1. Autotransplantation as a Method for Treatment of a Giant Left Atrium Mitrev Z, Anguseva T, Vogt P Cardiosurgery - Skopje Special hospital for Cardiosurgery “Fillip II”, Skopje, Macedonia

2. Background : Heart autotransplantation has been used for treatment of several cardiac diseases such are: Heart autotransplantation has been used for treatment of several cardiac diseases such are: - long QT Syndrome - long QT Syndrome [Pfeiffer, 1992]. - cardiac tumors - cardiac tumors - refractory Printz-metal angina - refractory Printz-metal angina - permanent atrium fibrillation due to giant left atrium combined with mitral valve disease ( - permanent atrium fibrillation due to giant left atrium combined with mitral valve disease ( Giovanni Troise et al, 2004) Cardiosurgery - Skopje

3. Giant LA – clinical expression - Rhythm disturbances - blood stagnation in the LA  consequent thrombosis formation - pressure of the : - left ventricle - pulmonary vessels - pulmonary vessels - bronchial tree - bronchial tree Ultrasound findings: - giant LA with spontaneous echo contrast - thromboembolism - thromboembolism Cardiosurgery - Skopje

4. Type of surgery for LA size reducing Para-annular wall plication Para-annular wall plication Posterior wall plication Posterior wall plication Ligation of the appendix of the LA Ligation of the appendix of the LA Partial auto-transplantation for pts with LA<8cm diameter Partial auto-transplantation for pts with LA<8cm diameter Auto-transplantation for pts with LA>8cm diameter Auto-transplantation for pts with LA>8cm diameter Cardiosurgery - Skopje

5. Case – report : patient characteristics 2 cases: 1 st 58 –year-old man / non-smoker Severe mitral insufficiency, combined with a tricuspid one (myxomatous degeneration combined with severe atherosclerosis) LA 15x12cm - dilated cardiomyopathy (7y), with dominant right heart failure - cahexia - BW=52.4kg, BH= 162cm, BSA = 1.52m2 - ECG- atrial fibrilloflater / last 3 years Comorbidities: lever cirrhosis and ascites; benign prostate hyperplasia 2 nd 61y old lady / non smoker Terminal stadium of mitral valve stenosis with tricuspid insuff. LA 14x16cm Cahexia –BW=48kg,BH 158cm,BSA = 1.2m2 ECG – atrial fibrilloflutter Comorbidities : liver insuff. Both pat. were refractory of the optimal medical therapy Both pat. were refractory of the optimal medical therapy Cardiosurgery - Skopje

6.  TTE & TEE – giant left atrium ( 15 x 16cm/14x14cm) & small atrium - septal aneurysm & severe MR & TR Diagnosis Cardiosurgery - Skopje

7. Autotransplantation - surgery CBP time 89 min / t=36°C 82min/ t=35,8°C CBP time 89 min / t=36°C 82min/ t=35,8°C aorta clamping time 44 min 42min aorta clamping time 44 min 42min Heart out of the chest 9 min 8,5min Heart out of the chest 9 min 8,5min retrograde cardioplegia through the sinus coronaries retrograde cardioplegia through the sinus coronaries mitral annuli reconstruction mechanic mitral valve mitral annuli reconstruction mechanic mitral valve reduction of the left atrium with atria-septal plastic reduction of the left atrium with atria-septal plastic tricuspid valve reconstruction tricuspid valve reconstruction Cardiosurgery - Skopje 1 st pat 2 nd pat

8. Surgery Cardiosurgery - Skopje

9. Postoperative monitoring Cardiac status: - atrium fibrillation : convert in sinus rhythm after 24 hours postoperatively by performing Amiodarone (both pts): after 3 months after 6 months EDV=175/145ml EDV=150/102ml ESV=90/78ml ESV = 78/67ml EF= 40/45% EF = 45/50% CO=3.8/3.6l CO=4.7/5.1l CI= 2.9/3.0 CI=3.3/3.8 LA=58/49 mm LA=55/52mm no mitral and tricuspid valve regurgitation ECG : sinus rhythm with intermittent atrium fibrillation Cardiosurgery - Skopje

10. Follow up  Patients get 10 / 12kg on weight  Ascites was completely cured conservatively after 3 months (haemodynamic improvement). months (haemodynamic improvement).  NYHA class II, good quality of life  Medical treatment with: - digitalis, - digitalis, - ACE inhibitors - ACE inhibitors - spironolacton - spironolacton - diuretics - diuretics - amjodarone (first 3 months) - amjodarone (first 3 months) Cardiosurgery - Skopje

11. C o m m e n t - Autotransplantation seems to be an efficient method to reduce extreme LA dilatation. - Eventually should be considered as a method of choice for patients with long lasting mitral valve disease and severe enlargement of the left atrium - Eventually should be considered as a method of choice for patients with long lasting mitral valve disease and severe enlargement of the left atrium Cardiosurgery - Skopje