Commentary: Tricuspid insufficiency after heart transplant: More of an art than a science.

J. Hunter Mehaffey, MD, MSc, Robert B. Hawkins, MD, MSc, and John A. Kern, MD

There are technical factors associated with tricuspid insufficiency after biatrial heart transplant and a bicaval approach may simplify restoration of atrial geometry.

See Article page 25.

In this issue of the Journal, Hajiyev and colleagues present a single-center retrospective analysis of tricuspid insufficiency (TR) after orthotropic heart transplant (OHT) using a biatrial technique performed between 1986 and 2010. This highly respected group from Berlin should be commended on their robust early experience with OHT and the scientific approach they take in attempting to identify factors associated with the development of “functional” TR. They identify the following risk factors as associated with post-OHT TR in multivariable analysis: (1) donor-to-recipient right atrium anterior wall ratio, (2) number of endomyocardial biopsies, and (3) recipient dialysis. The donor-to-recipient right atrium anterior wall ratio is important when attempting to recreate the atrial geometry.

After reading this article, I remain unclear as to what to do with these data and how to apply the results using a biatrial approach. The authors suggest leaving a “generous cuff.” but this is not the entire picture. On the recipient side, there is the atrial septum as well as the free wall. Leaving the free wall larger with a shorter septum is very different in terms of potential distortion of the atrial geometry than leaving both the free wall and the septum long. In addition, there is the donor atrium and the incision to open the donor atrium. Where should this incision be? It is naive to think that only the recipient atrium is important; both the location and the length of the donor atrium will affect rotation of the right heart.

Several groups have described the importance of restoring atrial geometry during biatrial OHT., Simplification of atrial geometry is one of several reasons that several groups have moved to a bicaval approach, including these authors by their own report. With the use of a bicaval approach, many patients are also able to avoid a permanent pacemaker, and United Network for Organ Sharing database studies have demonstrated a slight survival advantage. Ultimately, the authors emphasize technical aspects of biatrial OHT that highlight how reconstruction of the atrial geometry is more of an art than a science. The heterogeneous nature of this reconstruction requires that the surgeon understand and be able to recreate native geometry.