Bench mitral valve repair of donor hearts before orthotopic heart transplantation.

C ardiac transplantation remains the most effective therapy for end-stage heart failure in appropriate candidates, with a median posttransplant survival of 10 years. At any given point of time there are ≈3000 candidates on the heart transplant waiting list in the United States with annual mortality on the waiting list ≈15%. The number of heart transplants performed in the United States per year has been fairly constant at ≈2500. In spite of this, many donor hearts remain unused. Bench repair of mitral valves remains rarely practiced and significant mitral valve regurgitation (MR) remains a standard contraindication to use of a donor heart. A 53-year-old male donor who had a cerebral infarct became available for a 61-year-old man with blood group O who received left ventricular assist device, Heartmate II (Thoratec, Pleasanton, CA), for decompensated dilated cardiomyopathy. The donor coronary angiogram was normal. Donor transtho-racic echocardiogram (TTE) showed inferior wall hypokine-sis, interventricular septum 1.15 cm, left ventricular ejection fraction (LVEF) 55%, and moderate MR with a posteriorly directed jet (Figure 1). Bench analysis of the mitral valve showed a dilated annulus. Saline test revealed a central leak caused by inadequate leaflet coaptaion secondary to annular dilataion and leak through prominent indentations in the posterior leaflet. (Carpentier type I dysfunction). The heart was kept in ice, and continuous retro-grade cold blood cardioplegia was perfused. The indentations in the posterior leaflet were closed. On saline test now there was no leak through the indentations; however, there was persistent central leak. A 27-mm ATS annuloplasty band (Medtronic, Minneapolis, MN) was placed. Saline test showed no residual leak across the mitral valve (Figure 2A and 2B). The donor heart was then implanted with bicaval technique (ischemic time 127 minutes). After weaning cardiopulmonary bypass, the echocardiogram showed good left ventricular function without regional wall motion abnormality and moderate right ventricular dysfunction. In the intensive care unit, the patient had ventricular fibrillation needing bedside resternotomy and temporary Centrimag biventricular assist device support. At 1-month post transplant, the predischarge TTE showed LVEF 66% and trivial MR. At 14 months, he remained in New York Heart Association class I with similar TTE. A 58-year-old woman with dilated cardiomyopathy with left ventricular assist device had a body mass index of 38 kg/m 2. A 30-year-old donor who had intracranial hemorrhage was identified. TTE showed good function, mild mitral valve prolapse, and moderate central MR. Intraoperative mitral valve analysis showed annular …