Case
Reports
Gregory N. Messner, DO
Igor D. Gregoric, MD
Thomas Chu, MD
Branislav Radovancevic, MD
Biswajit Kar, MD
Scott D. Flamm, MD
O.H. Frazier, MD
Key words: Heart defects,
congenital/physiopathology/
surgery; heart transplanta-
tion/methods; transposition
of the great vessels
From: The Cardiopulmonary
Transplant Service and the
Cullen Cardiovascular
Research Laboratories of
the Texas Heart Institute,
Houston, Texas 77030
Address for reprints:
O.H. Frazier, MD, Texas
Heart Institute, MC 2-114A,
P.O. Box 20345, Houston, TX
77225-0345
E-mail:
knowlin@heart.thi.tmc.edu
© 2005 by the Texas Heart ®
Institute, Houston
Texas Heart Institute Journal
Orthotopic Heart Trans-
plantation in a Patient
with D-Transposition
of the Great Arteries
after a Mustard Procedure
During heart transplantation, the atrial septum is most often used to reconstruct the
right atrial reservoir. We report the case of a patient with corrected D-transposition of
the great arteries who underwent successful cardiac transplantation despite the lack of
an atrial septum. We then used the donor heart’s atrial septum for the roof of the left
atrium and used the recipient’s left atrium for the back wall of the left atrium. The out-
come was a more anatomically positioned transplanted heart, which avoided the dupli-
cation of the right and left atria that occurs in conventional orthotopic transplantation
and that often leads to left-lower-lobe atelectasis and tricuspid regurgitation. This
method of orthotopic transplantation should be considered for, but not limited to, the
growing number of adults with congenital heart disease who require heart transplanta-
tion. (Tex Heart Inst J 2005;32:541-3)
T
he number of adult patients with congenital heart disease is approximately
800,000 in the United States alone.1 An increasing number of these pa-
tients develop systemic ventricular failure, leading to evaluation for cardiac
transplantation. The literature contains few reports of heart transplantation in pa-
tients with a previous Mustard or Senning procedure.2 - 5 Nevertheless, because of
their high late complication rates, these complex operations for transposition of the
great arteries will necessitate more heart transplantation in the future.
Historically, surgeons have used the atrial septum to reconstruct the right atrial
reservoir during heart transplantation. We report the case of a patient with D-trans-
position of the great arteries that had been corrected previously with a Mustard pro-
cedure. We performed successful transplantation despite the patient’s lack of an
atrial septum. We developed a unique method of reconstruction that resulted in a
more anatomically positioned transplanted heart; this method avoided the duplica-
tion of the right and left atria that occurs in conventional orthotopic transplantation
and that often leads to left-lower-lobe atelectasis and tricuspid regurgitation.6
Case Report
In May 2001, a 37-year-old woman with end-stage systemic right ventricular dys-
function was evaluated for cardiac transplantation. The patient had been born with
D-transposition of the great arteries. She had undergone a Blalock-Hanlon atrial
septectomy during infancy and a Mustard repair with complete removal of the atri-
al septum at age 12 years. She was evaluated for heart transplantation and was placed
on the transplant waiting list in May 2001. Thirteen months later, in June 2002, or-
thotopic transplantation was performed.
Surgical Technique
The donor heart was excised in toto, with a long length of aorta to allow for correc-
tion of the recipient’s anatomic abnormality caused by the transposition. After the
native heart was also excised, we prepared the donor heart by removing the back
wall of the left atrium between the entry sites of the pulmonary veins (Fig. 1A). We
then anastomosed the donor heart to the recipient’s left atrium with 3-0 polypropy-
Orthotopic Transplantation with Corrected D-Transposition of the Great Arteries 541
 A B

D
C

E thoracic cavity, and the suture line was created superi-

Fig. 1 A–E) Surgical technique (see text).
lene sutures, beginning at the midpoint where the su-
perior and inferior right pulmonary veins entered the
donor heart (Fig. 1B). The corresponding point, lo-
cated 180° opposite, was marked on the recipient’s left
atrium. The donor heart was then placed in the right
orly and inferiorly to the midpoint of the left superior
and inferior pulmonary veins, with a running 4-0
polypropylene suture (Fig. 1C). As this anastomosis
was being completed, the donor heart was gradually
transposed from its original position in the right tho-
racic cavity to its permanent anatomic position within
the pericardial sac, in the recipient’s left thoracic cavi-
ty. The recipient’s superior and inferior venae cavae
were then juxtaposed, in their normal anatomic posi-
tions, to the donor’s superior and inferior venae cavae.
This maneuver enabled us to create the primary cava-
to-cava anastomoses easily and rapidly (Fig. 1D). The
inferior vena caval anastomosis was also performed
with a running 4-0 polypropylene suture. The pul-
monary artery anastomosis was constructed with 5-0
polypropylene suture, with use of bovine pericardium
to reinforce the suture line. The aortic anastomosis was
completed with 4-0 polypropylene suture and a strip
of donor aorta (Fig. 1E). The aortic clamp was re-
moved, and perfusion of the donor heart was initiated.
After de-airing, with the donor heart beating, the su-
perior vena caval anastomosis was created with a run-

542 Orthotopic Transplantation with Corrected D-Transposition of the Great Arteries Volume 32, Number 4, 2005
ning 4-0 polypropylene suture, and the orthotopic trans-
plantation was complete.
The patient recovered uneventfully and was easily
weaned from cardiopulmonary bypass. She was dis-
charged from the hospital 20 days postoperatively. Be-
cause of retained pacemaker leads, we were unable to
perform postoperative magnetic resonance imaging;
however, electrocardiographic-gated computed tomog-
raphy revealed an anatomically positioned transplant-
ed heart with a normal-sized left atrium (Fig. 2). In-
A ventional orthotopic heart transplantation, because
B 1993;7:65-70.
Fig. 2 Computed tomographic (CT) scan highlights the new
technique. A) Multiplanar reconstruction in the 4-chamber pro-
jection of a contrast-enhanced multidetector CT scan. The left
atrium is normal in size, and the reconstructed interatrial sep-
tum appears in the normal position. The arrow denotes a stent
in the ostium of the right-upper-lobe pulmonary vein placed
before transplantation. B) Three-dimensional-volume rendered
reconstruction from the contrast-enhanced CT scan using a
commercially available workstation (Vitrea ® 2, Vital Images;
Minnetonka, Minn). The left atrium (arrow) has been rendered in
blue-green and isolated to allow volumetric measurements (the
left atrium has a volume of 39 cc and a surface area of 85 cm 2).
Texas Heart Institute Journal Orthotopic Transplantation with Corrected D-Transposition of the Great Arteries
travascular stents were present in the native right low-
er and left upper lobe pulmonary veins as a result of
procedures done before transplantation. There was no
evidence of pulmonary vein stenosis or misalignment.
Superior and inferior venae caval drainage to the right
atrium was unobstructed and appeared anatomically
normal. At the last follow-up visit in June 2005, the
patient was doing well and was fully ambulatory.
Comment
For most patients with congenital heart disease who
undergo orthotopic heart transplantation, only minor
surgical modifications are required.7 In this patient,
however, the absence of an atrial septum necessitated
the use of an entirely different approach to transplan-
tation. By beginning the left atrial anastomosis on the
opposite side and retaining a normal amount of left
atrial tissue, we could easily perform the cava-to-cava
anastomosis because the venae cavae were in a normal
anatomic position. This arrangement prevented du-
plication of the atrial tissue, which can cause prob-
lems in positioning the heart in the left thoracic
cavity. Our method is easy to perform and may also
be beneficial for patients scheduled to undergo con-
the normalized position of the left atrium prevents
duplication of the right and left atrial tissue.
References
1. Summary of recommendations—care of the adult with
congenital heart disease. J Am Coll Cardiol 2001;37:1167-
9.
2. Carrel T, Neth J, Pasic M, Laske A, Jenni R, Maggiorini M,
Turina M. Should cardiac transplantation for congenital
heart disease be delayed until adult age? Eur J Cardiothorac
Surg 1994;8:462-9.
3. Mayer JE Jr, Perry S, O’Brien P, Perez-Atayde A, Jonas RA,
Castaneda AR, Parness IA. Orthotopic heart transplanta-
tion for complex congenital heart disease. J Thorac Cardio-
vasc Surg 1990;99:484-92.
4. Hasan A, Au J, Hamilton JR, Hunter S, Hilton CJ, Dark
JH. Orthotopic heart transplantation for congenital heart
disease. Technical considerations. Eur J Cardiothorac Surg
5. Menkis AH, McKenzie FN, Novick RJ, Kostuk WJ, Pflug-
felder PW, Goldbach M, Rosenberg H. Expanding appli-
cability of transplantation after multiple prior palliative pro-
cedures. The Paediatric Heart Transplant Group. Ann Thorac
Surg 1991;52:722-6.
6. Aziz TM, Burgess MI, Rahman AN, Campbell CS, Dei-
raniya AK, Yonan NA. Risk factors for tricuspid valve regur-
gitation after orthotopic heart transplantation. Ann Thorac
Surg 1999;68:1247-51.
7. Harjula AL, Heikkila LJ, Nieminen MS, Kupari M, Keto P,
Mattila SP. Heart transplantation in repaired transposition
of the great arteries. Ann Thorac Surg 1988;46:611-4.
543