Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2018 Dec 18;18(1):239.
doi: 10.1186/s12872-018-0966-2.

Cardiac autotransplantation and ex vivo surgical repair of giant left atrium: a case presentation

Zan Mitrev  1 , Milka Klincheva  2 , Tanja Anguseva  2 , Igor Zdravkovski  2 , Rodney Alexander Rosalia  2
Affiliations
Case Reports

Cardiac autotransplantation and ex vivo surgical repair of giant left atrium: a case presentation

Zan Mitrev et al. BMC Cardiovasc Disord. .

Abstract

Background: Chronic Mitral Valve disease is strongly associated with Left atrial enlargement; the condition has a high mortality risk. Clinical manifestations include atrial fibrillation, pulmonary hypertension, thromboembolic events, and in cases of Giant Left Atrium (GLA) and a distorted cardiac silhouette. Full sternotomy, conventional open-heart surgery, reductive atrioplasty and atrioventricular valve repair are required to resolve symptoms. However, these procedures can be complicated due to the posterior location of the GLA and concomitant right lateral protrusion. Cardiac autotransplantation is superior under these conditions; it provides improved visual access to the posterior atrial wall and mitral valve, hence, facilitates corrective surgical procedures. We aimed to assess the clinical outcome of patients undergoing cardiac autotransplantation as the primary treatment modality to resolve GLA. Moreover, we evaluated the procedural safety profile and technical feasibility.

Case presentation: Four patients, mean EuroSCORE II of 23.7% ± 7.7%, presented with heart failure, atrial fibrillation, left atrial diameter > 6.5 cm and a severe distorted cardiac silhouette; X-ray showed prominent right lateral protrusion. We performed cardiac autotransplantation using continuous retrograde perfusion with warm blood supplemented with glucose followed by atrioplasty, atrial plication, valve annuloplasty and valve repair on the explanted beating heart. The surgical approach reduced the left atrial area, mean reduction was - 90.71 cm2 [CI95% -153.3 cm2 to - 28.8 cm2, p = 0.02], and normalized pulmonary arterial pressure, mean decrease - 11.25 mmHg [CI95% -15.23 mmHg to - 7.272 mmHg, p = 0.003]. 3 out of 4 patients experienced an uneventful postoperative course; 2 out of 4 patients experienced a transient return to sinus rhythm following surgery. One was operated on in 2017 and is still in good condition; two other patients survived for more than 10 years; Kaplan-Meier determined median survival is 10.5 years.

Conclusions: Cardiac autotransplantation is an elegant surgical procedure that facilitates the surgical remodelling of Giant Left Atrium. Surgical repair on the ex vivo beating heart, under continuous warm blood perfusion, is a safe procedure applicable also to high-risk patients.

Keywords: Atrial fibrillation; Cardiac autotransplantation; Giant left atrium; Warm blood perfusion.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate

The clinical practice and treatment procedures described in this case series were approved by the ethical committee of the Zan Mitrev Clinic.

Consent for publication

Written and signed informed consent was obtained from patient #4, hospitalised on 28/09/2017, for publication of this case report and any accompanying images. A copy of the signed consent can be submitted upon request for review by the Editor-in-Chief of this journal. The ZMC ethical committee approved the publication of clinical data of the deceased patients #1, #2 and #3 on the condition that full animosity.

Competing interests

Dr. Zan Mitrev is the hospital director at the Zan Mitrev Clinic. The authors of scientific publications receive financial incentives, as a function of the scientific impact of the journal, awarded by the ZMC board.

The ZMC chief scientific officer, R.A. Rosalia, is exempt from any financial incentive system and attests that all clinical and patient data described in this manuscript is devoid of any deliberate falsification or other fraudulent practices. The authors declare no other competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Intraoperative images of the cardiac autotransplantation procedure. a Explanted and ex vivo handling of the enlarged heart. b Preserved, cannulated vena cava and residual Right Atrial wall tissue. c The open left Atria with the diseased mitral valve. d The full excision of the diseased mitral valve. e Implantation biological valve prosthesis. f depicts the sternum with the re-implanted, surgically corrected heart
Fig. 2
Fig. 2
Perioperative Echocardiography, Laboratory analysis results and Survival. Panels depict the paired pre- and postoperative measurements for Left Atrium area (a), Left Ventricular Ejection Fraction (b) and Pulmonary Arterial Pressure (c). Panels show the paired pre- and postoperative creatine clearance (d), blood Urea levels (e), the liver enzyme Alanine transaminase (f) and Aspartate transaminase (g) levels. The estimated median survival following cardiac autotransplantation to perform atrial corrective surgery and atrioventricular valve reconstruction or replacement, censored subject (patient #4) is indicated, (h). Symbols in graphs correspond to the patient case # described in Tables 1 and 2
Fig. 3
Fig. 3
The Radiological examinations of a patient with GLA and right lateral protrusion. Pre- (a) and postoperative (b) AP X-ray images of the cardiac silhouette of a 65-year-old woman with severe mitral regurgitation, pulmonary hypertension, tricuspid regurgitation and dilation of the left atrium (LA area, 81 cm2 and a cardiothoracic ratio of 0.8). Red arrows point to the right heart border (a and b). Heart auto-transplantation was performed to replace the mitral valve with a biological prosthesis (yellow arrow) (St. Jude Medical, 27 mm). Excess atrial tissue was surgically removed followed by LA atrioplasty. Red arrows point to the right-lateral lining of the cardiac silhouette (a and b). The procedure successfully restored normal concave left heart border (b), (LA area, 23 cm2 and a cardiothoracic ratio of 0.6). Postoperative echocardiogram displayed a normalised left atrium area (indicated by the dotted line) and other chambers without significant morphological distortions (c)
See this image and copyright information in PMC

References

    1. Ray R, Chambers J. Mitral valve disease. Int J Clin Pract. 2014;68(10):1216–1220. doi: 10.1111/ijcp.12321. - DOI - PubMed
    1. El Maghraby A, Hajar R. Giant left atrium: a review. Heart views : the official journal of the Gulf Heart Association. 2012;13(2):46–52. doi: 10.4103/1995-705X.99227. - DOI - PMC - PubMed
    1. Di Eusanio G, Gregorini R, Mazzola A, Clementi G, Procaccini B, Cavarra F, Taraschi F, Esposito G, Di Nardo W, Di Luzio V. Giant left atrium and mitral valve replacement: risk factor analysis. Eur J Cardiothoracic Surg : official journal of the European Association for Cardio-thoracic Surgery. 1988;2(3):151–159. doi: 10.1016/1010-7940(88)90063-2. - DOI - PubMed
    1. Hoit BD. Left atrial size and function: role in prognosis. J Am Coll Cardiol. 2014;63(6):493–505. doi: 10.1016/j.jacc.2013.10.055. - DOI - PubMed
    1. Apostolakis E, Shuhaiber JH. The surgical management of giant left atrium. Eur J Cardiothoracic Surg : official journal of the European Association for Cardio-thoracic Surgery. 2008;33(2):182–190. doi: 10.1016/j.ejcts.2007.11.003. - DOI - PubMed

Publication types

MeSH terms