背景:对位反肌患者进行心脏移植具有挑战性,特别是在全身静脉回流的重建方面。已经提出了几种重新路由技术,但它们与外部压缩的脆弱性有关,这可能会导致血液动力学不稳定,尤其是在胸部畸形的情况下。在这项研究中,我们报告了一例罕见的在有腹位和漏斗胸的情况下成功进行心脏移植的病例。
方法:一个55岁的男人,有矫正大动脉转位伴室间隔缺损的手术史,因心力衰竭进展而登记心脏移植。随后,他接受了左心室辅助装置植入;登记后14年,他接受了解剖结构正常的心脏移植。通过用供体心脏的逆时针旋转吻合左心房并通过用由残余右心房组织制成的导管延长受体下腔静脉来重建下腔静脉。使用足够长度的供体无名静脉重建上腔静脉。体外循环成功断奶后,胸部无法闭合,因为胸部畸形导致心脏受压,导致血流动力学不稳定。因此,为了排除左肺,使用牛心包创建左心包筛查,允许以可接受的血流动力学封闭胸部。患者术后静脉压较高,提示术后早期静脉回流阻塞。梗阻逐渐解决,病人被转院接受康复治疗.
结论:在存在倒位的情况下进行心脏移植具有挑战性;此外,漏斗胸的存在使手术更加复杂。矛盾的是,左肺和胸部畸形较大,压缩并损害了重建的全身静脉回流。虽然左肺胸腔内隔绝术是有效的,术中或术后早期进行漏斗胸成形术也是可行的选择.患者特定管理是强制性的,取决于解剖结构。
BACKGROUND: Heart transplantation in patients with situs inversus is challenging, especially in terms of reconstruction of the systemic venous return. Several rerouting techniques have been presented but are associated with vulnerability to external compression, which might cause hemodynamic instability, especially in the presence of chest deformity. In this study, we report a rare case of successful heart transplantation in the presence of situs inversus and pectus excavatum.
METHODS: A 55-year-old man, with a history of surgeries for corrected transposition of the great arteries with ventricular septal defect, was registered for heart transplantation owing to progression of heart failure. Subsequently, he had undergone a left ventricular assist device implantation; 14 years after registration, he underwent transplantation of the heart with normal anatomy. The inferior vena cava was reconstructed by anastomosing the left atria with a counterclockwise rotation of the donor heart and by lengthening the recipient inferior vena cava with a conduit made of the residual right atrial tissue. The superior vena cava was reconstructed using a donor innominate vein harvested with sufficient length. After successful weaning from cardiopulmonary bypass, the chest could not be closed because the heart was compressed owing to chest deformity, resulting in hemodynamic instability. Therefore, to exclude the left lung, a left pericardial screen was created using a bovine pericardium, allowing the chest to be closed with acceptable hemodynamics. The patient suffered postoperatively from a higher venous pressure, suggesting an obstruction of venous return early after surgery. The obstruction gradually resolved, and the patient was transferred for rehabilitation.
CONCLUSIONS: Heart transplantation in the presence of situs inversus is challenging; moreover, the presence of pectus excavatum further complicates the procedure. The paradoxically larger left lung and chest deformity compressed and impaired reconstructed systemic venous return. Although intrathoracic exclusion of the left lung was effective, an intraoperative or early postoperative thoracoplasty for pectus excavatum was also a viable option. Patient-specific management is mandatory, depending on the anatomy.