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Ann Thorac Surg 1995;59:992-993
© 1995 The Society of Thoracic Surgeons

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Invited Commentary

Department of Cardiothoracic Surgery, National Heart and Lung Institute, Dovehouse St, London SW3 6LY England

See also page 990

This excellent report by Martinelli and his colleagues raises very important issues. The first relates to the utility of heterotopic cardiac transplantation, a technique which I believe is generally underused. As Martinelli and colleagues point out, the operation is used mainly when there is a discrepancy in body size between the donor and recipient. In addition, it is very useful in patients with moderately severe reversible pulmonary hypertension. At our hospital, of the 1,124 patients who underwent cardiac transplantation in the past 12 years, 79 underwent heterotopic transplantation. The second issue is the almost invariable progressive deterioration in recipient heart function that results in a loss of benefit from the operation. In an attempt to stop this deterioration, we have used a technique involving electrical linkage of the two hearts to allow counterpulsation. This technique has been shown to enhance cardiac output in the acute stage [1], to improve the hemodynamics and metabolic function of both hearts [2], and to improve the functional capacity of the patients [3]. The long-term effects of the linkage in terms of preventing recipient heart deterioration is currently being studied.

Another issue raised by the report is the cause of the dissection in this patient. Martinelli and colleagues have demonstrated that the site of entry was at the level of the donor aortic anastomosis, which suggests that the dissection might have started at the time of operation and extended acutely 18 months later. This is supported by the large size of the aneurysm at the time of operation, which suggests chronicity. Finally, an important issue relates to the use of repair versus replacement in patients with aortic regurgitation secondary to acute dissection in general, but particularly in patients after heterotopic transplantation.

We believe that valve repair is feasible in all patients except those with organic affection of the cusps. We have developed and used a technique of radical excision of the aortic root, including all of the sinuses right down to the annulus, which acts as excellent material for suturing with resuspension of the aortic valve and implantation of the coronary arteries [4]. We share Martinelli and colleagues' concern about the clot that forms around a prosthetic valve which opens only occasionally. Repair would prevent that problem, which might be helped further by electrical linkage to promote regular ejection by the recipient's heart. Both heterotopic transplantation and acute dissection deserve a fresh look. This article is a welcome addition to the literature.

References

1. Cowell R, Morris-Thurgood J, Coghlan J, et al. Postoperative hemodynamic improvement with paced linkage of the donor and recipient hearts following heterotopic cardiac transplantation. Clin Cardiol 1994;17:542–6.[Medline]
2. Morris-Thurgood J, Cowell R, Paul V, et al. Hemodynamic and metabolic effects of paced linkage following heterotopic cardiac transplantation. Circulation 1994;90:2342–7.[Abstract/Free Full Text]
3. Cowell R, Morris-Thurgood J, Coghlan J, et al. Effects of paced counterpulsation on exercise capacity and hemodynamics after heterotopic heart transplantation. Am J Cardiol (in press).
4. Yacoub MH, Sundt TM, Rasmi N. Management of aortic valve incompetence in patients with Marfan syndrome. In: Hetzer R, Gehle P, Ennker J, eds. Cardiovascular aspects of Marfan syndrome. Darmstadt: Dietrich Steinkopff (in press).

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Magdi H. Yacoub Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yacoub, M. H. Search for Related Content PubMed Articles by Yacoub, M. H. Related Collections Related Article