Case Report
A forty-year-old male patient was diagnosed with dilated cardiomyopathy
and treated by heart transplantation 10 years ago. Donor was a
15-year-old female. After HTx, he developed hypertension and diabetes
mellitus (DM). The patient has recently admitted to our clinic with
developing chest pain and dyspnea. In his first surgery, it was noted
that the mismatch between the recipient and donor aorta was compensated
by plication of the recipient aorta. The patient’s immunosuppressive
regimen was cyclosporin, mycophenolate mofetil and steroids. The patient
was checked regularly for ten years, and no signs of aortic pathology
were detected. However, for the last month he described shortness of
breath and chest pain. In echocardiography, left ventricular and
valvular functions were normal. Ascending aortic diameter was reported
as 75 mm. In thorax computed tomography (CT) angiography, the donor
aorta was seen normally to the suture line level. Dissection begins from
the native ascending aorta (beginning from the suture line), extends
through the iliac arteries (Figure 1). All vessels were originated from
the true lumen except the left renal and celiac arteries. There was a
reentry at renal artery level. Coronary CT angiography was performed,
and coronary arteries were found to be normal. There was no problem in
the blood tests except for mild urea and creatinine elevation.
Cyclosporin levels were within the desired limits.
In the operation, subclavian arterial and right femoral venous
cannulation was performed. Redo sternotomy was performed without
entering the cardiopulmonary bypass (CPB). There were tight adhesions on
the aneurysm, vena cava superior and the right atrium side. There was
almost no adhesion around the inferior vena cava, diaphragmatic and
lateral face. The adhesions were dissected. The second venous cannula
from the superior vena cava, retrograde canula and vent canula was
placed. Ascending aorta was found to be very wide and about 8 cm in
diameter.
In the heart transplant surgery, teflon reinforced stitches was noticed
within the antero-lateral part of the anastomosis line. The
brachiocephalic artery has been turned and, cross clamp has been placed,
then aneurysm/dissection sac opened. The dissection seen from the
beginning of the suture line, and the native aorta and the donor aorta
were seen to be separated from each other. The donor aorta was normal.
False lumen was seen moving towards the large curvature (Figure 2).
Blood cardioplegia from the coronary ostia was given and the heart was
arrested. Afterwards, cardiac protection was continued with retrograde
cardioplegia plus intermittent antegrade perfusion at 25 minutes. The
patient was cooled to 28 C°. The proximal side was trimmed to the donor
aorta. By using 28 mm Dacron graft and 4/0 polypropylene sutures,
proximal anastomosis was made. The donor tissue was intact, and no
reinforcement was needed (Figure 3).
Arcus branches were inspected. It was all originated from the true
lumen. The tissues were intact. There was a slight flow from the false
lumen. Both lumens were combined to generate the true lumen and
reinforced with teflon felt and fibrin sealant (Tisseel, Baxter) (Figure
4). Distal anastomosis was made with 4/0 polypropylene sutures and
reinforced with teflon felts as standard (Figure 5). The cross clamp was
removed, following the removal of the air from the proximal side. The
cross-clamping time was 59 minutes, the selective brain perfusion time
was 25 minutes, and the CPB time was 102 minutes. After decamping, the
heart started in sinus rhythm spontaneously. The patient was heated and
CPB terminated without the need for inotropic support. The postoperative
period of the patient went smoothly. Immediately after the extubation,
the immunosuppressive regimen was initiated. The patient was closely
monitored from the cardiac point of view and no problems were
encountered. The patient was discharged on the 10th day. A month later,
the thorax CT showed that the false lumen was completely thrombosed.