Cardiectomy is the surgical removal of the heart, performed most often as the critical step in a heart transplant when the recipient’s failing organ is excised to make room for a donor heart. The term also applies when a heart is removed for tumor resection, for replacement with a mechanical device, or during organ procurement from a donor. Though less familiar than words like “bypass” or “transplant,” cardiectomy sits at the center of some of the most dramatic procedures in modern surgery, and the techniques surrounding it continue to evolve in ways that reshape who can receive a new heart and how long a donor organ stays viable.
Why the Heart Gets Removed
The vast majority of cardiectomies happen during heart transplantation. A patient with end-stage heart failure who has exhausted other options receives a donor organ, but first the surgeon must remove the diseased one. In rarer circumstances, a cardiectomy is performed because the heart harbors a tumor that cannot be resected while the organ remains in the chest. And in a small but growing number of cases, the heart is removed entirely and replaced with a mechanical total artificial heart, either as a bridge to transplant or, occasionally, as a longer-term solution. One case report describes a 34-year-old patient with an unresectable cardiac sarcoma who underwent total cardiectomy followed by implantation of two continuous-flow pumps configured as a total artificial heart.1Annals of Thoracic Surgery Short Reports. HeartMate 6 in a Total Artificial Heart Configuration After Total Cardiectomy for Cardiac Sarcoma A review of cardiac operations in organ transplant recipients also documented a native cardiectomy performed as a standalone procedure in at least one case.2The Annals of Thoracic Surgery. Cardiac operations in solid-organ transplant recipients
How a Recipient Cardiectomy Works
The standard technique used today for removing a recipient’s heart during transplant is the bicaval method, which preserves separate cuffs of the major veins rather than leaving large portions of the recipient’s atria behind. The procedure begins with a full sternotomy, opening the breastbone to access the chest cavity. The ascending aorta, the superior vena cava, and the inferior vena cava are isolated, and the patient is connected to a cardiopulmonary bypass machine, which takes over the work of circulating and oxygenating blood while the heart is out of commission.3PubMed Central. Basics of cardiopulmonary bypass
Once bypass is established, the aorta is cross-clamped as far from the heart as practical to leave the surgeon maximum length for connecting the donor organ later.4CTSNet. Recipient Cardiectomy: Bi-Caval Technique The veins are snared to ensure full bypass, and cardioplegia (a solution that stops the heart) is typically not needed at this stage because the recipient’s heart is being removed rather than repaired. Carbon dioxide is flowed continuously into the open pericardial cavity to lower the risk of air embolism. The aorta is cut above the junction where it meets the heart, the main pulmonary artery is cut at the level of its valve commissures, and the left atrium is incised and separated. Any pacemaker or defibrillator leads inside the right side of the heart are cut. Cuffs are fashioned around the superior and inferior vena cava, and the remaining right atrial tissue is trimmed and sutured for hemostasis. If a patent foramen ovale is present, it is closed.5CTSNet. Orthotopic Heart Transplant Using Bicaval Technique Part 1: Recipient Cardiectomy
The entire removal takes only a portion of the overall transplant operation, but it demands precision because every cut dictates how well the donor heart can be sewn into place. Leaving the right structures too long or too short creates problems at the anastomosis, the connection points where the donor organ meets the recipient’s vessels.
Donor Cardiectomy and the Race Against Ischemia
Cardiectomy is also what happens on the donor side: the heart must be carefully removed from the deceased donor and transported to the recipient’s hospital. The moment the donor heart loses its blood supply, ischemic time begins, and the clock is unforgiving. Cold ischemic time, the interval during which the heart sits in cold preservation solution, has traditionally been kept under four hours. One study of 62 transplant recipients found that about 43% of patients whose cold ischemic time exceeded four hours died within 30 days, compared with 31% of those below that threshold, though the difference did not reach statistical significance in that sample.6PubMed Central. Heart Transplantation and Cold Ischemia: Towards Crossing the Border? Warm ischemia time matters too: when the warm interval stretches beyond about 80 minutes, survival drops compared with cases where it stays under 60 minutes.7PubMed. Impact of warm ischemia time on survival after heart transplantation
To extend the window, some centers now use ex vivo heart perfusion devices that keep the donor heart warm and beating outside the body after the donor cardiectomy, rather than relying on traditional static cold storage.8PubMed. Ex-vivo heart perfusion attenuates early post-transplant risk after prolonged agonal period in DCD heart transplantation These machines pump oxygenated blood through the organ during transport, which has expanded the geographic distance a donor heart can travel and opened the door to using hearts from donors who previously would have been considered too risky.
Donation After Circulatory Death
For decades, hearts for transplant came almost exclusively from donors who had been declared brain dead while their hearts were still beating. A newer pathway, donation after circulatory death (DCD), retrieves hearts from donors whose death is determined by the irreversible cessation of circulation rather than brain function. The practical difference is significant: in DCD, the heart has already stopped beating for some period before the donor cardiectomy, which means additional warm ischemia. Despite that challenge, early U.S. data show encouraging results. Between 2019 and 2021, the share of heart transplants from DCD donors rose from about 0.2% to roughly 6%, and the number of centers performing DCD transplants jumped from 3 to 20. After propensity matching, one-year survival was about 93% for DCD recipients compared with 90% for traditional brain-death donors, a difference that was not statistically significant.9Circulation: Heart Failure. Early Outcomes of Heart Transplantation Using Donation After Circulatory Death Donors in the United States
DCD heart procurement does raise ethical questions that do not arise in the same way with brain-dead donors. The main concern centers on the “dead donor rule,” the principle that organ removal must not be the cause of a donor’s death. Whether DCD heart retrieval respects this rule depends on how death is defined and how much time elapses between circulatory arrest and procurement.10PubMed. The Ethics of Heart Donation After the Circulatory Determination of Death Some programs use normothermic regional perfusion, which restores warm blood flow to the abdominal and thoracic organs after death is declared, to assess and preserve the heart before removal. Others worry that restoring circulation to the body could theoretically restore some brain function, complicating the determination of death. Because of these concerns, some institutions have adopted an ex vivo perfusion approach instead, removing the heart first and then restarting it on a machine outside the body.11JTCVS Techniques. First-in-human beating-heart transplant
Cardiac Autotransplantation
Not every cardiectomy ends with a donor organ going in. In cardiac autotransplantation, the patient’s own heart is removed, repaired on a back table, and reimplanted. This approach was developed specifically for complex or malignant tumors of the left side of the heart that cannot safely be resected while the organ remains connected to the body’s circulation. Removing the heart gives the surgeon a complete 360-degree view of the tumor and surrounding tissue, making it possible to achieve clean margins that would be impossible from inside the chest.
A series spanning 1998 to 2008 documented 20 patients who underwent 21 cardiac autotransplantations for left-sided tumors that were not amenable to conventional surgery. There were no operative deaths among the 15 patients who had autotransplantation alone. However, when the procedure was combined with pneumonectomy (removal of a lung), the mortality rate was 50%. Local recurrence occurred in 3 of 18 patients with malignant disease, and the average survival for all sarcoma patients was about 22 months.12PubMed Central. Cardiac autotransplantation for malignant or complex primary left-heart tumors A later analysis of 57 consecutive autotransplantation cases through 2022 compared a full technique with a simplified partial version. The partial approach involved shorter time on cardiopulmonary bypass (roughly 148 versus 191 minutes) and fewer blood transfusions (a median of 2 versus 5 units), suggesting that less invasive variants can reduce the procedural burden while still allowing adequate tumor removal.13PubMed Central. Outcomes of Full and Partial Cardiac Autotransplantation for Complex Left-Sided Heart Tumors
Total Artificial Hearts After Cardiectomy
When a patient’s heart fails on both sides and a single ventricular assist device is not enough, the total artificial heart (TAH) is the only FDA-approved option for bridging to transplant.14PubMed Central. Total artificial heart: surgical technique in the patient with normal cardiac anatomy Implanting a TAH requires removing most or all of the native ventricles, making it one of the most complete forms of cardiectomy performed. The device replaces the pumping chambers entirely and connects to the patient’s remaining atrial tissue and great vessels.
In the cardiac sarcoma case mentioned earlier, surgeons went a step further by using two continuous-flow ventricular assist devices in a TAH configuration after a total cardiectomy that removed both atria and both ventricles. That case highlights a distinct hemodynamic challenge: without any native heart tissue to act as a reservoir, balancing blood flow between the left and right sides of the circulation depends entirely on adjusting pump speeds and managing the patient’s fluid status.15Annals of Thoracic Surgery Short Reports. HeartMate 6 in a Total Artificial Heart Configuration After Total Cardiectomy for Cardiac Sarcoma The philosophical dimension is not trivial either. Scholars have noted that artificial heart devices can reshape how patients experience their own bodies, potentially encouraging a view of the body as machinelike and separable from the self, while simultaneously altering subjective experience in ways that feel deeply personal.16Hastings Center Report. A Heart without Life: Artificial Organs and the Lived Body
What the Explanted Heart Reveals
Once a heart is removed, it does not simply get discarded. The explanted organ undergoes detailed pathological examination, including dissection, histologic analysis, and sometimes cryopreservation or genetic testing.17PubMed Central. Processing of the explanted heart This workup is not just academic bookkeeping. It regularly turns up surprises. An 11-year study of 149 explanted pediatric hearts found that the anatomic diagnosis at pathologic examination differed from the clinical diagnosis in eight cases. The study also showed that children with congenital heart defects who had excessive fibrosis in one or both ventricles faced higher rates of death or retransplantation.18PubMed Central. Pathology of explanted pediatric hearts: An 11-year study
Explant pathology can also reveal diseases that are difficult to confirm in a living patient. A review of 13 cardiectomy specimens from patients with chronic Chagas cardiomyopathy found that all hearts showed inflammation and fibrosis, but the actual Chagas parasites were visible under the microscope in only about 15% of specimens. A tissue-based genetic test detected the organism in roughly half the cases, demonstrating how pathological examination of the removed heart fills diagnostic gaps that imaging and blood tests cannot.19American Journal of Clinical Pathology. Pathology of Chronic Chagas Cardiomyopathy in the United States
Pig Hearts and Xenotransplantation
The chronic shortage of human donor hearts has pushed researchers toward xenotransplantation, the transplantation of organs across species. The recipient cardiectomy in a xenotransplant is essentially the same procedure as in a human-to-human transplant; what changes is the organ going in. In a study using genetically modified pigs with 10 gene edits designed to reduce immune rejection, researchers transplanted porcine hearts into two brain-dead human recipients and monitored them for 66 hours. Both hearts functioned immediately after transplantation, with no evidence of cellular or antibody-mediated rejection on histology. One heart did show declining function over the study period, which the team attributed to a size mismatch between the smaller pig and the larger recipient.20Nature Medicine. Pig-to-human heart xenotransplantation in two recently deceased human recipients
These early experiments are proof-of-concept rather than clinical practice, but they underscore that the cardiectomy itself is not the bottleneck in expanding heart replacement surgery. The surgical technique for removing a failing human heart and connecting a new one is well established. The frontier lies in what can serve as a viable replacement, how long donor organs stay usable outside the body, and how the immune system can be persuaded to accept something foreign.
Animal Models in Cardiac Surgery Research
Much of what surgeons know about cardiectomy technique was refined through animal research, particularly in dogs. Canine models have been used for decades in cardiac surgery experimentation because the anatomy of a dog’s heart and great vessels is similar enough to a human’s to test surgical approaches before applying them clinically. However, the perioperative mortality rate in canine cardiac surgery research remains substantially higher than in human cardiac surgery, reflecting the challenges of performing complex procedures in animals without the same level of infrastructure and monitoring available in human operating rooms.21PubMed. A Guide to the Anesthetic Management of Canine Models in Cardiac Surgery Guidelines for anesthetic management in these models emphasize that many researchers performing cardiac procedures in dogs lack formal training in anesthesiology, which compounds the risk. As surgical techniques have matured and simulation tools have improved, the relative role of animal models has shifted, but they remain a part of the research pipeline for novel devices like the total artificial heart and for testing new approaches to organ preservation.