Abstract
We report the case of a 30-year-old man who underwent orthotopic heart transplant via biatrial anastomosis technique. His post-operative electrocardiogram showed atrial dissociation, which is infrequently seen with newer surgical techniques in heart transplantation. (Level of Difficulty: Advanced.)
Key Words: biatrial anastomosis, bicaval anastomosis, heart transplant
Graphical abstract
A 30-year-old man with Marfan syndrome, pectus excavatum, and mitral valve endocarditis, status post-bioprosthetic mitral valve replacement complicated by dehiscence, who underwent HeartWare ventricular assist device (Medtronic, Minneapolis, Minnesota) implantation, mitral valve re-replacement, and tricuspid valve repair in 2017. In March 2020, the patient underwent an orthotopic heart transplant via biatrial anastomosis technique and tricuspid valve repair. The ischemic time was 183 min. The post-operative course was complicated by a chyle leak requiring thoracic duct embolization. On post-operative day 45, after the removal of his epicardial leads, his telemetry monitoring showed complete heart block with narrow-complex rhythm (Figure 1). The patient had a temperature of 36.7°C, heart rate of 93 beats/min, blood pressure of 102/57 mm Hg, respiratory rate of 16 breaths/min, and peripheral oxygen saturation of 96% on room air. He was warm and euvolemic. An electrocardiogram was obtained (Figure 2).
Figure 1.
Telemetry Monitor Suggesting Narrow-Complex Rhythm With Complete Heart Block
Figure 2.
Electrocardiogram on Postoperative Day 45 After Orthotopic Heart Transplant
The electrocardiogram demonstrates atrial dissociation with 2 distinct P-wave morphologies, from both the donor and native sinus nodes (Figure 3). Native sinus node activity is dissociated from the active rhythm. Distinguishing this from other atrial arrhythmias and, specifically, atrioventricular block is important, because the management is different. The patient underwent a heart transplant using the biatrial anastomosis technique, which involves suturing the donor right atrium to a portion of the native right atrium. This was done to displace the ventricles more laterally to the left and reduce the amount of compression on the right ventricle by his pectus excavatum after chest closure. In the biatrial technique, the native sinus node is frequently preserved but does not conduct to the transplanted donor heart because of disruption of blood supply and denervation. There is also conduction block across the suture line in the right atrium (1). Atrial dissociation after orthotopic heart transplant is not commonly seen these days because the bicaval anastomosis technique is considered a more preferable approach except under unique circumstances (2,3).
Figure 3.
The Electrocardiogram Demonstrates Atrial Dissociation With 2 P-Wave Morphologies, From Both the Donor and Native Sinus Nodes
Author Relationship With Industry
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reportsauthor instructions page.
References
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