Asian Cardiovasc Thorac Ann 2004;12:111-114
© 2004 Asia Publishing EXchange Ltd
Partial Cardiac Autotransplantation for Reduction of the Left Atrium
Hasan B Erdo
an, MD,
Kaan Kirali, MD,
Suat N Ömerolu, MD,
Deniz Göksedef, MD,
Ömer I
ik, MD,
Cevat Yakut, MD
Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Istanbul, Turkey
For reprint information contact: Kaan Kirali, MD Tel: 90 216 326 6969 Fax: 90 216 339 0441 Email: imkkirali{at}yahoo.com Department of Cardiovascular Surgery, Kouyolu Heart and Research Hospital, Kadiköy 81020, Istanbul, Turkey.
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ABSTRACT
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Various surgical procedures have been employed to treat a greatly enlarged left atrium. We review the use of partial cardiac autotransplantation to reduce left atrial volume in 7 patients with rheumatic mitral valve disease and left atrial and ventricular volume in 2 patients with idiopathic dilated cardiomyopathy. There were 5 males and 4 females aged 25 to 62 years. The patients with rheumatic etiology had atrial fibrillation, while those with dilated cardiomyopathy had sinus rhythm. The mitral valve was replaced in 6 patients and reconstructed in 3. Mean aortic cross clamp time in the operations involving isolated left atrial resection was 119 ± 44 min. Mean left atrial volume fell from 331 mL to 92 mL, while mean left atrial diameter decreased from 8.6 cm to 4.7 cm. Sinus rhythm was restored in 5 of the 7 patients who had preoperative atrial fibrillation. There was no operative mortality. The patients with dilated cardiomyopathy died in the postoperative period, one on the 14th day from low cardiac output and the other on the 113th day from multiorgan failure. Partial cardiac autotransplantation can be effective in reducing heart chamber size in selected patients, especially those with giant left atrium.
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INTRODUCTION
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Heart autotransplantation has been used in the treatment of various types of cardiac diseases, including cardiac masses situated on the posterior aspect of the heart that cover a wide area and are unreachable using conventional techniques;1,2 long QT syndrome that presents with paroxysmal ventricular tachycardia refractory to medical therapy;3 and Prinzmetal’s angina unresponsive to medical therapy.4 Another important use is in the treatment of giant left atrium. A greatly enlarged left atrium may compress the left ventricle, the pulmonary vessels, and the bronchial tree. Untreated, low cardiac output and thromboembolism can develop after cardiac surgery. Although plication techniques have been used for a long time, they do not effectively reduce left atrial (LA) dimensions.5 In 1996, a cardiac autotransplantation technique was introduced to reduce LA volumes in patients with giant left atrium.6 More recently, partial left ventriculectomy was used in patients with end stage dilated cardiomyopathy (DCM) as a bridge to heart transplantation.7
We report on 9 patients with giant left atrium (diameter > 7 cm) who were surgically treated with partial cardiac autotransplantation.
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PATIENTS AND METHODS
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Between 1997 and January 2003, partial cardiac autotransplantation was performed for LA volume reduction in 7 patients with rheumatic mitral valve disease and for left atrial and ventricular volume reduction in 2 patients with idiopathic DCM at our hospital. There were 5 male and 4 female patients with a mean age of 43.1 years (range, 25 to 62 years). Preoperative diagnosis was made by transthoracic and transesophageal echocardiography. Tricuspid regurgitation was graded by the conventional 4-grade classification based on the distance reached by the tricuspid regurgitation jet in 2-dimensional doppler echocardiography.8 Tricuspid regurgitation was also graded by echocardiography as mild to moderate or severe based on occupancy of the right atrial area: it was considered mild to moderate if the jet area occupied 20% to 33% of the right atrium, and severe if occupancy exceeded 33%.9
Table 1
summarizes some of the pre- and postoperative data of the patients. Severe tricuspid insufficiency was detected in 4 patients, LA thrombosis in 1 patient, and LA spontaneous echo contrast (SEC) in 3 patients. Preoperatively, all the patients with rheumatic etiology had atrial fibrillation, while the DCM patients had sinus rhythm. LA diameters measured 7.7 to 11.2 cm (mean, 8.6 ± 1.3 cm), and LA volumes were 265 to 455 mL (mean, 331 ± 62 mL). The 2 patients with DCM were in New York Heart Association (NYHA) functional class IV, with left ventricular ejection fraction of 22% and 24%, respectively. The 7 patients with rheumatic heart disease had normal cardiac function (ejection fraction > 60%), with 4 of them in NYHA class III and 3 in class II.
All patients were operated through a median sternotomy under cardiopulmonary bypass (CPB) and moderate systemic hypothermia (28°C to 30°C). CPB was instituted through standard aortic and inferior vena caval cannulation, while the superior vena cava (SVC) was cannulated 3 cm above the junction between the right atrium and the SVC using an L-shaped cannula. Continuous retrograde isothermic blood cardioplegia was administered for myocardial protection. When right atriotomy was performed, the coronary sinus was cannulated selectively. When tricuspid valvuloplasty was not necessary, the coronary sinus was cannulated through the right atrium. The LA venting cannula was inserted through the right superior pulmonary vein after aortic cross clamping to avoid thromboembolism.
After aortic cross clamping, the SVC, aorta, and pulmonary artery were transected in the same way as in heart transplantation (Figure 1A). The inferior vena cava (IVC) was left intact. The heart was then lifted up and shifted inferiorly for better surgical exposure. The left atrium was resected except for its base, conserving the left and right pulmonary vein orifices; this portion was left intact in a button shape. The lateral wall, atrial appendage, atrial roof, and the region between the pulmonary veins and the mitral annulus were resected leaving enough area for suturing (Figure 1B). The mitral valve was then replaced or repaired as needed, with replacement performed in 6 patients, mitral commissurotomy in 1 patient, and Kay annuloplasty in 2 patients. LA thrombectomy was also performed in 1 patient. Finally, all parts of the atrium were reattached using running 4/0 polypropylene sutures (Figure 1C). LA closure began from the periannular region near the posterior leafl et and continued to the pulmonary veins and the lateral wall. The LA roof was closed last. An ellipsoid shaped left ventricular wall resection was performed in the DCM patients. The left ventricle was closed using running over-and-over 3/0 polypropylene sutures through 2 layers of the ventricular wall and a layer of the epicardium. De Vega tricuspid annuloplasty was performed in 4 patients after left heart procedures were completed. Atrial and ventricular pacing wires were left routinely in all patients.
Mean aortic cross clamping time was 119 ± 44 min (range, 85 to 160 min) and CPB time was 145 ± 23 min (range, 115 to 175 min) in the patients who had isolated LA resection. In the 2 patients who underwent partial left ventriculectomy, aortic cross clamping time and CPB time were, respectively, 128 and 136 minutes in 1 patient and 168 and 183 min in the other. All patients were evaluated by echocardiography and 24-hour Holter monitoring before discharge from hospital. Since discharge, the surviving patients had been followed up for 0 to 36 months.
Results were analyzed using SPSS version 10.0 (SPSS, Inc., Chicago, IL, USA). Descriptive variables are expressed in mean ± standard deviation. Differences between continuous variables (pre and postoperative LA diameters) were analyzed using the paired t-test, and nonparametric variables (pre and postoperative heart rhythm) by the chi-squared test. Differences were considered statistically significant if p < 0.05.
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RESULTS
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There was no operative mortality. Inotropic support was necessary during weaning from CPB in 4 patients. Intraaortic balloon pump support was used in the 2 patients with DCM who underwent partial left ventriculectomy. Both died during the postoperative period. One died from low cardiac output syndrome on the 14th postoperative day despite balloon pumping and inotropic support. The other developed peripheral edema, ascites, and pleural effusion 35 days after operation and died 78 days later from multiorgan failure.
Postoperatively, as well as during follow-up, 7 patients were in sinus rhythm (Table 1
). After releasing the aortic cross clamping, atrial fibrillation continued in 1 patient while junctional rhythm, which turned into atrial fibrillation on the 3rd postoperative day, developed in another. Echocardiographic "A" wave was observed in the 5 patients who reverted to sinus rhythm. Permanent pacing was not required in any patient. LA thrombosis or SEC was not observed in any patients. Mean LA diameter decreased from the preoperative value of 8.6 ± 1.3 cm to 4.7 ± 0.8 cm (range, 4.0 to 6.5 cm) ( p < 0.001 between pre and postoperative values), while mean LA volume fell from 331 ± 62 mL to 92 ± 12 mL (range, 75 to 110 mL) ( p < 0.001). In terms of postoperative functional capacity, 4 patients were in NYHA class II and 2 patients in class I. The remaining patient had been in the intensive care unit for 2 months. She received antibiotic therapy for pulmonary infection, and tracheostomy had been performed to wean her from mechanical ventilation.
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DISCUSSION
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Various surgical procedures, such as paraannular and posterior wall plication, have been employed to reduce the size of a giant left atrium. The aim of these plication techniques is to relieve the pressure exerted by the atrium on the left ventricle and the bronchial system. Because of limited size reduction with these techniques, Batista and colleagues6 developed the method of cardiac autotransplantation for LA size reduction in patients with atrial fibrillation. Using this technique, the heart is lifted from the pericardial sac and the left atrium is partially resected and sutured in a short period of time. However, cardiac autotransplantation is an aggressive and sophisticated method. Comparatively, partial cardiac autotransplantation can be easily performed, especially in centers familiar with heart transplantation. In our procedure, the IVC is not transected and thus does not have to be reattached. Consequently, cross clamping time is shortened, and the narrowing, bending, and twisting of the IVC is avoided.10
Giant left atrium is the most important predictor of postoperative mortality and low cardiac output.5 For this reason, LA resection can be considered during mitral valve surgery.11 In addition, giant left atrium and atrial fibrillation are major predictive factors of atrial blood stagnation.12 With plication techniques, because of limited LA size reduction, stagnation persists. Using partial cardiac autotransplantation, excellent exposure of the posterior and superior LA walls is achieved, making suturing of the atrium after resection easier and safer. The pulmonary veins are conserved; and after resection of the LA appendage and walls, the various parts of the atrium are sutured together leaving no leaks. Moreover, postoperative bleeding decreases with this method. In our series, late LA thrombosis or SEC was not observed after LA resection. This may be due to restoration of sinus rhythm besides atrial size reduction. This technique was also performed to reduce LA size in 2 patients with DCM, but partial cardiac autotransplantation is usually not mandatory for partial left ventriculectomy.
In our opinion, partial cardiac autotransplantation allows superior exposure of the left atrium so that effective size reduction can be obtained and suturing performed safely. Furthermore, sinus rhythm can be restored and compression of neighboring structures minimized. We believe that the procedure should be considered especially for the surgical reduction of giant left atrium.
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ABSTRACT
INTRODUCTION
