Donor Mitral Valve Repair in Cardiac Transplantation

In vivo mitral valve repair for the transplanted donor heart in orthotopic heart transplantation

A 53-year-old woman with the dilated phase of hypertrophic cardiomyopathy underwent orthotopic heart transplantation. The donor heart was evaluated as normal preoperatively without mitral regurgitation or the left atrium dilation, transplanted using the modified bicaval technique. Although the heart beat satisfactorily after aortic declamping, massive mitral regurgitation was observed without any prolapse or annular dilation. Because of the difficulty in weaning from cardiopulmonary bypass, a second aortic cross-clamp was applied, and we detached the inferior vena cava and the right side of the left atrial anastomosis to approach the mitral valve, obtaining a satisfactory exposure. No abnormalities were observed in the mitral valve leaflets, annulus or subvalvular apparatus. Subsequent in vivo mitral annuloplasty using prosthetic full ring successfully controlled the regurgitation, and the patient was easily weaned from cardiopulmonary bypass. She discharged to home with good mitral valve and cardiac functions. And the patient has been doing well without any recurrence of MR or heart failure for over a year after surgery.

Expanding Selection Criteria to Repairable Diseased Hearts to Meet the Demand of Shortage of Donors in Heart Transplantation

Heart transplant surgery is considered the destination therapy for end-stage heart disease. Unfortunately, many patients in the United States of America who are eligible candidates for transplants cannot undergo surgery due to donor shortage. In addition, some donors' hearts are being labeled as unacceptable for transplant surgery because of the rigorous and restricted rules placed on the approval process of using a donor's heart. Over the last few decades, the rising discrepancy between the scarcity of donor hearts and the demand for such organs has led to the discussion of expanding the donor heart selection criteria. A softer view on using marginal hearts for transplants would help those on the waitlist to receive a heart transplant. Marginal hearts that contain the hepatitis c virus (HCV), COVID-19, older age, or repairable heart defects have become viable options to use for a heart transplant. Also, the prioritization based on the new heart allocation system would help efficiently decide which recipients would be the first to get a donor's heart. Recently there has been a consensus to broaden the eligibility of donor's hearts by accepting valvular abnormalities, coronary artery disease, and congenital abnormalities. This review highlights some of those expansions in selection criteria in particular using repairable hearts, which could be fixed in the operating room on the back table before transplantation.

Bench valvular surgery in donor's hearts before transplantation: Choice versus necessity

The severe shortage of donor's hearts has increased the mortality of patients on the transplant waiting list. However, donor hearts with valvular dysfunction are rarely used. Utilizing donor hearts with valvular lesions that can be repaired or replaced at the time of transplant will decrease waitlist mortality and offer many patients a second chance in life.

Marginal donors and organ shortness: concomitant surgical procedures during heart transplantation: a literature review

Heart transplantation represents the gold standard for end-stage heart failure. However, due to the increasing demand and the shortage of available organs, donor supply remains the main limitation. Marginal donor hearts in high-risk candidates who do not meet standard listing criteria are the only alternative when life expectancy is limited, but their use is still debated. Surgical correction of detected coronary lesions or valvular heart defects allows further enlargement of the number of available organs. In this article, we offer a literature review on this topic and report two marginal donor hearts with angiography evidence of coronary stenosis and preserved ventricular function, which underwent concomitant myocardial revascularization during heart implantation.

Valvular surgery in donor hearts before orthotopic heart transplantation

BACKGROUND

Donor heart shortage has extended the waiting time and increased the mortality of patients on the transplant waiting list. Widening old standard donor criteria has successfully increased the number of heart transplantations, but for many years, a valve disease in a donor heart has been considered a primary contraindication for organ donation.

AIMS

To analyse the results of aortic and mitral valvular surgery in marginal donor hearts with valvulopathy before orthotopic heart transplantation.

METHODS

Between January 2012 and November 2015, we performed 53 heart transplantations in our department. In four donors, echocardiography performed at the time of organ procurement showed a valvular disease: three had moderate-to-severe mitral regurgitation; and one had moderately severe aortic valve stenosis.

RESULTS

The mean bench mitral repair and aortic replacement time, aortic cross-clamp time and total ischaemic time were: 18 (range 7-25) minutes, 78.7 (range 57-98) minutes and 184 (range 89-255) minutes, respectively. Intraoperative transoesophageal echocardiography showed good mitral repair or aortic prosthetic valve function, and good right and left ventricular function. One patient died of infectious pneumonia after 1 month. The mean duration of follow-up for the patients discharged home was 75±13 months, and all have returned to an active unrestricted lifestyle.

CONCLUSIONS

Our limited series demonstrates that conventional valvular procedures performed on otherwise healthy donor hearts with mitral and aortic valve pathology can efficaciously expand the donor pool for orthotopic cardiac transplantation and decrease the mortality rate on the waiting list.

Primary graft failure after cardiac transplantation: prevalence, prognosis and risk factors

OBJECTIVES

Primary graft failure (PGF) is a common and devastating complication, despite the advances in perioperative treatment. We aim to evaluate the prevalence of PGF and its impact on survival and to explore associated risk factors.

METHODS

From November 2003 through December 2015, 290 patients submitted to cardiac transplantation were classified into non-PGF (243; 84%) and PGF (47; 16%) groups. The characteristics of the recipients were similar regarding age (54.6 ± 10.6 vs 54.0 ± 9.4 years; P = 0.74), male gender (78.2% vs 72.3%; P = 0.38) and transpulmonary gradient (9.4 ± 4.2 vs 10.5 ± 5.6 mmHg; P = 0.15); donors to the PGF group had similar age (35.5 ± 11.4 vs 37.5 ± 10.7 years; P = 0.27) but were predominantly female (21% vs 42.6%; P = 0.002).

RESULTS

Mean ischaemic (89.0 ± 36.8 vs 103.3 ± 44.7 min; P = 0.019) and cardiopulmonary bypass (92.8 ± 14.5 vs 126.3 ± 62.4 min; P < 0.001) times were longer in the PGF group. Length of hospital stay was 13.5 ± 7.5 vs 28.9 ± 35.2 days (P= 0.005). Hospital mortality was 4.1% [1.6% for non-PGF and 17% for PGF (P < 0.001)]. Survival at 1, 5 and 10 years was 95.5 ± 1.3% vs 55.3 ± 7.3%, 84.1 ± 2.5% vs 47.4 ± 7.6% and 67.1 ± 3.8% vs 14.4 ± 12%, respectively (P < 0.001). Risk factors for PGF were female donor [odds ratio (OR): 2.56; 95% confidence interval (CI): 1.29-5.09; P = 0.007], total ischaemic time (OR: 1.01; 95% CI: 1.00-1.02; P = 0.032) and preoperative mechanical extracorporeal circulatory support (OR: 11.90; 95% CI: 2.62-54.12; P = 0.001).

CONCLUSIONS

Our results demonstrate that PGF is associated with poor outcomes that extend beyond the 1st month and the 1st year after heart transplantation. We found female donor, total ischaemic time and preoperative mechanical extracorporeal circulatory support to be risk factors for PGF.

Combined mitral valve repair and heart transplantation

In times of donor organ shortage, organs with extended allocation criteria, for example, valve pathologies, have to be taken into consideration for transplantation. The donor pool can be extended to hearts with mitral valve insufficiency. Mitral valve repair can rapidly be performed in the donor heart on the back table with excellent results.

Current practice of heart donor evaluation in Germany: multivariable risk factor analysis confirms practicability of guidelines

Background. Organ shortage has liberalised the acceptance criteria of grafts for heart transplantation, but which donor characteristics ultimately influence the decision to perform transplantation? For the first time this was evaluated using real-time donor data from the German organ procurement organization (DSO). Observed associations are discussed with regard to international recommendations and guidelines. Methods. 5291 German donors (2006–2010) were formally eligible for heart donation. In logistic regression models 160 donor parameters were evaluated to assess their influence on using grafts for transplantation (random split of cases: 2/3 study sample, 1/3 validation sample). Results. Successful procurement was determined by low donor age (OR 0.87 per year; 95% CI [0.85–0.89], P < 0.0001), large donor height (OR 1.04 per cm; 95% CI [1.02–1.06], P < 0.0001), exclusion of impaired left ventricular function or wall motion (OR 0.01; 95% CI [0.002–0.036], P < 0.0001), arrhythmia (OR 0.05; 95% CI [0.009–0.260], P = 0.0004), and of severe coronary artery disease (OR 0.003; 95% CI [<0.001–0.01], P < 0.0001). Donor characteristics differed between cases where the procedure was aborted without and with allocation initiated via Eurotransplant.

Evaluation of skill-acquisition process in mitral valve repair techniques: a simulation-based study

INTRODUCTION

Increased patient awareness, duty-hour restrictions, escalating costs, and time constraints in the operating room have revolutionized surgical education. A bovine heart model was designed for training in mitral valve repair procedures. In this article, we aimed to share our experience with this model and to test the validity of simulation with respect to skill acquisition during the training course.

METHODS

After reviewing instructional video recordings of mitral valve repair techniques, 5 junior residents (first and second year) and 5 senior residents (year 4 or higher), who had no experience in mitral valve repair surgery previously, performed mitral valve repair techniques on bovine heart model in a three-month period. Nine different internet videos demonstrating surgical techniques were watched prior to performance in each case. Different text books were studied before the study course. Following repair in each case, the left ventricle of each bovine heart was statically pressurized, the coaptation depth was measured, and the regurgitation (if any) was scored. Each performance was recorded. At the end of the study, video records were evaluated in a blind fashion by 3 different surgeons experienced in mitral valve repair techniques. The monthly scores obtained were statistically analyzed.

RESULTS

The mean coaptation depth values measured on a monthly basis were as follows: 2.75±0.63, 4.90±0.91, and 6.55±0.88 for the junior residents and 4.30±0.65, 5.45±0.68, and 7.00±0.64mm for the senior residents. Regurgitation scores noted were 2.20±0.52, 1.65±0.58, and 0.10±0.30 for the junior residents and 1.50±0.60, 0.65±0.67, and 0.70±0.65 for the senior residents During the study period, the practice improved in terms of the aforementioned parameters in both groups (p<0.05).

CONCLUSIONS

This simulation model of mitral valve repair helped in skill acquisition on monthly basis in both resident groups.

Mitral valve repair and redo repair for mitral regurgitation in a heart transplant recipient

A 37-year-old man with end-stage idiopathic dilated cardiomyopathy underwent an orthotopic heart transplant followed by a reoperation with mitral annuloplasty for severe mitral regurgitation. Shortly thereafter, he developed severe tricuspid regurgitation and severe recurrent mitral regurgitation due to annuloplasty ring dehiscence. The dehisced annuloplasty ring was refixated, followed by tricuspid annuloplasty through a right anterolateral thoracotomy. After four years of follow-up, there are no signs of recurrent mitral or tricupid regurgitation and the patient remains in NYHA class II. Pushing the envelope on conventional surgical procedures in marginal donor hearts (both before and after transplantation) may not only improve the patient’s functional status and reduce the need for retransplantation, but it may ultimately alleviate the chronic shortage of donor hearts.