Successful Cavoatrial Anastamosis in Technically Challenging Liver Transplant Recipients.

Abstract

Introduction: There is an increasing number of patients on the waiting list for liver transplantation who have had previous liver resections or transplants. These cases can be technically challenging and there can be difficulty in obtaining an adequate suprahepatic vena caval cuff for anastamosis. Use of a cavoatrial anastamosis has been reported in Budd-Chiari syndrome only. We report using a cavoatrial anastamosis without need for median sternotomy. Methods: Four patients underwent liver transplantation at a single institution with a cavoatrial anastamosis between 2006-2010. It was determined intraoperatively that there was an inadequate caval cuff to perform a suprahepatic caval anastamosis. In all cases, the anastamosis was performed to the right atrium. The heart was accessed by undermining the sternum. The pericardium was opened in the midline to avoid the phrenic nerves. A side-biting clamp was used to clamp a small portion of the atrium. An atriotomy was made, and the atrium was anastamosed to the suprahepatic cava. The pericardium was closed at the conclusion of the case. Results: The demographic data of the recipients are summarized below.Table: No Caption available.The mean age of the patients was 56 years and the mean survival was 653 days. One of the four patients required a sternotomy to repair an atrial tear that occurred during the hepatectomy. Post-operative ultrasounds demonstrated patent vasculature in all patients. Three of the four patients are currently alive. The fourth died on post-operative day 6 from aspiration. Two of the three surviving patients did not have any persistent cardiac dysrhythmias from surgery. The third patient developed atrial fibrillation and was placed on warfarin anticoagulation that has since been discontinued. Conclusion: In the patient who does not have an adequate cuff of suprahepatic vena cava to perform an anastamosis, a cavoatrial anastamosis is a viable option. The heart can be approached without need for median sternotomy. Patient outcome is comparable to conventional anatomic liver transplantation.