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(Circulation. 1998;97:1368-1374.)
© 1998 American Heart Association, Inc.

Clinical Investigation and Reports

Influence of Type of Surgery on the Occurrence of Parasympathetic Reinnervation After Cardiac Transplantation

Luciano Bernardi, MD; Cinzia Valenti, MD; Joanna Wdowczyck-Szulc, MD; Axel W. Frey, MD; Mauro Rinaldi, MD; Giammario Spadacini, MD; Claudio Passino, MD; Luigi Martinelli, MD; Mario Viganò, MD; ; Giorgio Finardi, MD

From the Department of Internal Medicine (L.B., C.V., G.S., C.P., G.F.) and Department of Cardiac Surgery (M.R., L.M., M.V.), University of Pavia and IRCCS S Matteo, Pavia, Italy; the First Department of Cardiology, Medical University of Gdansk, Poland (J.W.-S.); and the Herz-Zentrum, Bad Krozingen, Germany (A.W.F.).

Correspondence to Luciano Bernardi, MD, Clinica Medica 1, Università di Pavia–IRCCS S Matteo, 27100 Pavia, Italy. E-mail LBern1ps{at}ipv36.unipv.it

Background—Cardiac autonomic reinnervation after human cardiac transplantation has been demonstrated frequently but to date only for sympathetic efferents. Standard surgical techniques leave many parasympathetic branches intact in the original atria and thus with less stimulus to reinnervate the donor atria.

Methods and Results—We used changes in the RR-interval power spectrum induced by sinusoidal modulation of arterial baroreceptors by neck suction at different frequencies to detect both parasympathetic and sympathetic reinnervation in 79 subjects with "standard" and 10 "bicaval" heart transplants. In 24 subjects (17 standard and 7 bicaval), the protocol was repeated 6 and 11 months after transplantation. Neck suction at 0.20 Hz produced a component at 0.20 Hz in the RR-interval spectrum not due to respiration (fixed at 0.25 Hz), which suggested parasympathetic reinnervation, in 4 of 10 bicaval but in only 2 of 79 standard transplant subjects (whose recipient atria underwent >50% resection to remove scars of previous interventions), P<.001. In only 1 (bicaval) transplant subject was parasympathetic reinnervation present 6 months after transplantation (confirmed 3 months later); in 4 subjects, it was absent at 6 months but appeared after 11 months after transplantation. Atropine (0.04 mg/kg IV) abolished the response to fast (0.20 Hz) and reduced that to slow stimulation, confirming the presence of parasympathetic reinnervation (4 subjects).

Conclusions—Parasympathetic reinnervation depends on the surgical technique: because bicaval surgery cuts all sympathetic and parasympathetic nerves, regeneration might be stimulated similarly in both branches. Standard surgery cuts only 50% of sympathetic fibers; most recipient parasympathetic axons remain intact, hence their regeneration might not be stimulated.

Key Words: heart rate • transplantation • arrhythmia • baroreceptors

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