The bicaval Wythenshawe technique in 2018

We read with interest the brief report by Shudo et al., entitled ‘A modified technique for orthotopic heart transplantation to minimize warm ischaemic time’ [1]. In this article, the authors present a successful modification of their implantation technique in order to minimize warm ischaemic time utilized in a single recipient. The interval from procurement to implantation is subdivided into cold and warm ischaemia times and has been extensively studied [2, 3]. The bicaval technique was popularized in the 1990s with 2 different approaches being described a few years apart from the Lubeck and Wythenshawe groups [4, 5]. The former report presented the initial experience with 2 patients, while the latter publication was a randomized study with 20 patients in each arm. Since describing the bicaval Wythenshawe technique 25 years ago [5], we have also modified our technique over recent years in an attempt to reduce the warm ischaemic insult in the recipient. Following left atrial anastomosis, the posterior aspect of the inferior caval anastomosis is carried out whilst a single shot of antegrade cold blood cardioplegia is delivered. Prior to releasing the aortic cross-clamp, the posterior aspect of the pulmonary arterial and aortic anastomoses are carried out in that order. Once the cross-clamp is released, the inferior vena caval and pulmonary arterial anastomoses are completed. The superior vena caval anastomosis is the final anastomosis performed. On occasion, we have found that fashioning the posterior aspect of the inferior caval as well as the pulmonary arterial anastomoses may prove technically challenging once the cross-clamp has been removed. This is particularly true in redo cases with friable tissue, as in the presence of abundant coronary sinus return and right ventricular ejection, respectively, access and visibility may be significantly compromised. Repair of an anastomotic imperfection may invariably require reapplication of the cross-clamp in these instances. We therefore accept the trade-off between minor prolongation in warm ischaemia to meticulous surgical technique. Undeniably an appealing approach to reduce warm ischaemic times, the impact on compensating for prolonged travel times is probably limited. From our experience especially with DCD donation, the use of organ preservation platforms is presently the most promising technological advancement in that respect [6].