Objective:The last 10 years have ushered in the clinical reality of upper extremity and face transplantation with animal models and basic science evidence to support the implementation of vascularized composite allotransplantation (VCA) and its potential role in uncovering the holy grail of graft tolerance.Indeed transplantation of immunomodulator organs as vascularized bone marrow (VBM) have been proven in animal model to play a major role in establish a chimerism condition that reduce the immunosuppressive drug regimen and establish graft tolerance.The integration of VCA technology into clinical cardiac transplantation (HTx) include the allograft harvest of the chest wall with the VBM within the sternum, thymus and heart in an en bloc technique.The purpose of this study is to explore a proof-of-concept cadaveric model to describe technical aspects using en bloc technique.This procedure is evaluated by its ability of integration into clinical practiceMethods:4 surgical simulations on 8 cadavers were performed involving procurement and inset. Debriefing addressed technical feasibility and anatomical considerations.A vascular dye perfusion study was performed to determine the need for bilateral arterial inflow to the chest as well as perfusion of the bone marrow and thymus.Results: Mean donor age was 88.5 years old.Allograft harvest mean duration was 94.5 mins. Graft inset duration was 90.5 mins.Conclusion:Surgical advancement in HTx is currently at an innovation plateau.The need to expand the donor pool, prolong allograft survival and decrease immunosuppression are challenges that remain unsolved.VBM within the construct of a VCA facilitates the uninterrupted transfer of donor bone marrow cells inducing tolerance.Co-transplantation of the thymus plays a supportive role in the induction of chimerism and maintenance of the T-cell population.After exploring the technique of chest wall transplantation in mice,our group propose to develop a strategy of incorporating VBM and thymus tissue within the construct of a chest wall and heart VCA in human.The purpose of the entire chest wall transplantation is to immunoregulate the allograft, reduce immunosuppressive requirements and prolong allograft survival.Adoption of this novel concept by a multidisciplinary team is essential for this to be translated to the clinical forum

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