Ann Thorac Surg 1997;64:1188-1190
© 1997 The Society of Thoracic Surgeons
How To Do It
Aortic Mismatch in Heart Transplantation: Readaptation
Albert Miralles, MD
Department of Cardiac Surgery, Ciutat Sanitària i Universitària de Bellvitge, Barcelona, Spain
Accepted for publication April 24, 1997.
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Abstract
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Great vessel mismatch between donor and recipient is very usual in heart transplantation. Different procedures have been used to manage this situation. A tailoring aortoplasty is described, as a technical alternative, in cases of considerable size incongruence between donor and recipient aortic diameters.
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Introduction
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During heart transplantation, vessel size disparity can appear on the pulmonary artery, aorta or both. Readjusting the pulmonary arteries can be easily achieved at the time of the anastomosis with optimal distribution of the suture. Aortic matching also usually can be achieved; however, in some cases with important disproportion in vessel diameter some other technical approaches must be used. We describe here the technique of tailoring aortoplasty used in some of our patients with important donor/recipient aortic size mismatch.
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Technique
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Patients
From November 1991 to December 1996, 75 patients underwent orthotopic heart transplantation for end-stage heart disease at the Ciutat Sanitària i Universitària de Bellvitge. They were 64 male and 10 female patients with a mean age of 52 ± 8 years (range, 15 to 65 years). Indications for heart transplantation were dilated cardiomyopathy in 30 patients, coronary artery disease in 36, and other in 9. The mean weight was 69 ± 9 kg (range, 47 to 86 kg) for recipients and 74 ± 8 kg (range, 55 to 90 kg) for donors. Only 3% of patients had a donor/recipient weight ratio less than 0.75. In all cases the surgical technique used was the standard described by Lower and Shumway [1]. Disparity between atrial cuff and great vessel sizes was usually resolved with optimal distribution of the suture lines.
In 5 cases there was an important difference between donor and recipient aortic diameters. The donor's aortic diameter was less than one third of the recipient's in all of them. The donor/recipient weight ratio was considered normal (0.75, 1.01, 0.97, 0.93, and 1.02). All these patients had been previously operated on, 2 patients for coronary artery bypass grafting and 3 patients for aortic valvular replacement. Pretransplantation echography showed ascending aorta diameter larger than 45 mm in all patients but 1.
Readjusting of both donor and recipient aortic diameters was achieved in the first case with the more usual procedure of increasing the donor's diameter with a longitudinal incision in the upper level of the anastomosis. In the remaining cases of important vessel mismatch, the procedure chosen was a tailoring aortoplasty of the recipient's aorta.
Operative Procedure
The donor graft harvesting was done as usual except in 1 case in which the whole aortic arch was preserved.
Preparation of the recipient for heart transplantation was done in the usual manner. Venous cannulation was performed as usual as was aortic cannulation, only trying to be near the brachiocephalic artery outflow.
Cardiac excision was performed with the standard Shumway technique. Anterograde cold blood cardioplegia was infused every 20 minutes. The atrial anastomoses were performed with a continuous running 3/0 polypropylene suture. Pulmonary artery diameter incongruence was present in 3 of these patients. Because of the highest elasticity of the pulmonary artery wall, the discordance could be easily managed by trimming while performing the continuous suture with 4/0 polypropylene.
Unfortunately, at the level of the aortic arteries a very important diameter mismatch was present. The donor's aorta was less than one third of the recipient's in all 5 cases. This anatomic incongruence was too important to perform direct terminoterminal anastomosis, so we decided in the last 4 patients to reduce the circumference of the recipient's aorta. For this purpose a 3- to 4-cm triangular longitudinal incision was made in the anterior part of the recipient's ascending aorta (Fig 1
). The tailoring excision was then sutured with a 4/0 polypropylene continuous running suture. The result was a 40% to 50% reduction in the recipient's aortic diameter, allowing better anastomotic matching of the donor/recipient aortas. Aortic anastomosis was then realized also with a 4/0 polypropylene continuous running suture (Figs 2, 3).
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Fig 1. . Tailoring aortoplasty procedure in heart transplantation. A triangular incision is made in the recipient's aorta and then sutured with a continuous running 4/0 polypropylene suture. Later the donor's aorta is anastomosed on the reduced circumference of the recipient's aorta.
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In 1 patient the tailoring aortoplasty was recovered with a pericardial patch to reinforce the area. In the remaining patients this was not considered necessary.
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Comment
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The conventional criteria used for donor/recipient matching in orthotopic heart transplantation are based exclusively on the ABO histocompatibility and the weight ratio. It has been accepted that the donor/recipient weight ratio must be 1 ± 0.25, but some reports with a donor/recipient ratio around 0.50 have proved that there is no detrimental effect on the graft function and long-term survival [2]. In some instances, when preoperative pulmonary hypertension is present, the use of oversized donors has been recommended, but no studies have clearly proved the benefit of this policy [3]. Size matching is especially relevant in pediatric heart transplantation, where different reports have suggested contradictory conclusions [2, 4–6]. In cases of considerable size mismatch between donor and recipient some technical modifications are necessary. Total orthotopic heart transplantation or bicaval anastomosis have been recommended in case of considerable atrial size mismatch [7, 8]. The problem can be more relevant in case of arterial vessel incongruence. A difference in diameter between the donor/recipient pulmonary arteries is very common, but in general it can be easily resolved by trimming with the continuous suture. Division of the trunk of the pulmonary artery can also be used to enlarge the diameter of the donor's pulmonary artery.
In contrast, when there is an important mismatch in the aorta sizes, trimming is not always possible and sometimes it is not recommended. Because of the distribution of the suture and the lesser elastic capacity of the aortic wall, there are very important stress forces over the wall that can lead to tearing with an increase in the arterial pressure. Like many surgeons, in case of mild incongruence of aortic diameters, we used at the beginning of our experience the very usual procedure of doing a 1- to 3-cm longitudinal incision in the anterior part of the donor's aorta to enlarge the diameter. In these cases we observed very frequent leakage an d bleeding at the angle of the longitudinal incision, probably due to higher stress in this area.
Actually, we use the tailoring aortoplasty of the biggest aorta (usually the recipient's) because we think that wall stress can be reduced to a high degree, avoiding bleeding problems. None of the patients presented important bleeding and none should be reoperated on.
Deleuze and associates [7] have reported a technical alternative in such cases as this with the interposition of a Dacron graft of intermediate diameter. We believe that this alternative has two major concerns: leaving prosthetic material in the immunosuppressed patient and the increased length of the ascending aorta.
In conclusion, the tailoring aortoplasty is a very useful alternative procedure in patients with important mismatch between donor and recipient aortic diameters. It is a very simple procedure that does not require a long time to perform. We believe that the reduction in the wall stress by the suture makes this procedure safer and may decrease the risk of bleeding.
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Footnotes
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Address reprint requests to Dr Miralles, Department of Cardiac Surgery, Ciutat Sanitària i Universitària de Bellvitge, Feixa Llarga S/N, L'Hospitalet de Llobregat, 08907 Barcelona, Spain.
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References
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- Lower RR, Shumway EN. Studies on the orthotopic homotransplantation of the canine heart. Surg Forum 1960;11:18–23.[Medline]
- Constanzo-Nordin MR, Liao YL, Grusk BB, et al. Oversizing of donor hearts: beneficial or detrimental? J Heart Lung Transplant 1991;10:717–30.[Medline]
- Serrano-Fiz S, Ugarte J, Garcia Montero C. Selección de donantes. Donantes marginales. Rev Esp Cardiol 1995;48(Suppl 7):37–40.
- Tamisier D, Vouhé P, Le Bidois J, Mauriat P, Khoury W, Leca F. Donor-recipient size matching in pediatric heart transplantation: a word of caution about small grafts. J Heart Lung Transplant 1996;15:190–5.[Medline]
- Fullerton DA, Gundry SR, Alonso de Begona J, et al. The effects of donor-recipient size disparity in infant and pediatric heart transplantation. J Thorac Cardiovasc Surg 1992;104:1314–9.[Abstract]
- Yeoh TK, Frist WH, Lagerstrom C, et al. Relationship of cardiac allograft size and pulmonary vascular resistance to long-term cardiopulmonary function. J Thorac Cardiovasc Surg 1992;6:1168–76.
- Deleuze PH, Mazzucotelli JP, Benvenuti C, et al. Donor/recipient aorta size mismatch in heart transplantation: a technical alternative J Card Surg 1994;9:70–3.[Medline]
- Dreyfus G, Jebara V, Mihaileanu S, et al. Total orthotopic heart transplantation: an alternative to the standard technique. Ann Thorac Surg 1991;52:1181–4.[Abstract]
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Abstract
Introduction
