Ann Thorac Surg 1998;65:857-858
© 1998 The Society of Thoracic Surgeons
How to Do It
Endomyocardial Biopsy in the Heterotopic Heart Transplant Patient
David A. Arzouman, MD,
Francisco A. Arabia, MD,
Gulshan K. Sethi, MD,
Jack G. Copeland, MD
Section of Cardiovascular and Thoracic Surgery, University Heart Center, The University of Arizona Health Sciences Center, Tucson, Arizona, USA
Accepted for publication October 1, 1997.
Dr Arzouman, Cardiovascular and Thoracic Surgery, College of Medicine, The University of Arizona Health Sciences Center, 1501 N. Campbell Ave, Tucson, AZ 85724.
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Abstract
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We present a technique for rapid and easy endomyocardial biopsy of the heterotopic transplanted heart. With a recent resurgence in heterotopic heart transplantation, we believe that ours is a sound technique in obtaining both routine surveillance biopsies as well as evaluating "right-sided pressures" in the "piggy-back" heart.
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Introduction
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The year 1997 marks the twentieth anniversary of a landmark paper by Losman and Barnard describing the heterotopic heart transplant read at the Fifty-seventh Annual Meeting of the American Association for Thoracic Surgery [1]. At that time Losman and Barnard depicted their technique as a left ventricular bypass with a homologous cardiac graft. They noted that this technique would be ideal in recipients with high pulmonary vascular resistances as severe pulmonary hypertension was not tolerated in the normal, unprepared donor right ventricle. We have begun to offer this technique as an alternative to the orthotopic transplant in patients with pulmonary hypertension and in large patients who might otherwise anticipate a prolonged waiting period because of their size or blood type. In the ensuing discussion of Losman and Barnard’s paper, one of us (J.G.C.) noted that cardiac biopsy was found by the Stanford group to be essential in diagnosing rejection, and asked how one performs biopsy of the heterotopic heart. The reply was that because of the difficulty in performing biopsy of the right ventricle, they routinely performed biopsy of the left ventricle.
We have developed a biopsy technique that is safe, reliable, and easily performed in the outpatient setting. Recently we have reexamined the heterotopic heart transplant [1][2] and used this method in 2 patients.
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Technique
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If two hemostatic clips are inserted at the uppermost portions of the donor superior vena cava to recipient superior vena cava anastomosis (Fig 1) during the heterotopic heart transplantation, the anastomosis may be readily identified. The patient is positioned on the fluorotable in a supine position, prepared and draped for a routine internal jugular approach. The skin overlying the anterior triangle is infiltrated with 1% xylocaine and the right internal jugular vein is localized. A 14-gauge angio- catheter is then introduced into the right internal jugular vein. A 0.035 x 50 cm Argon J-curve guidewire (Argon, Athens, TX) is gently curved to approximately 180 degrees. Under fluoroscopic guidance the guidewire is then passed into the internal jugular vein and then between the clips into the donor right ventricle. A 7F 23-cm sheath (Cordis Corporation, Miami, FL) is then threaded into the donor right ventricle. Through the sheath the Pediatric 6.5F Bioptome (Scholten Surgical Instruments, Redwood City, CA) is introduced and the endomyocardial biopsy is performed in the usual manner (Fig 2).
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Comment
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It is challenging to perform surveillance endomyocardial biopsy in patients with heterotopic heart transplants. Cooper and associates [3] described a percutaneous approach through either the right or left subclavian vein. Boffa and associates [4] performed the biopsy of heterotopically transplanted hearts through the right femoral vein, similar to a right heart catheterization. Neither of these techniques has proved successful for our group. Since 1990 we have performed more than 3,300 endomyocardial biopsies on orthotopic heart transplant recipients using the standard right internal jugular approach. Most if not all of the biopsies are performed in the outpatient setting by us and occasionally by the transplant fellow. We do not routinely halt administration of the anticoagulants in these patients and have been fortunate not to have any major complications. We have successfully performed this technique more than 30 times in 2 patients and have had no complications or problems. An additional aid in cannulating the donor superior vena cava is to use an Amplatz super-stiff 0.035 inch x 260 cm guidewire (Boston Scientific Corp, Watertown, MA) and a Meditech Torque Vise (Boston Scientific Corp). In our experience this is a safe, dependable, and relatively easy technique for endomyocardial biopsy in heterotopic heart transplant recipients.
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Acknowledgments
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We thank Ms Judy Patterson, BSN, for her assistance in the preparation of the manuscript.
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References
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- Losman JG, Barnard CN Hemodynamic evaluation of left ventricular bypass with homologous cardiac graft. J Thorac Cardiovasc Surg 1977;74:695-708.[Medline]
- Barnard CN, Wolpowitz A Heterotopic versus orthotopic heart transplantation. Transplant Proc 1979;11:309-312.[Medline]
- Cooper DKC, Frazer RC, Rose AG, et al. Technique, complications, and clinical value of endomyocardial biopsy in patients with heterotopic heart transplant. Thorax 1982;37:727-731.[Abstract/Free Full Text]
- Boffa GM, Grassi G, Cocco P, et al. Endomyocardial biopsy in heterotopic heart transplant recipients via the femoral vein. Cathet Cardiovasc Diagn 1993;28:18-21.[Medline]
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Abstract
Introduction
