Materials and Methods
A 53-year-old male patient presented to our institution with the
clinical picture of biventricular failure. The echocardiogram revealed
cc-TGA, dextrocardia with situs solitus, atrioventricular discordance
and ventriculoatrial discordance (figure 1A&B), severe systemic
(morphologic tricuspid valve) and sub-pulmonary atrioventricular
(morphologic mitral valve) valves regurgitation, and severe pulmonary
hypertension (PH) (mean pulmonary artery pressure: 51 mmHg). His past
medical history was remarkable for complete heart block mandating
pacemaker implantation, and atrial fibrillation. The patient was
evaluated and was deemed a candidate for HLTx. A 25-year-old male donor
who died of hemorrhagic stroke became available and the en-bloc
heart-lung was recovered by an experienced team (figure 2A).
The patient underwent HLTx via a clamshell incision. Because of
hemodynamic instability, we commenced cardiopulmonary bypass (CPB) with
an aortic cannula and a dual-stage venous cannula placed in the right
atrium. After the heart was decompressed, the venous cannulation was
converted from atrial into bi-caval configuration.
Cardiectomy was performed, including complete removal of right and left
atria, leaving a stump of atrial tissue on the inferior vena cava. The
recipient trachea was resected one tracheal ring above the carina. The
left recurrent laryngeal and the vagus nerves were identified and
preserved during dissection. The two phrenic nerves were identified and
protected by leaving pericardial flaps on each side. Tracheal
anastomosis was performed first followed by the IVC, aorta and then the
superior vena cava. The aortic cross clamp was removed and the patient
was safely weaned from the CPB. Inotropic support was initiated using
Dobutamine at 5 mcg/kg/min and epinephrine at 0.05 mcg/kg/min. At the
end of the procedure, the patient was taken to the intensive care unit
in a stable condition.
The
ischemic
time was 296 minutes The CPB time was 280 minutes.
The standard
immunosuppression
protocol was initiated:
1- Methylprednisone 1 g IV intraoperatively, then 125 mg bid for the
first day, then 1mg/kg/day in divided doses for 3 days then prednisone
20 mg daily for 4 weeks then 10 mg daily.
2- Mycophenolate 1g IV intraoperatively, followed by 500 mg bid. Dose
was temporarily increased to 1000 mg bid on POD 18 with suspicion of
humoral rejection.
3- Single dose induction with Alemtuzumab 30 mg IV administered on POD
1.
4- Tacrolimus 0.15mg/kg/day dose titrated to achieve level of 6-10
mcg/L.
On postoperative day 2 the patient was extubated and ambulation was
initiated. The patient progressed steadily and ready for discharge,
however on POD 18, he developed pleural effusion and lung infiltrates.
Transbronchial lung biopsy revealed focal vasculitis. The diagnosis of
possible humoral rejection was considered and the patient received a
single dose of 500 mg, methylprednisone and 5 daily sessions of plasma
exchange. Also he developed gastroparesis which completely resolved
before discharge. Postoperative chest radiograph showed the heart and
lungs in the proper position (figure 2B).