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Pediatric Orthotopic Heart Transplant

Monday, November 25, 2019

By

Claudia Herbst

Urganci E, Aschacher T, Wiedemann D, et al. Pediatric Orthotopic Heart Transplant. November 2019. doi:10.25373/ctsnet.10563401.

Introduction
In pediatric patients with severe congenital heart disease and end-stage heart failure, cardiac transplant may be the only option. Especially in patients with a medical history of multiple open-heart surgeries, it is a technically demanding procedure and requires a well-trained team with experience in congenital heart disease. The first attempt of pediatric heart transplantation was made by Dr Adrian Kantrowitz in New York in 1967. Considerable progress has been made since that time in surgical technique as well as immunosuppressive treatment. The authors’ immunosuppression protocol starts with an induction therapy using corticosteroids after release of the aortic cross-clamp, followed by antithymocyte globulin combined with mycophenolate mofetil until initiation of tacrolimus. 

Case description
The patient in the presented video is a 17-month-old infant boy of 8.4 kg suffering from cardiomyopathy, tricuspid valve dysplasia with severe regurgitation, mitral valve regurgitation, and recurrent supraventricular tachycardia. Initial surgical repair was performed at the age of two weeks including a tricuspid valvuloplasty, patent ductus arteriosus closure, and a right atrial reduction plasty. At the age of six months, the tricuspid valve required a second valvuloplasty in addition to a mitral valvuloplasty, left atrial reduction plasty, and a partial closure of the atrial septal defect.

Technical description

  1. Cannulation technique
    Cardiopulmonary bypass was commenced by cannulation of the distal ascending aorta as well as bicaval cannulation in the standard fashion.
  2. Explantation of the recipient’s heart
    The aorta was cross-clamped and the superior vena cava was cut through, followed by the separation of the ascending aorta as well as the main pulmonary artery. In the next step, the inferior vena cava was separated from the right atrium. A generous cuff of atrial tissue was left on the caval vein.
  3. Inspection and preparation of the donor heart
    The donor heart was inspected for any lesions or a patent foramen ovale. The aorta was separated from the pulmonary artery.
  4. Left atrial anastomosis
    Implantation started with the left atrial anastomosis fashioned with a running suture. Therefore, the donor´s heart was placed on the assistant´s side with the apex pointing to the left downward side of the patient and the left atrium facing the surgeon.
  5. Pulmonary artery anastomosis
    In the next step, the recipient’s main pulmonary artery was anastomosed end-to-end with the main pulmonary artery of the donor’s heart.
  6. Construction of the aortic connection and releasing the aortic cross-clamp
    The ascending aorta was anastomosed in standard fashion, followed by the release of the aortic cross-clamp, and thereby ended the ischemia period of the donor´s heart.
  7. Construction of the systemic venous connection
    Lastly, the systemic venous connection was reconstructed by an end-to-end anastomosis of the caval veins. After a short period of reperfusion, the patient was weaned from the cardiopulmonary bypass.

Discussion
The patient spent nine days in the pediatric intensive care unit and was extubated on the fifth postoperative day. He was finally discharged after a total of four weeks in the hospital. There were no complications and no signs of acute rejection in the immediate postoperative period. The patient was discharged with antihypertensive therapy consisting of amlodipin and enalapril due to high blood pressure.

Reference

  1. Hetzer R, Weng Y, Delmo Walter EM. State of the art in paediatric heart transplantation: the Berlin experience. Eur J Cardiothorac Surg. 2013 Feb 1;43(2):258-267.

Comments

Submitted by Georgios Belitsis on
Congratulations for your effort to present the case. I am making the following comments with great respect to your practice and the operation you offered to your patient. You are presenting an OHTx in an infant using standard bicaval technique. My comments: Technique of explanting heart from recipient is not focusing at all on the incision within the LA (ie, cut through the mouth of the CS and through the Interatiral septum and finally the incision running very near to the MV). Following the MV is allowing a safety distance from the PVs, even in cases that LA and MV are very small (like in cases of HLHS). Regarding the implantation one would expect you to mention the starting point of the LA anastomosis: (LA appendage to recipients LSPV). In contrast you are only showing the superior part of the anastomosis which is the final step for most of surgeons. Regarding the PA anastomosis you perform MPA to mid MPA of recipient. How do you orientate, to avoid twists? To avoid kinking of the MPA anastomosis one can anastomose the MPA to the bifurcation (or very near to the bifurcation) of the recipient. Further to that, one can extend the bifurcation in the LPA, by a small cut towards the mouth of the LPA, direct the anastomosis towards the LPA. Small kinks (or twists) on the MPA can easily add numerically ‘small gradients’, that are clinically significantly gradients that make the RV to straggle. The Aortic anastomosis also needs to be free of any twists. Once again there is no mention on the orientation technique you use (ie the most posterior stitch needs to correspond to the ascending aorta that is above of the commissure of non and left coronary sinuses). Parenthetically I should mention that there is rule in Transplantation (that I am sure you are aware, but worth’s mentioning): Keep the MPA ‘short’ and the Aorta ‘long’. A ‘short’ Aorta can lead to a ‘waist’ on the aortic anastomosis adding unnecessary gradients. You need to be congratulated that you are releasing the X-Cl after the aortic anastomosis to reduce ischemic time. This though makes even more necessary to share, how you orientate the IVC anastomosis (ie: using as the most distal landmark of the donors IVC the os of the CS …). Same applies to SVC anastomosis. How do you orientate the SVC anastomosis (ie do you use the Azygos as the most posterior landmark for the recipient, and RA appendage of the donor corresponding to the most anterior part). Do you use a marking stitch, to open up the anastomosis? You have done a great work and I congratulate You, in a very humble manner, for both your operation and for the outcome. It is just that I expected you to share with the specialized community a bit more of details, taking into account of the high educational value that such a video can carry. Can you please clarify: Do you use corticosteroids ?after you release the cross-clamp, as you describe in Your text: ‘The authors’ immunosuppression protocol starts with an induction therapy using corticosteroids after release of the aortic cross-clamp..’ Thank you. George Belitsis, Dr.med
Submitted by Georgios Belitsis on
Dear Authors please answer: Can you please clarify: Do you use corticosteroids ?after you release the cross-clamp, as you describe in Your text: ‘The authors’ immunosuppression protocol starts with an induction therapy using corticosteroids after release of the aortic cross-clamp..’ Thank You, George

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