Asian Cardiovasc Thorac Ann 2007;15:446-448
© 2007 Asia Publishing EXchange Ltd
Orthotopic Heart Transplantation through Minimally Invasive Approach
Jose L Navia, MD,
Eric E Roselli, MD,
Fernando A Atik, MD,
Gonzalo V Gonzalez-Stawinski, MD,
Nicholas G Smedira, MD
Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, USA
For reprint information contact: Jose L Navia, MD, Tel: 1 216 444 5104, Fax: 1 216 445 3272, Email: naviaj{at}ccf.org, Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue/F24, Cleveland, OH 44195, USA.
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ABSTRACT
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Minimal access approaches are a trend in cardiothoracic surgery. Gained experience in these minimally invasive techniques have allowed its application to more complicated procedures, such as heart transplantation. Both classic and bicaval techniques of cardiac transplant were performed through a partial lower sternotomy in 10 end-stage heart failure patients with no previous cardiac surgery. The procedure was considered safe with adequate exposure, minimal postoperative pain medication requirements, acceptable operative times, and good long-term outcome.
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INTRODUCTION
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To limit the morbidity of surgical trauma, minimally invasive techniques for most cardiac operations have been described and continue to be refined. Minimal access operations have become standard approaches for the treatment of heart valve diseases and coronary artery disease in many centers.1–3 As experience has been gained with minimally invasive techniques, efforts have been made to apply them to increasingly complicated procedures. Results of our initial experience with a minimally invasive approach to cardiac transplantation are reported.
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SURGICAL TECHNIQUE
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Prior to incision, external defibrillation patches are placed. Partial lower sternotomy is performed through a 10 to 12 cm skin incision overlying the distal aspect of the sternum. The sternotomy is extended from the sternoxiphoid junction upwards to the second intercostal space and extended into the right intercostal space. Care is taken to prevent injury to the right internal thoracic artery. The pericardium is opened in the midline (Figure 1
), and once confirmation is received that the donor heart is acceptable, the ascending aorta and bicaval cannulae are placed. After arrival of the donor heart, cardiopulmonary bypass is instituted and recipient cardiectomy is performed (Figure 2). The donor heart is removed from the transport cooler and prepared on the back table. The left atrium is prepared by connecting the pulmonary vein orifices and excess atrial tissue is trimmed forming a circular cuff tailored to the size of the recipient left atrial remnant.
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Figure 1. Exposure after partial lower sternotomy and pericardial tacking sutures; dotted lines represent cardiectomy incisions.
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Figure 2. Cardiectomy completed, and the remainder of the heart prepared for implantation with the classic heart transplant technique.
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The heart transplant can be performed either with the classic technique described by Lower and Shumway4 or with the Wythenshawe bicaval technique.5 Intermittent cold blood cardioplegia is administered during the procedure. In the classic technique, implantation begins with placement of a double-armed 3-0 Prolene suture through the recipient left atrial cuff at the level of the left superior pulmonary vein, and then through the donor left atrial cuff near the base of the atrial appendage (Figure 3). The allograft is lowered into the recipient mediastinum and the suture is continued in a running fashion caudally and then medially to the inferior aspect of the interatrial septum. The second arm of the suture is run along the roof of the left atrium and down the interatrial septum. Once the left atrial anastomosis is complete, a curvilinear incision is made from the inferior vena caval orifice toward the right atrial appendage of the allograft in order to avoid injury to the sinoatrial node. The right atrial anastomosis is performed in a running fashion similar to the left in such a way that the ends of the suture meet in the middle of the anterolateral wall. The end-to-end pulmonary artery anastomosis is next performed using a 4-0 Prolene suture beginning with the posterior wall from inside the vessel and then completing the anterior wall from the outside. It is crucial that the pulmonary artery ends be trimmed to eliminate any redundancy in the vessel that might cause kinking.
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Figure 3. Left atrial anastomosis beginning at the level of recipient’s left superior pulmonary vein and donor’s left atrial appendage.
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Finally, the aortic anastomosis is performed using a technique similar to the pulmonary artery except that some redundancy is desirable in the aorta as it facilitates visualization of the posterior suture line. Routine de-airing techniques are then employed and the aortic cross clamp is removed (Figure 4). The patient is weaned from cardiopulmonary bypass after heart rhythm and adequate hemodynamics are ensured. Temporary epicardial pacing wires are placed in the donor right atrium and ventricle. Following insertion of mediastinal and pleural tubes, the partial sternotomy is closed with five interrupted stainless steel wires.
The alternative technique to orthotopic heart transplantation involves complete excision of the recipient heart with bicaval end-to-end anastomoses and single cuff left atrial anastomosis (Figure 5). Usually the superior vena cava anastomosis is performed on the beating heart. The remainder of the procedure is similar to the classic technique.
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DISCUSSION
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There are several potential advantages of the minimal access approach besides the cosmetic aspect. Smaller surgical incisions are less traumatic and therefore have potential advantages in terms of reduced postoperative pain, less postoperative bleeding, shorter hospitalization, and lower hospital costs.1–3
Lower partial sternotomy has been performed extensively as an approach to mitral valve surgery, with excellent exposure and good results.6 Usually there are some concerns about the exposure of distal segments of the ascending aorta and main pulmonary artery with this approach. For that reason, femoral artery or axillary artery are alternative cannulation sites.
Between March 1998 and December 2000, ten patients underwent heart transplantation through a primary partial lower sternotomy. Indications for transplant included ischemic cardiomyopathy (n = 7), dilated cardiomyopathy (n = 2), and restrictive cardiomyopathy (n = 1). Mean age was 48 ± 17 years (range 24–70 years) and 70% were males. Comorbid conditions included diabetes mellitus (n = 2), atrial fibrillation (n = 4), hypertension (n = 3), history of ventricular tachycardia (n = 2), and chronic renal insufficiency (n = 2). Standard aortic and bicaval cannulation was used in all but one patient, whose cardiopulmonary bypass was initiated through the femoral artery. The large pericardial space occupied by the recipient’s heart allowed adequate exposure in all patients, and the operation was feasible with no conversion to full sternotomy.
The heart transplant was performed with the classic technique in 7 patients and with the bicaval technique in 3 patients. More recently, our group has preferred the bicaval technique due to a lower prevalence of atrial arrhythmia, conduction abnormalities, atrioventricular valve dysfunction, and right ventricular failure.5,7 All these advantages were supported by improved survival at 1 year after the bicaval technique.8
There is no question that the procedure was more demanding than in patients with full sternotomy, but it could be performed with acceptable ischemic times. Average ischemic time, duration of cardiopulmonary bypass, and cross clamp times were 212 ± 32, 112 ± 35, and 72 ± 17 minutes, respectively. Mean intubation time was 16.4 ± 6.8 hours and median intensive care unit and postoperative length of stay were 2 days and 10 days, respectively. No patients required re-exploration for bleeding, mean 24 hours mediastinal drainage was 729 ± 499 mL, and a mean of 2.2 ± 1.1 units of blood were transfused. There was no hospital death. Morbidity included acute renal failure (n = 2), deep venous thrombosis (n = 1), and pancreatitis (n = 1). Mean postoperative pain medication requirements were 17 mg of morphine and 14 oral narcotic doses. At median follow-up of 57 months (range 10.5 to 60.5 months), nine of ten patients are alive and well. The one late death was secondary to trauma. There were no wound complications at late follow-up.
Heart transplantation through a mini-sternotomy is a safe and reliable alternative with adequate exposure, minimal postoperative pain medication requirements, acceptable operative times, and good long-term outcome.
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ACKNOWLEDGMENTS
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The authors thank Mr. Jeffrey Loerch for providing the surgical illustrations for this paper.
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REFERENCES
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ABSTRACT
INTRODUCTION
