Original article: cardiovascular
Heterotopic Heart Transplantation: An Expanding Role in the Twenty-First Century?

https://doi.org/10.1016/j.athoracsur.2004.03.071Get rights and content

Abstract

Background

Heterotopic heart transplantation was first performed in humans in 1974, the main advantage being the continuing function of the patient's native heart, in the event of life-threatening acute rejection. The effect of cyclosporine on acute rejection saw the heterotopic transplantation technique wane. Our unit revisited heterotopic transplantation in response to a growing number of waiting list patients with high pulmonary artery pressures. We also anticipated an increased cardiac allograft utilization, and improvement of our waiting list times.

Methods

We retrospectively analyzed 151 patients undergoing heart transplantation by our unit between August 1997 and September 2003. Twenty received allografts in the heterotopic position. This cohort was compared with the 131 contemporary orthotopic heart transplant recipients with respect to their outcomes.

Results

The indication for transplantation was ischemic cardiomyopathy in 14 (70%) of the heterotopic cohort and 47 (36%) of the orthotopic cohort (p = 0.004), and dilated cardiomyopathy in 3 (15%) and 48 (37%) in the heterotopic and orthotopic groups, respectively (p = 0.06). Heterotopic recipients were significantly older than orthotopic recipients, and they had higher pulmonary artery pressures. The heterotopic donors were also older and the ischemic times were longer. A subgroup analysis was made among those patients who had high pulmonary artery pressures as these groups were better matched. Major morbidity in the heterotopic heart transplantation group consisted of reversible allograft dysfunction in 4 patients, renal dysfunction requiring hemofiltration in 3 patients, profound myopathy in 4 patients, and cerebrovascular events in 2 patients. There were two early deaths in the heterotopic transplant group and eight in the orthotopic group (p = 0.87). Kaplan-Meier survival analysis of survival was performed.

Conclusions

Heterotopic heart transplantation is a viable transplant option for selected high-risk heart transplant recipients in spite of somewhat poorer outcomes.

Section snippets

Patients

Since the inception of the heart and lung transplant program at The Alfred Hospital, Australia, in March 1989, until the end of September 2003 this unit performed 420 heart transplants. The heterotopic heart transplant program was initiated in August 1997, and 20 male patients had undergone this procedure by the end of September 2003. During the same period 131 orthotopic heart transplants were performed and will be used to provide contemporary outcome comparisons.

The inclusion criteria for

Results

Mean follow-up for the heterotopic group was 25 months (range, 0 to 67 months) and for the orthotopic cohort 34 months (range, 0 to 75). Hospitalization and outcome data are detailed in Table 3.

Comment

The main benefits of using the heterotopic heart transplant are the ability to transplant patients with a high pulmonary vascular resistance and the ability to use organs that would otherwise be wasted. The predominant indication for heterotopic heart transplant is high pulmonary artery pressures in the recipient. This is because of the previously documented poor survival in these patients who undergo orthotopic transplantation 2, 5. Nakatani and associates [5] showed good intermediate-term

Acknowledgements

We acknowledge the statistical assistance of Michael Bailey in the Department of Epidemiology and Preventative Medicine, Monash University, Melbourne; the assistance of Anne Griffiths, Julie Johns, and Sharon Daly for data collection for the manuscript; and Leah B. Edwards, Associate Director of Data Analysis for the International Society for Heart and Lung Transplantation, for the data used in our comparative analyses.

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