280
Heart Transplantation: Intraoperative Management. Postoperative Therapy and Complications A. lIaverich. !.. Dammenhaun. J . Albes. G. Zi emer. Ch. S chmid. Th. Wahlers. H.-J. Sch iifers. l. Wagel/bret h. and II. G. Borst Division or Thoracic a nd Cardiovasc ular Surgery. Su rgical Center , lIannover Medical School. Han nover . FRG
Currently. heart transplantat ion (HTX) is performed as a n ort hotopic ca rdia c replacement accord ing to the technique of Lower a nd Shumway in over 95 % ofthe cases with good res ults . Survival afte r heter otopic IITX, by cont rast, rem ain poor (one yea r survival: 50 %), Postoperat ive therapy compiles pr imaril y pr ophylactic measu res to pr event complications. especia lly orga n rejection a nd infections. Immunosup pressive prophylaxis gene ra lly includ es a trip le drug thera py consisting of cyclosporin, predn isolone. a nd azath iopr ine for ma intenance therapy. Initia lly the re is often an additional a pplicat ion of poly- or mo noclonal a ntibod ies . The pr ime measure to preve nt infection duri ng the initia l hospita l stay will be reversed isolat ion of the recipient. Initial antibiotic pro phylaxis resem bles tha t of conservative car diac surgery, but in ad dition antiviral a nd a ntifungal prophylaxis is a pplied. The most common postoper ative complicat ion following IITX is ca rdiac rejection , which is det ected by routine end omyocar dia l biopsies. At our instit ution the inciden ce of rejection decr eases from 3.07 ep isodes per patient in the first 3 months to 1.97 episodes duri ng the last 6 months of the first yea r after III X. ln genera l, acute rejection is treated by met hylpredn isolon (3 x 500 mglda y) or anti-Te cell-antibodies. Infections often occur following intervals of incr eased immuno suppressio n, usually ea rly postoper at ively a nd followi ng ther apy of a cute rejections. Often. invasive diag nostic measur es ha ve to be taken rap idly in orde r to a llow for specific therap y (antibi otics . a ntimycotic treatment, virusta tic agents ]. Close follow-up of the heart transpl ant recipien t and rapid therap y of possible postoper ative complications en a ble the current one-year survival rat es of80 % or mor e.
tterztrans planta tton. Intraop erati ve ~l a 8n ahm cn .
pestcper atlveTherapie und Komplikationen Die Ilcrz tran splantation (1ITX)wird heut e in Uber 9S %der Fiille als ort hoto pe r Ersatz na ch der von Lower und ShwllU'oy a ngegeb en en Technik a usgefilhrt. Die Erge bnisse nach heterotoper HTX sind mit eine r t -Jahr es -Uberl eb ens rat e von ca. 50 % deutlich schlechte r. Die postoperative Thera pie bein haltet im wesentli chen prophyla ktische Malma hmen zur VerhUtung von Komplikationen, vor allem der OrganabstoBung un d Infektion. Die imm un s uppressive Proph yla xe besteht he ute a us c ine r 3fach-Kombination a us Cyclosporin A, Prednisolon und Azath ioprin als Erha ltungs therapie, wo bei zur Induktion h fiuflg poly- oder monoklonale Antiktirper hinzugefligt werden. Wichtig stes Instru men t zur Infektionsverh titung ist wah-e nd des sta tion a re n Aufenthaltns die Expositio nspro phylaxe du rch Umke hr isolatio n. Mcdika me ntOs wird proph ylaktisch nur gegcn virale und fungale Infektionen vorg cga ngcn . Ha uflgst c postoper ative Kom plikati on ist die ka rdiale AbstoBung. die irnmcr noch mitte ls routinemagtg vorgc nommenc r Endomyoka rd biopsie a ufgede ckt wird . Die Inziden z sin kt von 3,07 Episode n pro Patient in den ers ten 3 Monate n au f 1, 97 Episoden im zweite n lIa lbja hr nach Transpla ntatio n. Eine AbstoBung wi rd in de r Hegel mit Methylpredn isolon (500 rug/die x 3) oder T-Zell-Antikorpe rn bcha ndelt. lnfektio ne n treten gehaun frtlhpostop eratlv und nach Thera pie einer AbstoBung au f. Sie e rfordern cine rasche. oft invasive Diagno stik und gezielte Thc rapie (Antiblose. Ant imykose. Virostatika). Durch engmaschige Kontrolle und rasche Th er api e auftretend er postop er a tiver Kompl ikation en na ch IITX sind heute 1J ahres-Ubcrl ebensr at cn von tibe r 80 % mog lich.
Key words Heart trans plantation - ImmunosuppressionInfectious complications
Intr od uction During the last decade. ca rdiac tra nsplantation has been performed in yea rly increas ing numbers for pati ents with medica lly intractab le heart failure. Cur re nt worldwid e resu lts depict an operative mortality of below 10 % an d oneyea r surviva l rates of 80% or more. These success rates are clearly su perior to thos e obta ined with th e same proced ure in the previous deca de (3).
The main reasons for this increa se in survival are improved operat ive techn ique. sup erio r postoperative therapy. and better managem en t of complications. These 3 factors a re addresse d in this commun ication according to a protocol derived from our experience with more tha n 300 ca rdiac transplan t procedur es.
Head at the 191h Annua l Meeting of the Germa n Society for Tho racic and Ca rdiovascula r Surger y. Bad Nauheim . Februa ry 22 -2 4. 1990 Tho ra e. ca rdiovasc . Surgeon :!8 (1990) 280-2 84 © Geor g- Thieme Verlag-Stuttgart- New York
Received for Publication : February 28. 1990
Downloaded by: Universite Laval. Copyrighted material.
Summar)'
lIeart Tra'lsp lantatioll: Illl raop erat ive Managemellt. Poslo pe ratil1en zerapy and Complications Thorae. card iOl'(Jsc . Surgeon.18 (1990)
Orthotopic tran splanta tion A mid ste rno to my is performed a nd th e pericardium ope ne d in the usual fashi on . Th e ascending aorta is ca n nulated an d bica val ca nnulation throu gh the righ t a triu m is pe rformed . Caution must be taken to position these cannulation sites as far posterior as possible in orde r to minimize the remainder of th e righ t a trium on th e recipient side . Following he pa rini zation . rou tine ca rdio pu lmonary byp ass is in st ituted. Both cavae a re sna red for tota l ca rd iopulmonary bypass. Afte r fibrill a tion of the heart. th e asce ndi ng aorta is cross clamped as far downstream as possi ble in orde r to maximize th e len gth availab le for th e ao rt ic anastomosis. Th e recipient' s heart is excised beginn ing at the right at ri um close to th e AV-grove a t th e level of th e righ t a trial a ppe ndage. Thi s incis ion is ca rried on downward un til th e coro nary sinus can be iden tified from th e inside. wh ich is th en incised . The interatrial septum is opene d and the incision is carried down into the coronary sinus as well. Then . the ce pha lad portion of th e se ptum as well as th e right a trial wa ll a re inci sed . Followin g tr a nsverse division of both th e aorta a nd main pulmona ry artery about 1.5cm a bove th e valve com miss ure s . th e free wall of th e left atri um is trans ecte d posterior to th e left atrial a ppe ndage. Ut ilizing thi s mod e of transection of the great ves sels . homografts can be retrieved from both semilunar valves . Usua lly. no furt her pr e pa ration on the re cip ient's sid e is necessary. However, conside rable amounts of tissue may be resected from th e right at rial wa ll a nterior of the ca va l canulae . Meanwhile. the donor heart has been pr epared for im pla nt ati on a t th e ba ck table by conn ecting a ll four ostia of the pulmonary veins to one common incisi on in the posterior aspect of th e left atrium . Th e SVC sut ure is ligat ed a nd th e right a triu m is incised beginning at th e lat eral aspec t of th e ost ium of th e IVC towa rds th e right at rial appendage. Th e length of thi s incision has to be determ ined by th e recipi ent's righ t a trial size. At thi s stage. max imu m len gth is reta ined a t th e don or ao rta and pu lmona ry a rtery. since considerable size mismatches can appear and are eas ier to control with redundant tissue available on either side. Insertion of the don or heart is com me nced by sut u ring a dou ble a rmed 3-0-prolene sutu re inside-out on bot h recipient a nd don or left at rium a t the level of the left a tr ia l appendage . A continuous suture is used to anastomose the inferio r aspect of bo th left a tria unt il the intera tri al septu m is reach ed . The seco nd pa rt of the suture is then used to a nasto mose the left a trial roof towards the at rial se ptum . A second 3-0 running suture serves to anasto mose both right a tria . Thi s suture sta rts in th e mid portion of the a trial se ptu m a nd is run in both direction s until th e sutu res meet a t th e la tera l aspec t of th e right atri al free wall. Next. the diam et er of th e recipi ent pulm on ary arte ry is es ti ma ted a nd th e pu lm on ary a rte ry stu m p of th e donor is tail ored acco rd ingly in size a nd length . End-to-end a nastom osis is performed using a running 4-0-pro lene suture. This procedure is rep eated for both ao rt ic stumps. Here. deairing of th e heart is performed pri or to tying down the suture in th e anter ior asp ect of th e ascend ing ao rta. Follow ing unclamping of the aorta. add itional dea ir ing has to be ca rried out through the a pex of the left ventr icle. since a ir embolism from the previou sly com pletely emp ty left side of the donor
heart is a frequent comp lication during hea rt transp lantation. Usua lly. the h eart resumes s ponta neo us fibrilla tion ea rly a nd ca n be defibrillat ed within th e first 2 m inutes aft er rep erfusion . In our hands . exte nded rep erfusion (30 minutes) has proven helpful in orde r to allow th e hea rt to recover.
Heterotopic transplanta tion Today. het erotop ic tran spl antat ion of a n aux iliary heart represents a rare indication for treatment of patients with heart failure . Recipi ents in nee d of very urge nt transplantation may be se rved by a very sma ll do nor heart tr ansplan ted in a heterotopi c fas hion . whi ch would not be ab le to support the pa tien t' s circulation if impl anted orthotop ica lly. A secon d ind icati on would be seve re . irreversi ble pulmon a ry hyp erten sion . wh er e th e het er otopi c transplant is used to primarily su ppo rt th e recipi en t's left ve ntricle. while pulmonary cir culati on will be sus tai ne d by th e reci pien t' s righ t heart (6). Fin ally. heterotopic tr a nsp lants ha ve bee n perform ed in rare cases of presu med rever sibl e heart failure du e to acu te viral myo ca rditis (4). Thi s procedu re is also done th rough a mid ste rno to my a nd on total ca rdiopulm onary bypass . During excision of the donor heart the superior vena cava is ligated above the osti um of the az ygos vein. which is th e n ligat ed . Maximum length of dono r aorta a nd pulm on ary a rtery sho uld be pro vide d . The right pu lmon a ry veins and the inferior vena cava of th e dono r hea rt a re closed by a su ture, the left pulm on ary veins are co nnected to one single ostium and the righ t atrium is incised at its posterior aspect well into the superior vena cava . Left atrial anastomosis is performed following an incision of the recipient's left a trium behind th e inter atrial grove. The right atrial connection is done by an anastomosis of 'dia m ond ' sha pe . End -to-side a nastomoses are used for th e great arteri es . Commo nly. a graft int erposition is nee de d to connect the donor pulmonary artery to the main pulmonary a rte ry of th e recipi en t (6). Heterotopi c h eart tr ansp lantati on ca nnot be considered a reali sti c alte rnative. si nce the resul ts with resp ect to both sho rt- te rm and long-t erm survival are poor when compared to th ose afte r ort ho topic pr ocedures . Current oneyea r su rvival in the registry of th e Internation al Society for Heart Transplantation is about 50 % for heterotopic. as opposed to 80 % for orthoto pic trans plants (Fig .) I.
An aest hesiologic a l ma na gement In ort hotopic tr ansplants. impl antati on of th e donor hea rt rarely repres ents su rgica l pr ob lem s (Fig. 21. These ma y occur. however. in case of re pea ted operations. e. g. Fontan ope ra tio n. or if a large ASD is pr ese nl. Ana esth esiologic managem ent during the period of reperfusion and termination of ca rdiopulmon ary bypass. by cont rast. is of prim e importance to as sure a succes sful completion of th is operation. In our experience . early vasodil ative and positive inotropic thera py nitroglycerine , isoprenaline. and adrenaline has proved a very useful combination of drugs . After loose ning the ca val sna res. the hea rt activity is su pported by a ll 3 drugs on parti al ca rdio pulmonary bypass . Ra rely, Iidocain infusions are nee ded to control ventricular extra beats . At
Downloaded by: Universite Laval. Copyrighted material.
Intra opera tive Manag'cm cnt
281
71lOrac. cardiovasc. Surgeo ll.18 (1990)
A. Ilaverich et al.
% survival
1: ~
orthoto pic
\-------...
•
. _ _. ..
....
60
_
•
heterotopic
... ...
_ _.
40
monly. however. isolated failure of the right ventri cle is observed. Several hypotheses have been put up to explain this phenomenon. Pulmona ry hypert ension in the recipient. sma ller size of the donor hea rt , preferential reduction of right ventricular contract ility duri ng ischemia and intraoperative tricuspid regurgitation are currently disputed. We prospectively investigated the pulmonary circulation of 19 trans plant recipients perioperatively. In these patients. preoperative cardiac output (CO) was 3.4 ± 0.3 U min and pulmonary arteriolar resistance (PAR) was calcu-
20 0 +--~-~-~-~-~-----1
o
2
3
5
4
years
Fig. 1 Datafromthe RegistryoftheInternationalSociety for HeartTransplantationcomparingsurvival afterorthotopic andheterotopiccardiactransplants (I)
lated 278 ± 33 dynes.sec.cm", Two hours after tran splan tation. corresponding data were 6.5 ± 1.7 Umin (CO) and 172 ± 43 dynes.sec.cm" WAR) . While CO and left atrial pr essures remained constant during the next 24 to 48 hours. PAil dec reased furth er to 135 ± 43 a nd 124 ± 37 dynes.sec.cm'" (Fig. 3). Thus. PAR remain ed abnormally elevated ea rly after tran spla ntation despit e maximum 250
% mortality
16 , - --
-
-
- --
-
-
-
- --
-
---, 1::1 200
hemodynamics after HT X (n '" 191
6.5
t
1.7
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6.3
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Heart Transplantation: Intraoperative Management. Postoperative Therapy and Complications A. lIaverich. !.. Dammenhaun. J . Albes. G. Zi emer. Ch. S chmid. Th. Wahlers. H.-J. Sch iifers. l. Wagel/bret h. and II. G. Borst Division or Thoracic a nd Cardiovasc ular Surgery. Su rgical Center , lIannover Medical School. Han nover . FRG
Currently. heart transplantat ion (HTX) is performed as a n ort hotopic ca rdia c replacement accord ing to the technique of Lower a nd Shumway in over 95 % ofthe cases with good res ults . Survival afte r heter otopic IITX, by cont rast, rem ain poor (one yea r survival: 50 %), Postoperat ive therapy compiles pr imaril y pr ophylactic measu res to pr event complications. especia lly orga n rejection a nd infections. Immunosup pressive prophylaxis gene ra lly includ es a trip le drug thera py consisting of cyclosporin, predn isolone. a nd azath iopr ine for ma intenance therapy. Initia lly the re is often an additional a pplicat ion of poly- or mo noclonal a ntibod ies . The pr ime measure to preve nt infection duri ng the initia l hospita l stay will be reversed isolat ion of the recipient. Initial antibiotic pro phylaxis resem bles tha t of conservative car diac surgery, but in ad dition antiviral a nd a ntifungal prophylaxis is a pplied. The most common postoper ative complicat ion following IITX is ca rdiac rejection , which is det ected by routine end omyocar dia l biopsies. At our instit ution the inciden ce of rejection decr eases from 3.07 ep isodes per patient in the first 3 months to 1.97 episodes duri ng the last 6 months of the first yea r after III X. ln genera l, acute rejection is treated by met hylpredn isolon (3 x 500 mglda y) or anti-Te cell-antibodies. Infections often occur following intervals of incr eased immuno suppressio n, usually ea rly postoper at ively a nd followi ng ther apy of a cute rejections. Often. invasive diag nostic measur es ha ve to be taken rap idly in orde r to a llow for specific therap y (antibi otics . a ntimycotic treatment, virusta tic agents ]. Close follow-up of the heart transpl ant recipien t and rapid therap y of possible postoper ative complications en a ble the current one-year survival rat es of80 % or mor e.
tterztrans planta tton. Intraop erati ve ~l a 8n ahm cn .
pestcper atlveTherapie und Komplikationen Die Ilcrz tran splantation (1ITX)wird heut e in Uber 9S %der Fiille als ort hoto pe r Ersatz na ch der von Lower und ShwllU'oy a ngegeb en en Technik a usgefilhrt. Die Erge bnisse nach heterotoper HTX sind mit eine r t -Jahr es -Uberl eb ens rat e von ca. 50 % deutlich schlechte r. Die postoperative Thera pie bein haltet im wesentli chen prophyla ktische Malma hmen zur VerhUtung von Komplikationen, vor allem der OrganabstoBung un d Infektion. Die imm un s uppressive Proph yla xe besteht he ute a us c ine r 3fach-Kombination a us Cyclosporin A, Prednisolon und Azath ioprin als Erha ltungs therapie, wo bei zur Induktion h fiuflg poly- oder monoklonale Antiktirper hinzugefligt werden. Wichtig stes Instru men t zur Infektionsverh titung ist wah-e nd des sta tion a re n Aufenthaltns die Expositio nspro phylaxe du rch Umke hr isolatio n. Mcdika me ntOs wird proph ylaktisch nur gegcn virale und fungale Infektionen vorg cga ngcn . Ha uflgst c postoper ative Kom plikati on ist die ka rdiale AbstoBung. die irnmcr noch mitte ls routinemagtg vorgc nommenc r Endomyoka rd biopsie a ufgede ckt wird . Die Inziden z sin kt von 3,07 Episode n pro Patient in den ers ten 3 Monate n au f 1, 97 Episoden im zweite n lIa lbja hr nach Transpla ntatio n. Eine AbstoBung wi rd in de r Hegel mit Methylpredn isolon (500 rug/die x 3) oder T-Zell-Antikorpe rn bcha ndelt. lnfektio ne n treten gehaun frtlhpostop eratlv und nach Thera pie einer AbstoBung au f. Sie e rfordern cine rasche. oft invasive Diagno stik und gezielte Thc rapie (Antiblose. Ant imykose. Virostatika). Durch engmaschige Kontrolle und rasche Th er api e auftretend er postop er a tiver Kompl ikation en na ch IITX sind heute 1J ahres-Ubcrl ebensr at cn von tibe r 80 % mog lich.
Key words Heart trans plantation - ImmunosuppressionInfectious complications
Intr od uction During the last decade. ca rdiac tra nsplantation has been performed in yea rly increas ing numbers for pati ents with medica lly intractab le heart failure. Cur re nt worldwid e resu lts depict an operative mortality of below 10 % an d oneyea r surviva l rates of 80% or more. These success rates are clearly su perior to thos e obta ined with th e same proced ure in the previous deca de (3).
The main reasons for this increa se in survival are improved operat ive techn ique. sup erio r postoperative therapy. and better managem en t of complications. These 3 factors a re addresse d in this commun ication according to a protocol derived from our experience with more tha n 300 ca rdiac transplan t procedur es.
Head at the 191h Annua l Meeting of the Germa n Society for Tho racic and Ca rdiovascula r Surger y. Bad Nauheim . Februa ry 22 -2 4. 1990 Tho ra e. ca rdiovasc . Surgeon :!8 (1990) 280-2 84 © Geor g- Thieme Verlag-Stuttgart- New York
Received for Publication : February 28. 1990
Downloaded by: Universite Laval. Copyrighted material.
Summar)'
lIeart Tra'lsp lantatioll: Illl raop erat ive Managemellt. Poslo pe ratil1en zerapy and Complications Thorae. card iOl'(Jsc . Surgeon.18 (1990)
Orthotopic tran splanta tion A mid ste rno to my is performed a nd th e pericardium ope ne d in the usual fashi on . Th e ascending aorta is ca n nulated an d bica val ca nnulation throu gh the righ t a triu m is pe rformed . Caution must be taken to position these cannulation sites as far posterior as possible in orde r to minimize the remainder of th e righ t a trium on th e recipient side . Following he pa rini zation . rou tine ca rdio pu lmonary byp ass is in st ituted. Both cavae a re sna red for tota l ca rd iopulmonary bypass. Afte r fibrill a tion of the heart. th e asce ndi ng aorta is cross clamped as far downstream as possi ble in orde r to maximize th e len gth availab le for th e ao rt ic anastomosis. Th e recipient' s heart is excised beginn ing at the right at ri um close to th e AV-grove a t th e level of th e righ t a trial a ppe ndage. Thi s incis ion is ca rried on downward un til th e coro nary sinus can be iden tified from th e inside. wh ich is th en incised . The interatrial septum is opene d and the incision is carried down into the coronary sinus as well. Then . the ce pha lad portion of th e se ptum as well as th e right a trial wa ll a re inci sed . Followin g tr a nsverse division of both th e aorta a nd main pulmona ry artery about 1.5cm a bove th e valve com miss ure s . th e free wall of th e left atri um is trans ecte d posterior to th e left atrial a ppe ndage. Ut ilizing thi s mod e of transection of the great ves sels . homografts can be retrieved from both semilunar valves . Usua lly. no furt her pr e pa ration on the re cip ient's sid e is necessary. However, conside rable amounts of tissue may be resected from th e right at rial wa ll a nterior of the ca va l canulae . Meanwhile. the donor heart has been pr epared for im pla nt ati on a t th e ba ck table by conn ecting a ll four ostia of the pulmonary veins to one common incisi on in the posterior aspect of th e left atrium . Th e SVC sut ure is ligat ed a nd th e right a triu m is incised beginning at th e lat eral aspec t of th e ost ium of th e IVC towa rds th e right at rial appendage. Th e length of thi s incision has to be determ ined by th e recipi ent's righ t a trial size. At thi s stage. max imu m len gth is reta ined a t th e don or ao rta and pu lmona ry a rtery. since considerable size mismatches can appear and are eas ier to control with redundant tissue available on either side. Insertion of the don or heart is com me nced by sut u ring a dou ble a rmed 3-0-prolene sutu re inside-out on bot h recipient a nd don or left at rium a t the level of the left a tr ia l appendage . A continuous suture is used to anastomose the inferio r aspect of bo th left a tria unt il the intera tri al septu m is reach ed . The seco nd pa rt of the suture is then used to a nasto mose the left a trial roof towards the at rial se ptum . A second 3-0 running suture serves to anasto mose both right a tria . Thi s suture sta rts in th e mid portion of the a trial se ptu m a nd is run in both direction s until th e sutu res meet a t th e la tera l aspec t of th e right atri al free wall. Next. the diam et er of th e recipi ent pulm on ary arte ry is es ti ma ted a nd th e pu lm on ary a rte ry stu m p of th e donor is tail ored acco rd ingly in size a nd length . End-to-end a nastom osis is performed using a running 4-0-pro lene suture. This procedure is rep eated for both ao rt ic stumps. Here. deairing of th e heart is performed pri or to tying down the suture in th e anter ior asp ect of th e ascend ing ao rta. Follow ing unclamping of the aorta. add itional dea ir ing has to be ca rried out through the a pex of the left ventr icle. since a ir embolism from the previou sly com pletely emp ty left side of the donor
heart is a frequent comp lication during hea rt transp lantation. Usua lly. the h eart resumes s ponta neo us fibrilla tion ea rly a nd ca n be defibrillat ed within th e first 2 m inutes aft er rep erfusion . In our hands . exte nded rep erfusion (30 minutes) has proven helpful in orde r to allow th e hea rt to recover.
Heterotopic transplanta tion Today. het erotop ic tran spl antat ion of a n aux iliary heart represents a rare indication for treatment of patients with heart failure . Recipi ents in nee d of very urge nt transplantation may be se rved by a very sma ll do nor heart tr ansplan ted in a heterotopi c fas hion . whi ch would not be ab le to support the pa tien t' s circulation if impl anted orthotop ica lly. A secon d ind icati on would be seve re . irreversi ble pulmon a ry hyp erten sion . wh er e th e het er otopi c transplant is used to primarily su ppo rt th e recipi en t's left ve ntricle. while pulmonary cir culati on will be sus tai ne d by th e reci pien t' s righ t heart (6). Fin ally. heterotopic tr a nsp lants ha ve bee n perform ed in rare cases of presu med rever sibl e heart failure du e to acu te viral myo ca rditis (4). Thi s procedu re is also done th rough a mid ste rno to my a nd on total ca rdiopulm onary bypass . During excision of the donor heart the superior vena cava is ligated above the osti um of the az ygos vein. which is th e n ligat ed . Maximum length of dono r aorta a nd pulm on ary a rtery sho uld be pro vide d . The right pu lmon a ry veins and the inferior vena cava of th e dono r hea rt a re closed by a su ture, the left pulm on ary veins are co nnected to one single ostium and the righ t atrium is incised at its posterior aspect well into the superior vena cava . Left atrial anastomosis is performed following an incision of the recipient's left a trium behind th e inter atrial grove. The right atrial connection is done by an anastomosis of 'dia m ond ' sha pe . End -to-side a nastomoses are used for th e great arteri es . Commo nly. a graft int erposition is nee de d to connect the donor pulmonary artery to the main pulmonary a rte ry of th e recipi en t (6). Heterotopi c h eart tr ansp lantati on ca nnot be considered a reali sti c alte rnative. si nce the resul ts with resp ect to both sho rt- te rm and long-t erm survival are poor when compared to th ose afte r ort ho topic pr ocedures . Current oneyea r su rvival in the registry of th e Internation al Society for Heart Transplantation is about 50 % for heterotopic. as opposed to 80 % for orthoto pic trans plants (Fig .) I.
An aest hesiologic a l ma na gement In ort hotopic tr ansplants. impl antati on of th e donor hea rt rarely repres ents su rgica l pr ob lem s (Fig. 21. These ma y occur. however. in case of re pea ted operations. e. g. Fontan ope ra tio n. or if a large ASD is pr ese nl. Ana esth esiologic managem ent during the period of reperfusion and termination of ca rdiopulmon ary bypass. by cont rast. is of prim e importance to as sure a succes sful completion of th is operation. In our experience . early vasodil ative and positive inotropic thera py nitroglycerine , isoprenaline. and adrenaline has proved a very useful combination of drugs . After loose ning the ca val sna res. the hea rt activity is su pported by a ll 3 drugs on parti al ca rdio pulmonary bypass . Ra rely, Iidocain infusions are nee ded to control ventricular extra beats . At
Downloaded by: Universite Laval. Copyrighted material.
Intra opera tive Manag'cm cnt
281
71lOrac. cardiovasc. Surgeo ll.18 (1990)
A. Ilaverich et al.
% survival
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orthoto pic
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heterotopic
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monly. however. isolated failure of the right ventri cle is observed. Several hypotheses have been put up to explain this phenomenon. Pulmona ry hypert ension in the recipient. sma ller size of the donor hea rt , preferential reduction of right ventricular contract ility duri ng ischemia and intraoperative tricuspid regurgitation are currently disputed. We prospectively investigated the pulmonary circulation of 19 trans plant recipients perioperatively. In these patients. preoperative cardiac output (CO) was 3.4 ± 0.3 U min and pulmonary arteriolar resistance (PAR) was calcu-
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years
Fig. 1 Datafromthe RegistryoftheInternationalSociety for HeartTransplantationcomparingsurvival afterorthotopic andheterotopiccardiactransplants (I)
lated 278 ± 33 dynes.sec.cm", Two hours after tran splan tation. corresponding data were 6.5 ± 1.7 Umin (CO) and 172 ± 43 dynes.sec.cm" WAR) . While CO and left atrial pr essures remained constant during the next 24 to 48 hours. PAil dec reased furth er to 135 ± 43 a nd 124 ± 37 dynes.sec.cm'" (Fig. 3). Thus. PAR remain ed abnormally elevated ea rly after tran spla ntation despit e maximum 250
% mortality
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hemodynamics after HT X (n '" 191
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