J Thorac Cardiovasc Surg 1994;108:1150
© 1994 Mosby, Inc.
Effect of previous nontransplant cardiac operations on the outcome of heart transplantation
Gary Ott, MD,
Adnan Cobanoglu, MD
Oregon Health Sciences University
Portland, OR 97201-3098
Reply to the Editor:
We appreciate the interest expressed by Dr. Vijayanagar and his colleagues concerning our report "Heart Transplantation in Patients with Previous Cardiac Operations" (1994;107:203-9). Those of us involved with reoperative cardiac surgery certainly appreciate the added complexities and risk of these procedures; however, in our reported experience this was limited to longer pump and operation times only. No significant association with increased transfusion requirement or surgical morbidity and mortality was found.
If our series of patients having primary transplantation are further subdivided, as suggested by Dr. Vijayanagar, we find the following: no prior sternotomy (group 1, n = 85); one prior sternotomy (group 2, n = 45); and more than one previous sternotomy (group 3, n = 16). Interestingly, operative mortality did not vary among these groups (group 1, 4.7%; group 2, 6.7%: group 3, 6.2%: p > 0.5). Long-term survival was also not compromised by previous surgery (3-year actuarial survival: group 1, 79.4%; group 2, 76.2%; group 3, 74.2%; p > 0.5). Analysis of blood product utilization indicates a trend toward increased platelet concentrate use in repeat procedures (group 1, 16.7%; group 2, 29.5%, group 3, 26.7%; p = 0.22), which did not reach significance. Transfusion of more than 2 units of packed red blood cells did not differ among these groups (group 1, 38.1%; group 2, 36.4%; group 3, 33.3%; p = 0.94). In addition, no differences could be demonstrated between these groups regarding use of preoperative anticoagulation, perioperative renal or hepatic failure, surgical complications, or postoperative length of hospital stay. It is worthy of note that a significant number of patients required transfusions even without prior operations, although to a lesser extent than that reported by the Tampa group. This trend is related to the combination of difficult to quantitate preoperative factors, including chronic low output states, hepatic congestion, and systemic anticoagulation so often prescribed by cardiologists.
With our total series of cardiac transplants now approaching 250 procedures, the proportion of patients with previous sternotomy continues to increase. Recent patients with multiple prior sternotomies have been treated with aprotinin (Trasylol, Miles Inc., West Haven, Conn.) and early results are favorable. This treatment modality may affect the risk of reoperative procedures in the future. It certainly should help to decrease the need for cellular and blood component transfusion. In addition to the precautions cited in our report, favorable results with reoperative surgery in transplant procedures require special attention to the timing of donor and recipient operations. It is our practice to allow extra time on the recipient end to allow for meticulous, unhurried dissection of the scarred chest; at times, the recipient procedure may begin even before the donor operation. Although occasionally lengthening time in the operating room while waiting for the donor organ, we believe this policy allows optimal hemostasis and the best overall surgical outcome.
