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Special procedures in cardiac transplantation


Left thoracotomy

In contemporary practice, cardiac transplantation is occasionally undertaken in patients who have undergone previous cardiac procedures that render reentry by midsternal incision impractical or inadvisable. Prior sternal wound infection is an obvious case in which a midline incision is best avoided. In these patients, cardiac transplantation can be performed through a left anterior thoracotomy. The procedure is technically more demanding than a midline approach, but it is certainly feasible and may be preferable to a dangerous reentry.

Figure 41-1, A Cardiopulmonary bypass is established by cannulation of the right ventricle with a single venous uptake cannula, with oxygenated blood returned to the descending thoracic aorta. The venous cannula is simple to insert in the dilated right ventricle through a purse-string stitch for retention. The aortic return site is conveniently located at the posterior margin of the exposure. B The body temperature is reduced to 20 o C by the usual core-cooling technique. The circulation from the bypass pump is temporarily stopped, and the venous cannula is removed. The heart is excised, and the great vessels are divided. The lateral wall of the right atrium is easily exposed once the enlarged heart is out of the chest. Purse-string stitches are placed in the wall of the right atrium and the superior vena cava. Venous uptake cannulae are inserted, passing them into the superior and inferior venae cavae. Caval tourniquets are secured, and bypass flow is restored. Circulatory arrest is required for about 10 to 15 minutes during this part of the procedure. C One would imagine that the exposure for implantation of the donor heart would be difficult. Actually, the orientation is simply rotated 90 degrees anteriorly, and the arrangement of the atria is such that the operation proceeds exactly as it would for a midline anastomosis of the atria. The only difficult part is that the heart must be held anteriorly rather than allowing it to lie back in the pericardium, as is the practice when working through a midsternal incision. The suturing begins in the left atrium near the appendage and proceeds inferiorly to the atrial septum, then superiorly to complete the joining of the left atria. D As in usual transplant operations, a double septal suture line is placed as the posterior edge of the right atriotomy of the donor heart is folded back to the septum of the recipient. The right atrial anastomosis is completed anteriorly. E The great vessel anastomoses overlie each other more in the left approach than they do in the midline operation. The aortic anastomosis is performed in an end-to-end fashion. Attention to detail during suture placement is especially important because the anastomosis will be covered by the pulmonary artery. The pulmonary artery anastomosis is the final step of the operation. F Decannulation of the atrium may provoke some anxiety because the stab incisions in the right atrium and superior vena cava are relatively inaccessible. They can be reached, however, if necessary. Normally, once the transplant is complete, the apex of the heart is oriented anteriorly into the thoracotomy wound. When the patient is placed supine, the transplant settles into its natural position.

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