Autotransplantation as a Method for Treatment of a Giant Left Atrium

1. Autotransplantation as a Method for Treatment of a Giant Left Atrium Mitrev Z, Anguseva T, Vogt P Special hospital for Cardiosurgery “Fillip II”, Skopje, Macedonia Cardiosurgery - Skopje

2. Background: Heart autotransplantation has been used for treatment of several cardiac diseases such are: - long QT Syndrome [Pfeiffer, 1992]. - cardiac tumors - refractory Printz-metal angina - permanent atrium fibrillation due to giant left atrium combined with mitral valve disease (Giovanni Troise et al, 2004) Cardiosurgery - Skopje

3. Giant LA – clinical expression - Rhythm disturbances - blood stagnation in the LA  consequent thrombosis formation - pressure of the : - left ventricle - pulmonary vessels - bronchial tree Ultrasound findings: - giant LA with spontaneous echo contrast - thromboembolism Cardiosurgery - Skopje

4. Type of surgery for LA size reducing Para-annular wall plication Posterior wall plication Ligation of the appendix of the LA Partial auto-transplantation for pts with LA<8cm diameter Auto-transplantation for pts with LA>8cm diameter Cardiosurgery - Skopje

5. Case – report : patient characteristics 2 cases: 1st 58 –year-old man / non-smoker Severe mitral insufficiency, combined with a tricuspid one (myxomatous degeneration combined with severe atherosclerosis) LA 15x12cm - dilated cardiomyopathy (7y), with dominant right heart failure - cahexia - BW=52.4kg, BH= 162cm, BSA = 1.52m2 - ECG- atrial fibrilloflater / last 3 years Comorbidities: lever cirrhosis and ascites; benign prostate hyperplasia 2nd 61y old lady / non smoker Terminal stadium of mitral valve stenosis with tricuspid insuff. LA 14x16cm Cahexia –BW=48kg,BH 158cm,BSA = 1.2m2 ECG – atrial fibrilloflutter Comorbidities : liver insuff. Both pat. were refractory of the optimal medical therapy Cardiosurgery - Skopje

6. Diagnosis • TTE & TEE – giant left atrium ( 15 x 16cm/14x14cm) & small atrium - septal aneurysm & severe MR & TR Cardiosurgery - Skopje

7. Autotransplantation - surgery 1st pat 2nd pat CBP time 89 min / t=36°C 82min/ t=35,8°C aorta clamping time 44 min 42min Heart out of the chest 9 min 8,5min retrograde cardioplegia through the sinus coronaries mitral annuli reconstruction mechanic mitral valve reduction of the left atrium with atria-septal plastic tricuspid valve reconstruction Cardiosurgery - Skopje

8. Surgery Cardiosurgery - Skopje

9. Postoperative monitoring Cardiac status: - atrium fibrillation : convert in sinus rhythm after 24 hours postoperatively by performing Amiodarone (both pts): after 3 months after 6 months EDV=175/145ml EDV=150/102ml ESV=90/78ml ESV = 78/67ml EF= 40/45% EF = 45/50% CO=3.8/3.6l CO=4.7/5.1l CI= 2.9/3.0 CI=3.3/3.8 LA=58/49 mm LA=55/52mm no mitral and tricuspid valve regurgitation ECG : sinus rhythm with intermittent atrium fibrillation Cardiosurgery - Skopje

10. Follow up • Patients get 10 / 12kg on weight • Ascites was completely cured conservatively after 3 months (haemodynamic improvement). • NYHA class II, good quality of life • Medical treatment with: - digitalis, - ACE inhibitors - spironolacton - diuretics - amjodarone (first 3 months) Cardiosurgery - Skopje

11. C o m m e n t -Autotransplantation seems to be an efficient method to reduce extreme LA dilatation. - Eventually should be considered as a method of choice for patients with long lasting mitral valve disease and severe enlargement of the left atrium Cardiosurgery - Skopje