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Heart Transplantation for a Failed Fontan

Wednesday, November 21, 2018

Petrucci O, Simon-Lee R. Heart Transplantation for a Failed Fontan. November 2018. doi:10.25373/ctsnet.7342751.

This patient was a 15-year-old male with hypoplastic left heart syndrome, status post extracardiac Fontan. The left pulmonary artery was stented and the tricuspid valve ring was placed years previously. This was the fifth time the authors re-entered the chest. A suitable donor became available, and the patient presented for orthotopic heart transplant.


Good idea to publish OHTx technique post extracardiac Fontan (TCPC I guess). You name the 'right atrial anastomosis', referring obviously to the LA anastomosis (3 minutes and 24 Seconds of video). From Your video, one can appreciate the fact that the LA and Pulmonary veins are behind the Conduit in these recipients. One will not be able to see clearly the LA and the veins (right and left veins), unless he removes the conduit first. Despite the unbalanced atria, the heart should still be explanted, with an incision from the RA free wall to the interatrial septum remnants, down and around the small LAAV/mitral annulus (even if the mitral is very small like in HLHS). Like this the PV will be protected. I highlight your comment: The donor's PA is trimmed as much as possible. Long PAs tend to kink and gradients develop. If the branch PAs need augmentation, then one possibly will require to make a hole into the augmentation patch he used, as there is always a danger, for kinking of the MPA. One should not be 'economical' with the aortic length, especially in small weight patient. The aorta needs to have enough length, because strictures can develop in the suture lines. Congrats on doing the IVC anastomosis on beating heart. The Posterior wall can be done with the clamp still on. Additionally in small patients, and provided still cooled the IVC anastomosis can be done, removing the IVC cannula, with low flow and suction return from IVC (holding hand held sucker in IVC). Congratulations for the very successful operation and wonderful outcome for Your patient. Thank you for the opportunity offered for comments.
Congratulations in such a bizarre transplant setting, dear friends. Not only re-do surgery is an issue, but handling with previously deployed stents is nearly becoming routine business. Amazing that the patient was discharged so quickly.

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