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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 3  |  Page : 96-98

Using donor ascending aorta for venous reconstruction in a situs inversus heart transplantation


1 Division of Cardiovascular Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City; Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
2 Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei City, Taiwan
3 Division of Cardiovascular Surgery, Department of Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan

Date of Submission21-Aug-2018
Date of Decision20-Nov-2018
Date of Acceptance23-Jan-2019
Date of Web Publication17-Jun-2019

Correspondence Address:
Dr. Chien-Sung Tsai
No. 325, Sec. 2, Chenggong Road., Neihu District, Taipei City 114
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_89_18

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  Abstract 


A 66-year-old female was a case of situs inversus that developed heart failure. Heart transplantation was performed with the modified method. While we harvested the donor's heart, we left an extra-aortic conduit in the ascending aorta. Donor's superior vena cava (SVC) and inferior vena cava were also retained for available anastomoses to the systemic venous return of the recipient. The donor's right atrium (RA) and lower half of the recipient's RA were connected using a 4-cm long conduit (from the retained aortic segment). The donor's SVC was anastomosed to the upper half of the recipient's RA. We placed a titanium vascular ring around the donor's SVC between the aorta and pulmonary artery (PA). In the present case, we preserved the extra-aortic conduit for reconstruction of the venous return system. The allogeneic aortic conduit had the advantage that it could avoid external compression and may have prevented thrombosis in anastomoses between the vena cava and atrium. A titanium ring could maintain the donor's SVC that passed through the aorta and PA. Future efforts should be directed to follow the patency of the venous pathway.

Keywords: Extra-aortic conduit, heart transplant, situs inversus


How to cite this article:
Song JY, Tsai YT, Shen TC, Tsai CS. Using donor ascending aorta for venous reconstruction in a situs inversus heart transplantation. Formos J Surg 2019;52:96-8

How to cite this URL:
Song JY, Tsai YT, Shen TC, Tsai CS. Using donor ascending aorta for venous reconstruction in a situs inversus heart transplantation. Formos J Surg [serial online] 2019 [cited 2019 Jul 23];52:96-8. Available from: http://www.e-fjs.org/text.asp?2019/52/3/96/260442




  Introduction Top


According to the literature, only five cases of patient with situs inversus undergoing heart transplantation have been reported since 1990.[1],[2],[3],[4] We describe the case of a patient with situs inversus who received heart transplantation using donor aortic conduit for venous reconstruction. The primary technical problem that we faced in this procedure was the reconstruction of venous anastomosis using a donor heart of normal anatomy.

A 66-year-old female diagnosed with end-stage heart failure had been awaiting heart transplantation since 2012. She was admitted in an emergency condition caused by palpitation and dyspnea on April 7, 2013. The electrocardiogram indicated atrial fibrillation with a rapid ventricular response of 140. Hypotension and oliguria were also noted; then, inotropic and intravenous antiarrhythmic agents were administered. The patient was transferred to an intensive care unit, and an intra-aortic balloon pump was inserted through the femoral artery on the same day.

Computed tomography (CT) of the chest indicated dextrocardia, with the superior vena cava (SVC) and inferior vena cava (IVC) connecting to the right atrium (RA) in the left-sided mediastinum. The aortic arch was rotated to the right-sided posterior mediastinum. The liver was located in the left abdomen and the stomach in the right abdomen, thus resulting in the diagnosis of situs inversus [Figure 1].
Figure 1: Computer tomography of the chest revealed dextrocardia with superior vena cava connected to the right atrium in left-sided mediastinum. Aortic arch was rotated to the right-sided posterior mediastinum. LV: Left ventricle, PA: Pulmonary artery

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A suitable donor was found and the patient underwent heart transplantation surgery on April 16, 2013. A cardiopulmonary bypass was established through median sternotomy. An arterial cannula was inserted through the ascending aorta; one venous cannula was inserted in the left SVC for upper body venous drainage, with another was inserted in the left femoral vein for lower body venous drainage.

After the left SVC and IVC were snared and the aorta was clamped, the recipient's heart was removed. Her aorta, pulmonary artery (PA), and left atrium (LA) were excised as per routine procedure. The free wall of RA and atrial septum of the recipient were sutured to create a tunnel-like chamber to connect SVC to IVC.

When we harvested the donor's heart, we left an extra-aortic conduit in the ascending aorta. Donor's SVC and IVC were also retained for available anastomoses to the recipient's systemic venous return. The donor's RA and lower half of the recipient's tunnel-like RA were connected using a 4-cm long conduit (from the retained aortic segment). The donor's SVC was anastomosed to the upper half of the recipient's tunnel-like RA. We placed a titanium vascular ring (Vasoring; outer diameter: 16 mm, length: 20 mm) around the donor's SVC between the aorta and PA [Figure 2]. Other anastomoses (LA, PA, and aorta) were created using the standard procedure. After the aorta was declamped, the donor's heart spontaneously rotated slightly in a clockwise direction. The aortic conduit and donor's SVC were not compressed after the patient was weaned from cardiopulmonary bypass.
Figure 2: The donor's right atrium and lower half of the recipient's tunnel-like right atrium were connected using a 4-cm long conduit. The donor's superior vena cava was anastomosed to the upper half of the recipient's tunnel-like right atrium. We placed a titanium vascular ring around the donor's superior vena cava to prevent its compression by the aorta and pulmonary artery

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A postoperative transthoracic echocardiogram demonstrated that ejection fraction of the left ventricle was 55%. The patient was discharged on the postoperative day 28. One year after the operation, chest CT demonstrated the donor's SVC could pass through the aorta and pulmonary arteries without compression [Figure 3]. The patient has been followed up in the outpatient department until May 2018.
Figure 3: After operation 1 year, computer tomography of the chest demonstrated the donor's superior vena cava (red arrow) could pass through aorta and pulmonary arteries. Ao: Aorta, RPA: Right pulmonary artery, LPA: Left pulmonary artery

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According to the literature, reconstruction of the venous pathway and conduits free from tension remains the essential technique for heart transplantation in patients with situs inversus. Dacron graft is a choice for venous rerouting if no extra length exists on the donor IVC and SVC. Because of the risk of thrombosis in the artificial graft, long-term patency should be considered.[5]

In the present case, we preserved the extra-aortic segment for reconstruction of the venous return system. The allogeneic aortic conduit had the advantage of avoiding external compression and may have prevented thrombosis in anastomoses between the vena cava and atrium. Future efforts should be directed at following the patency of the venous pathway. The allogeneic conduit may be an option for mirror image system rerouting.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Doty DB, Renlund DG, Caputo GR, Burton NA, Jones KW. Cardiac transplantation in situs inversus. J Thorac Cardiovasc Surg 1990;99:493-9.  Back to cited text no. 1
    
2.
Cooper DK, Ye Y, Chaffin JS, Zuhdi N. A suggested technique for “orthotopic” heart transplantation in a patient with situs inversus. Tex Heart Inst J 1993;20:281-4.  Back to cited text no. 2
    
3.
Rubay JE, d'Udekem Y, Sluysmans T, Ponlot R, Jacquet L, de Leval MR, et al. Orthotopic heart transplantation in situs inversus. Ann Thorac Surg 1995;60:460-2.  Back to cited text no. 3
    
4.
Chang YL, Wei J, Chang CY, Chuang YC, Sue SH. Cardiac transplantation in situs inversus: Two cases reports. Transplant Proc 2008;40:2848-51.  Back to cited text no. 4
    
5.
Hanson SR, Kotze HF, Savage B, Harker LA. Platelet interactions with Dacron vascular grafts. A model of acute thrombosis in baboons. Arteriosclerosis 1985;5:595-603.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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