ECHO ROUNDS Two Hearts in One Chest: Transesophageal Echocardiography Images of a Heterotopic Heart Transplant Edward Gologorsky, MD, FASE,* Prashanth Manjunath, MD,* Angela Gologorsky, MD,† Enisa M. Carvalho, MD,‡ Marco Ricci, MD, PhD,‡ Anthony L. Panos, MD,‡ and Thomas A. Salerno, MD‡ A 77-year-old man presented for right video-assisted thoracoscopy, pleural biopsy, and pleurodesis. His medical history was significant for nonischemic cardiomyopathy with pulmonary hypertension, for which he had undergone a heterotopic heart transplant 7 years earlier, as well as chronic obstructive pulmonary disease, hypertension, and diabetes mellitus. Written informed con- sent for this presentation was obtained from the patient. Intraoperatively, transesophageal echocardiography (TEE) was used as a monitoring tool. Transgastric (TG) short-axis imaging visualized a severely dilated and hypokinetic native left ventricle (LV). Slight rotation to the right allowed an appreciation of the preserved native right ventricle (RV) function (Video 1, Clip 1 and Clip 2, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video cap- tion). Slowly withdrawing the transducer to the midesophageal (ME) 4-chamber view revealed spontaneous echo contrast in the native left atrium (LA) and LV and a continuous (systolic and diastolic) aortic insufficiency jet, as well as mild mitral insufficiency (Video 1, Clip 3, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appen- dix for video caption). Color Doppler examination re- veals continuous aortic insufficiency and mild mitral insufficiency. The donor heart was visualized to the right of the native heart in the right chest. Slowly turning the transducer rightward from the 4-chamber view of the native heart, after the wide connection between the native and donor left atria, allowed for a simultaneous visualization of the ME 4-chamber view of the native heart and the ME 2-chamber view of the donor left heart (Video 1, Clip 4, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Ap- pendix for video caption). Anteflexion of the probe brought the ME short axis of the donor aortic valve into view (Video 1, Clip 5, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). Rotation of the imaging plane to 83° obtained the ME long-axis view of the donor LV and aortic valve (Video 1, Clip 6, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption). TG short-axis view of the native LV (Video 1, Clip 7, see Supplemental Digital Content 1, http://links.lww.com/AA/A118; see Appendix for video caption) was obtained by slow advancement of the slightly anteflexed transducer and a backward rotation of the imaging plane (23° in our patient). The same view could also be obtained by a rightward turn from the TG short-axis view of the native heart with a slight withdrawal of the probe. Donor LV systolic function was preserved and the mitral and aortic valves were competent. Spontaneous echo contrast was seen entering the donor LA from the native LA. The donor RV could not be visualized because of the intervening air in the right pleural cavity during the right thoracoscopy. Postoperatively, the patient was noted to have sus- tained a mild embolic stroke despite stable hemody- namic and cerebral oximetry values and an unchanged TEE examination. DISCUSSION Heterotopic heart transplantation refers to the placement of a donor heart without recipient cardiectomy. Developed by Losman and Barnard for patients whose myocardium was expected to recover (i.e., myocardial infarction), it was used in the precyclosporine era, because rejection of the allograft did not lead to the recipient’s demise. 1,2 Compared with orthotopic transplants, preservation of the “precondi- tioned” native RV seemed to offer better survival to recipi- ents with severe pulmonary hypertension. Thus, the heterotopic approach remains a valuable option in recipi- ents with high transpulmonary pressure gradients and expands the donor pool through use of undersized or otherwise compromised allografts. 2,3 In patients who did not qualify for an orthotopic heart transplantation because of the high transpulmonary gradient or size mismatch, the heterotopic technique yielded a 1-year survival rate of 82%, in contrast to a 52% 1-year survival rate for LV mechanical assist devices recipients. 3 Between 1987 and 2007, 187 heterotopic heart transplantations were performed in the United States, 3 and experience with these patients is likely to be highly regional and center specific. Anatomically, the allograft is placed to the right of the native heart in the right chest to avoid compression by the sternum and at an angle close to 90° to the native heart to allow for the widest possible connection between the native and donor atria. Donor LA and right atria are connected to the corresponding recipient atria, and the corresponding aortas are anastomosed. The donor pulmonary artery may be connected to the donor right atrium (LV assist configu- ration) or, as in the presented case, to the pulmonary artery From the *Department of Anesthesiology, Jackson Memorial Hospital/ University of Miami, Miller School of Medicine, Miami; †Department of Anesthesiology, Memorial Regional Hospital, Hollywood; and ‡Department of Cardiothoracic Surgery, Jackson Memorial Hospital/University of Miami, Miller School of Medicine Miami, Florida. Accepted for publication February 6, 2010. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.anesthesia-analgesia.org). Address correspondence and reprint requests to Edward Gologorsky, MD, FASE, Anesthesiology, Jackson Memorial Hospital/University of Miami, Miller School of Medicine, 1611 NW 12th Ave., C-300, Miami, FL 33136. Address e-mail to egologorsky@med.maimi.edu. Copyright © 2010 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e3181da8357 June 2010 • Volume 110 • Number 6 www.anesthesia-analgesia.org 1587