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O rthotopic heart transplantation (OHT) remains the operation of choice in patients with end-stage chronic heart failure. Nowadays, up to 3,800 such operations are performed annually. Only 2.7% of patients undergo transplantation as a consequence of valvular cardiomyopathy.1 In patients with rheumatic heart disease, the presence of giant left atrium (GLA) makes the technical aspects of transplantation more difficult because of substantial size mismatch between donor and recipient at the point of anastomosis. We present a rare case of OHT in a recipient with GLA. Case ReportIn July 2011, a 48-year-old man presented with an enlarged heart caused by chronic rheumatic disease (Fig. 1). His height was 174 cm and his weight was 79 kg. Twentythree years earlier, he had undergone mitral valve replacement with an EMIKS 27-mm disk graft (produced in the Union of Soviet Socialist Republics). Preoperative echocardiography showed a GLA (70 × 96 mm), with a calculated volume of 350 mL. Abdominal ultrasonic examination revealed ascites.Upon reoperative median sternotomy, we encountered intensive adhesions. After exposing the ascending aorta and the superior vena cava, we instituted partial cardiopulmonary bypass (CPB). We continued to perform cardiolysis, exposing the inferior vena cava. We then switched to full CPB with bicaval cannulation. Cardiomegaly was found, chiefly in the left atrium (LA), right atrium, and left ventricle (LV). After cross-clamping the aorta, we explanted the heart (Fig. 2). After excising the right atrium, right ventricle, and LA, we found that the remaining wall of the LA presented a particular difficulty. The residual posterior wall was considerably enlarged (18 × 16 cm) and calcified, with immovable pulmonary veins (PVs) adjoined to the surrounding tissues. After freeing the PVs, we used 2 Prolene 4-0 monofilaments on 4 × 7-mm felt pads to approximate (via gathered sutures) the ostia of the PVs laterally along the posterior wall (Fig. 3A). Each horizontal suture was located between the upper and lower PVs. These were supplemented with Prolene 4-0 sutures on felt pads introduced vertically. Placing stitches only on the posterior left atrial wall (Fig. 3B), we implanted the LA of the donor heart. All told, posterior-wall reduction and donor left atrial implantation took 57 minutes. Other anastomoses were carried out uneventfully. Cardiopulmonary bypass time was 198 min. The donor heart was anoxic for 125 min, and the operation took 299 min in total. At the end of the procedure, up to 4 L of ascitic fluid was evacuated from the abdominal cavity through the diaphragm. The patient

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Surgical treatment of aortic root and ascending aorta aneurysms with aortic insufficiency is still controversial. A valvesparing operation is the procedure of choice for such patients, and the reimplantation technique is preferable. We describe a simple technique for aortic root reconstruction that has been successfully performed for patients with aneurysms of aortic root and ascending aorta with aortic insufficiency.