Heterotopic heart transplantation: a reliable option for a select group of high-risk patients.

From July 1982 through February 1988, 229 patients underwent heart transplantations at the Texas Heart Institute, Houston, 11 of whom had heterotopic transplantations. Indications for the heterotopic procedure included pulmonary hypertension (eight patients) and marked body-weight mismatch (greater than or equal to 20%) between the recipient and donor (three patients). The 1-year actuarial survival rate for the heterotopic group is 80.4% compared with 77.9% for the orthotopic group. Despite similar immunosuppressive regimens, the incidence of advanced rejection within 60 days after transplantation was 9.1% (one of 11 patients) for the heterotopic patients and 33.7% (68 of 202 patients) for the orthotopic group. The one heterotopic patient who experienced rejection in this period had a positive retrospective lymphocyte crossmatch. Seven patients who had heterotopic heart transplantations had right pleural effusions; three of these required tube thoracotomy. Two others experienced angina of the native heart, but the symptoms abated with cessation of native heart function. Despite anticoagulant therapy, one patient had reversible neurologic events caused by emboli. Some of the patients had pulmonary and embolic complications, but all of these problems were readily manageable and resolved without permanent sequelae. In orthotopic transplantation, the presence of pulmonary hypertension can compromise donor heart function in the intraoperative or immediate postoperative periods. Patients with this problem, previously considered unsuitable candidates for transplantation, may have a successful transplantation with the heterotopic technique. Although heterotopic heart transplantation is technically more demanding and may be associated with complications that do not occur in orthotopic transplantation, our experience has shown that it is a reliable surgical option for these high-risk patients.