Chest Wall, Thymus, and Heart Transplant: Pushing the Boundary of Solid Organ and Vascularized Composite Allotransplantation

Abstract

Background: The purpose of this study is to design a proof-of-concept cadaveric model to describe technical aspects of allograft harvest and recipient inset of an en bloc chest wall, thymus, and heart transplant. Materials and Methods: Two surgical simulations were performed involving procurement and inset. Four cadavers were obtained and identified as donor or recipient. Debriefing following each simulation addressed technical feasibility, anatomical considerations, degree of difficulty, length of surgery, and formulating a bailout strategy. An intraoperative vascular dye perfusion study was performed to determine the vascular territories of the chest wall and the need for bilateral arterial inflow to the chest. Results: Both transplant procedures were successfully completed. Mean donor age was 88.5 y old (range: 83-94). Allograft harvest mean duration was 94.5 minutes (range: 89-100). Graft inset duration was 90.5 minutes (range: 88-93), with a mean duration of 33 minutes (range: 25-41) of chest wall fixation. The right and left IMA, each demonstrated ipsilateral colored staining of the chest wall, without evidence of dye crossing midline. Strong skin and muscle staining was observed with moderate staining of bone. Conclusion: This cadaveric surgical simulation supports the en bloc chest wall, thymus, and heart transplant to be technically feasible for clinical application.

Contact-Free Optical Assessment of Changes in the Chest Wall Perfusion after Coronary Artery Bypass Grafting by Imaging Photoplethysmography

“…The local effects of ITA preparation are demonstrated in a reduced sternal perfusion, which is partially balanced out by a collateral vascularization but is still evident seven days after surgery [33]. The ITA is also the main feeding vessel of the skin on the anterior chest wall with a restriction to the respective side of the body [25]. The resection of an ITA thus gives reason for a reduced cutaneous perfusion, though a collateral vascularization exists as well.…”

“…Patients undergoing coronary artery bypass grafting (CABG) with the use of a unilateral internal thoracic artery (ITA) graft were investigated. As the ITA is the main supplying vessel of the chest wall, the chest wall perfusion is inevitably affected after this procedure [23][24][25]. Hence, two issues are addressed: the global effect of major surgery on the peripheral circulation as well as the regional impact of ITA preparation on the chest wall perfusion.…”

Split Tolerance in a Murine Model of Heterotopic En Bloc Chest Wall Transplantation

“…Gottlieb et al 12 have designed a concept for an en bloc chest wall, thymus, and heart VCA in the cadaveric setting. Although this shows the feasibility of clinical application of such a procedure, 13 we herein present the first mouse model for a heterotopic, en bloc chest wall, thymus, and heart transplantation. Using this murine model system, we investigate immunological features inherent to a bone marrow and thymus containing VCA combined with SOT.…”