Heart Transplantation in Argentina: Tips and Tricks After 200 Cases

Case Presentation

This is the case of a 62-year-old man (recipient patient) with a history of idiopathic dilated cardiomyopathy, symptomatic for dyspnea (New York Heart Association classification III), and a left ventricular ejection fraction of 36%. Additional patient information includes a height/weight of 168 cm/ 90 kg and AB+.

A donor patient matches for this patient with the following features:
Donor Patient Data
- 27-year-old man
- Height/Weight: 160 cm/ 80 kg
A+
Death Cause: Head Injury by firearm
Left Ventricular Ejection Fraction >60%
Infectious Disease Serologies negative except for Toxoplasmosis and CMV.

Orthotopic heart transplantation was decided.

Operative Technique

First Team (Donor´s Heart Harvesting)

1. A full sterno-laparotomy was performed in the donor with the aim to approach the heart, lungs, and liver for harvesting.
2. The pericardium was opened and the heart was inspected.
3. The superior vena cava was dissected carefully and extensively. This is truly important. The superior vena cava can be ligated as well as the left innominate vein.
4. The right pulmonary and aorta artery junction was separated. This is advisable when the lungs are also harvested to avoid injuries to this pulmonary artery.
5. The left atrial appendage was opened and the inferior vena cava was divided at the diaphragm. After the aorta clamp, a cold cardioplegic solution (University of Wisconsin, Belzer) was used in the author’s team.
6. The cold cardioplegic solution was administered through the aortic root to cool the heart and ensure cardiac arrest.
7. Cardiectomy proceeded by dividing the left atrium, the pulmonary artery, the aorta, and lastly, the superior vena cava.
8. The organ was placed in four sterile plastic bags and transferred to an ice chest for transport.

Second Team (Cardiac Transplantation)

When the first team was coming back to our institution, the second team started the sternotomy.

1. A bi-caval cannulation was used as usual. First, the aorta was divided above the sinus rim and then the pulmonary artery. Second, the right atrium was opened and the left atrium was achieved. The left atrial incision was then extended to the left and superiorly, in front of the left pulmonary veins and behind the left atrial appendage. The aorta was retracted to expose the left atrium.
2. A few minutes were spent trimming the heart and preparing it for implantation. The cardiac chambers were inspected to verify the absence of septal defects. The left appendage was closed with a running suture. The aorta was separated from the pulmonary artery. The pulmonary artery was opened at the bifurcation to preserve the maximal circumference, which may be needed to match the dilated recipient vessel. Then, a blood cold cardioplegia was infused for five minutes on average.
3. The first step was the left atrial anastomosis with a 4.0 prolene with a 26 mm needle. A good trick is to match the donor's left atrial appendage with the recipient’s atrial appendage. It´s important to keep and match the anatomy.
4. The second step was the pulmonary anastomosis with a 5.0 prolene. The authors used to place the Swan-Ganz catheter at this moment.
5. The third step was the aorta anastomosis with a single running suture of 4.0 prolene with a 22 needle.  After the anastomosis is finished, the authors proceed with the reperfusion and unclamp the aorta.
6. The fourth step was the inferior vena cava to right atrium anastomosis with a 4.0 prolene with the on-pump beating heart.
7. The last step was the superior vena cava anastomosis with 4.0 prolene. The authors strongly recommend performing this anastomosis carefully and softly in order to avoid narrowing or obstruction of the vein.

References

1. Chadi Alraies M, Eckman P. Adult heart transplant: indications and outcomes. J Thorac Dis. 2014 Aug; 6(8): 1120–1128.
2. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. 2011;123:e18-e209.
3. Metra M, Ponikowski P, Dickstein K, McMurray JJ, Gavazzi A, Bergh CH, et al. Advanced chronic heart failure: A position statement from the Study Group on Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail. 2007;9:684-694.

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