Ann Thorac Surg 2000;69:618-620
© 2000 The Society of Thoracic Surgeons
Case Reports
Surgical management of massive atrial size mismatch in heart transplantation
Ehab S. Bishay, FRCSa,
Nicholas G. Smedira, MDa
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
Address reprint requests to Dr Smedira, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Ave, F25, Cleveland, OH 44195
e-mail: smedirn{at}cesmtp.ccf.org
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Abstract
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We describe a surgical technique that we successfully used in a case involving severe size mismatch between the recipient’s atrial remnants and the donor heart atria. Complete recipient left atrial excision, extensive pulmonary vein mobilization, and plication of the right atrial remnant achieved this goal.
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Introduction
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Patients with end-stage heart failure secondary to chronic mitral or tricuspid valvular disease, or both, often have gross cardiomegaly with massive biatrial enlargement. This results in significant size mismatch between the recipient’s enlarged atrial remnants and the donor’s heart atria. We describe a surgical technique for orthotopic cardiac transplantation that we used on a 59-year-old female patient with end-stage congestive cardiac failure secondary to prosthetic mitral valve regurgitation.
The recipient was a 59-year-old woman, 161 cm in height and 59 kg in weight, with longstanding rheumatic mitral valve disease. Twenty-four years before transplantation she underwent a mitral valve replacement with a Lillehei-Kaster valve and it was noted at that time that the left atrium was significantly dilated. Preoperative echocardiography revealed a giant left atrium with a cavity area of 84 cm2 during systole.
Division of the cavae, pulmonary artery, and aorta was carried out in the standard fashion. The pulmonary veins were divided distally, and then the ipsilateral openings were joined on each side, thus creating a single left and right orifice, leaving a wide bridge of posterior left atrial wall between them.
The median sternotomy was reopened and the aorta and the right side of the heart were dissected free. The ascending aorta was cannulated for arterial return and bicaval cannulation was achieved for venous return. Cardiectomy was then performed. The left atrial dimension once the heart was excised was 17 x 17 cm and the wall of the left atrium was found to be extensively calcified. The right superior and inferior pulmonary veins were widely displaced by approximately 8 cm, whereas the left veins were closer to normal (Fig 1). The left atrium was then completely resected, leaving only two left atrial cuffs, which included the ostia of the pulmonary veins. The right and left pulmonary veins were then extensively mobilized. By doing this, the two atrial cuffs were brought closer to a midline position (Fig 2). The left atrial cuff containing the left pulmonary veins was anastomosed to the corresponding orifice in the donors left atrium. The right pulmonary veins are then anastomosed in the same fashion. Because of the depth of the pericardial sac, the donor heart sat well below the level of the superior and inferior venae cavae and the plane of the right atrial free wall; therefore, we believed that mobilization of the superior and inferior venae cavae to perform bicaval anastomoses was not going to be possible. To accommodate this, the right atrial free wall and the septum were plicated, inferiorly initially and then superiorly, creating tunnellike extensions of the inferior and superior venae cavae and the resulting smaller orifice was then anastomosed to the donor’s right atrium (Fig 3). The pulmonary artery and aortic anastomoses were then carried out in the usual fashion. The patient was weaned easily from cardiopulmonary bypass. She was discharged after 36 days and is presently doing well 9 months after transplantation with no embolic episodes, neither systemic nor pulmonary.
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Fig 1. After cardiectomy, the recipient’s right and left atrial remnants are massively dilated. The right and left pulmonary veins are widely displaced.
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Fig 2. The left atrium is completely resected, leaving only two cuffs of tissue including both ostia of the pulmonary veins. The pulmonary veins are extensively mobilized allowing these cuffs to be brought to a midline position.
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Fig 3. The right atrial free wall and septum are plicated creating tunnellike extensions of the inferior and superior venae cavae. After achieving the appropriate size match, the right atrial anastomosis is completed.
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Comment
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Orthotopic heart transplantation has been performed traditionally with the technique originally described by Shumway and colleagues [1]. More recent modifications have been made by Dreyfus and associates [2] advocating "total atrial orthotopic as well as ventricular transplantation." These modifications may decrease the incidence of postoperative mitral and tricuspid regurgitation as well as conduction abnormalities [3, 4]. Very few reports, however, address the problem of large donor/recipient atrial size mismatch.
In addition to laterally displacing the pulmonary veins, massive atrial dilatation enlarges the pericardial cavity resulting in distortion of the normal relationships between the aorta, pulmonary artery, cavae, and pulmonary veins. Duncan and colleagues [5] proposed reducing the circumference of the recipient’s atria by plication of the atrial remnants to accommodate for large donor/recipient atrial size discrepancies. We used this technique, for the right atrial anastomosis, creating tunnellike extensions of both the inferior and superior venae cavae. With regard to the left atrial plication this would have been impossible in our patient because of the extensive calcification present throughout the left atrial wall. To plicate the left atrium would have required an extensive endarterectomy to provide tissue to sew to. Another consideration is the creation of a sizable "chamber" inferior to where the pulmonary veins drain by left atrial plication. This creates a potential for blood stasis and thrombus formation necessitating anticoagulation postoperatively [5].
The technique of extensive pulmonary vein mobilization, total left atrial excision, and right atrial plication results in normal left atrial size, anatomic configuration, and geometric shape and accommodates the size and space discrepancies between donor and recipient. This likely reduces postoperative thromboembolic episodes and atrioventricular valve regurgitation.
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References
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Shumway N.E., Lower R.R., Stofer R.C. Transplantation of the heart. Adv Surg 1966;2:265-284.[Medline]
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Dreyfus G., Jebara V., Mihaileanu S., Carpentier A.F. Total orthotopic heart transplantation. Ann Thorac Surg 1991;52:1181-1184.[Abstract/Free Full Text]
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Czer L.S.C., Trento A., Blanche C., et al. Orthotopic heart transplantation. J Am Coll Cardiol 1993;21(Suppl A):168A.
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Blanche C., Valenza M., Aleksic I., Czer L.S.C., Trento A. Technical considerations of a new technique for orthotopic heart transplantation. J Cardiovasc Surg 1994;35:283-287.[Medline]
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Duncan J.M., Miodrag M., Frazier O.H. Orthotopic cardiac transplantation in patients with large donor/recipient atrial size mismatch. Ann Thorac Surg 1987;44:420-421.[Abstract/Free Full Text]
Accepted for publication June 20, 1999.
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Abstract
Introduction
