Transplantation for univentricular hearts—prepare to succeed!

Heart transplantation for the failed univentricular circulation is technically demanding. Frequently, there are many collaterals complicating re-entry and systemic and pulmonary arteries often require complex reconstruction. Furthermore, with the increasing number of patients with Norwood-type repairs surviving to Fontan, a higher proportion of patients will also require complex arch reconstruction at the time of transplantation [1]. Mortality rates as high as 20–40% have been reported for transplantation in this setting [2–4]. However, in large volume institutions with combined experience in complex congenital heart surgery, durable mechanical circulatory support and transplantation, much better results have been reported [5–7].

In this issue of the Journal, Yoneyama and Imamura [8] describe a technique for transplantation in a patient with bilateral bidirectional cavopulmonary shunts (BCPS). We have previously described the similar technique for transplantation after univentricular palliation [6]. To deal with the lack of innominate vein, they retained the central pulmonary artery between the 2 bidirectional cavopulmonary shunt anastomoses as a type of ‘neo-innominate vein’ and completed the transplant using a bi-atrial technique. They then replaced the central pulmonary arteries with a Goretex graft. This is an interesting solution to a difficult problem and can be expected to overcome the shortfalls associated with prosthetic graft use for the creation of an innominate vein, where there is a high risk of thrombosis. However, there should be some caution about the adequacy of the space under the aortic arch to accommodate both the ‘neo-innominate vein’ and the graft for the central pulmonary arteries. It is especially critical that the pulmonary arteries not be compromised for the sake of the systemic veins, particularly, in patients without azygos continuation of the inferior vena cava.

We believe that the preparation and co-ordination are key to achieve optimal results in heart transplantation in this setting. We aim to complete the reconstruction of major vessels prior to the arrival of the donor heart [1, 6, 7]. As such reconstruction can be quite daunting and time-consuming, it is crucial that donor heat ischaemic time is minimized. Our recent experience with XVIVO (XVIVO Perfusion AB, Gothenburg, Sweden) perfusion system appears to ease the pressure and allow some extra time for vascular reconstruction prior to heart transplantation. We communicate extensively with the retrieving team to ensure that the innominate vein, additional pericardium and central pulmonary arteries are harvested when required.

To achieve optimal outcomes in this challenging group of patients, preparation is a must. This requires preparation of the recipient prior to the arrival of the heart. In addition, it requires the surgeon to have a prepared mind, with knowledge of a range of techniques to deal with challenging situations. The technique described by Yoneyama and Imamura is a useful addition to the armamentarium of cardiac surgeons taking on these challenging cases.

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