A Patient with Giant Left Atrium Undergoes Orthotopic Heart Transplantation

Abstract

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

Successful treatment of drug-induced esophageal ulcer in a patient with chronic heart failure

“…However, over the last decade, heart transplantation has been increasingly performed worldwide. [9] A previous case of a patient with a giant LA who received heart transplantation was reported in 2014, [10] but the efficacy of the transplantation against esophageal compression after the operation was not assessed. In our case, heart transplantation resolved the cardiomegaly as a fundamental cause of anatomical deformities.…”

Cardiac autotransplantation and ex vivo surgical repair of giant left atrium: a case presentation

“…Several surgical techniques have been described for the treatment of GLA. Conventional cardiac surgery [5], partial autotransplantation [26–28] and orthotopic heart transplantation [29] have been performed to resolve GLA and mitral valve disease with varying success [5].…”

“…One successful case of cardiac autotransplantation was previously reported [29] with a 30-day follow up; few studies have evaluated cardiac autotransplantation as a treatment modality for mitral valve diseases with concomitant GLA.…”