Cardiac surgery after heart transplantation: coronary artery bypass grafting and heart valve replacement

Due to increasing need for and a shortage of donor organs, therapeutic procedures such as heart valve replacement for valve insufficiency and coronary artery bypass grafting (CABG) for graft vasculopathy (GVP) must be performed to improve allograft function to avoid retransplantation.

We performed a retrospective analysis of patients who underwent surgical procedures after orthotopic heart transplantation. Since 1989, we have performed more than 1400 heart transplantation procedures. Valve replacement was necessary in 8 patients and CABG was necessary in 3 patients. Five patients received valve prostheses (3 bioprostheses and 2 mechanical valves) at the tricuspid position. Three patients received a Hancock bioprosthesis at the mitral position. One of the 3 received the valve 3 years after heart transplantation while suffering from mitral regurgitation grade IV, and another patient received the valve 1 year following heart transplantation while suffering from mitral insufficiency grade III due to infective endocarditis. Three patients underwent coronary artery revascularization, 2 patients underwent the procedure 1 and 7 years after heart transplantation because of GVP, 1 patient underwent the procedure simultaneously with heart transplantation because of donor coronary artery disease. One patient received concomitant CABG with heart transplantation because of 75% left anterior descending stenoses in the donor organ, and one patient received CABG 1 year after heart transplantation because of rapidly progressive GVP in the left anterior descending artery. The third patient had 3-vessel disease with 95% left stem and 75% ramus circumflex, ramus marginalis, and ramus diagonalis.

Two patients who underwent CABG and 4 patients who underwent valve replacement are still alive and maintain good clinical performance. One patient with a graft at the mitral position died 9 years after heart transplantation and 6 years after mitral valve replacement. Two patients with a graft at the tricuspid position died 17 and 4 years after heart transplantation (6 and 3 years after valve replacement, respectively). One patient with a bioprostheses at the tricuspid position had to be retransplanted 2 years following valve replacement while suffering from a paravalvular leakage grade III.

Cardiac surgical procedures can be safely performed after heart transplantation. To improve graft and patient survival, such procedures must be carefully performed after heart transplantation to avoid retransplantation. The shortage of donor organs will and must lead to an increase in the number of conventional procedures performed to improve allograft function in transplanted hearts.