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Ann Thorac Surg 1996;61:1833-1835
© 1996 The Society of Thoracic Surgeons

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Case Report

Bench Repair of Donor Mitral Valve Before Heart Transplantation

Department of Thoracic and Cardiovascular Surgery and Section of Cardiac Transplantation, Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, Ohio

Accepted for publication January 8, 1996.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
Bench repair of the donor mitral valve was performed before orthotopic heart transplantation in a 57-year-old status I recepient. Mitral regurgitation in the structurally normal mitral valve was due to annular dilatation at the attachment of the posterior leaflet and was corrected with posterior annuloplasty. The patient is clinically well 18 months after transplantation.

	Introduction

Top Footnotes Abstract Introduction Comment References

 
Orthotopic heart transplantation is now an acceptable treatment for end-stage cardiomyopathy. Donor shortage, however, continues to plague the field of organ transplantation. Review of recent data from centers transplanting high-risk donor organs have shown no adverse effect on intensive care unit or postoperative hospital stay, or in-hospital costs [1, 2]. Moreover, the rates of rejection and survival for patients with compromised donor hearts have been shown to be comparable with those of patients with noncompromised donor hearts [1]. In this report, we describe our first experience of bench repair of the donor mitral valve before orthotopic transplantation.

A 57-year-old man with ischemic cardiomyopathy in New York Heart Association class IV heart failure was evaluated and listed for cardiac transplantation (blood group B) on August 26, 1992. His medical condition continued to deteriorate, requiring hospitalization and inotrope support (dobutamine, 10 µg•kg^-1•min^-1). His condition was upgraded to status I on the transplant list. On May 9, 1994, a 23-year-old donor from North Carolina was identified. The donor died of a gunshot wound to the head, and had not had any cardiopulmonary resuscitation. The donor had no prior history of cardiac problems and was evaluated with surface and transesophageal echocardiography. These studies showed normal ventricular function but moderate mitral regurgitation with a structurally normal mitral valve. No pulmonary artery catheter recordings were available. Because of the mitral regurgitation, the donor was turned down by other transplant programs. As there were no other contraindications to heart donation, we decided to proceed with transplantation. The donor's echocardiogram was returned to our center with the donor heart, and was reviewed before cannulating for cardiopulmonary bypass. We determined that the valve could be repaired.

The donor mitral valve was easily exposed through the posterior left atriotomy (Fig 1). The donor left ventricle was distended with cold normal saline solution after the donor aorta was clamped and that demonstrated a central jet of mitral regurgitation secondary to annular dilatation at the attachment of the posterior leaflet. Bench repair of the mitral valve was performed using a posterior annuloplasty [3]. The posterior annulus was plicated with seven 2-0 Ticron sutures placed from trigone to trigone. The sutures were passed through a portion of bovine pericardium modified based on a 30-mm sizer (Fig 1, inset). Competence of the mitral valve was documented by direct inspection after the left ventricle was distended. A small patent foramen ovale was closed primarily. Standard orthotopic heart transplantation was then performed. The aortic cross clamp was removed after 37 minutes. Ischemic time on the donor heart was 219 minutes. Intraoperative transesophageal echocardiography revealed no evidence of mitral regurgitation. Donor heart function was excellent.

View larger version (78K): [in this window] [in a new window]   Fig 1. . Dilatation of the annulus along the attachment of the posterior leaflet of the mitral valve. (Inset) Correction with posterior annuloplasty: the posterior annulus was plicated with seven 2-0 Ticron sutures placed from trigone to trigone and passed through bovine pericardium. (Reprinted with the permission of the Cleveland Clinic Foundation.)

	Comment

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In 1991, about 30% of patients waiting for cardiac transplants died before acceptable donor hearts could be identified [4]. Because of that, several groups have expanded the donor pool by liberalizing the criteria for acceptable heart donation [1, 2, 5, 6]:

• Age up to 50 years [1]
  
• Undersizing by more than 20% body weight [1, 2]
  
• Prolonged hospitalization [1]
  
• History of chest trauma [1]
  
• Open cardiac massage [2]
  
• Elevation of myocardial enzyme levels [2]
  
• Prolonged cardiopulmonary resuscitation (>5 minutes) [2]
  
• Transient hypotension (<30 minutes) [1]
  
• High-dose inotrope requirement [1, 2]
  
• Wall motion abnormality by echocardiography [2]
  
• Long-distance procurement (1,600 km)
  
• Recurrent or persistent conduction disturbance [2]
  
• Cold ischemia time more than 5 hours [2]
  
• Bypassable coronary artery disease [4, 6]
  
• Valvular dysfunction by echocardiography [5]
  

Even so, some centers still consider echocardiographic evidence of organic valvular dysfunction as an absolute contraindication to cardiac donation [2].

Ex vivo donor organ procedures have increased donor utilization in renal and hepatic transplantation and may play a similar role for donor heart utilization [6]. Previous reports have demonstrated success with coronary artery bypass grafting performed at the time of orthotopic transplantation [5, 7]. In 1970, tricuspid valvuloplasty was performed for severe tricuspid regurgitation at the Ochsner Clinic during orthotopic heart transplantation to wean the patient from bypass [6]. Bench open mitral commissurotomy has also been reported before orthotopic transplantation in 1994 [6]. Experience at our center with mitral valve repair for moderate to severe mitral regurgitation has demonstrated a low mortality and morbidity [3, 8]. Although, in this case, the donor heart might have been used without repair, we thought that the structurally normal donor mitral valve could be made competent with a relatively simple plication, without detriment to left ventricular function [3]. Therefore, for young donors with otherwise excellent cardiac function, we recommend bench mitral valvuloplasty as needed before cardiac transplantation.

	Footnotes

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Address reprint requests to Dr McCarthy, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Desk F-25, 9500 Euclid Ave, Cleveland, OH 44195.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Schuler S, Parnt R, Warnecke H, Matheis G, Hetzer R. Extended donor criteria for heart transplantation. J Heart Transplant 1988;7:326–30.[Medline]
2. Ott GY, Herschberger RE, Ratkovec RR, Norman D, Hosenpud JD, Cobanoglu A. Cardiac allografts from high risk donors: excellent clinical results. Ann Thorac Surg 1994;57:76–81.
3. Cosgrove DM, Arcidi JM, Rodriguez L, Stewart WJ, Powell K, Thomas JD. Initial experience with the Cosgrove-Edwards annuloplasty system. Ann Thorac Surg 1995;60:499–504.
4. The 1993 Annual Report of the U.S. Scientific Registry of Transplant Recepients and the Organ Procurement and Transplantation Network. Richmond, VA: UNOS, 1993:III-31.
5. Burnett CM, Radovancevic B, Birovljev S, et al. Concomitant donor heart coronary artery bypass grafting during orthotopic heart transplantation. Tex Heart Inst J 1990;17:126–8.[Medline]
6. Risher WH, Ochsner JL, Van Meter C. Cardiac transplantation after donor mitral valve commisurotomy. Ann Thorac Surg 1994;57:221–2.[Abstract/Free Full Text]
7. Thompson DJ, Kostuk W, Pflugfelder P, Menkis A, McKenzie FN. De novo coronary artery grafting in a heart transplant recepient. J Heart Transplant 1988;7:468–70.[Medline]
8. Cosgrove DM, Stewart WJ. Mitral valvuloplasty. Curr Probl Cardiol 1989;14:353–416.

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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): Malek G. Massad Nicholas G. Smedira Patrick M. McCarthy Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Massad, M. G. Articles by McCarthy, P. M. Search for Related Content PubMed PubMed Citation Articles by Massad, M. G. Articles by McCarthy, P. M.