Ann Thorac Surg 1999;68:2334-2336
© 1999 The Society of Thoracic Surgeons
Case Reports
Heterotopic heart transplantation through a right thoracotomy
Asghar Khaghani, FRCSa,
Roberto Casula, FRCSa,
Natasha E. Khan, MBBSa,
Magdi H. Yacoub, FRSa
a Royal Brompton and Harefield Hospitals Trust, Harefield, Middlesex, United Kingdom
Address reprint requests to Dr Khaghani, Royal Brompton and Harefield NHS Trust, Hillend Rd, Harefield, Middlesex UB9 6JH, UK
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Abstract
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Heterotopic heart transplantation was performed via a right thoracotomy in a patient with elevated pulmonary vascular resistance and previous coronary artery bypass grafting using both internal mammary arteries. The right thoracotomy approach is the safest way to approach the native heart while preserving the patent grafts.
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Introduction
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Heterotopic transplantation, first reported by Barnard and Losman [1] in 1977, has become an alternative method to orthotopic heart transplantation with particular indications [2, 3]. In the clinical setting, heterotopic heart transplantation has been reported only through a median sternotomy. This report describes a heterotopic heart transplantation for left ventricular assist performed through a right thoracotomy, emphasizing the technical advantages offered in this particular case.
The patient was a 54-year-old retired racing car driver who had acute myocardial infarctions in 1990 and 1991. In 1992, he underwent emergency coronary artery bypass with left internal mammary artery (IMA) to left anterior descending coronary artery, right IMA to right coronary artery, and saphenous vein graft to the circumflex coronary artery. Over the following 2 years, he developed symptoms of heart failure and exertional angina, and underwent a second cardiac catheterization. It showed severe ventricular dysfunction with an ejection fraction of 23%, moderate mitral incompetence, and patent grafts with good distal run-off. There was progressive deterioration of his cardiac failure despite maximal medical therapy, and he was referred for cardiac transplantation assessment. Right heart catheterization documented a pulmonary artery pressure of 75/20 mm Hg, transpulmonary gradient of 20 mm Hg, and calculated pulmonary artery resistance of 8 Wood units, with no response to pulmonary vasodilators.
In view of these findings, he was considered unsuitable for an orthotopic transplant (OCT), and hence, was listed for a heterotopic cardiac transplant (HCT). On November 27, 1997, he underwent surgery, receiving a heart from a 17-year-old cystic fibrosis patient as part of a Domino procedure.
An HCT was performed using a right anterolateral thoracotomy through the fourth intercostal space. Cardiopulmonary bypass was established with right femoral arterial and bicaval venous cannulae. Moderate hypothermia (32°C) was used and the recipient heart electrically fibrillated. The pericardium was opened just anterior and parallel to the right phrenic nerve. The interatrial groove was dissected, as in the standard mitral valve approach, and an incision made in the left atrium to underneath the inferior vena cava. Native left ventricular distension was prevented by positioning a cardiotomy sucker through the mitral valve into the left ventricle.
The donor heart was prepared by oversewing the orifice of the inferior vena cava (IVC) and preserving long segments of the aorta, pulmonary artery (PA), and superior vena cava (SVC). The donor left atrium (LA) was opened widely by connecting the orifices of the four pulmonary veins. The LA to LA anastomosis was performed first. The donor SVC was anastomosed end-to-side high on the recipient SVC. The aortic anastomosis was performed end-to-side on the recipient ascending aorta, using a side-biting clamp on the ascending aorta. The donor PA was finally anastomosed to the recipient right atrium (Fig 1), representing a modification of the technique described by Novitsky and associates [4], but actually a return to the original heterotopic technique first described by Barnard and Losman [1].
Removal of air was accomplished by sustained venting of both aortas, and through the donor heart left ventricular apical vent site. The patient was successfully weaned from cardiopulmonary bypass with minimal inotropic support. Total bypass time and total ischemic time were 126 and 90 minutes, respectively. The patient was discharged to the ward 2 days later. Postoperative complications included mild hepatic impairment and permanent pacemaker insertion. The patient is presently well and angina-free 12 months after transplantation.
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Comment
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Patients with pulmonary hypertension and transpulmonary gradient greater than 12 mm Hg comprise a high-risk group of recipients for orthotopic heart transplantation. The accepted surgical options in this group of patients are twofold. The first is HCT, where the native right ventricle is preserved to support the pulmonary circulation with pressures approaching systemic levels [3, 5]. The second is OCT with a preconditioned heart from a Domino procedure. The results of HCT in patients with elevated pulmonary vascular resistance appears to be significantly better than using Domino orthotopic hearts in the same group.
The purpose of this case report was to emphasize the feasibility and technical advantages of using a right thoracotomy approach as opposed to the conventional redo median sternotomy. This patient presented us with the challenge of preserving the patent grafts to his native heart, especially the right IMA to the right coronary artery supplying his native right ventricle. The right thoracotomy approach minimized the high risk of injury to these grafts in the case of a conventional redo sternotomy.
With this approach, we found that pleural adhesions were not excessive, and it was relatively easy to mobilize and deflate the right lung. To this end, the patient was intubated using a double lumen endotracheal tube. Reasonable exposure was achieved and all the anastomotic sites were accessible. The problem of accessibility to the native PA for the PA to PA anastomosis was overcome by our preferred modified technique of anastomosing the donor PA to the native right atrium.
In the presence of a competent aortic valve, ventricular fibrillation with hypothermic perfusion of the native heart is a valid option to achieve myocardial protection, with no need for aortic cross-clamping. The removal of air was easily performed through the vent site in the donor left ventricle.
In conclusion, a right thoracotomy is a feasible alternative to a reoperative median sternotomy in cases of heterotopic heart transplantation. The presence of a patent right IMA graft presents a strong argument in favor of this approach. In addition, the right anterolateral approach offers excellent surgical exposure in concomitant procedures to the native heart, such as mitral or tricuspid valve repair.
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References
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Barnard C.N., Losman J.G. Left ventricular bypass. S Afr Med J 1974;48:303-312.
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Ridley P.D., Khaghani A., Musumeci F., et al. Heterotopic heart transplantation and recipient heart operation in ischemic heart disease. Ann Thorac Surg 1992;54:333-347.[Abstract/Free Full Text]
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Cochrane A.D., Adams D.H., Radley-Smith R., Khaghani A., Yacoub M.H. Heterotopic heart transplantation for elevated pulmonary vascular resistance in pediatric patients. J Heart Lung Transplant 1995;14:296-301.[Medline]
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Novitzky D., Cooper D.K., Barnard C.N. The surgical technique of heterotopic heart transplantation. Ann Thorac Surg 1983;36:476-482.[Abstract/Free Full Text]
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Bourge R.C., Kirklin J.K., Naftel D.C., White C., Mason D.A., Epstein A.E. Analysis and predictors of pulmonary vascular resistance after cardiac transplantation. J Thorac Cardiovasc Surg 1991;101:432-434.[Abstract]
Accepted for publication May 6, 1999.
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Abstract
Introduction
