Autotransplantation as a Method for Treatment of a Giant Left Atrium

Autotransplantation as a Method for Autotransplantation as a Method for Treatment of a Giant Left AtriumTreatment of a Giant Left Atrium

Mitrev Z, Mitrev Z, Anguseva TAnguseva T, Vogt P, Vogt P

Cardiosurgery - SkopjeCardiosurgery - Skopje

Special hospital for Cardiosurgery Special hospital for Cardiosurgery “Fillip II”, Skopje, Macedonia“Fillip II”, Skopje, Macedonia

BackgroundBackground ::

Heart autotransplantation has been used for Heart autotransplantation has been used for treatment of several cardiac diseases such are:treatment of several cardiac diseases such are:

- long QT Syndrome - long QT Syndrome [Pfeiffer, 1992]. - cardiac tumors- cardiac tumors - refractory Printz-metal angina- refractory Printz-metal angina - permanent atrium fibrillation due to giant - permanent atrium fibrillation due to giant

left atrium combined with mitral valve left atrium combined with mitral valve disease disease ( (Giovanni Troise et al, 2004)

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Giant LA – clinical expressionGiant LA – clinical expression

- Rhythm disturbances- Rhythm disturbances- blood stagnation in the LA - blood stagnation in the LA consequent consequent

thrombosis formationthrombosis formation- pressure of the : - left ventricle- pressure of the : - left ventricle - pulmonary vessels- pulmonary vessels - bronchial tree- bronchial tree

Ultrasound findings: - giant LA with spontaneous Ultrasound findings: - giant LA with spontaneous echo contrast echo contrast

- thromboembolism- thromboembolism

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Type of surgery for LA size reducingType of surgery for LA size reducing

Para-annular wall plicationPara-annular wall plication Posterior wall plicationPosterior wall plication Ligation of the appendix of the LALigation of the appendix of the LA Partial auto-transplantation for pts with Partial auto-transplantation for pts with

LA<8cm diameterLA<8cm diameter Auto-transplantation for pts with LA>8cm Auto-transplantation for pts with LA>8cm

diameterdiameter

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Case – report : patient characteristicsCase – report : patient characteristics2 cases:2 cases:11stst 58 –year-old man / non-smoker 58 –year-old man / non-smoker Severe mitral insufficiency, combined with a tricuspid one (myxomatous degeneration combined with Severe mitral insufficiency, combined with a tricuspid one (myxomatous degeneration combined with

severe atherosclerosis) LA 15x12cmsevere atherosclerosis) LA 15x12cm- dilated cardiomyopathy (7y), with dominant right heart failure- dilated cardiomyopathy (7y), with dominant right heart failure- cahexia - BW=52.4kg, BH= 162cm, BSA = 1.52m2- cahexia - BW=52.4kg, BH= 162cm, BSA = 1.52m2- ECG- atrial fibrilloflater / last 3 years- ECG- atrial fibrilloflater / last 3 yearsComorbidities: lever cirrhosis and ascites; benign prostate hyperplasiaComorbidities: lever cirrhosis and ascites; benign prostate hyperplasia22ndnd 61y old lady / non smoker 61y old lady / non smokerTerminal stadium of mitral valve stenosis with tricuspid insuff. LA 14x16cmTerminal stadium of mitral valve stenosis with tricuspid insuff. LA 14x16cmCahexia –BW=48kg,BH 158cm,BSA = 1.2m2Cahexia –BW=48kg,BH 158cm,BSA = 1.2m2ECG – atrial fibrilloflutterECG – atrial fibrilloflutterComorbidities : liver insuff.Comorbidities : liver insuff. Both pat. were refractory of the optimal medical therapyBoth pat. were refractory of the optimal medical therapy

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TTE & TEE – giant left atrium ( 15 x TTE & TEE – giant left atrium ( 15 x 16cm/14x14cm) & small atrium - septal 16cm/14x14cm) & small atrium - septal aneurysm aneurysm & severe MR & TR& severe MR & TR

Diagnosis

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Autotransplantation - surgery

CBP time 89 min / t=36CBP time 89 min / t=36°C 82min/ t=35,8°C°C 82min/ t=35,8°C aorta clamping time 44 min 42minaorta clamping time 44 min 42min Heart out of the chest 9 min 8,5minHeart out of the chest 9 min 8,5min retrograde cardioplegia through the sinus coronariesretrograde cardioplegia through the sinus coronaries mitral annuli reconstruction mechanic mitral valvemitral annuli reconstruction mechanic mitral valve

reduction of the left atrium with atria-septal plasticreduction of the left atrium with atria-septal plastic tricuspid valve reconstructiontricuspid valve reconstruction

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1st pat 2nd pat

Surgery Surgery

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Postoperative monitoringCardiac status:Cardiac status:- atrium fibrillation : convert in sinus rhythm after 24 hours - atrium fibrillation : convert in sinus rhythm after 24 hours postoperatively by performing Amiodarone (both pts):postoperatively by performing Amiodarone (both pts):after 3 months after 6 monthsafter 3 months after 6 monthsEDV=175/145ml EDV=150/102mlEDV=175/145ml EDV=150/102mlESV=90/78ml ESV = 78/67mlESV=90/78ml ESV = 78/67mlEF= 40/45% EF = 45/50%EF= 40/45% EF = 45/50%CO=3.8/3.6l CO=4.7/5.1lCO=3.8/3.6l CO=4.7/5.1lCI= 2.9/3.0 CI=3.3/3.8CI= 2.9/3.0 CI=3.3/3.8LA=58/49 mm LA=55/52mmLA=58/49 mm LA=55/52mmno mitral and tricuspid valve regurgitationno mitral and tricuspid valve regurgitationECG : sinus rhythm with intermittent atrium fibrillationECG : sinus rhythm with intermittent atrium fibrillation

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Follow up Follow up

Patients get 10 / 12kg on weightPatients get 10 / 12kg on weightAscites was completely cured conservatively after 3Ascites was completely cured conservatively after 3 months (haemodynamic improvement).months (haemodynamic improvement).NYHA class II, good quality of lifeNYHA class II, good quality of lifeMedical treatment with: Medical treatment with: - digitalis,- digitalis, - ACE inhibitors- ACE inhibitors - spironolacton- spironolacton - diuretics- diuretics - amjodarone (first 3 months)- amjodarone (first 3 months)

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C o m m e n t

-- Autotransplantation seems to be an efficient Autotransplantation seems to be an efficient method to reduce extreme LA dilatation. method to reduce extreme LA dilatation.

- Eventually should be considered as a - Eventually should be considered as a method of choice for patients with long method of choice for patients with long lasting mitral valve disease and severe lasting mitral valve disease and severe enlargement of the left atriumenlargement of the left atrium

Cardiosurgery - Skopje