Operative method of transplantation in neonates and young infants with cardiomyopathy is the same as for adults with the option of utilizing profound hypothermic circulatory arrest. Method of transplantation in neonates and young infants with hypoplastic left heart syndrome is somewhat different because the portion of donor aorta distal to the arch vessels has to be anastomosed to the neoaorta in the recipient. In some cases, a heart lung transplant has to be performed and surgery differs.

Orthotopic Heart Transplant: Bicaval technique

In children with cardiomyopathy, the operative method of transplantation is the same as it is in adults. A median sternotomy is made, a thymectomy is performed, and the recipient’s native heart is exposed. If the donor heart is significantly larger than the native heart, the entire left pericardium anterior to the phrenic nerve is removed. A standard orthotopic technique using bicaval connection is used.

In general, bicaval anastomosis is the best technique used to minimize sinus node dysfunction and to maintain optimal tricuspid annulus configuration. Patients <10 kg at transplant could be underwent biatrial anastamosis to minimize vena caval stenosis.

During the cardiac transplantation procedure, the ventricles are excised, leaving the great vessels, right atrium, and left atrium of the recipient. The donor heart is then sewn to these areas.

Complex cardiac anomalies in heart transplant

Although intracardiac congenital malformations are replaced during heart transplant, extracardiac malformations (congenital, acquired, or iatrogenic) can present considerable challenges to the operative team. Before transplantation, a full comprehension of the operative plan for the management of each individual patient is essential for both the donor team and the recipient surgical

In some cases, some techniques have to be done to adapt the different variants of anatomic anomalies existing between the recipient and donors. The most common congenital abnormalities that require reconstruction at the time of heart transplant are: left superior SVC, absence of IVC, management of position of the great arteries, primary reconstruction of pulmonary arteries following prior congenital procedures or comprehensive reconstruction after prior hybrid type palliation (Chen J. Heart Transplant: Transplantation for Congenital Heart Disease, 2014).

Biventricular, complex congenital heart anomalies, such as transposition of the great arteries, can often be managed by means of direct anastomosis if sufficient lengths of donor arterial and venous connections are procured.