Orthotopic heart transplantation with prolonged donor ischemic time: report of 3 cases and literature review

Abstract

Objective Heart transplantation has become an effective therapy for patients with end stage heart failure. The preservation of the donor heart is an important factor that affects the results of the operation. We performed 3 cases of orthotopic heart transplantation and obtained some experience in the preservation of the donor heart. Methods Three male patients with end stage heart failure received the operation in our department successfully. Doppler echocardiography showed left ventricular end diameter (LVED) of the patients were 91, 87, and 83 mm, and ejection fraction (EF) were 24%, 20%, 12.9%, respectively. Once the declaration of brain death had been made, the median sternotomy was performed with a sternal saw. Haparin at a dose of 300 U/kg of body weight was administered. After at least 2-min heparin circulation, the procurement proceeded. The superior vena cava and the inferior vena cava were nearly completely divided. When the heart was empty, the ascending aorta was cross-clamped and the St. Thomas solution was infused by gravity. The heart was excised by transection of the inferior vena cava, the superior vena cava and all pulmonary veins. After donor heart was removed, it was infused with University of Wisconsin (UW) solution by gravity at a temperature of 4–6 °C, then placed in UW solution for storage during transportation. The temperature of solution was maintained at about 4–6 °C. The ischemic times of donor heart were 9, 8 and 6 h, respectively. The bicaval anastomotic heart transplantation was adopted. The left atrial anastomoses were constructed using 3.0 polypropylene. The inferior vene cava anastomosis was constructed, the donor and native aorta were cut to an appropriate length. Then the aorta and main pulmonary artery anastomosis were performed respectively. The superior vene cava anastomosis was usually constructed during the rewarming phase. The intraoperative course with a cardiopulmonary bypass of the 3 patients was 96, 44 and 49 min, respectively. Standard triple immunosuppression therapy was commenced in the immediate post-operative period. Results The operation procedure was smooth and no perioperative death occurred. The follow-up was carried out carefully. The patient's condition was fine in 25, 30 and 32 months after operation. The blood pressure was 130/90, 140/95 and 120/80 mmHg, respectively, and LVED was 51, 49 and 53 mm; EF was 50%, 54% and 60%, respectively. Cardiothoracic ratio was 0.63, 0.55, and 0.64, respectively. Conclusion Preservation time of donor heart with St. Thomas solution infusion and UW solution storage at 0−4 °C may exceed 6 h, and receive comparable middle-term outcomes.