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Ann Thorac Surg 1996;61:1832-1833
© 1996 The Society of Thoracic Surgeons

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Case Report

Mitral Valve Replacement in the Transplanted Heart

Department of Cardiothoracic Surgery, Wilford Hall USAF Medical Center, Lackland Air Force Base, Texas

Accepted for publication December 18, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Because of the scarcity of donor hearts, conventional operations on heart allografts are now being performed in lieu of retransplantation. Our experience with mitral valve replacement in the orthotopically transplanted heart is presented, supporting the utility of conventional operations when indicated.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
As donor organs become increasingly scarce, cardiothoracic transplant surgeons need to consider conventional operations to correct abnormalities in previously transplanted hearts. Accelerated atherosclerosis in heart allografts and valvular dysfunction caused by repeated endomyocardial biopsy are well described and may lead to life-threatening conditions that require prompt surgical therapy. Finding a suitable donor heart for retransplantation in such a situation may not be a tenable option for these patients. Conventional operations on heart allografts therefore are now being attempted in lieu of retransplantation. Indeed, mitral valve replacement [1], tricuspid valve replacement/repair [2, 3], aortic valve replacement [4, 5], and coronary artery bypass grafting [6] have all been performed successfully in transplanted hearts. Here, we present our experience with mitral valve replacement in the orthotopically transplanted heart.

The patient is a 47-year-old woman with a history of dysfibrinogenemia and hypercoagulable state in whom severe ischemic cardiomyopathy (ejection fraction 0.18) developed after a myocardial infarction in 1980. In June 1992 she underwent orthotopic heart transplantation, which was complicated by a single episode of acute rejection and sudden cardiac death in the early posttransplantation period. Her immunosupressive regimen has consisted of FK506, azathioprine, and prednisone after cyclosporine administration was discontinued secondary to paresthesias. Also of note, this patient had undergone several endomyocardial biopsies via the left side of the heart instead of the right secondary to thrombosed femoral and neck veins due to her prior hypercoagulable state.

The patient presented to our facility in August 1994 with complaints of decreasing exercise tolerance and increasing shortness of breath. Cardiac catheterization performed earlier in June 1994 had shown irregular two-vessel coronary artery disease in the left anterior descending and left circumflex arteries, normal left ventricular function (ejection fraction, 0.70), and severe mitral regurgitation. It was thought that the mitral insufficiency was a result of iatrogenic trauma to the valve during the patient's repeated left-sided endomyocardial biopsies.

Shortly after admission, transesophageal echocardiography was performed, which showed severe mitral regurgitation with severe prolapse of both the anterior and posterior leaflets and a torn posterior mitral valve chorda tendinae. Because of the patient's severe valvular dysfunction and progressive symptoms, urgent mitral valve replacement was deemed appropriate. The patient gave informed consent and was brought to the operating room 26 months after transplantation.

A redo sternotomy was performed, and the patient was placed on cardiopulmonary bypass without complication. Myocardial protection was produced by anterograde cold blood cardioplegia. After the heart was arrested, the mitral valve was exposed using a transseptal approach via the right atrium. Operative findings included multiple torn chordae tendineae involving both the anterior and posterior leaflets. The anterior leaflet was then completely excised, the flail chordae were trimmed, and a 25-mm Medtronic-Hall (Medtronic, Inc, Minneapolis, MN) mechanical valve was seated without difficulty using supraannular pledgeted horizontal mattress sutures. Valve function during intraoperative testing was excellent. Closure of the atrial septum, deairing of the left ventricle, and closure of the right atrium all took place without problem. Weaning from cardiopulmonary bypass was then accomplished with the aid of a dobutamine drip. The remainder of the procedure was uneventful.

The patient did well postoperatively except for an episode of acute renal failure that resolved with an increase in diuretic therapy and a decrease in FK506 dosing. Renal function was back to baseline by postoperative day 4 and the patient was subsequently discharged to home on postoperative day 12 and is doing well.

	Comment

Top Footnotes Abstract Introduction Comment References

 
Mitral valve replacement in a heart allograft was also reported by Copeland and associates in 1991 [1]. Their patient had an episode of staphylococcal mediastinitis in the immediate posttransplantation period and then progressive mitral insufficiency over the next 6 years. At operation, both valve leaflets were severely ``thinned-out'' with an approximately 5-mm hole in the posterior leaflet. It was thought, therefore, that the mitral valve failure was probably the result of endocarditis. In contrast, our patient had multiple torn chordae tendineae and flail leaflets. This was almost certainly the result of iatrogenic injury to the valve sustained during multiple endomyocardial biopsies. The patient had biopsies of the left ventricle secondary to femoral and neck venous thrombosis, which precluded the more standard right heart biopsies. Iatrogenic injury to the tricuspid valve during endomyocardial biopsy has been postulated as a cause of tricuspid insufficiency in heart allografts [3]. Experience with this problem appears to be growing, and tricuspid replacement and repair have been shown to be viable alternatives in the patient with severe dysfunction. Mitral insufficiency after transplantation is clearly less common, and iatrogenic injury probably has little role, if any, in its etiology. Admittedly, our case is unusual in this regard.

Exposure via a transseptal approach simplified mitral valve exposure and replacement. Avoidance of the recipient atrium and the transplant suture line was possible, and replacement was without incident. Coronary sinus cannulation was not attempted in this patient.

We wish to add our experience to the small but growing body of work that suggests that conventional operations, in lieu of retransplantation, may be performed in heart allografts when the clinical situation warrants prompt intervention. Fortunately, these situations rarely arise, with mitral insufficiency in allografts remaining exceedingly uncommon.

	Footnotes

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Address reprint requests to Dr Myers, WHMC/PSST, 59 MDW AETC, 2200 Bergquist Dr, Ste 1, Lackland AFB, TX 78236-5300.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Copeland JG, Rosado LJ, Sethi G, Huston C, Lee RW. Mitral valve replacement six years after cardiac transplantation. Ann Thorac Surg 1991;51:1014–6.[Abstract]
2. Votapka TV, Appleton RS, Pennington DG. Tricuspid valve replacement after orthotopic heart transplantation. Ann Thorac Surg 1994;57:752–4.
3. Stahl RD, Karwande SV, Olsen SL, Taylor DO, Hawkins JA, Renlund DG. Tricuspid valve dysfunction in the transplanted heart. Ann Thorac Surg 1995;59:477–80.[Abstract/Free Full Text]
4. Fiane AE, Svennevig JL, Froysaker T. Aortic valve replacement four years after cardiac transplantation. Eur Heart J 1993;14:1140–2.[Abstract/Free Full Text]
5. Goenen MJ, Jacquet L, Dekock M, Van Dyck M, Schoevardts JC, Chalant CH. Aortic valve replacement thirty-one months after orthotopic heart transplantation. J Heart Lung Transplant 1991;10:604–7.[Medline]
6. Copeland JG, Butman SM, Sethi G. Successful coronary artery bypass grafting for high-risk left main coronary artery atherosclerosis after cardiac transplantation. Ann Thorac Surg 1990;49:106–10.[Abstract]

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				J. S. Ladowski Mitral valve repair in a transplanted heart via right thoracotomy Ann. Thorac. Surg., November 1, 2000; 70(5): 1723 - 1725. [Abstract] [Full Text] [PDF]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John C. Myers Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Myers, J. C. Articles by Coopwood, J. B. Search for Related Content PubMed PubMed Citation Articles by Myers, J. C. Articles by Coopwood, J. B.