Orthotopic heart transplantation with reconstruction of persistent left superior vena cava

Reintervention for Superior Vena Cava Obstruction After Heart Transplant

BACKGROUND

Children undergoing orthotopic heart transplant (OHT) may require complex reconstruction of superior vena cava (SVC) anomalies. SVC anatomy and mode of reconstruction are potential risk factors for SVC obstruction.

METHODS

A retrospective single-center review was conducted of patients undergoing initial OHT between January 1, 1990, and July 1, 2021. Simple SVC anatomy included a single right SVC to the right atrium or bilateral SVCs with a left SVC to an intact coronary sinus, without prior superior cavopulmonary connection. Presence of anomalous SVC anatomy, superior cavopulmonary connection, or previous atrial switch operation defined complex anatomy. Reconstructive strategies included atrial anastomosis; direct SVC-to-SVC anastomosis; and augmented SVC anastomosis using innominate vein, patch, cavopulmonary connection, or interposition graft. The primary outcome was reintervention for SVC obstruction.

RESULTS

Of 288 patients, pretransplant diagnoses included congenital heart disease (n = 155 [54%]), cardiomyopathy (n = 125 [43%]), and other (n = 8 [3%]). Most (n = 208 [72%]) had simple SVC anatomy compared with complex SVC anatomy (80 [28%]). Reintervention for SVC obstruction occurred in 15 of 80 (19%) with complex anatomy and 1 of 208 (0.5%) with simple anatomy (P = .0001). Reintervention was more common when innominate vein or a patch was used (9/25 [36%]) compared with an interposition graft (1/7 [14%]) or direct anastomosis (6/82 [7%]; χ2 = 13.1; P = .001). Most reinterventions occurred within 30 days of OHT (14/16 [88%]).

CONCLUSIONS

Patients with complex SVC anatomy have a higher rate of reintervention for SVC obstruction after OHT compared with those with simple SVC anatomy. In cases of complex SVC anatomy, interposition grafts may be associated with less reintervention compared with complex reconstructions using donor tissue.

Heart Transplant Using a Donor Heart With Only a Persistent Left Superior Vena Cava: A Case Report

A persistent left superior vena cava (PLSVC) is a congenital anomaly wherein the left superior cardinal vein fails to regress. We describe the case of a successful orthotopic heart transplant using a donor heart with a PLSVC and congenital absence of a right superior vena cava (SVC) in a recipient with normal anatomy. After donor cardiectomy, the donor organ's PLSVC was ligated near the insertion site into the coronary sinus. The recipient underwent cardiectomy such that the native SVC was left with a long right atrial cuff. A modified bicaval technique was used to anastomose the recipient's right atrial cuff directly to the donor's right atrial appendage. This technique restored the recipient's normal anatomy, and we demonstrated that donor hearts with a PLSVC and absent right SVC might be used for transplant. Without other disqualifying abnormalities, surgeons should consider accepting these organs for life-saving transplant operations.