Case Report
A forty-year-old male patient was diagnosed with dilated cardiomyopathy and treated by heart transplantation 10 years ago. Donor was a 15-year-old female. After HTx, he developed hypertension and diabetes mellitus (DM). The patient has recently admitted to our clinic with developing chest pain and dyspnea. In his first surgery, it was noted that the mismatch between the recipient and donor aorta was compensated by plication of the recipient aorta. The patient’s immunosuppressive regimen was cyclosporin, mycophenolate mofetil and steroids. The patient was checked regularly for ten years, and no signs of aortic pathology were detected. However, for the last month he described shortness of breath and chest pain. In echocardiography, left ventricular and valvular functions were normal. Ascending aortic diameter was reported as 75 mm. In thorax computed tomography (CT) angiography, the donor aorta was seen normally to the suture line level. Dissection begins from the native ascending aorta (beginning from the suture line), extends through the iliac arteries (Figure 1). All vessels were originated from the true lumen except the left renal and celiac arteries. There was a reentry at renal artery level. Coronary CT angiography was performed, and coronary arteries were found to be normal. There was no problem in the blood tests except for mild urea and creatinine elevation. Cyclosporin levels were within the desired limits.
In the operation, subclavian arterial and right femoral venous cannulation was performed. Redo sternotomy was performed without entering the cardiopulmonary bypass (CPB). There were tight adhesions on the aneurysm, vena cava superior and the right atrium side. There was almost no adhesion around the inferior vena cava, diaphragmatic and lateral face. The adhesions were dissected. The second venous cannula from the superior vena cava, retrograde canula and vent canula was placed. Ascending aorta was found to be very wide and about 8 cm in diameter.
In the heart transplant surgery, teflon reinforced stitches was noticed within the antero-lateral part of the anastomosis line. The brachiocephalic artery has been turned and, cross clamp has been placed, then aneurysm/dissection sac opened. The dissection seen from the beginning of the suture line, and the native aorta and the donor aorta were seen to be separated from each other. The donor aorta was normal. False lumen was seen moving towards the large curvature (Figure 2). Blood cardioplegia from the coronary ostia was given and the heart was arrested. Afterwards, cardiac protection was continued with retrograde cardioplegia plus intermittent antegrade perfusion at 25 minutes. The patient was cooled to 28 C°. The proximal side was trimmed to the donor aorta. By using 28 mm Dacron graft and 4/0 polypropylene sutures, proximal anastomosis was made. The donor tissue was intact, and no reinforcement was needed (Figure 3).
Arcus branches were inspected. It was all originated from the true lumen. The tissues were intact. There was a slight flow from the false lumen. Both lumens were combined to generate the true lumen and reinforced with teflon felt and fibrin sealant (Tisseel, Baxter) (Figure 4). Distal anastomosis was made with 4/0 polypropylene sutures and reinforced with teflon felts as standard (Figure 5). The cross clamp was removed, following the removal of the air from the proximal side. The cross-clamping time was 59 minutes, the selective brain perfusion time was 25 minutes, and the CPB time was 102 minutes. After decamping, the heart started in sinus rhythm spontaneously. The patient was heated and CPB terminated without the need for inotropic support. The postoperative period of the patient went smoothly. Immediately after the extubation, the immunosuppressive regimen was initiated. The patient was closely monitored from the cardiac point of view and no problems were encountered. The patient was discharged on the 10th day. A month later, the thorax CT showed that the false lumen was completely thrombosed.