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Ann Thorac Surg 2001;72:319
© 2001 The Society of Thoracic Surgeons

Correspondence

Sparing of the native right ventricle for heart transplantation: Reply

John A. Elefteriades, MDa, Gary S. Kopf, MDa, Constantinos J. Lovoulos, MDa a Cardiothoracic Surgery, Yale University School of Medicine, 333 Cedar St, 121 FMB, New Haven, CT 06520, USA

e-mail: john.elefteriades{at}yale.edu

To the Editor

We are in complete agreement with Dr Calderón-Abbo and colleagues regarding the great importance and major clinical usefulness of heterotopic cardiac transplantation, and we are very pleased to note their excellent clinical results with this procedure. The development of heterotopic transplantation so early in the history of cardiac transplantation [1] is a testimony to the insight and creativity of the pioneers in the field and an indication of their full awareness of the challenges posed by antecedent pulmonary hypertension.

Nonetheless, the potential pitfalls of heterotopic transplantation including arrhythmias, embolism, and pulmonary compression have been well described. The fact that the application of heterotopic transplantation is not widespread is an indication that it does not represent a panacea. Also, in addition to the complications after transplantation, many patients preoperatively manifest features that exclude them as candidates for heterotopic transplantation. Among the absolute and relative contraindications enumerated by Galbraith and Yacoub [2], which are based on their wealth of experience, are history of ventricular arrhythmia, history of embolism, known clot in the left ventricle, presence of angina, massive left ventricular dilatation, and atrial fibrillation.

Especially in environments where ischemic rather than infective etiologies of end-stage heart disease are common, many patients may be excluded from the option of heterotopic transplantation. The right ventricle–sparing heart transplantation operation has the potential to have a favorable impact vis-à-vis ventricular arrhythmias, systemic embolism, and pulmonary compression. Ventricular clots would no longer be an issue, as the left ventricle is excised.

We are also in agreement regarding the potential limitations of the right ventricle sparing heart transplant procedure and with all the areas for future clarification that Dr Calderón-Abbo and colleagues have indicated. The issues of flow balance and right-sided stasis as well as right ventricular morphology and long-term behavior are currently under investigation in our laboratories. Ultimately, these issues will require clinical evaluation in humans to determine if the potential benefits of right ventricle–sparing heart transplantation can be realized.

We congratulate Dr Calderón-Abbo and associates on their excellent results with heterotopic transplantation, which we think deserves a major clinical role. We thank them for their interest in, suggestions regarding, and kind comments about our laboratory investigations into the new transplant technique that we are exploring.

References

  1. Barnard C.N., Barnard M.S., Cooper D.K., et al. The present status of heterotopic cardiac transplantation. J Thorac Cardiovasc Surg 1981;81:433-439.
  2. Galbraith T.A., Yacoub M. Heterotopic heart transplantation: operative technique and results. In: Myerowitz P.D., ed. Heart transplantation. Mt Kisco, NY: Futura, 1987.

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