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Keywords:

  • Ablation;
  • cryoablation;
  • orthotopic heart transplant;
  • surgical ablation;
  • Wolff-Parkinson-White Syndrome

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case Report
  5. Discussion
  6. Disclosure
  7. References

This report describes the use of a donor heart with ventricular pre-excitation for pediatric orthotopic heart transplantation and the successful surgical cryoablation of the donor heart prior to transplantation. The issues related to the preoperative evaluation and surgical management of the donor heart with Wolff-Parkinson White syndrome are discussed.


Abbreviations: 
AV

atrioventricular

AVNERP

AV nodal effective refractory period

EP

electrophysiology

SVT

supraventricular tachycardia

VAERP

ventriculo-atrial effective refractory period

WPW

Wolff-Parkinson-White Syndrome

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case Report
  5. Discussion
  6. Disclosure
  7. References

Radiofrequency or cryoablation of accessory pathway tissue is the standard treatment for symptomatic Wolff-Parkinson-White (WPW) syndrome in children and adolescents (1). The procedure has been demonstrated to be curative and is both safe and effective (2). There are limited reports of the use of donor hearts with ventricular preexcitation for orthotopic heart transplantation in adults (3,4). We report the successful transplantation of a donor heart identified prior to transplantation to have WPW. Based on the pattern of preexcitation on the surface electrocardiogram (ECG), the donor heart was successfully surgically ablated out of the body using cryoenergy prior to transplantation.

Case Report

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case Report
  5. Discussion
  6. Disclosure
  7. References

A 17-year-old patient weighing 40 kg with restrictive cardiomyopathy presented with shortness of breath, fatigue, lower extremity edema and severe abdominal distension and was referred for cardiac transplant evaluation. At the time of listing for transplantation, the patient had a pulmonary capillary wedge pressure of 22 mmHg and cardiac index of 1.5 L/min/m2 by Fick calculation with a low pulmonary vascular resistance of 2.5 woods units. A suitable donor was identified who had no cardiac symptoms and suffered a respiratory arrest. The donor had a structurally normal heart with normal biventricular function by echocardiogram. One year earlier the donor had been diagnosed with WPW when a screening ECG was performed prior to elective orthopedic surgery. The pattern of preexcitation on the ECG suggested the accessory pathway to be located in the left lateral position, as there was a positive delta wave in lead V1 with a positive delta wave in AVF (Figure 1) (5). The donor heart was accepted with the plan of performing an empiric surgical cryoablation prior to implantation. Using a CryoMaze linear ablation device from ATS Medical (Minneapolis, MN, USA), a 60-second application at –100° C was placed along the left lateral mitral annulus by the transplant surgeon. The cyroablation added roughly 3 min to the total donor heart ischemic time, which was 216 min. A 12 lead ECG in the intensive care unit posttransplantation revealed no evidence of ventricular preexcitation.

image

Figure 1. Donor electrocardiogram. The donor 12-lead electrocardiogram prior to transplantation demonstrating ventricular preexcitation with a left lateral accessory pathway.

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An electrophysiology (EP) study was performed 8 days after transplantation using the temporary epicardial atrial and ventricular wires placed at the time of transplantation. Standard atrial and ventricular pacing protocols were employed. Rapid atrial pacing demonstrated a Wenckebach cycle length of 220 ms with clear lengthening of the PR interval and no evidence of preexcitation. Atrial extrastimulus testing revealed decremental atrioventricular (AV) conduction with an AVNERP of 400/220 ms. Ventricular extrastimulus testing revealed decremental VA conduction with VAERP of ≤400/230 ms. There was no inducible tachycardia and no echo or reentry beats were noted. In summary, there was no evidence of accessory pathway conduction. At 3-month follow-up, the ECG continued to demonstrate no evidence for ventricular preexcitation (Figure 2).

image

Figure 2. Recipient electrocardiogram posttransplantation. The recipient 15-lead electrocardiogram at 3 months posttransplant demonstrating sinus rhythm with a right ventricular conduction delay and no evidence of preexcitation.

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Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case Report
  5. Discussion
  6. Disclosure
  7. References

There are several reports on the use of a donor heart with ventricular preexcitation for cardiac transplantation (3,4,6,7). In 1989, Thompson et al. described the surgical ablation of a left lateral accessory pathway at the time of transplantation in a donor heart (4). The surgical ablation was performed by an incision made along the posterior aspect of the mitral annulus at the time of transplantation. Since that report there have been several reports of donor hearts with WPW being used for transplantation and recipients undergoing catheterization with EP study and radiofrequency ablation in the posttransplant period (3,6,7). To our knowledge we report the first use of surgical cryoablation at the time of transplantation in a pediatric patient prior to cardiac transplantation. Preoperative evaluation of the 12-lead ECG allowed localization of the accessory pathway for guided application of the cryoenergy (5). The cryoapplication added only several minutes of donor ischemic time and was performed in a location that was distant to the cardiac conduction system, therefore adding minimal perioperative risks. The location of the accessory pathway on the left side of the heart also allowed for an empiric cryolesion to be placed without the need for detailed intraoperative mapping or risk of AV nodal injury as may have been a concern for a right-sided accessory pathway. The novel approach of using cryotherapy was theoretically preferable over a classic “cut-and-sew” ablation as a cryoablation should be faster, and surgical cryoablation has largely replaced surgical radiofrequency ablation as the primary perioperative ablation tool (8). Ablation at the time of transplantation also obviated the need for a repeat procedure in the posttransplant period and prevented the risk of supraventricular tachycardia (SVT) in the immediate postoperative period, as has been demonstrated in other recipients when donor hearts with WPW were used (3).

This report demonstrates that an appropriate donor heart with WPW can be safely used for cardiac transplantation and that surgical cryoablation can be used to diminish the recipient's risk of supraventricular tachycardia and sudden death. Furthermore, it re-emphasizes the importance of careful review of the pretransplantation ECG which, in this case, identified not only the presence of WPW but also allowed localization of the accessory pathway for surgical cryoablation. The risk of sudden death in otherwise healthy patients with WPW is rare, roughly 0.0015 per patient year in the general population, and the cause of sudden death in these patients is usually atrial fibrillation with rapid conduction via the accessory pathway (9). The need for an EP study and ablation in otherwise healthy individuals with WPW has been debated, though many electrophysiologists perform routine EP studies for risk assessment with possible ablation in these patients (10–12). In heart transplant recipients with a donor heart with WPW, Kao et al. suggested that a conservative approach without intervention may be warranted, and medications or catheter-based intervention can be considered in the event of postoperative arrhythmias (3). Cardiac transplantation patients, however, can frequently develop supraventricular arrhythmias including intraatrial reentry tachycardia, ectopic atrial tachycardia and atrial fibrillation which can be related or unrelated to graft rejection (13,14). Though there is limited experience with WPW in the cardiac transplant recipient, surgical ablation at the time of transplant appears to be a safe and effective mode of treatment for the donor heart with WPW. The ablation thus poses minimal additional risk to the recipient at the time of transplantation and potentially reduces the complexity of posttransplantation management in this multifaceted patient population.

Disclosure

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case Report
  5. Discussion
  6. Disclosure
  7. References

The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Case Report
  5. Discussion
  6. Disclosure
  7. References
  • 1
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  • 2
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