Ann Thorac Surg 2005;80:313-315
© 2005 The Society of Thoracic Surgeons
Case report
Bench Repair of Donor Aortic Valve With Minimal Access Orthotopic Heart Transplantation
José L. Navia, MD*,
Fernando A. Atik, MD,
Antonino Marullo, MD,
Randall C. Starling, MD,
Mario Garcia, MD,
Pablo Ruda Vega, MD,
Nicholas G. Smedira, MD,
Patrick M. McCarthy, MD
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
Accepted for publication January 14, 2004.
* Address reprint requests to Dr Navia, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Desk F-25, 9500 Euclid Ave, Cleveland, OH44195 (Email: naviaj{at}ccf.org).
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Abstract
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While the number of people waiting heart transplantation increases, the number of organ donors decreases. This shrinking donor pool has prompted reassessment of donor selection for heart transplantation. Bench repair of a donor aortic valve was performed before minimal access orthotopic heart transplantation. Aortic insufficiency in the structurally normal tricuspid aortic valve was due to annular dilatation and was corrected with subcommissural annular plication. The postoperative period was uneventful. Follow-up at 4.5 years showed good results and no evidence of aortic regurgitation.
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Introduction
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Heart transplantation remains the gold standard and last resort therapy for end-stage heart failure, however, the shortage of available donor hearts is a limiting factor. Currently, the waiting list for heart transplantation numbers around 7,000 annually. The mortality rate in this patient population is substantial, an overall 17% per year [1] and 45% for status I patients [2]. These statistics have prompted some centers to adopt extended donor criteria that has resulted in expansion of the donor pool without demonstrating a negative impact on survival [3].
Usually, the presence of most valvular and congenital cardiac abnormalities is a contraindication to transplantation [4]. In some cases, however, bench repair can be performed on a donor heart with as much as moderate mitral or tricuspid regurgitation or ostium secundum atrial septal defect. Aortic valve surgery in a donor heart has not been done previously. This paper reports the first case of bench repair of the donor aortic valve before minimal access orthotopic heart transplantation.
A 48-year-old man presented in the emergency room with progressive shortness of breath, dyspnea on exertion, increased weight gain, and decreased urinary output. His medical history was relevant for ischemic cardiomyopathy, multiple myocardial infarctions, chronic atrial fibrillation, status post internal cardiac defibrillator for nonsustained ventricular tachycardia, and gout. The patient was diagnosed with ischemic cardiomyopathy, New York Heart Association (NYHA) functional class IV, and admitted to the hospital for compensation of heart failure. The patient was considered for heart transplantation after a Fick cardiac index of 1.47 L·min–1·m–2 under inotropic support dependency and was listed as status I.
The donor was a 40-year-old man who died because of severe head trauma after a car accident. He had compatible blood type and no history of cardiac disease. Routine transthoracic echocardiography showed moderate central aortic insufficiency, normal valve structure and apparatus, preserved biventricular function, and normal ventricular diameters. Because of the presence of aortic insufficiency, three different transplant programs turned down the donor heart for transplantation. Considering the status I of this potential recipient, and having met the other eligible criteria, the decision was made to proceed with recovery and to repair the aortic valve, if needed. The heart was harvested, protected with antegrade cold crystalloid cardioplegia, and packed with iced slush in a bag.
When the donor heart arrived at the transplant center, a cardiologist from the echocardiography laboratory reviewed the taped echocardiography of the donor heart and confirmed the diagnosis of moderate central-jet aortic regurgitation. All other valves were normal. The donor aortic valve was directly inspected and tested with antegrade cardioplegia, on the bench, confirming a significant regurgitation into the left ventricle. The anatomy of the aortic valve suggested annular dilatation as the mechanism of incompetence, since the leaflets and sinus of Valsalva were unremarkable.
On the bench, the valve repair was performed with subcommissural annular plication using the technique originally described by Cabrol [5] and more recently reviewed by Cosgrove and Fraser [6]. To achieve a greater area of leaflet coaptation and reduce the valvular incompetence, annular plication was performed by using horizontal 2-0 braided polyester mattress sutures buttressed with Teflon felt placed through the annulus at each commissure. The suture went through the annulus into the inflow track and back to the annulus. The depth of the suture placed in the aortic sinus determined the amount of leaflet coaptation and annular plication. One of the advantages of bench repair is the outstanding exposure (Fig 1), making the procedure technically easier and consuming no more than 7 minutes of additional ischemic time. A 10-cm skin incision, lower-half ministernotomy was performed, preserving the manubrium of the sternum. The pericardium was opened in the usual fashion, and several stay sutures ensured a good exposure of the heart in a small operative field. Cardiopulmonary bypass was established with 21F ascending aorta cannulation and 22F right-angle double venous cannulation with vacuum-assisted venous drainage. The total donor ischemic time was 185 minutes. The orthotopic heart transplant was performed using the Shumway-Lower technique. The heart recovered well in normal sinus rhythm, and weaning from cardiopulmonary bypass was unremarkable. Intraoperative transesophageal echocardiography showed an excellent heart function and no evidence of aortic insufficiency.
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Fig 1. Bench aortic repair through subcomissural annular plication, emphasizing the good surgical exposure.
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The patient was extubated after 12 hours, although there was a transient compromise of renal function. Routine endomyocardial biopsy at 1 week revealed no evidence of rejection. The patient was discharged home on postoperative day 8. After 4.5 years, he remains in good clinical condition and in NYHA functional class I. Echocardiography (Fig 2) showed normal left ventricular function with moderate hypertrophy and no aortic regurgitation. Endomyocardial biopsy detected mild rejection.
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Fig 2. Bidimensional echocardiographic views of the aortic valve at late follow-up of the heart transplant: (A) in systole, showing normal valve opening; (B) in diastole, showing subcomissural annular plication with adequate leaflet coaptation.
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Comment
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As the heart transplant waiting list continues to expand, the shortage of cardiac donors has forced the organ donor criteria to be revisited. Use of marginal or even high-risk donors should not compromise transplant outcomes. Each case requires careful analysis and consideration [7]. Some centers have produced good outomes, especially in high-risk patients [8], by using organs that might have been discarded. The presence of most valvular cardiac diseases are considered a contraindication to transplantation. After some successful reports of bench mitral valve repair [9–10] before heart transplant, the current recommendations [4] include mild or moderate mitral or tricuspid regurgitation in potential donors. The presence of a normally functioning bicuspid aortic valve does not preclude the indication to transplantation. Although the presence of significant aortic valve disease is among the exclusion criteria, the excellent experience at our center with aortic valve repair for moderate to severe aortic regurgitation stimulated us to proceed with the donor recovery. In this case report, the aortic valve repair was a viable option because annular dilatation was the mechanism of insufficiency, with mild leaftet prolapse. The valve could be repaired with excellent exposure and without extending the ischemic time significantly.
In conclusion, aortic valve repair can be performed safely before heart transplantation. It is our suggestion that this alternative can be considered an option to expand the donor criteria in transplant centers with experience in valve conservation procedures.
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References
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- Gridelli B, Remuzzi G. Strategies for making more organs available for transplantation N Engl J Med 2000;343:404-410.[Free Full Text]
- 1999 Annual Report of the U.S. Scientific Registry of Transplant Recipients and the Organ Procurement and Transplantation Network: transplant data 1989–1998. Richmond, VA: HHS/GRSA/OSP/DOT and United Network for Organ Sharing, 1999..
- Shuler S, Parnt R, Warnecke H, Matheis G, Hetzer R. Extended donor criteria for heart transplantation J Heart Transplant 1988;7:326-330.[Medline]
- Zaroff JG, Rosengard BR, Armstrong WF, et al. Maximizing use of organs recovered from the cadaver donorcardiac recommendations. Circulation 2002;106:836-841.[Abstract/Free Full Text]
- Cabrol A, Guiraudon G, Bertrand M. Le traitement de l’insuffisance aortique par l’annuloplastie aortique Arch Mal Coeur 1966;59:1305-1312.
- Fraser CD, Cosgrove DM. Surgical techniques for aortic valvuloplasty Tex Heart Inst J 1994;21:305-309.[Medline]
- Young JB. Age before beautythe use of "older" donor hearts for cardiac transplantation. J Heart Lung Transplant 1999;18:488-491.[Medline]
- Jeevanandam V, Furukawa S, Prendergast TW, et al. Standard criteria for an acceptable donor heart are restricting heart transplantation Ann Thorac Surg 1996;62:1268-1275.[Abstract/Free Full Text]
- Rischer WH, Ochsner JL, Van Meter C. Cardiac transplantation after donor mitral valve commissurotomy Ann Thorac Surg 1994;57:221-222.[Abstract]
- Massad MG, Smedira NG, Hobbs RE, Hoercher K, Vandervoort P, McCarthy PM. Bench repair of donor mitral valve before heart transplantation Ann Thorac Surg 1996;61:1833-1835.[Abstract/Free Full Text]
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Abstract
Introduction
