Interim cardiac replacement with a mechanical heart: staged cardiac transplantation

Lack of donor heart availability complicates the management of terminally ill patients who are candidates for cardiac replacement. The total artificial heart has been used as a bridge to transplantation in three patients with terminal cardiomyopathy. Acute allograft rejection and the lack of another donor heart prompted us to use the mechanical heart as a bridge to re-transplantation in a 33-year-old man. The cardiac prosthesis functioned well for 11 hours, when a second transplantation was performed, but the patient died of right heart failure 48 hours after the second transplantation. Critical factors in such cases include (1) a prompt decision to proceed with cardiac replacement; (2) avoidance of long periods of cardiopulmonary bypass; (3) prosthetic device availability; and (4) surgical team preparedness, with technical expertise in transplantation, allograft explantation, and total artificial heart implantation/explantation, with re-transplantation.