over the CFA/V was
performed and taken down to expose them. Pursestring sutures were placed in preparation for bypass.” OR “Femoral artery
and femoral vein access was obtained with 5Fr catheters prior to beginning redo sternotomy to facilitate rapid femoral vessel
access, should it be needed.”] Communication with the procurement team was continued throughout the case. The heart and
LVAD were dissected free. Careful dissection was continued to free up the native heart and great vessels. Aortic cannulation
sutures were then placed in the distal ascending aorta close to the arch. Bicaval cannulation sutures were placed in the SVC
and IVC/right atrium junction. With the donor heart near the hospital, intravenous heparin was given. The aortic cannula was
then inserted, secured, and deaired. The PA catheter was withdrawn into the sheath. SVC and IVC venous cannulas were then
placed and secured. Umbilical tape snares were passed around the SVC and IVC. After verifying adequate ACT,
cardiopulmonary bypass was initiated, and the patient was cooled to 28 oC.
The aortic crossclamp was applied, and the caval snares were tightened. The native cardiectomy is performed starting with an
incision in the right atrium taken caudal to the coronary sinus. We then exposed the fossa ovalis and entered the left atrium.
The proximal aorta and PA were transected ensuring adequate cuffs for the anastomoses. The left atrium was then cut above
the level of the left atrial appendage and then taken along the dome of the left atrium to the fossa ovalis. From the coronary
sinus we excised the left atrium to the left atrial appendage, leaving an adequate cuff and visualization of all four pulmonary
veins. The SVC and IVC were also dissected out, leaving sufficient length for anastomoses. The heart, along with the LVAD,
was explanted. Hemostasis was achieved, and the vessels and atrial cuff were examined and trimmed in preparation for
anastomosis. During this time, the donor heart had been brought into the room and was prepared at the back table. This was
done by Dr. [BLANK]. A patent foramen ovale was found in the donor heart and was closed. The heart was of good quality,
and all valves were inspected and adequate. ABO compatibility was verified and documented in the chart. The donor heart was
then brought onto the field. We first performed the left atrial anastomosis using a double-armed 4-0 prolene suture. A catheter
was placed in the right superior pulmonary vein and fed into the left ventricle just before closing the anastomosis. We then
turned our attention to the inferior vena cava. The IVC anastomosis was partially completed. Then, the PA anastomosis was
performed using 4-0 prolene suture. Rewarming was then begun. We then turned our attention to the aortic anastomosis which
was completed with 4-0 prolene suture. The aortic crossclamp was removed after giving 1 gram of Solu-Medrol. The heart was
allowed to reperfuse. We then turned our attention back to the completion of the IVC anastomosis. The SVC anastomosis was
then completed as the heart continued to be reperfused. We made sure that there was no narrowing at the caval anastomoses.
We were careful not to injure the sinoatrial node during manipulation of the SVC. The heart continued to be reperfused for
approximately 20 minutes before attempting to wean from bypass. Caval snares were released, and the heart was briefly
elevated to allow us to evaluate the left atrial suture line, which appeared hemostatic. The lungs were suctioned, and ventilation
was started. The heart chambers were checked for air on TEE, and deairing maneuvers were performed. Inotropes and pressors
were started by anesthesia, and the patient was weaned off cardiopulmonary bypass. TEE showed good biventricular function
and widely patent anastomoses. The venous cannulae were removed and the PA catheter was re-advanced into the main PA.
Protamine was administered and hemostasis was achieved. The remaining suture lines were inspected carefully. Atrial and
ventricular pacing wires were placed, and atrial pacing was started. After ensuring hemodynamic stability, the aortic cannula
was removed. Two 28Fr chest tubes were placed in the mediastinum: one curved tube at the diaphragm and one straight tube
anteriorly. 19Fr Blake drains were placed in the right and left pleural spaces. The sternum was closed with a total
of [BLANK] stainless steel sternal wires. The fascia was closed with #1 PDS suture in running fashion. The deep dermal layer
was then closed with running 2-0 vicryl suture. The skin was closed with 4-0 monocryl suture in a running fashion, and a sterile
dressing was applied. All sponge and needle counts were correct, twice. The total cardiopulmonary bypass time was
[NUMBER] minutes. The total ischemic time of the donor heart was [NUMBER] minutes. The patient tolerated the procedure
well and was taken to the cardiac intensive care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
52-year-old male is 8 years status post heart transplant for non-ischemic cardiomyopathy. He presents to the ED with dyspnea
on exertion and fatigue and is found to be in cardiogenic shock. He has remained compliant on his immunosuppression
medications and has regular follow-up. He is admitted to your ICU for close monitoring. Cardiology has started
immunosuppressive medications and CT surgery has been called to evaluate for possible transplantation. What is the best next
step?
A. Evaluation for IABP placement
B. Continue with steroids
C. Left and right heart catheterization
D. Retransplantation
Answer: C. Left and right heart catheterization to assess degree of cardiac allograft vasculopathy. While continuation of steroids
and additional immunosuppressive measures are possible at this time, attempting to delineate the degree of rejection and
assessment of hemodynamics, including evaluation of coronaries, will help inform subsequent steps.
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Transplantation (ISHLT) Infectious Diseases, Pediatric and Heart Failure and Transplantation Councils. The 2016
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