Heterotopic heart transplantation: A valid alternative to orthotopic transplantation: Results, advantages, and disadvantages

Abstract

Thirty-eight heterotopic heart transplantations (HHT) were performed in Cape Town from November 1975 to April 1981. Indications were ischemic heart disease (61%), cardiomyopathy (31%), and rheumatic heart disease (8%). No operative death occurred; 1 year survival is 60% and 4 year 50%. These results compare favorably with the best orthotopic heart transplant results at Stanford (63% 1 year and 44% 4 year survival). The longest HHT alive is now 6 1 2 year posttransplant, back to normal activity. Infections caused over 50% of deaths, rejection over 34%. A major advantage of HHT is to be suitable in cases with severe pulmonary hypertension (PHT): four patients had PHT > 6 Wood units, and two had PHT > 8 Wood units. None had post-HHT right-sided failure. A significant advantage is that assisted ventilation and intravenous catecholamines can be stopped shortly after surgery ( ±5 1 2 hr), the recipient heart assisting the donor heart through its postischemic recovery. Should acute donor heart failure occur the patient survival is assured by his own heart. Similarly, during acute rejection the recipient heart assists, and was life-saving in one case when the graft arrested for hours. Two patients survived irreversible acute rejection requiring removal of the donor heart 1 and 3 months after HHT. Retransplantation after HHT is easy, not urgent as it is after orthotopic heart transplantation and was successful in both cases when performed. The disadvantages have been one case of endocarditis in the recipient heart, successfully managed by partial recipient's heart resection, and two nonfatal cerebral emboli probably originating from the recipient's left heart, or progress of the disease in the recipient heart. A specific disadvantage of HHT is the greater difficulty in diagnosing acute rejection early, the recipient's heart limited work masking minor donor heart alterations. HHT appears thus a valid alternative to orthotopic heart transplantation, with significant intrinsic advantages.