Cardiac Surgery After Heart Transplantation: Elective Operation or Last Exit Strategy?

Abstract

BackgroundBecause of improved long-term survival after heart transplantation (HTx), late graft pathologies such as valvular disease or cardiac allograft vasculopathy (CAV) might need surgical intervention to enhance longer survival and ensure quality of life. To this date, there exist no guidelines for indication of cardiac surgery other than retransplantation after HTx.MethodsIn this retrospective, single-center study, we evaluated patients who underwent cardiac surgery after HTx at our institution.ResultsBetween March 1984 and October 2016, 17 (1.16%) of 1466 HTx patients underwent cardiac surgery other than retransplantation after HTx. Indication were valvular disease (n = 7), CAV (n = 6), and other (n = 4). Of these, 29.4% (n = 5) were emergency procedures and 70.6% were elective cases. Median age at time of surgery was 61 years (interquartile range, 52-66 years); 82.4% (n = 14) were male. Median time to surgery after HTx was 9.3 years (2.7-11.1 years). In-hospital, mortality was 11.8% (n = 2); later need of retransplantation was 11.8% (n = 2) due to progressing CAV 3 to 9 months after surgery. One-year survival was 82.35%; overall survival was 47.1% (n = 8) with a median follow-up of 1477 days (416-2135 days). Overall survival after emergency procedures was 209 days (36-1119.5 days) whereas, for elective procedures, it was 1583.5 days (901.5-4319 days).ConclusionsIncidence of cardiac surgery after HTx in our cohort was low (1.16%) compared with that of other studies. In elective cases, long-term survival was good.

A Clean Cut: Minimally Invasive Mitral Valve Replacement after Heart Transplantation

“…In a retrospective study, Goekler et al first described MV replacement for stenosis after hemodialysis for 2 years following HTX. 3 Our case reports the first study published on minimally invasive MV replacement for valve stenosis with intraluminal aortic clamping. Despite worldwide long experience in the field of HTX, numbers of secondary surgical interventions in HTX recipients are scarce.…”

Surgical techniques for aortic valve xenotransplantation

“…For example, valvular dysfunction is not clinically recognized even in patients dying of fulminant myocardial rejection [ 33 ]. The incidence of aortic valve intervention after heart transplantation is exceedingly low, occurring in 0 in 867 and 2 in 1466 consecutive heart transplant recipients in two large institutional series at a median follow-up greater than 4 years [ 34 , 35 ]. In addition, our group has demonstrated that structural integrity, cellular viability, and cellular proliferation in neonatal rat aortic grafts is maintained even after 48 h of cold storage in University of Wisconsin preservation solution [ 36 ].…”

Pseudoaneurysm of the ascending aorta: case report of a donor-derived Pseudomonas infection in a heart transplant recipient

“…The following predisposing factors for aortic wall infection and formation of mycotic pseudoaneurysm are documented in literature: intrathoracic infection (50%) [ 6 – 8 , 10 , 14 – 16 , 24 , 25 , 30 , 33 , 35 , 36 ], pneumonia or bronchitis (20%) [ 4 , 13 , 17 , 19 , 21 , 25 , 26 ], heart–lung transplantation (17.5%) [ 4 , 14 , 15 , 19 , 25 ], reoperation due to bleeding (15%), [ 4 , 8 , 13 , 31 ] diabetes mellitus (15%), [ 7 , 12 , 15 , 31 , 35 , 37 ] infection of a previous ventricular assist device (12.5%) [ 9 , 14 , 22 , 23 ], transmission of microorganisms from the donor (7.5%) [ 8 , 25 ], acute cholecystitis (5%) [ 28 , 33 ], urinary tract infection (5%) [ 18 , 31 ], other septicaemia (5%), [ 17 , 21 ] pacemaker endocarditis (2.5%), [ 13 ] skin disruption (2.5%), [ 29 ] heart–lung retransplantation (2.5%) [ 25 ].…”

“…Early diagnosis, surgical intervention and adjuvant antibiotic therapy seem to be the keys to successful management of mycotic pseudoaneurysms after HTX. Based on literature data of heart transplant patients with ascending aortic mycotic pseudoaneurysms with a median follow-up time of 8 months after diagnosis, almost two-thirds of patients recovered after operation [ 4 – 7 , 9 , 10 , 13 – 15 , 17 , 21 , 23 , 24 , 26 – 32 , 34 , 35 , 37 ], a sixth of them died due to pseudoaneurysm [ 4 , 6 , 8 , 14 , 16 , 25 , 33 ], and an eighth of them presented with a recurrent pseudoaneurysm later [ 7 , 8 , 12 , 19 – 21 ]. Median time between first surgical treatment for pseudoaneurysm and the verification of recurrence was 2 months.…”