Interact CardioVasc Thorac Surg 2009;9:715-716. doi:10.1510/icvts.2009.210724
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Transplantation |
Early acute aortic dissection of the donor aorta after orthotopic heart transplantation
Carlos Esteban Martin Lopez*,
Maria Jesus Lopez,
Javier de Diego and
Jose Maria Cortina
Department of Cardiac Surgery, University Hospital 12 de Octubre, Madrid, Spain
Received 2 May 2009;
received in revised form 4 June 2009;
accepted 5 June 2009
*Corresponding author. C/La Alcazaba n° 2 3°Dcha, Madrid, 28041, España. Tel.: +34-651566239.
E-mail address: carlosestebanmartin{at}hotmail.com (C.E. Martin Lopez).
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Abstract
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Acute type A aortic dissection is an uncommon complication after orthotopic heart transplantation and usually affects the native aorta. Seven cases reported in the literature describe an aortic dissection confined to the donor aorta and only in two of them were they detected during the early postoperative period. We describe the case of a 58-year-old man, the recipient of a cardiac allograft for ischemic cardiomyopathy 20 days earlier, who presented an acute type A aortic dissection limited to the donor aorta. Transesophageal echocardiography revealed severe aortic regurgitation and an intimal tear 2 cm above commissures. The patient was successfully treated with a composite valve graft. This case is the first successful repair in a cardiac allograft with acute aortic dissection of the donor aorta during the early postoperative period using a Bentall procedure.
Key Words: Aortic dissection; Heart transplantation
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1. Introduction
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Orthotopic heart transplantation is standard treatment for patients with end-stage cardiomyopathy [1]. Although very uncommon, aortic dissection of the donor aorta is one of the fatal complications that can occur after heart transplantation [2–7]. We report the first successful Bentall procedure performed in a cardiac allograft recipient with acute type A aortic dissection of the donor aorta during the early postoperative period.
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2. Case report
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A 58-year-old male underwent an urgent orthotopic heart transplantation for end-stage ischemic heart disease. Previously, he had undergone a coronary artery bypass surgery in 1988 and a prophylactic ICD was placed in 2006. The donor was a 43-year-old man with hypertension who died of subarachnoidal hemorrhage. The immediate postoperative course was uneventful and the patient received cyclosporine, micofenolato and oral prednisolone as immunosuppressive therapy. Initial transthoracic echocardiography showed a normal myocardial function and competent aortic valve. Twenty days after the transplantation the patient referred sudden onset of dyspnea. Transesophageal echocardiography revealed a newly developed severe aortic valve regurgitation and dissection flap in the ascending aorta without distal extension (Fig. 1). Diagnosis was confirmed by a CT-scan and the patient underwent an urgent surgery. Redo-sternotomy and aortic root replacement was performed using a St Jude 21 mm composite valve graft (St Jude Medical, Inc, St Paul, USA) with Bentall–de Bono technique. Intra-operative findings demonstrated an intimal tear 2 cm above commissures in anterior side of ascending aorta just below the anastomosis between donor and recipient aorta (Fig. 2). Dissection affected the non-coronary cusp and partially right coronary cusp with right coronary artery ostium dissected. The native aorta was not involved in the dissection. Following de-airing maneuvers and rewarning, he was weaned from cardiopulmonary bypass with minimal inotropic support. The patient had no significative operative complications and he was discharged in good condition on day 18. Histological examinations showed intimal hyperplasia of the donor aorta and fibrosed aortic leaflets.
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Fig. 1. Transesophageal echocardiography, long-axis view, showing the dissection flap in the ascending aorta.
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Fig. 2. Intra-operative view; dissection is located in anterior side of ascending aorta just below the anastomosis between donor and recipient aorta.
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3. Comment
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Acute aortic dissection in a cardiac allograft recipient is extremely rare with a frequency varying between 1–2% [8]. In fact, only seven cases in the literature have been reported, most of which occurred several years after heart transplantation and only in two of them the dissection was diagnosed during the early postoperative period [2–7]. The diagnosis of aortic dissection in cardiac allograft recipients is complex because it may mimic various pathologies including heart failure, myocardial infarction and pericardial effusion. Furthermore, as the heart is denervated, dissection can occur without pain and mediastinal scarring may contain aortic rupture difficulting the adequate diagnosis. Several risk factors are associated with aortic dissection. Hypertension, diabetes mellitus, connective tissue disorder, accelerated atherosclerosis caused by immunosuppressive agents, especially glucocorticosteroids, and technical mistakes predispose to this complication. According to the pathophysiology and the time of onset, the aortic dissection in the early phase after heart transplantation might be associated to weakness of the aortic tissue and mismatch between the donor and recipient aorta, generating a difference in wall tension at the suture line and the likely risk of aorta rupture. However, in later phases, although the site of the aortic anastomosis might be a potential source of complications, the degenerative processes associated to hypertension and immunosupression are the most common predisposing factors for aortic dissection.
In the case presented, an aortic dissection 20 days postransplantation, we believe that a discrete mismatch of aortic diameters (donor 2.1 cm, recipient 2.7 cm), intrinsic arterial pathology of the donor (history of hypertension and histological findings of intimal hyperplasia in the aorta resected) as well as hypertensive episodes could be the cause of dissection in this early period.
In conclusion, we report a successful Bentall procedure performed in a cardiac allograft recipient with acute type A aortic dissection of the donor aorta during the early postoperative period. Meticulous investigation of the donor, careful aortic anastomosis trying to avoid excessive wall tension and strict antihypertensive treatment might prevent this complication. When the aortic dissection appears, a prompt diagnosis is mandatory because an appropriate medical treatment and aggressive surgical approach can be performed safely on cardiac allograft and improves the prognosis of these patients.
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References
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Abstract
1. Introduction