A Preclinical Model of Orthotopic Heart Transplantation in Bama Miniature Pigs Using Biatrial Technique

Summary

This study proposes a preclinical orthotopic heart transplantation model in Bama miniature pigs, utilizing the biatrial technique. The model is applicable for transplant immunology, drug evaluation, and surgical technique optimization, providing support for clinical heart transplantation applications.

Abstract

Although significant progress has been made in heart transplantation, issues such as graft preservation, primary graft dysfunction, cardiac allograft vasculopathy, and long-term immune tolerance remain unresolved. Due to anatomical size and immunological differences, mouse models are unable to effectively replicate clinical heart transplantation surgeries and immune responses. In contrast, pig models, which share more similarities with humans in terms of heart anatomy and immune response, are particularly suitable for orthotopic heart transplantation research. In this study, we established a biatrial orthotopic heart transplantation model in Bama miniature pigs. The transplanted hearts demonstrated prompt and robust contractility postoperatively without signs of elevated central venous pressure or other hemodynamic complications. Following a short period of intensive care unit monitoring, the pigs regained consciousness and resumed spontaneous feeding, indicating stable postoperative recovery. In summary, this model offers a clinically relevant experimental platform for evaluating new technologies and therapeutic approaches in the field of heart transplantation research.

Introduction

Since the first heart transplant in 1967, significant advancements have been made in heart transplantation. However, in the past two decades, there have been few major breakthroughs in clinical practice. Core issues such as graft dysfunction, cardiac allograft vasculopathy (CAV), and long-term immune tolerance remain unresolved^1,2,3,4. Despite numerous findings in basic research, these discoveries have been challenging to translate into clinical applications, leading to a stagnation in the progress of heart transplant treatments. Therefore, effectively evaluating new technologies and therapies has become a critical issue, which highlights the importance of animal models, especially appropriate preclinical models, in addressing these challenges.

While mouse models have been widely used in heart transplantation research, they have significant limitations due to anatomical and physiological differences from humans, making it difficult to fully replicate the clinical heart transplant procedure and postoperative immune responses. Moreover, the immune system is relatively different, which fails to adequately reflect the complex immune responses seen in large animal models^5,6,7. Additionally, due to their small size, heart transplants in mice are limited to heterotopic transplants, which diverges from the clinical practice of orthotopic heart transplantation^8,9,10,11. Therefore, the use of appropriate large animal models, particularly pigs, is crucial.

Pig models offer significant advantages in heart transplantation research, especially in orthotopic heart transplantation. The pig heart is anatomically similar to the human heart, and pigs exhibit immune responses and organ physiological functions that are much closer to those of humans, making them an ideal platform for heart transplantation studies. Furthermore, pig models provide more complex and detailed experimental data, enabling researchers to better evaluate new immunosuppressive strategies, cardiac protection methods, and long-term outcomes post-transplant^12,13,14,15. While some studies have utilized abdominal heterotopic models in pigs, which avoid the use of cardiopulmonary bypass and reduce surgical complexity, they fail to fully replicate the clinical scenario of orthotopic heart transplantation¹⁶. Therefore, in this study, we have established a dual-atrium orthotopic heart transplantation model in Bama miniature pigs, providing a more clinically relevant experimental platform for advancing heart transplantation techniques.

Protocol

The animal experimental protocol for this study was approved by the Institutional Animal Care and Use Committee (IACUC) of Fuwai Hospital, Chinese Academy of Medical Sciences, with the ethical approval number 0108-1-70-ZX(X)-41. All experiments were conducted in strict accordance with animal welfare and ethical guidelines, ensuring compliance with relevant ethical standards.

1. Preoperative preparation

1. Select male Bama miniature pigs weighing 35-40 kg (10-12 months old) for the orthotopic heart transplantation experiment and allow them to acclimate to the housing environment for 1 week prior to surgery.
2. Perform routine blood tests (hematology and chemistry panels), liver and kidney function assessments, and echocardiography to evaluate organ systems and ensure overall health of the animals.
3. Match the donor and the recipient based on ABO blood type and heart size. Determine the blood type according to the method reported by Choi et al.¹⁷, and assess the heart size via echocardiography to ensure proper matching.
   NOTE: Since body weight does not have a linear relationship with heart size, heart size measured by echocardiography was used as the basis for matching. Specifically, the diameter difference of the ascending aorta was limited to less than 2 mm, the difference in left ventricular end-diastolic diameter to less than 3 mm, and the difference in end-systolic diameter to less than 2 mm.

2. Donor procedure

1. Anesthesia and animal preparation
   1. Subject the donor pigs to fasting for 12 h and withhold water for 4 h before surgery to ensure the stomach is empty, thereby reducing the risk of vomiting and aspiration during anesthesia.
   2. Induce anesthesia with a combination of Ketamine (10 mg/kg) and Midazolam (1 mg/kg) through intramuscular injection. Following induction, maintain anesthesia using inhalational Isoflurane (2-3%) along with an infusion of Dexmedetomidine (1 U/kg) and Propofol (1-2 mg/kg/h) to maintain anesthesia depth.
   3. Confirm whether anesthesia is adequate by ensuring a relaxed jaw tone and the absence of pain response during a toe pinch. Perform orotracheal intubation using a 6.5-8 mm endotracheal tube, ensuring unobstructed airflow and providing 100% oxygen.
   4. Establish peripheral venous access via the ear vein to facilitate intravenous fluid administration and drug injections. Establish femoral artery access for blood pressure monitoring, ensuring real-time monitoring of hemodynamic parameters.
   5. Throughout the procedure, continuously monitor a 12-lead electrocardiogram (ECG) to track the heart status of the animal. Maintain the depth of anesthesia consistently, adjusting the drug dosage as needed to ensure an appropriate level of anesthesia.
2. Harvesting of the donor heart
   1. Thoracotomy: After shaving the pig, disinfect the surgical area with povidone-iodine and drape the field, then use high-frequency electrocautery to make a midline incision from the mid-cervical region to below the xiphoid process, followed by a sternal incision. Cauterize the sternum and apply bone wax to achieve hemostasis (Figure 1A).
   2. Heparinization: After opening the chest, administer 300 U/kg of heparin for systemic anticoagulation to prevent thrombosis during the procedure.
   3. Thymectomy: Carefully lift and separate the thymus from the pericardium using electrocautery to excise the thymus, ensuring no bleeding occurs.
   4. Open the pericardium and clear the connective tissue from the anterior aspect of the main pulmonary artery (Figure 1B). Use electrocautery to dissect the space between the ascending aorta and pulmonary artery to expose the great vessels. Then, ligate the left hemi-azygous vein (Figure 1C).
      NOTE: The left hemi-azygous vein in pigs directly drains into the coronary sinus, and it needs to be ligated during heart retrieval.
   5. Use a 5-0 Prolene suture to place a purse-string suture on the adventitia of the proximal ascending aorta and secure it with a tourniquet. Insert the cardioplegia cannula into the ascending aorta and secure it with the purse-string suture.
   6. Cardioplegia infusion: Apply aortic cross-clamps and administer 500 mL of modified St. Thomas solution (based on 500 mL of sodium acetate Ringer's solution with the addition of 4 mL of 25% magnesium sulfate, 1 g of potassium chloride, 40 mL of 5% sodium bicarbonate, and 10 mL of 2% lidocaine) and 500 mL of UW solution at 4 °C and a flow rate of 300-600 mL/min, ensuring an aortic root pressure of 80-100 mmHg. At this stage, incise the right atrial appendage for venting (Figure 1D).
      NOTE: To prevent excessive blood loss, use additional clamps on the superior and inferior vena cava to collect blood for later use in postoperative transfusion.
   7. Place ice slush (0.9% NaCl) in the thoracic cavity and over the organ for cooling, starting simultaneously with the cardioplegia infusion (Figure 1E).
   8. Cut the main pulmonary artery and the superior and inferior vena cava as distally as possible, ensuring that each vessel retains a length of at least 2 cm to facilitate tension-free anastomosis during implantation (Figure 1F). After removal, place the heart in an organ bag with at least 500 mL of saline solution. Keep it on ice and store at 4 °C until transplantation (Figure 1G).
      NOTE: Ensure that all blood vessels are kept long enough. Excessively long vessels can be trimmed during implantation, but inadequate length cannot be corrected.
   9. Donor blood collection: Collect blood from the cut ends of the superior and inferior vena cava to be used for postoperative transfusion in the recipient.

3. Recipient procedure

1. Recipient preparation
   1. Follow steps 2.1.1-2.1.4 for anesthesia and the tracheal intubation procedures. Place the recipient in a supine position, with all four limbs secured using soft ropes to ensure stability and facilitate surgical operations.
   2. Make an incision on the neck to expose the jugular vein and carotid artery. Insert a central venous catheter into the jugular vein for central venous pressure (CVP) monitoring and drug administration, and an arterial catheter into the carotid artery for real-time arterial blood pressure monitoring.
      NOTE: Commonly used vasoactive drugs during the procedure include dopamine (200 mg dopamine diluted in 50 mL of 5% glucose or saline, yielding a concentration of 4 mg/mL), dobutamine (250 mg diluted in 50 mL of 5% glucose to a concentration of 5 mg/mL), epinephrine (1 mg diluted in 49 mL of saline to 0.02 mg/mL), isoproterenol (1 mg diluted in 50 mL of 5% glucose to 0.02 mg/mL), and norepinephrine (4 mg diluted in 50 mL of saline to 0.08 mg/mL). The dosage should be adjusted based on the recipient's hemodynamic status.
   3. Bladder fistula: Make a small incision in the lower abdomen to expose the bladder wall. Secure the bladder to the edges of the incision with fine sutures. After incising the bladder wall, insert a urinary catheter and fix it to the bladder with sutures. Connect the catheter to a collection bag for urine drainage and monitoring.
      NOTE: Due to the curved and elongated urethra in male pigs, routine urinary catheterization is not feasible. A bladder fistula is necessary to ensure effective urine drainage.
   4. Make an incision in the femoral region to expose the femoral artery. Insert an arterial catheter for monitoring lower limb blood pressure and oxygen saturation. Ensure the catheter is securely fixed to prevent dislodgement or vascular injury.
2. Cardiopulmonary bypass (CPB) establishment
   1. Thoracotomy and great vessel exposure: Perform thoracotomy as described in steps 2.2.1-2.2.4 to fully expose the ascending aorta, superior vena cava (SVC), and inferior vena cava (IVC). Inspect the great vessels to ensure suitability for cannulation. Administer 300 U/kg heparin to achieve systemic anticoagulation, confirming an activated clotting time (ACT) greater than 300 s before proceeding.
   2. Assemble the CPB machine and prime it with 2 L of lactated Ringer's solution and 500 mg of methylprednisolone.
      NOTE: Due to the relatively small blood volume of Bama miniature pigs, ensure sufficient priming volume in the CPB machine. If excessive blood dilution occurs, blood transfusion can be considered as needed.
   3. Caval snaring: Separate the space between the ascending aorta and pulmonary artery and place a snare around the ascending aorta for traction to the left. Expose the medial side of the SVC and use a right-angle clamp to encircle the SVC posteriorly for snaring. Apply the same procedure for the IVC, preparing both for subsequent cannulation.
   4. Arterial cannulation: On the distal ascending aorta, place two concentric purse-string sutures using 5-0 sutures (avoiding full-thickness penetration, stitching only the adventitia). Position the suture openings on the left and right sides and secure them with hemostatic forceps for cannulation and fixation. Use a small circular blade to create an incision slightly smaller than the diameter of the 18 Fr arterial cannula at the purse-string center. Immediately insert the arterial cannula into the incision, tighten the purse strings with hemostatic forceps, and fix the cannula to the hemostatic forceps with a heavy suture. Connect the arterial cannula to the CPB arterial circuit, ensuring no air bubbles are present.
   5. Venous cannulation: Place purse-string sutures on both the SVC and IVC and connect hemostatic forceps. Make incisions within the purse strings, insert a 28 Fr cannula into the SVC and a 32 Fr cannula into the IVC, and secure them by tightening the hemostatic forceps. Fix the cannulas to the vessel walls with heavy sutures. Connect the cannulas to the venous line of the CPB circuit.
   6. Cardioplegia cannulation: Place a purse-string suture on the adventitia of the proximal ascending aorta using 5-0 Prolene and secure it with hemostatic forceps. Insert the cardioplegia cannula into the ascending aorta through the purse string and fix it in place. Connect the cannula to the cardioplegia delivery system.
   7. Initiation of CPB: Verify all cannulas and connections are correctly positioned and unobstructed. Initiate CPB and run it for a few minutes before progressively snaring the SVC and IVC to establish complete CPB, redirecting all venous blood to the CPB machine (Figure 1H).
      NOTE: Maintain a mean arterial pressure (MAP) of 60-90 mmHg and a CVP of 6-12 cmH₂O during the procedure.
   8. Aortic cross-clamping: When the core body temperature drops to approximately 30 °C, lift the ascending aorta snare and apply a pediatric aortic cross-clamp. Administer 4 °C cold modified St. Thomas solution (10-15 mL/kg) through the cardioplegia cannula into the aortic root and apply ice slush to the cardiac surface for rapid cooling and cardioplegia (Figure 1I).
      NOTE: Ensure the cross-clamp is positioned correctly to avoid compressing the brachiocephalic trunk or common carotid artery, which could compromise cerebral blood flow.
3. Recipient heart excision
   1. Right atrium excision: After opening the pericardium, begin by excising the recipient's right atrium. Make an incision along the middle of the right atrium, extending the incision downward to the inferior vena cava opening and upward to the superior vena cava opening, leaving enough right atrial wall for subsequent anastomosis.
      NOTE: Since the left hemiazygos vein drains directly into the coronary sinus, the coronary sinus should be preserved, and the drainage from the left hemiazygos vein should continue. To avoid interference with the surgical field, use a bulldog clamp to clamp the left hemiazygos vein and remove it after the donor heart is implanted.
   2. Transect the aorta and pulmonary artery at their roots, ensuring that they are of sufficient length for subsequent anastomosis.
   3. Incise the left atrium, starting from the left atrial appendage and making a circular incision around the pulmonary vein openings, leaving sufficient left atrial cuff. Finally, excise the entire recipient heart, ensuring all blood vessels are of adequate length for donor heart implantation (Figure 1J).
4. Donor heart trimming
   1. Pulmonary artery trimming: Trim the donor heart as needed by removing excess tissue. First, dissect the connective tissue between the aorta and pulmonary artery, and trim the aorta and pulmonary artery to ensure proper length, avoiding excessive length, which can lead to twisting after anastomosis, or insufficient length, which can cause excessive tension.
   2. Left atrium trimming: For the left atrium, merge the pulmonary veins into a single left atrial cuff and trim the edges to match the size of the recipient's left atrial cuff.
   3. Right atrium trimming: For the right atrium, ligate the superior vena cava; then, cut the right atrium from the right atrial appendage to the inferior vena cava, forming a right atrial cuff and trimming the edges to match the recipient's right atrial cuff (Figure 1K,L).
      NOTE: The sinoatrial node is located at the junction of the superior vena cava and right atrium. Great care should be taken not to damage the donor heart's sinoatrial node, as this will result in postoperative dependence on a pacemaker.
5. Donor heart anastomosis to the recipient
   1. Anastomosis sequence: left atrium-right atrium-aorta-pulmonary artery
   2. Left atrium anastomosis: Use the double-needle sliding suture technique to anastomose the recipient's left atrial cuff at the left upper pulmonary vein level with the donor's left atrial cuff near the base of the left atrial appendage. Begin the implantation of the donor heart (Figure 1M).
      1. Place the donor heart into the recipient's mediastinum, ensuring the heart is cooled with ice slush to prevent heat transfer to adjacent chest tissue. Continue suturing down to the mid-lower part of the atrial septum. On the other side, continue suturing along the top of the left atrium down to the septum. Constantly assess the size difference between the donor and recipient's left atrium and fold any excess tissue appropriately to complete the anastomosis. After de-airing the left atrium, tie the suture ends tightly.
         NOTE: Careful suturing of the left atrial posterior wall is essential to prevent postoperative bleeding. After the heart restarts, bleeding in this area may be difficult to detect and control.
   3. Right atrium anastomosis: Adjust the donor heart to near-normal anatomical position, starting from the lower end of the right atrial septum. Pass one suture line upwards along the septum in a counterclockwise direction and then pass it to the right atrial lateral wall. Ensure the other suture line goes downward along with sutures along the right atrial wall from the inferior vena cava opening. Tie the two suture lines where they meet at the middle of the right atrium's lateral wall (Figure 1N).
   4. Aorta anastomosis: Perform an end-to-end anastomosis using the sliding technique, starting from the posterior wall of the vessel and completing the anastomosis from the donor to recipient pulmonary arteries. Finally, tie the suture tightly at the front wall.
   5. Pulmonary artery anastomosis: Use the same technique for pulmonary artery anastomosis as that described for the aorta, typically starting rewarming before performing the pulmonary artery anastomosis (Figure 1O).
6. Heart resuscitation and subsequent procedures
   1. Heart resuscitation: After completing the pulmonary artery anastomosis, insert an air venting needle into the root of the ascending aorta to remove any residual air from the donor heart and remove the aortic cross-clamp. Have the anesthetist assist with lung inflation.
   2. Auxiliary circulation: After the heart restarts, rely on the extracorporeal circulation for assistance for some time (Figure 1P).
      NOTE: The duration of assistance is determined by the ischemia time and the recovery of heart function.
   3. Hemostasis and closure: Carefully check all anastomoses for bleeding and ensure hemostasis. Place a temporary pacemaker, remove the extracorporeal circulation, and withdraw the cannulas. Place a temporary epicardial pacemaker wire on the right atrium and right ventricle surface, and place drainage tubes in the mediastinum and thoracic cavity. Finally, close the midline incision using standard techniques.
      NOTE: Porcine vascular tissue is fragile, especially in the right atrium and pulmonary artery, and is prone to tearing. Extra care should be taken during the procedure.

4. Postoperative care

1. After surgery, transfer the animal immediately to the dedicated ICU for close monitoring. Continuously monitor hemodynamic parameters, including CVP, arterial blood pressure, heart rate, and oxygen saturation. Based on real-time monitoring results, promptly adjust vasoactive drugs and supportive treatments to maintain stable blood pressure and cardiac output.
2. Cardiac function monitoring: Monitor the electrocardiogram continuously postoperatively to observe any arrhythmias or signs of myocardial ischemia. If arrhythmias occur, administer electrical cardioversion or pharmacological treatment.
   NOTE: Early postoperative arrhythmias are often caused by cardiac resumption and should be closely monitored. Antiarrhythmic drugs should be administered as needed based on changes in the ECG. Postoperative sinus tachycardia is common because the transplanted heart lacks vagal nerve suppression. Ivabradine is recommended to control sinus rhythm, and beta-blockers should be avoided because pig hearts are highly sensitive to them, which may cause hypotension.
3. Respiratory management: Provide early postoperative respiratory support using mechanical ventilation to ensure stable breathing. As cardiac and pulmonary function gradually recovers, reduce sedative drugs, and once the animal resumes spontaneous breathing, remove the endotracheal tube.
   NOTE: Early removal of the endotracheal tube and restoration of spontaneous breathing is crucial. Prolonged intubation may lead to respiratory failure and affect postoperative recovery.
4. Postoperative pain management: Provide pain relief based on the animal's signs of pain (common analgesic drugs, including non-steroidal anti-inflammatory drugs (NSAIDs) and opioids).
5. Kidney function monitoring: Regularly monitor urine output and kidney function indicators (such as creatinine and urea nitrogen) after surgery. Administer diuretics in case of any decrease in urine output or rise in creatinine.
   NOTE: Recovery of kidney function is crucial for maintaining electrolyte balance and acid-base balance.
6. Prevention of postoperative complications: Closely observe the animal for postoperative complications, such as infection and bleeding. Administer appropriate antibiotics, hemostatic drugs, and blood transfusions to prevent and treat complications.

Results

Figure 1 illustrates the key procedural steps of orthotopic heart transplantation in pigs, including midline sternotomy, opening the pericardium to expose major blood vessels, aortic infusion of cardioplegic solution, cooling the heart with ice slush, and preserving the donor heart. A critical aspect highlighted is the management of the left azygos vein, which is a pivotal step in the transplantation procedure. For the donor heart, the left azygos vein should be ligated to prevent excessive ...

Discussion

The porcine heart orthotopic transplantation model is an effective experimental platform that simulates clinical heart transplantation¹⁵. The porcine heart shares many anatomical and physiological similarities with the human heart¹². Therefore, this model has significant application value in studying various aspects of heart transplantation, particularly in heart protection, surgical procedures, and transplant immunology. However, despite these advantages, performing orthot...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
10-degree aortic cross-clamp	Sinoview	CP40431-19	Donor Surgery
10-degree aortic cross-clamp	Sinoview	CP40431-19	Recipient surgery
30-degree arch branch vascular clamp	Sinoview	CP40432-19	Donor Surgery
45-degree aortic cross-clamp	Sinoview	CP40044-18	Donor Surgery
45-degree aortic cross-clamp	Sinoview	CP40044-18	Recipient surgery
Affinity Fusion Oxygenation System	Medtronic	BB841	Cardiopulmonary bypass
Anesthesia machine	Mindray	A9	Anesthesia and others
Arterial cannula	Medtronic	18Fr	Cardiopulmonary bypass
Atracurium	Hengrui Pharmaceutical	-	Anesthesia and others
Atraumatic flat forceps	SureMed	GF04021-25	Donor Surgery
Atraumatic flat forceps	SureMed	GF04021-25	Recipient surgery
Atraumatic flat forceps	SureMed	GF04016-25	Recipient surgery
Balanced handle pen-style microsurgical forceps	Sinoview	FC12010-21	Donor Surgery
Balanced-handle pen-style microsurgical forceps	Sinoview	FC12010-21	Recipient surgery
Bama miniature pigs	Institute of Zoology, Chinese Academy of Sciences, Northern Large Animal Research Facility	-	Experimental animals
Belzer UW Cold Storage Solution	Bridge to Life Ltd.	1000 ml/bag	Donor Surgery
Black-handle extreme-sharp scissors	Sinoview	SC35101-23UC	Donor Surgery
Black-handled extremely sharp scissors	Sinoview	SC35101-23UC	Recipient surgery
Blood gas analyzer	Ediagnosis	PT1000	Anesthesia and others
Cardiopulmonary bypass circuit	Medtronic	B-HL-159	Cardiopulmonary bypass
Central venous catheter	Baihe Medical	-	Anesthesia and others
Curved forceps	SureMed	GC01002-16	Donor Surgery
Curved forceps	SureMed	GC01002-12	Recipient surgery
Curved forceps	SureMed	GC01002-16	Recipient surgery
Disposable blood microembolus filter	Sansin	FAF-2	Cardiopulmonary bypass
Disposable blood reservoir filter	Sansin	FCR300K	Cardiopulmonary bypass
Disposable cardioplegia delivery system	Medtronic	XP41	Cardiopulmonary bypass
Dopamine	Jiuan Pharmaceutical	-	Anesthesia and others
Endotracheal tube	Yaxin Medicine	YS-0000	Anesthesia and others
Epinephrine	Jinyao Pharmaceutical	-	Anesthesia and others
Fine dissecting forceps	SureMed	GC01090-20	Donor Surgery
Fine dissection forceps	SureMed	GC01090-20	Recipient surgery
Gold-handle ultra-sharp scissors	Sinoview	SC35001-23SC	Donor Surgery
Gold-handled ultra-sharp scissors	Sinoview	SC35001-23SC	Recipient surgery
Heart-lung machine	LivaNova	S5	Cardiopulmonary bypass
Heparin	North China Pharmaceutical	-	Anesthesia and others
Ice bucket	SureMed	GQ13018-00D	Donor Surgery
Ice bucket	SureMed	GQ13018-00D	Recipient surgery
Infusion pump	Sino MDT	SN-C8	Anesthesia and others
Intravenous catheter	KDL	16G-26G	Anesthesia and others
Isoflurane	Lunan Pharmaceutical	-	Anesthesia and others
Isoproterenol	Harvest Pharmaceutical	-	Anesthesia and others
Lactated Ringer's Solution	Kelun Pharmaceutical	-	Anesthesia and others
Large basin	SureMed	GQ13033-00D	Donor Surgery
Large basin	SureMed	GQ13033-00D	Recipient surgery
Laryngoscope	Hanfeiyl	TD-C-III	Anesthesia and others
Lidocaine hydrochloride injection	Kelun Pharmaceutical co.,Ltd	H20057816	Donor Surgery
Magnesium sulfate for injection	Zdjt Pharmaceutical co.,Ltd	H20051792	Donor Surgery
Medical electric sternum saw	Jingdong xiji	HF-X01	Donor Surgery
Medical sternum saw, electric sternum saw	Jingdong xiji	HF-X01	Recipient surgery
Medium basin	SureMed	-	Donor Surgery
Medium-sized sternum retractor	SureMed	GR04130-00	Recipient surgery
Modified St. Thomas Solution	Self-made	-	Anesthesia and others
Multiparameter monitor	Mindray	Benoversion N17	Anesthesia and others
Needle passer for purse-string sutures	SureMed	GR04074-00	Recipient surgery
Nerve and chordae retractor	SureMed	-	Donor Surgery
Nerve retractor	SureMed	-	Donor Surgery
Norepinephrine	Harvest Pharmaceutical	-	Anesthesia and others
Pediatric sternum retractor	SureMed	GR04114-00	Recipient surgery
Pen-style microsurgical needle holder	Sinoview	NH11300-21	Donor Surgery
Pen-style microsurgical needle holder	Sinoview	NH11300-21	Recipient surgery
Potassium chloride injection	Kelun Pharmaceutical co.,Ltd	H42021164	Donor Surgery
Protamine Sulfate	Youcare Pharmaceutical	-	Anesthesia and others
Purse-string suture introducer	SureMed	GR04074-00	Donor Surgery
Resano atraumatic magic forceps	Sinoview	FC25501-23S	Donor Surgery
Right-angle forceps	SureMed	GC01110-14	Donor Surgery
Right-angle forceps	SureMed	GC01089-18	Donor Surgery
Right-angled clamp	SureMed	GC01110-14	Recipient surgery
Right-angled clamp	SureMed	GC01089-18	Recipient surgery
Small basin	SureMed	-	Donor Surgery
Sodium acetate Ringer's injection	Duo Rui Pharmaceutical co.,Ltd	H20163331	Donor Surgery
Sodium bicarbonate injection	Kelun Pharmaceutical co.,Ltd	H20043739	Donor Surgery
Sternal retractor (medium size)	SureMed	GR04130-00	Donor Surgery
Straight forceps	SureMed	GC01001-12	Donor Surgery
Straight forceps	SureMed	GC01001-16	Donor Surgery
Straight forceps	SureMed	GC01001-12	Recipient surgery
Straight forceps	SureMed	GC01001-16	Recipient surgery
Suture 5-0 Prolene BB	Ethicon	-	Recipient surgery
Suture Prolene Blum 4-0 SH 36	Ethicon	-	Recipient surgery
Sutures 2-0 Prolene Blu M SH	Ethicon	-	Recipient surgery
Sutures BB 4-0 Prolene	Ethicon	-	Recipient surgery
Temperature probe	3M	-	Anesthesia and others
Tonsil forceps	SureMed	GC09009-20D	Donor Surgery
Tungsten carbide ring-handled needle holder	SureMed	GN01013-22K	Donor Surgery
Tungsten carbide ring-handled needle holder	SureMed	GN01013-22K	Recipient surgery
Tungsten carbide ring-handled needle holder	SureMed	GN01010-22K	Recipient surgery
UW Solution	Belzer	-	Anesthesia and others
Venous cannula	Medtronic	28Fr, 32Fr	Cardiopulmonary bypass
Ventilator	Mindray	SV300	Anesthesia and others
Weighted pen-style needle holder	Sinoview	NH10400-23	Recipient surgery