Ann Thorac Surg 1996;61:224-225
© 1996 The Society of Thoracic Surgeons
Case Report
Heart Transplantation With Bicaval Anastomoses After a Maze Operation
Paul R. Vogt, MD,
Erwin Oechslin, MD,
Tengis Tkebuchava, MD,
Ludwig K. von Segesser, MD,
Marko I. Turina, MD
Clinic for Cardiovascular Surgery and Division of Cardiology, University Hospital Zurich, Zurich, Switzerland
Accepted for publication July 24, 1995.
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Abstract
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A 49-year-old man had progressive low cardiac output syndrome after mitral valve repair combined with a maze operation. A biventricular assist device was implanted and, finally, emergency orthotopic heart transplantation was performed. The multiple incisions, especially right atrial incisions, were successfully avoided by heart transplantation with bicaval anastomoses.
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Introduction
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Standard technique in orthotopic heart transplantation consists of two atrial and two arterial anastomoses [1]. After a previous maze procedure, the multiple atrial incisions, especially on the right side, may offer difficult technical problems. We report a rare case of heart transplantation becoming necessary after a maze procedure.
A 49-year-old university professor had a questionable endocarditis at the age of 13 years. Twenty-four years later, recurrent paroxysmal supraventricular tachycardias led to the echocardiographic diagnosis of a mitral valve prolapse. After one episode of left heart decompensation, severe mitral valve regurgitation due to posterior chordal rupture was found in April 1993 and the patient was evaluated for mitral valve reconstruction.
Preoperatively, the patient was in New York Heart Association class IV. The physical findings were typical for a severe mitral valve regurgitation. The electrocardiogram demonstrated tachycardic atrial fibrillation. Echocardiography revealed a left ventricle with an end-diastolic diameter of 76 mm (normal values, 4.4 to 6.5 mm). The left atrial diameter was 72 mm (normal 1.5 to 4.0 mm). A floppy mitral valve with ruptured posterior and elongated anterior chordae was found. In addition, moderate tricuspid valve regurgitation was diagnosed. On the right heart catheterization the cardiac index was 2.2 L•mm-1•m-2. The pulmonary artery pressures were normal and the V wave on the capillary wedge pressure curve was 26 mm Hg. The left heart catheterization revealed a left ventricular ejection fraction of 0.56 and a mitral valve regurgitant fraction of 0.86. The coronary arteries were normal.
At the first operation, the tricuspid (Key annuloplasty) and mitral valve were reconstructed (chordal shortening on the anterior leaflet, quadrangular resection and reconstruction of the posterior leaflet, Wooler annuloplasty on the anterior and posterior commissure) and a maze operation was performed according to Cox's technique [2]. Despite successful valve reconstruction and sinus rhythm, the weaning from cardiopulmonary bypass was possible only with massive inotropic support and after implantation of an intraaortic balloon pump.
Due to progressive low cardiac output syndrome a biventricular assist device was implanted 12 hours later. The right atrial cannula was inserted ventral to the craniocaudal right atrial maze incision, whereas the left atrial cannula was introduced between the right pulmonary veins and the circular maze incision that isolates the pulmonary veins (Fig 1
) [2]. An emergency heart transplantation was planned.
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Fig 1. . Cannulation for biventricular support after a completed maze procedure. Note, that for heart transplantation, the maze incision (black arrow), isolating the pulmonary veins, is used for the left atrial anastomosis. At the right side, bicaval anastomoses were performed (white arrow).
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Emergency orthotopic cardiac transplantation was performed 20 hours later. The cardiopulmonary bypass was instituted with an aortic arch and a superior caval vein cannula, the biventricular assist device was removed, and the inferior caval vein was cannulated. At the level of the left atrium, the heart was excised along the left atrial maze incision that isolates the pulmonary veins (see Fig 1
, black arrow). On the right side, the superior and inferior caval veins were transected (see Fig 1, white arrow), avoiding the right atrial maze incisions. The orthotopic implantation of the donor heart followed the standard techniques except on the right atrium, where bicaval anastomoses were performed. The further postoperative course was uneventful. Eighteen months later the patient is in New York Heart Association class I and fully working.
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Comment
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The technique of orthotopic heart transplantation, developed by Lower and Shumway [1], consists of two atrial and two arterial anastomoses. Although bicaval anastomoses are reported to alleviate tricuspid valve regurgitation [3], anastomoses at the level of the right and left atrium are still mainly used today.
The maze procedure consists of complex left and right atrial incisions designed to subdivide the atria into several small fragments, preventing atrial macroreentry circuits, which are known to produce atrial fibrillation [4]. Therefore, after a previous maze operation, orthotopic heart transplantation with biatrial anastomoses may pose insurmountable technical problems. They may be avoided by performing superior and inferior caval anastomoses.
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Footnotes
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Address reprint requests to Dr Vogt, Clinic for Cardiovascular Surgery, University Hospital, Rämistr 100, CH-8091 Zurich, Switzerland.
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References
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- Lower RR, Shumway NE. Studies in orthotopic homotransplantation of the canine heart. Surg Forum 1960;11:18–9.[Medline]
- Cox JL. The surgical treatment of atrial fibrillation. IV. Surgical technique. J Thorac Cardiovasc Surg 1991;101:584–92.[Abstract]
- Sievers HH, Leyh R, Jahnke A, et al. Bicaval versus atrial anastomoses in cardiac transplantation. J Thorac Cardiovasc Surg 1994;108:780–4.[Abstract/Free Full Text]
- Cox JL, Canavan TE, Schuessler RB, et al. The surgical treatment of atrial fibrillation. II. Intraoperative electrophysiologic mapping and description of the electrophysiologic basic of atrial flutter and atrial fibrillation. J Thorac Cardiovasc Surg 1991;101:406–26.[Abstract]
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Abstract
Introduction
