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Pediatric heart transplantation: surgical considerations for congenital heart diseases
C Chartrand1, R Guerin, M Kangah
1Department of Cardiovascular Surgery, Ste-Justine Hospital, University of Montreal, Quebec, Canada.
Insights
Congenital heart anomalies in children previously considered contraindications for heart transplantation can be surgically corrected. These innovative techniques enable successful pediatric heart transplants with excellent long-term outcomes.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Organ Transplantation
Background:
- Congenital heart anomalies (CHAs) involving atria, great vessels, and venous return are often viewed as contraindications for heart transplantation.
- Pediatric heart transplantation is a complex procedure, especially when CHAs are present.
Purpose of the Study:
- To evaluate the feasibility and outcomes of heart transplantation in pediatric patients with complex congenital heart anomalies.
- To present surgical techniques for correcting these anomalies during transplantation.
Main Methods:
- Retrospective analysis of 10 pediatric heart transplant recipients with CHAs.
- Modified donor heart preparation and specific surgical techniques including atrial septation, enlargement, venous rerouting, and great vessel reconstruction.
- Post-transplant assessment using echocardiography, heart catheterization, and angiography.
Main Results:
- Five of the 10 patients had significant CHAs, including single atrium, Mustard operation, hypoplastic left atrium, anomalous venous return, great vessel transposition, and pulmonary artery hypoplasia.
- All 10 children survived the surgery and were discharged in excellent condition.
- Follow-up (6 months to 3 years) showed all patients were asymptomatic with no evidence of stenosis or shunts, and good atrial size and great vessel orientation.
Conclusions:
- Most atrial, venous return, and intrapericardial great vessel anomalies are correctable during orthotopic heart transplantation in children.
- Appropriate surgical techniques can lead to successful outcomes in pediatric heart transplantation for complex CHAs.
Abstract:
Congenital anomalies of the atrium, of the pulmonary and systemic venous return, and of the great vessels are sometimes regarded as contraindications to heart transplantation. Among 10 children who underwent heart transplantation in our institution, five, aged 4 to 15 years and weighting 9 to 32 kg, previously operated on, had congenital anomalies. These lesions, encountered singly or in association, were single atrium (2), previous Mustard operation (1), hypoplastic left atrium (1), anomalous systemic venous return (3), anomalous pulmonary venous return (2), transposition or malposition of the great vessels (5), pulmonary artery hypoplasia (1). To enable correction of these lesions and to perform heart transplantation, the donor heart preparation was modified in four ways. The surgical techniques used for correcting these anomalies in this group were atrial septation, atrial enlargement, superior and inferior reroofing, double venous rerouting, septal realignment, full-length mobilization of the great vessels, and pulmonary artery reconstruction. All children survived operation and left the hospital in excellent condition. Follow-up ranged from 6 months to 3 years. All children are totally asymptomatic. As demonstrated by echocardiography, heart catheterization, and angiography, there are no stenoses, no shunts, and there is good atrial size and good orientation of the great vessels. On the basis of our experience, we conclude that with appropriate surgical techniques, most atrial, venous return, and intrapericardial great vessel anomalies are correctable at the time of orthotopic transplantation and that these techniques allow for a successful outcome in children.