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Ann Thorac Surg 2004;78:1350-1351
© 2004 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, University Hospital Eppendorf, Martinistrasse 52, Hamburg D-20246, Germany
hcr{at}uke.uni-hamburg.de
The article by Newcomb and coworkers focuses on the role of heterotopic heart transplantation in the 21st Century. The technique of heterotopic heart transplantation was developed at the University of Cape Town by Barnard and Losman [1] in 1974. However at that time, this operation was planed purely as left ventricular assist technique. Because the majority of patients had right heart failure develop in this first series of patients, the technique was later modified by also connecting the right atria and the pulmonary arteries using a vascular graft tube to extend the donor pulmonary artery and facilitate end-to-side-anastomosis [2, 3]. In the series by Newcomb and coworkers as published in this journal, the left heart assist technique was primarily used in the majority of patients. However, in this series 4 of 20 patients had postoperative graft failure develop with 1 patient who died from graft failure on postoperative day 7. One patient experienced severe pulmonary embolism, which may also be a consequence of the left heart assist technique because the donor right heart is only transporting blood deriving from the coronary sinus. The 1-year survival rate in this heterotopic series is 70% and 51% at 4 years, which corresponds to the results published by the International Society for Heart and Lung Transplantation/United Network for Organ Sharing database.
During my surgical residency at the University of Cape Town we revisited the experience at Groote-Schuur Hospital, and in a series of 11 patients transplanted since 1984, we did not experience a case with postoperative graft failure using the previously described complete heterotopic technique [4]. Seven of the 11 patients survived the transplantation with life spans ranging from 6 months to 2.5 years after the operations. Causes of death were mainly infections (n = 3) and chronic graft rejection (n = 1).
The indications for heterotopic heart transplantations are correctly described as elevated pulmonary vascular resistance or severe donor-recipient weight mismatch, or both, and these are identical with those published by the Cape Town group in 1989 [4]. For this high-risk patient population, heterotopic heart transplantation offers an acceptable alternative to an otherwise very risky orthotopic transplant procedure. I believe that the heterotopic transplant technique offers no potential advantage for reoperation compared with the orthotopic technique. In contrast, the Cape Town group has performed a number of re-transplantations after heterotopic transplantation, and these can be extensive and difficult operative procedures. There is a potential risk of thromboembolic complications in this particular group of patients derived from the hardly contracting left recipient ventricle. In the series by Newcomb and coworkers, 1 patient who had a postoperative stroke was documented.
Despite the correctly described indications for heterotopic transplantation, there remains an ethical conflict that good donor hearts are subjected to a transplant technique that has inferior results compared with the orthotopic technique. For this reason, heterotopic heart transplantation has almost been abandoned in the Western European countries and North America where there are large waiting lists and almost all organs could be used for suitable recipients. In these countries, where it remains to be debated whether a heart should be offered for both heart transplant techniques or only for the orthotopic technique, it may be an option to use only organs for heterotopic transplantation that are not accepted for orthotopic transplantation.
The article by Newcomb and coworkers originates from Australia with a totally different organ distribution system. In spite of large transplant programs, the number of transplanting centers is small, but the region where the hearts are retrieved is extremely large. For this specific country it seems to make sense to use marginal donor hearts with extensive ischemic times in the heterotopic rather in the orthotopic position. Therefore the heterotopic heart transplantation technique seems to have an expending role in the 21st Century, particularly in specific areas such as Australia, New Zeeland, South America, or South Africa with few transplant centers being located in a large organ retrieval area.
References
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