Isolated Donor Cardiectomy

The heart and great vessels are exposed through an extended sternotomy incision, which is connected to the midline celiotomy incision (Fig 9.1). The central tendon of the diaphragm initially is left intact, and a pericardial cradle is created after dissection of the superior vena cava (SVC) to the level of the innominate vein. A visual assessment of right atrial and ventricular volume loading and contractility is made. Topographical anatomic evaluation of the heart is performed

Fig. 9.1. Contiguous midline celiotomy and median sternotomy for ample exposure during multiple organ procurement. (From Baumgartner WA, Reitz BA, Achuff SC. Heart and Heart-Lung Transplantation. Copyright 1990 Philadelphia W.B. Saunders Co. Harcourt Brace Jovanovich, Inc. p.114, with modifications)

Fig. 9.1. Contiguous midline celiotomy and median sternotomy for ample exposure during multiple organ procurement. (From Baumgartner WA, Reitz BA, Achuff SC. Heart and Heart-Lung Transplantation. Copyright 1990 Philadelphia W.B. Saunders Co. Harcourt Brace Jovanovich, Inc. p.114, with modifications)

and the presence or absence of visible or palpable epicardial atherosclerotic coronary plaque is noted. Coronary artery occlusive disease in the donor usually is a strong contraindication for transplantation. Although donor hearts with coronary disease have been revascularized at the time of transplant, the long-term outcome of this approach is uncertain.2

Following the administration of heparin (3 mg/kg) and SoluMedrol (10 mg/kg), the superior vena cava is ligated (or clamped) after retraction of any central venous or pulmonary artery catheters. The superior vena cava is divided above the azy-gous confluence if a bicaval anastomosis is anticipated (Fig 9.2). A vented needle or cannula is inserted into the ascending aorta for administration of the cardioplegic preservation solution. The inferior vena cava (IVC) is partially transected in coordination with the liver-harvesting surgeon. The cavotomy effluent is allowed to exsanguinate into the open right pleural space and a suction catheter is placed directly into the IVC. The distal ascending aorta is cross-clamped at the root of the innominate artery. The aortic root is infused with 20 ml/kg of cold asanguinous crystalloid preservation solution. Our preference is to use U W solution.

The left atrium is vented by transection of the right superior pulmonary vein at its entry point into the pericardium. Topical hypothermia is also induced with iced saline slush applied directly to the epicardial surface.

Following complete diastolic depolarized arrest, the apex of the heart is retracted cephalad and the transection of the IVC is completed. The inferior and superior pulmonary veins are amputated flush with the pericardial sac, as are the right and left pulmonary artery branches (Fig 9.3). The ascending aorta is transected at the level of the innominate artery. Additional segments of superior vena cava, branch pulmonary artery, or aortic arch may be required for some recipients with end stage congenital heart disease.

Fig. 9.2. Antegrade cardioplegic arrest with topical hypothermia, following division of the inferior and superior vena cava. (From Baumgartner WA, Reitz BA, Achuff SC. Heart and Heart-Lung Transplantation. Copyright 1990 Philadelphia W.B. Saunders co. Harcourt Brace Jovanovich, Inc. p.116, with modifications)

Fig. 9.2. Antegrade cardioplegic arrest with topical hypothermia, following division of the inferior and superior vena cava. (From Baumgartner WA, Reitz BA, Achuff SC. Heart and Heart-Lung Transplantation. Copyright 1990 Philadelphia W.B. Saunders co. Harcourt Brace Jovanovich, Inc. p.116, with modifications)

Fig. 9.3. Completion of isolated donor cardiectomy, by division of pulmonary veins. (From Baumgartner WA, Reitz BA, Achuff SC. Heart and Heart-Lung Transplantation. Copyright 1990 Philadelphia W.B. Saunders co. Harcourt Brace Jovanovich, Inc. p.117, with modifications)

Fig. 9.3. Completion of isolated donor cardiectomy, by division of pulmonary veins. (From Baumgartner WA, Reitz BA, Achuff SC. Heart and Heart-Lung Transplantation. Copyright 1990 Philadelphia W.B. Saunders co. Harcourt Brace Jovanovich, Inc. p.117, with modifications)

The excised heart is then examined for evidence of a patent foramen ovale, which is suture closed when encountered. The superior vena cava snare is reinforced with a suture ligature if a biatrial modified Lower-Shumway transplantation technique will be used. The superior vena cava is left open when a bi-caval anastomotic technique will be used. The heart is placed in a rigid sterile container which is filled with preservation solution and insulated with an iced slush bath. Both the container and iced slush are then placed inside two sterile plastic bags for transport in an iced cooler.

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