Related Experiment Videos
Pediatric heart transplantation after operations involving the pulmonary arteries
M M Cooper1, L Fuzesi, L J Addonizio
1Department of Surgery, Columbia-Presbyterian Medical Center, Columbia University College of Physicians and Surgeons, New York, NY 10032.
Insights
Pediatric heart transplantation is feasible after complex congenital heart defect surgeries. This study found no perioperative mortality, demonstrating that prior palliative pulmonary artery operations are not insurmountable obstacles.
Area of Science:
- Cardiology
- Pediatric Surgery
- Transplantation Immunology
Background:
- Pediatric heart transplantation historically faced high mortality after palliative operations for congenital heart disease (CHD) involving pulmonary arteries.
- Complex pulmonary artery anatomy presents challenges in surgical reconstruction during transplantation.
Purpose of the Study:
- To evaluate the feasibility and outcomes of pediatric heart transplantation in patients with prior palliative pulmonary artery operations.
- To identify distinct categories of pulmonary artery anatomy and tailor reconstruction strategies.
Main Methods:
- Retrospective review of 46 pediatric heart transplantations performed between June 1984 and February 1990.
- Analysis of 7 patients (15%) who previously underwent palliative operations for CHD involving pulmonary arteries.
- Individualized pulmonary arterial reconstruction techniques, including use of existing conduits/homografts and angioplasty.
Main Results:
- Successful transplantation in all 7 patients, with no perioperative mortality.
- Acceptable post-transplant right ventricular-pulmonary artery pressure gradients and pulmonary vascular resistance indices.
- Three late deaths (5-39 months post-transplant); all surviving patients are in New York Heart Association functional class I.
Conclusions:
- Pediatric heart transplantation is a viable option for patients with complex CHD and prior pulmonary artery palliative procedures.
- Individualized surgical reconstruction techniques can overcome anatomical challenges.
- Prior palliative operations involving pulmonary arteries are not absolute contraindications for heart transplantation.
Abstract:
A prohibitive perioperative mortality has been previously ascribed to pediatric heart transplantation after palliative operations for congenital heart disease involving the pulmonary arteries. Of 46 children who have undergone heart transplantation at our institution between June 1984 and February 1990, 7 (15%; mean age 8 +/- 3 years; range 1 to 18 years) have previously undergone such operations: right ventricle to pulmonary artery conduit/homograft for levo-transposition of the great arteries (2), Waterston shunt for tricuspid and pulmonary atresia (1), pulmonary artery banding for single ventricle (1), Fontan procedure for single ventricle (1), first-stage Norwood procedure for hypoplastic left heart syndrome (1), and classic right Blalock-Taussig shunt for atrioventricular canal with pulmonic stenosis (1). Three categories of pulmonary artery anatomy that require different approaches to reconstruction at the time of transplantation are recognized: abnormalities of position, pulmonary outflow obstruction, and previous systemic- or atrial-pulmonary connections. At operation, individualized pulmonary arterial reconstruction was employed, including use of previously created right ventricular-pulmonary artery conduits/homografts and angioplasty (with and without pericardial patches). Transplantation was successful in all patients. Posttransplant right ventricular-pulmonary artery pressure gradients and pulmonary vascular resistance indices were acceptable, with a tendency to decrease with time. Two patients had critical right ventricular failure postoperatively; one of them required support with extracorporeal membrane oxygenation. There was no perioperative mortality, with three deaths occurring from 5 to 39 months after transplantation. All surviving patients are in New York Heart Association functional class I. Techniques borrowed from the repair of congenital cardiac lesions can be applied to subgroups of children undergoing heart transplantation. Additional length of donor aorta and pulmonary artery should be harvested for possible use in designing pulmonary artery connections. Previous palliative operations involving the pulmonary arteries with associated complex pulmonary artery anatomy are not of themselves an insurmountable obstacle to successful heart transplantation.