Case Reports
Two Donor Hearts Beat in One Chest
Shu-Hsun Chu, MD Kuan-Ming Chiu, MD Tzu-Yu Lin, MD Thomas Waitao Chu, MD Dong-Feng Yeih, MD Ai-Hsien Li, MD
We present the case of a 52-year-old man who had end-stage dilated cardiomyopathy (left ventricular ejection fraction, 0.14) and type-A blood. He underwent orthotopic transplantation with a heart from a blood-type-A male donor on 18 January 2001. After transplantation, the patient could not be weaned from cardiopulmonary bypass. Due to calcification of the left main and right coronary arteries, we performed triple coronary artery bypass (left anterior descending, circumflex, and right coronary arteries) with the recipient’s saphenous vein. Despite high doses of inotropic agents and intra-aortic balloon pumping, the patient could not be weaned from cardiopulmonary bypass; he was put on extracorporeal membrane oxygenation 2 hours later. Meanwhile, there was another donor (a woman with type-O blood), who weighed 48 kg. Upon harvesting that heart for a recipient who weighed 68 kg, we found a laceration of the right ventricle. Therefore, we decided to use this marginal donor heart to rescue the graft-failure transplant by means of heterotopic heart transplantation. We left the 1st donor heart in situ. The postoperative series of endomyocardial biopsies showed variations between the 2 donor hearts in degrees of mild-to-moderate rejection. During the 6-year, 2-month followup period, the patient has fared well with 2 donor hearts, which beat independently but in conjunction. We conclude that heterotopic transplantation of a marginal donor heart can save an otherwise-dying orthotopic transplant recipient. (Tex Heart Inst J 2007;34:230-2)
T
o our knowledge, there has been no previous report of 2 donor hearts beating simultaneously in 1 chest after orthotopic heart transplantation immediately followed by heterotopic transplantation. We describe why and how we performed these transplants, and the results.
Case Report Key words: Allograft; heart failure/surgery; heart transplantation, heterotopic From: Departments of Cardiovascular Surgery (Drs. Chiu, SH Chu, and TW Chu), Anesthesiology (Dr. Lin), and Cardiology (Drs. Li and Yeih), Far Eastern Memorial Hospital, Taipei County 220, Taiwan Address for reprints: Shu-Hsun Chu, MD, Department of Cardiovascular Surgery, Far Eastern Memorial Hospital, 13F, 21, Sec 2, Nan-Ya S Rd, Pan-Chiao, Taipei County 220, Taiwan E-mail:
[email protected]
© 2007 by the Texas Heart ® Institute, Houston
230
A 52-year-old man with type-A blood presented with dilated cardiomyopathy. He had experienced progressive dyspnea, despite medical treatment, for 2 years. He was in New York Heart Association functional class IV. A series of examinations revealed atrial fibrillation, marked cardiomegaly, patent coronary arteries, a main pulmonaryartery pressure of 31/22 mmHg, a cardiac index of 1.2 L · min–1 · m–2, and a left ventricular ejection fraction (LVEF) of 0.14. An exercise cardiopulmonary function test showed a maximal oxygen consumption of 14 mL · min–1 · kg –1. On 18 January 2001, orthotopic heart transplantation was performed with a donor heart from a 52-year-old man with type-A blood. Transient shock of the donor had occurred during the apnea test in brain-death evaluation. His LVEF by echocardiography had been 0.50. Transplantation proceeded as usual, with a total ischemia time of 100 minutes. The donor heart regained sinus rhythm with fair contractility. However, the patient could not be weaned from cardiopulmonary bypass (CPB). Transesophageal echocardiography revealed regional wall-motion abnormalities. Some calcifications of the left main and right coronary arteries were noted by palpation. Due to this apparent coronary artery disease, we performed a triple coronary artery bypass with the recipient’s saphenous vein used as a conduit. Yet the patient could not be weaned from CPB, despite high-dose inotropic agents and intra-aortic balloon counterpulsation; consequently, he was put on extracorporeal membrane oxygenation (ECMO) and was weaned from CPB 2 hours later. On the same day, we planned another heart transplantation in a patient with dilated cardiomyopathy who weighed 68 kg. The donor was a blood-type-O, 48-kg woman. During the procurement of the heart, a 1-cm laceration was found in the right ventricle, possibly due to chest contusion. Considering the donor–recipient body-
Two Donor Hearts Beat in One Chest
Volume 34, Number 2, 2007
weight discrepancy and the injury to the right ventricle of the donor heart, we decided that this 2nd donor heart was of marginal value to the 2nd recipient. Therefore, we decided to use the 2nd donor heart for the 1st recipient, who had been on life-support by ECMO and intra-aortic balloon counterpulsation for 4 hours; the hemodynamic status of this patient was still so poor that recovery was unlikely. As soon as the 2nd donor heart arrived from another hospital, we converted the patient from ECMO to conventional CPB. The patient then underwent heterotopic heart transplantation, as described by Cooper and associates.1 We were then able to wean the patient from CPB. Postoperative coronary angiography confirmed the presence of coronary artery disease of the 1st donor heart and patency of the saphenous venous graft. Endomyocardial biopsy series undertaken on the 2 donor hearts showed different degrees of rejection (Table I).2 After transplantation and up until the time of this writing, 6 years and 2 months later, the 2 hearts from different donors have been beating independently, yet functioning in conjunction in the single recipient’s chest. Routine electrocardiography revealed 2 sets of cardiac electrical activity in 1 record (Fig. 1). Chest radiography showed an unusual (and huge) cardiac silhouette. Contrast medium injected at the superior vena cava went to the 2 donor right atria and right ventricles, and then merged at the native pulmonary artery. EchocardiograTABLE I. Grades of Rejection as Indicated by Endomyocardial Biopsy of the 2 Donor Hearts (per grading system of International Society of Heart and Lung Transplantation, 19902) Date
Donor 1
Donor 2
1/29/2001
1A
3A
2/5/2001
2
2
2/12/2001
0
1A
2/19/2001
0
0
3/5/2001
0
0
3/19/2001
0
0
4/20/2001
2
3A
4/27/2001
0
2
5/4/2001
0
2–3A
5/11/2001
0
1
6/12/2001
0
0
8/17/2001
1A
1A
2/22/2002
0
0
3/18/2004
0
0
Texas Heart Institute Journal
phy revealed that the LVEF was higher in the heterotopic heart (donor 2) than in the orthotopic heart (donor 1) (Fig. 2). Three-dimensional computed tomography of the chest showed 2 hearts connected side by side (Fig. 3).
Fig. 1 Electrocardiogram of the patient after orthotopic transplantation followed by heterotopic transplantation. The 2 QRS sets indicate the presence of the 2 donor hearts.
Fig. 2 Left ventricular ejection fractions (LVEF) of the 2 donor hearts in the year 2001 show that the LVEF of the heterotopically placed heart (donor 2) is better than that of the orthotopically placed heart (donor 1).
Fig. 3 A 3-dimensional computed tomographic scan shows the 2 hearts connected side by side.
Two Donor Hearts Beat in One Chest
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Discussion Ejection fraction as indicated by echocardiography showed that the left ventricular function of the donor 1 heart was poor (LVEF, 0.30) at the beginning, but that it gradually recovered—under the support of the donor 2 heart—to normal function (LVEF, 0.62) 3 weeks later. The differences in the grades of rejection appear to relate to the donors’ blood types, but this would be a matter for further study. Donor 1’s blood was type A, identical to that of the recipient, while donor 2’s blood was type O, compatible with that of the recipient. The rejection grades were higher in the donor 2 heart than in the donor 1 heart during the first 4 months after transplantation.
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Two Donor Hearts Beat in One Chest
This experience shows that the additional transplantation of a marginally acceptable donor heart in heterotopic position can save a patient who is dying of graft failure immediately after orthotopic heart transplantation.
References 1. Heart transplantation: the present status of orthotopic and heterotopic heart transplantation. Cooper DKC, Lanza RP, Barnard C. Lancaster (England): MTP Press; 1984. p. 11325. 2. Billingham ME, Cary NR, Hammond ME, Kemnitz J, Marboe C, McCallister [error for McAllister – ed.] HA, et al. A working formulation for the standardization of nomenclature in the diagnosis of heart and lung rejection: Heart Rejection Study Group. The International Society for Heart Transplantation. J Heart Transplant 1990;9:587-93.
Volume 34, Number 2, 2007
