Ann Thorac Surg 2002;73:962-963
© 2002 The Society of Thoracic Surgeons
Case report
Ex-vivo mitral valve repair prior to orthotopic cardiac transplantation
Robert E. Michler, MD*a,
Diego R. Camacho, MDa
a Division of Cardiothoracic Surgery, The Ohio State University School of Medicine, Columbus, Ohio, USA
Accepted for publication April 17, 2001.
* Address reprint requests to Dr Michler, Division of Cardiothoracic Surgery and Transplantation, Heart Hospital, The Ohio State University Medical Center, N820 Doan Hall, 410 West 10th Ave, Columbus, OH 43210, USA
e-mail: michler.1{at}osu.edu
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Abstract
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Mitral valve annuloplasty was performed prior to orthotopic cardiac transplantation in two donor hearts which were diagnosed with moderate to severe mitral regurgitation. The technical aspects are reviewed of ex-vivo mitral valve repair with concomitant heart transplantation. The recipients were classified as United Network for Organ Sharing (UNOS) I and both patients have had an excellent postoperative recovery. Over 2-year follow-up demonstrates normal mitral valve function without regurgitation.
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Introduction
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The continuing shortage of donor hearts remains a major limitation to widespread application of cardiac transplantation. Each year, the number of patients placed on transplantation waiting lists exceeds the supply of donor organs [1]. One approach to increase the number of available donors is to expand donor criteria [2]. Conventional cardiac procedures performed on impaired donor hearts can expand the donor pool by making these hearts suitable for orthotopic transplantation in critically ill patients [3, 4]. This report discusses 2 cases in which mitral valve repair was performed prior to orthotopic heart transplantation.
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Case reports
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Patient 1
A 58-year-old man, with end-stage congestive heart failure due to idiopathic cardiomyopathy, was placed on the cardiac transplant waiting list as United Network for Organ Sharing (UNOS) status I. A 21-year-old male donor without history of cardiac disease suffered brain death from a motor vehicle accident. Echocardiography obtained prior to organ procurement revealed moderate mitral regurgitation without evidence of leaflet or chordal disease. Regional and global myocardial contractility was unimpaired and the ejection fraction (EF) was 55%. At organ procurement, the mitral valve was carefully inspected and was without degenerative alterations. A secundum atrial septal defect was observed. The heart was transported to our institution and the mitral valve was tested with injection of cold saline in the left ventricle while holding up the edges of the left atrium. Central insufficiency was noted due to incomplete coaptation of the leaflets. This appeared to be secondary to annular dilation. Annuloplasty was performed ex-vivo with a #30 Baxter (Baxter, Deerfield, IL) ring. The valve was again tested and excellent coaptation of the leaflets was confirmed by the absence of regurgitation. The heart was then implanted using the biatrial parasepstal technique. An intraoperative transesophageal echocardiogram obtained after separation from cardiopulmonary bypass revealed no mitral regurgitation. Postoperatively, the patient had an uneventful recovery. The intensive care unit stay was 3 days, and he was discharged 9 days after surgery in excellent condition. Echocardiography 24 months after heart transplantation demonstrated normal mitral valve function without regurgitation and an EF of 55%.
Patient 2
A 54-year-old man with end-stage congestive heart failure secondary to ischemic cardiomyopathy was placed on the cardiac transplantation waiting list as a UNOS status I recipient. He had a history of multiple coronary artery bypass procedures in 1984 and in 1990, and he was not a candidate for a third revascularization procedure. A 24-year-old male donor without cardiac history suffered an intracranial bleed from a closed head injury. The echocardiogram demonstrated severe mitral regurgitation without evidence of primary valvular pathology. The annulus appeared dilated. Left ventricular contractility was normal with an ejection fraction of 55%.
Following explant, the mitral valve was inspected and annular dilatation was observed without evidence of valve disease. A #30 Baxter annuloplasty ring was implanted. The heart was then transplanted using the biatrial parasepstal technique. Intraoperative transesophageal echocardiography after separation from cardiopulmonary bypass demonstrated normal valve function and no mitral regurgitation. Sick sinus syndrome required placement of an AAI pacemaker (Medtronic 8160 Prodigy SR; Medtronic Inc, Minneapolis, MN). The patient was discharged in good condition on postoperative day 18. Echocardiography and cardiac catheterization performed over 24 months after surgery demonstrated an EF of 60%. Valve function was normal with no evidence of mitral regurgitation.
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Comment
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The imbalance between organ supply and organ demand remains a critical and tragic problem for the transplant community. This imbalance has resulted in numerous creative options to extend the donor pool. One such option is to expand donor selection criteria [2]. Bench-type repair techniques have been shown to be successful in hepatic transplantation [5] and cardiac transplantation [3, 4]. Incorporating conventional cardiac procedures on diseased donor hearts may allow these organs to be used in desperately ill patients.
In the 2 cases described in this report, both recipients suffered from end-stage dilated cardiomyopathy and were in-hospital UNOS status I. Medical management for such patients is associated with a significant mortality rate [6, 7]. Recognizing this mortality rate as well as the excellent results with mitral valve repair for annular dilatation, these authors felt justified in proceeding with conventional mitral valve repair in this situation.
The technical aspects of the procedure were similar to those used in standard mitral repair, and include: evaluation of the anatomy of the mitral apparatus, examination of leaflet coaptation under saline testing (albeit not physiologic, and not standard conditions), and identification of any structural abnormality of the ventricular wall following excision of the donor heart. Transesophageal echocardiography is an invaluable tool in the preoperative evaluation. This must be reviewed by either the transplant surgeon or the donor surgeon prior to the initiation of the transplant procedure. Should repair not be feasible, mitral valve replacement is a straightforward option. R.E.M. has had a favorable experience with mitral and tricuspid valve repair/replacement following orthotopic heart transplantation [8], and this experience now exceeds 11 patients.
It remains unclear to these authors why these young patients had developed mitral regurgitation. To the best of our knowledge, there were no prior symptoms or history of heart disease. Neither patient had sustained cardiac trauma. However, asymptomatic mitral regurgitation is not an uncommon cardiac lesion, and both of these young men may not have been thoroughly evaluated by a physician.
Over 2 years after surgery, both recipients remain healthy without any evidence of mitral regurgitation on examination or by echocardiography. These results demonstrate the efficacy of mitral valve repair in donor hearts used for orthotopic cardiac transplantation.
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References
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Laks H., Gates R.N., Ardehali A., et al. Orthotopic heart transplantation and concurrent coronary bypass. J Heart Lung Transplant 1993;12:810-815.[Medline]
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Sweeney M.S., Lammermeier D.E., Frazier O.H., Burnett C.M., Haupt H.M., Duncan J.M. Extension of the donor criteria in cardiac transplantation: surgical risks versus supply-side economics. Ann Thorac Surg 1990;50:7-11.[Abstract]
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Massad M.G., Smedira N.G., Hobbs R.E., Hoercher K., Vandervoot P., McCarty P.M. Bench repair of the donor mitral valve before heart transplantation. Ann Thorac Surg 1996;61:1833-1835.[Abstract/Free Full Text]
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Miyagawa S., Hashikura Y., Miwa S., et al. Concomitant caudate lobe resection as an option for donor hepatectomy in adult living related liver transplantation. Transplantation 1998;66:661-663.[Medline]
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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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Franciosa J.A., Wilen M., Ziesche S., Cohn J.N. Survival in men with severe chronic left ventricular failure due to either coronary heart disease of idiopathic dilated cardiomyopathy. Am J Cardiol 1983;51:831-836.[Medline]
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Fuster V., Gersh B.J., Giuliani E.R., Tajik A.J., Brandenburg R.O., Frye R.L. The natural history of idiopathic dilated cardiomyopathy. Am J Cardiol 1981;47:525-531.[Medline]
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Goldstein D.J., Aaronson K., Michler R.E. Mitral valve replacement and tricuspid valve repair following cardiac transplantation. Ann Thorac Surg 1997;63:117-123.[Abstract/Free Full Text]
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P. E. Antunes, D. Prieto, L. Eugenio, and M. J. Antunes
Donor mitral valve repair in cardiac transplantation
J. Thorac. Cardiovasc. Surg.,
January 1, 2005;
129(1):
227 - 228.
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Abstract
Introduction
