**3. The heterotopic surgical technique**

There are two published surgical techniques for the heterotopic heart transplant. Novitzky et al. [8] published the first surgical technique pioneered by Christian Barnard in the 1970s. The heterotopic transplant technique pioneered by Barnard started with the anastomosis of the donor left atrium to the recipient left atrium. Then, the donor right atrium is anastomosed to the recipient right atrium and superior vena cava. Next, the donor aorta is sutured to the recipient aorta in an end to side fashion. The pulmonary anastomosis is the remaining anastomosis. The pulmonary artery is sutured to a dacron graft. The dacron graft is used to extend the anastomosis to the recipient pulmonary artery. Without the interposition graft, the donor and recipient pulmonary arteries would not be able to be brought together without tension or possibly not at all because of lack of length on the donor tissue (**Figure 1**).

In 2017, Copeland et al. [9] published an alternate heterotopic heart transplant technique as a biologic left ventricular assist. The donor heart left pulmonary veins and inferior vena cava are oversewn. The right pleura is widely opened, and the right posterior pericardium is opened toward the phrenic nerve at the level of the diaphragm, cephalad and in-between. The donor and recipient left atria are anastomosed first. Then, the donor aorta is anastomosed to the recipient aorta in an end to side fashion. The aortic cross clamp is removed, and, the patient is placed in Trendelenburg position. The donor pulmonary artery is anastomosed to the recipient right atrium. The donor superior vena cava (SVC) is anastomosed to the recipient superior vena cava in an end to side fashion (**Figure 2**). The anastomosis of the SVC is marked with clips, in order to be able to identify the anastomosis later for endomyocardial biopsy through the right internal jugular vein.

**4. Series of patients with heterotopic heart transplants**

reprint. Arzouman et al. [13].

America until 2000; when the first was implanted in North America.

The Copeland heterotopic heart transplant technique was used in the series of patients at the University of Arizona and University of California San Diego (by Jack Copeland). Between May 1984 to February 2011, 5 patients received a heterotopic heart transplant. The reasons for a heterotopic heart transplantation included the following: (1) fixed pulmonary hypertension with pulmonary artery (PA) pressures of 85/53 mmHg with a mean of 60 mmHg and pulmonary vascular resistance of 10 Woods units, (2) severe pulmonary hypertension of 85/30 mmHg with a mean of 48 mmHg and a PVR of 6 Woods units, (3) PA pressure of 69/34 mmHg with a trans-pulmonary artery gradient of 17 mmHg and pulmonary vascular resistance of 9 Woods units, and (4) and (5) donor recipient size mismatch in two patients.

**Figure 2.** The Copeland heterotopic heart transplant technique. Permission granted by Annals of Thoracic Surgery for

Heterotopic Heart Transplantation

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http://dx.doi.org/10.5772/intechopen.74582

Of the three patients with severe pulmonary hypertension, one was a 9-year old child was diagnosed with restrictive cardiomyopathy and had heart failure since early infancy [10]. The patient presented for transplant evaluation with incessant supraventricular tachycardia and pulmonary hypertension with a PA pressure of 85/53 mmHg with a mean of 60, and, a PVR of 10 Woods units. The patient's cardiac index was 3.1 l/min/sqM with an ejection fraction of 33% on echocardiogram with normal right ventricular function. The fractional shortening on the echocardiogram was 18%. The patient began to develop hepatomegaly and the total bilirubin was elevated to 2.8 mg/dl. The patient was on medical management for heart failure prior to transplant including: furosemide, spironolactone, digoxin, captopril, amiodarone, coumadin and prednisone. The patient was not on inotropic therapy. The patient was listed for heart transplantation and it was deemed that the child would not tolerate an orthotopic heart transplant because of the fixed pulmonary hypertension. The patient was not eligible for a left ventricular assist device (LVAD) because pediatric LVADs were not available in North

**Figure 1.** The Barnard heterotopic heart transplant technique with an interposition Dacron Graft. Permission Granted by Annals of Thoracic Surgery for reprint. Novitzky et al. [8].

**Figure 2.** The Copeland heterotopic heart transplant technique. Permission granted by Annals of Thoracic Surgery for reprint. Arzouman et al. [13].
