Pediatric heart transplantation: surgical considerations for congenital heart diseases.

Congenital anomalies of the atrium, of the pulmonary and systemic venous return, and of the great vessels are sometimes regarded as contraindications to heart transplantation. Among 10 children who underwent heart transplantation in our institution, five, aged 4 to 15 years and weighting 9 to 32 kg, previously operated on, had congenital anomalies. These lesions, encountered singly or in association, were single atrium (2), previous Mustard operation (1), hypoplastic left atrium (1), anomalous systemic venous return (3), anomalous pulmonary venous return (2), transposition or malposition of the great vessels (5), pulmonary artery hypoplasia (1). To enable correction of these lesions and to perform heart transplantation, the donor heart preparation was modified in four ways. The surgical techniques used for correcting these anomalies in this group were atrial septation, atrial enlargement, superior and inferior reroofing, double venous rerouting, septal realignment, full-length mobilization of the great vessels, and pulmonary artery reconstruction. All children survived operation and left the hospital in excellent condition. Follow-up ranged from 6 months to 3 years. All children are totally asymptomatic. As demonstrated by echocardiography, heart catheterization, and angiography, there are no stenoses, no shunts, and there is good atrial size and good orientation of the great vessels. On the basis of our experience, we conclude that with appropriate surgical techniques, most atrial, venous return, and intrapericardial great vessel anomalies are correctable at the time of orthotopic transplantation and that these techniques allow for a successful outcome in children.