Heterotopic heart transplantation: an expanding role in the twenty-first century?
BACKGROUND
Heterotopic heart transplantation was first performed in humans in 1974, the main advantage being the continuing function of the patient's native heart, in the event of life-threatening acute rejection. The effect of cyclosporine on acute rejection saw the heterotopic transplantation technique wane. Our unit revisited heterotopic transplantation in response to a growing number of waiting list patients with high pulmonary artery pressures. We also anticipated an increased cardiac allograft utilization, and improvement of our waiting list times.


METHODS
We retrospectively analyzed 151 patients undergoing heart transplantation by our unit between August 1997 and September 2003. Twenty received allografts in the heterotopic position. This cohort was compared with the 131 contemporary orthotopic heart transplant recipients with respect to their outcomes.


RESULTS
The indication for transplantation was ischemic cardiomyopathy in 14 (70%) of the heterotopic cohort and 47 (36%) of the orthotopic cohort (p = 0.004), and dilated cardiomyopathy in 3 (15%) and 48 (37%) in the heterotopic and orthotopic groups, respectively (p = 0.06). Heterotopic recipients were significantly older than orthotopic recipients, and they had higher pulmonary artery pressures. The heterotopic donors were also older and the ischemic times were longer. A subgroup analysis was made among those patients who had high pulmonary artery pressures as these groups were better matched. Major morbidity in the heterotopic heart transplantation group consisted of reversible allograft dysfunction in 4 patients, renal dysfunction requiring hemofiltration in 3 patients, profound myopathy in 4 patients, and cerebrovascular events in 2 patients. There were two early deaths in the heterotopic transplant group and eight in the orthotopic group (p = 0.87). Kaplan-Meier survival analysis of survival was performed.


CONCLUSIONS
Heterotopic heart transplantation is a viable transplant option for selected high-risk heart transplant recipients in spite of somewhat poorer outcomes.
Heart and Lung Transplantation Service, Alfred Hospital, Melbourne, Victoria, Australia.
Andrew E
AE
Newcomb
Donald S
DS
Esmore
Franklin L
FL
Rosenfeldt
Meroula
M
Richardson
Silvana F
SF
Marasco
D058186:Acute Kidney Injury / Q000453:epidemiology / Q000628:therapy; D000328:Adult; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D016027:Heart Transplantation / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends*; D006440:Hemofiltration; D017052:Hospital Mortality; D006801:Humans; D015993:Life Tables; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000601:surgery; D011183:Postoperative Complications / Q000453:epidemiology / Q000401:mortality; D012189:Retrospective Studies; D020521:Stroke / Q000453:epidemiology; D016019:Survival Analysis; D016042:Transplantation, Heterotopic / Q000379:methods / Q000706:statistics & numerical data / Q000639:trends*; D014184:Transplantation, Homologous; D016896:Treatment Outcome