Pediatric Orthotopic Heart Transplant Requiring a Novel Cardiectomy with Anastomoses at the Atrioventricular Groove

Abstract

<h3>Introduction</h3> Transplantation is the definitive treatment of choice for congenital heart disease not amenable to further surgical repair. Many patients present with complex surgical histories, thus implantation of an orthotopic heart is challenging and preoperative planning imperative. We present a novel cardiectomy technique followed by a bi-atrial to bi-ventricular anastomoses <h3>Case Report</h3> To avoid taking down the calcified venous baffles, we performed a cardiectomy similar to that for a total artificial heart. An incision was made on the ventricular side of the right ventricular AV groove, which was extended anteriorly across the right ventricular outflow tract just proximal to the pulmonary valve. Posteriorly this was extended across the interventricular septum onto the left ventricular side of the AV groove leaving some residual anterior mitral leaflet and aortic valve tissue in situ. The atrial cuff consisted of approximately 1cm of residual muscle. The donor heart was prepared so that the atria would be anastomosed at the level of the corresponding AV groove. CPB, cross-clamp and ischemic time were 194, 99 and 218 minutes respectively. Post-operative ECHO showed excellent biventricular function, no evidence of mitral valve stenosis or insufficiency, and only mild tricuspid valve insufficiency. <h3>Summary</h3> This complex case demonstrates the critical need to carefully delineate the technical strategy to adequately plan for complex recipient anatomy in congenital heart patients undergoing transplantation. Utilizing advanced imaging modalities in coordination with pre-operative surgical planning is paramount to successful outcomes of novel transplantation techniques.