DOI:10.2214/AJR.07.3813
AJR 2008; 191:1711-1716
© American Roentgen Ray Society
CT of Two Hearts Beating in One Chest
Hsin-Yi Lai1,2,
Jeon-Hor Chen2,
Kuan-Ming Chiu3,
Kao-Lun Wang1,
Wing-Keung Cheung1,
Ai-Hsien Li4 and
Shu-Hsun Chu3,5
1 Department of Medical Imaging, Far Eastern Memorial Hospital, Taipei,
Taiwan.
2 Department of Radiology, China Medical University Hospital, Taichung,
Taiwan.
3 Department of Cardiovascular Surgery, Far Eastern Memorial Hospital, No. 21,
Nan-Ya S Rd. Sec. 2, Pan-Chiao, Taipei 220, Taiwan.
4 Department of Cardiology, Far Eastern Memorial Hospital, Taipei, Taiwan.
5 Department of Cardiovascular Surgery, National Taiwan University Hospital,
Taipei, Taiwan.
Received February 11, 2008;
accepted after revision July 9, 2008.
Address correspondence to S. H. Chu
(vupu612{at}gmail.com).
Abstract
OBJECTIVE. Because of the improvements in cardiac transplantation
technology, pharmacology, and diagnostic imaging, the survival rate of
patients who have undergone heterotopic heart transplantation has
significantly increased, which makes postoperative evaluation of these
patients increasingly important. Monitoring patients who have undergone
heterotopic heart transplantation is technically more demanding than those who
have undergone orthotopic heart transplantation because it is more difficult
to monitor two hearts beating in one chest. In this article, we describe and
evaluate cardiac and vascular anatomy and the status of the lungs in patients
who have undergone heterotopic heart transplantation.
CONCLUSION. ECG-gated cardiac CT has proven to be particularly
important in evaluating the complex anatomy and anastomoses of the donor and
recipient hearts as well as the postoperative follow-up status of the two
hearts, the cardiac arteries and great vessels, and the lungs, ultimately
contributing to the prolonged survival of heterotopic heart transplantation
patients.
Keywords: cardiac imaging • CT • heart surgery • heart transplantation • heterotopic heart transplantation
Introduction
Cardiac transplantation is the treatment for patients with end-stage
myocardial failure. Heterotopic heart transplantation adds a donor heart to
the right side of the native heart, which can maximize the use of donor organs
in cardiac transplantation. However, the procedure is technically more
demanding than orthotopic heart transplantation, and it is more difficult to
monitor two hearts beating in one chest. In this article we describe and
evaluate cardiac and vascular anatomy and the status of the lungs in patients
with a heterotopic heart transplant.
The first clinical heart transplantation was performed in 1967 by Barnard
[1]. The survival rate for this
and other early heart transplantations was poor because of postoperative
complications. Not until improvements of antibiotics and immunosuppressive
agents did heart transplantation become a viable medical treatment
[2]. Today, approximately 4,000
cardiac transplantations are performed worldwide each year; fewer than 3% of
those are heterotopic heart transplantations
[3,
4]. Orthotopic heart
transplantation is a widely accepted procedure; nevertheless, a shortage of
donor organs is still a problem worldwide. Heterotopic heart transplantation
can extend the inclusion criteria for both the donor and the recipient,
especially for recipients with severe pulmonary hypertension or
size-mismatched donor hearts
[4–6].
In 1974, the first clinical heterotopic heart transplantation was also
performed by Barnard [7].
Heterotopic heart transplantation leaves the native heart in situ while adding
a new heart to the right side of the native heart
[8] (Figs.
1A and
1B). In heterotopic heart
transplantation, the right atria, left atria, main pulmonary arteries, and
aortas are anastomosed; the pulmonary artery anastomosis may require placement
of a polyester textile fiber (Dacron, DuPont) tube graft
[8]
(Fig. 2).
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Fig. 1A —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. dAorta = aorta of donor
heart, dPA = main pulmonary arteries of donor heart, dRV = right ventricle of
donor heart, dLV = left ventricle of donor heart, dRA = right atrium of donor
heart, rRA = right atrium of recipient heart, rRV = right ventricle of
recipient heart, DG = polyester textile fiber (Dacron, DuPont) tube graft.
Heterotopic heart transplant is shown by 3D volume rendering (VR)
reconstructed by cardiac CT. VR image shows relationship between donor and
recipient hearts.
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Fig. 1B —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. dAorta = aorta of donor
heart, dPA = main pulmonary arteries of donor heart, dRV = right ventricle of
donor heart, dLV = left ventricle of donor heart, dRA = right atrium of donor
heart, rRA = right atrium of recipient heart, rRV = right ventricle of
recipient heart, DG = polyester textile fiber (Dacron, DuPont) tube graft.
Schematic diagram of heterotopic heart transplant. For heterotopic heart
transplantation, native heart remains in situ and new heart is added to right
side of native heart. Anastomoses between right atrium, left atrium, main
pulmonary arteries with a tube graft, and aortas are shown.
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Fig. 2 —Schematic of heterotopic heart transplantation shows
anastomoses and blood flow (arrows) in native and donor hearts. RA
and LA indicate right and left atria, respectively; RV and LV, right and left
ventricles; PA, pulmonary artery; Ao, aorta; SVC, superior vena cava; PV,
pulmonary vein; and dotted lines, polyester textile fiber (Dacron, DuPont)
tube graft.
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Evaluation of the condition of both the native and donor hearts is
important for postoperative survival. Although echocardiography is noninvasive
and does not expose the patient to radiation, it cannot fully show detailed
cardiac anatomy and vasculopathies. Conventional angiography, unlike
echocardiography, can depict detailed cardiac anatomy, but it is an invasive
procedure with a 1–2% risk of complication
[4]. Patients who have
undergone heterotopic heart transplantation pose a challenge to radiologists
relative to patients who have undergone conventional orthotopic heart
transplantation be cause the orientations of the two hearts are changed.
However, cardiac CT can offer detailed images with which to evaluate the
morphology and function of both the donor and the native hearts in a single
study.
To our knowledge, there has been no previous report dedicated to CT for the
evaluation of both the native and donor hearts in patients with a heterotopic
heart transplant. In this article, we describe the use of ECG-gated CT to
evaluate cardiac and vascular anastomoses, the pulmonary arteries, the
coronary arteries, and the condition of the lungs; detect malignancy; and
identify complications in patients with a heterotopic heart transplant. We
also discuss the protocol and the value of cardiac CT in evaluating patients
who have undergone heterotopic heart transplantation.
Cardiac and Vascular Anastomoses
CT can clearly depict the cardiac and vascular anastomoses of a heterotopic
heart transplant, and volume-rendering images reconstructed using the
ECG-gated CT images can clearly show the 3D morphology of the native and donor
hearts [4]. Furthermore,
multiplanar reconstruction (MPR) images can show detailed anatomy at the sites
of anastomoses (Figs. 3A and
3B). Redundancy or stenosis in
the anastomoses can be shown if there is a difference in the sizes of the
recipient and donor hearts [4].
The pressure gradient between the left atria of the recipient and donor
hearts, as noted on echocardiography, is evidence of stenosis in the left
atrial anastomosis. On CT images, the area of the left atrial anastomosis
should be the same as that of the mitral valve of the donor heart. If the area
of the left atrial anastomosis is smaller than the mitral valve of the donor
heart as traced by the region of interest on MPR images, the heterotopic heart
transplantation patient will suffer from exertional dyspnea, orthopnea, or
paroxysmal nocturnal dyspnea. The symptoms and mechanism are the same with
mitral stenosis (Figs. 4A and
4B).
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Fig. 3A —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. Same patient is shown in
Figures 1A and
1B. Coronal oblique CT image
shows normal aortic anastomosis (long arrow). Short arrow shows left
anterior descending coronary artery of recipient heart. rAo = aorta of
recipient heart, dAo = aorta of donor heart.
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Fig. 3B —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. Same patient is shown in
Figures 1A and
1B. Axial CT image shows normal
left atrial anastomosis (arrow). Old infarction with calcification in
septal and apical walls of recipient left ventricle is noted. Also seen is
regional wall motion abnormality. dAo = aorta of donor heart, dLA = left
atrium of donor heart, rLA = left atrium of recipient heart, rLV = left
ventricle of recipient heart.
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Fig. 4A —53-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 2 years earlier. dLA = left atrium of
donor heart, rLA = left atrium of recipient heart. Axial cardiac CT image
shows stenotic left atrial anastomosis (arrow) that is 0.8 cm in
diameter.
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Fig. 4B —53-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 2 years earlier. dLA = left atrium of
donor heart, rLA = left atrium of recipient heart. Volume-rendering image
shows stenotic anastomosis (arrows) of left atria.
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Leakage is a severe complication after heterotopic heart transplantation
that can be detected quickly on CT: Images show contrast extravasation,
pericardial hematoma, or pseudoaneurysm. However, this condition is very rare
because anastomosis leak usually can be detected during the operation and can
be repaired immediately by the surgeon.
In addition to the evaluation of cardiac and vascular anastomoses, CT can
also image left ventricular cardiac volume, old infarctions, left ventricular
aneurysms, and mural thromboses (Figs.
3A,
3B, and
5).
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Fig. 5 —53-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 2 years earlier. Same patient is shown in
Figures 4A and
4B. Surgical anterior
ventricular endocardial restoration was performed for apical aneurysm due to
old left ventricle infarction. Arrowhead shows surgical patch of left
ventricle. Leakage (short arrow) is indicated in lateral aspect of
left ventricle. In addition, small residual apical aneurysm (long
arrow) is noted.
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The Pulmonary Arteries
The main pulmonary arteries of the donor and recipient hearts are connected
in front of the ascending aorta. The pulmonary arteries are usually the last
ones to anastomose. They are always far apart and require a Dacron vascular
graft to be interposed between the donor and native main pulmonary arteries to
avoid stretching the vessels
[9].
Because of compression between the sternum in the front of the transplant
and the aorta behind the transplant, stenosis of the Dacron vascular graft is
a frequent complication that usually progresses to become pulmonary stenosis.
Pulmonary stenosis will induce right ventricular hypertension and result in
right heart failure. Balloon angioplasty and stent deployment can alleviate
stenosis in the main pulmonary arteries
[9]. Stenosis in the pulmonary
arteries or in the Dacron tube graft and the response to treatment can be
evaluated using MPR CT images (Figs.
6A,
6B,
6C, and
6D).
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Fig. 6A —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. Same patient is shown in
Figures 1A,
1B,
3A, and
3B. rAo = aorta of recipient
heart. Axial CT image shows patent metallic stent (arrow) in
polyester textile fiber (Dacron, DuPont) tube graft connecting recipient and
donor main pulmonary arteries. rPA = main pulmonary artery of recipient
heart.
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Fig. 6B —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. Same patient is shown in
Figures 1A,
1B,
3A, and
3B. rAo = aorta of recipient
heart. Oblique coronal CT view shows round shape of stent (arrow) in
Dacron tube graft without deformation.
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Fig. 6C —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. Same patient is shown in
Figures 1A,
1B,
3A, and
3B. rAo = aorta of recipient
heart. Axial (C) and oblique coronal (D) CT images show
intraluminal mural thrombus (arrow) with approximately 50% stenosis
in main pulmonary artery of donor heart.
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Fig. 6D —56-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 6 years earlier. Same patient is shown in
Figures 1A,
1B,
3A, and
3B. rAo = aorta of recipient
heart. Axial (C) and oblique coronal (D) CT images show
intraluminal mural thrombus (arrow) with approximately 50% stenosis
in main pulmonary artery of donor heart.
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The Coronary Arteries
Cardiac allograft vasculopathy (CAV) is a unique form of atherosclerosis
that results from chronic immune-mediated processes coupled with
nonimmunologic factors that attack the transplanted heart
[4,
10]. These two processes can
lead to endothelial injury, which may progress further to cause myointimal
hyperplasia [4,
10]. CAV may occur as early as
6 months after cardiac transplantation. It is the third most common cause of
death from cardiac transplantation, after infection and acute rejection
[11,
12]. Nearly 60% of
retransplantation procedures are necessitated by advanced CAV in the
transplanted heart [11]. In
addition, accelerated atherosclerotic change of the coronary arteries is a
major risk affecting long-term survival of cardiac transplantation patients
[12]. Because the donor heart
is denervated, most recipients with severe coronary stenosis in the
transplanted heart are clinically asymptomatic, without the typical symptoms
such as angina or chest pain. Therefore, it is important to evaluate the
condition of the coronary arteries in patients who have undergone heart
transplantation [11].
Although conventional cardiac angiography with intravascular sonography is
the standard technique for the evaluation of CAV, cardiac CT angiography
differs in that it offers a noninvasive method with which to evaluate the
coronary arteries (Figs. 7A
and 7B). CAV of the donor
heart is characterized by wall thickening and diffuse concentric narrowing of
the distal coronary arteries that progress proximally
[4,
10]. In contrast, classic
coronary atherosclerosis of the recipient shows focal eccentric stenosis of
the proximal arteries [4,
10]. The patency or in-stent
restenosis of the coronary arteries may also be estimated using cardiac CT
angiography (Fig. 8).
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Fig. 7A —52-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 7 years earlier. Curved multiplanar
reconstruction (MPR) of CT image shows normal left anterior descending (LAD)
artery and concentric noncalcified plaque (arrowheads) with
insignificant stenosis in proximal left circumflex coronary artery of donor
heart.
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Fig. 7B —52-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 7 years earlier. MPR of CT image shows
diffuse eccentric calcified plaques in proximal and middle right coronary
artery of recipient heart with insignificant stenosis.
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Fig. 8 —53-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 2 years earlier. Same patient is shown in
Figures 4A,
4B, and
5. Curved multiplanar
reconstruction of CT image shows in-stent total occlusion of left anterior
descending artery (LAD) of recipient heart (arrow). Chronic total
occlusion (arrowheads) is also noted distal to metallic stent.
Contrast enhancement of distal LAD is due to reversed blood flow.
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Coronary Artery Bypass Graft
Coronary artery bypass is performed to reduce the risk of death from
coronary artery disease [13].
According to a report by Halle et al.
[13], 12 of 3,710 patients
(0.32%) from 13 heart transplantation centers underwent coronary artery bypass
surgery a mean (± SD) of 57 ± 20 months after cardiac
transplantation. Arteries or veins from elsewhere in the patient's body can be
grafted from the aorta to the coronary arteries to bypass the original
stenosis and improve coronary circulation. Curved MPR of cardiac CT is the
best noninvasive technique with which to image the bypass graft in both the
donor and recipient hearts (Figs.
9A and
9B).
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Fig. 9A —52-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation with two coronary artery bypass grafts (CABG) was
performed 7 years earlier. Same patient is shown in Figures
7A and
7B. Three-dimensional
volume-rendering image shows one CABG (arrows) from right aspect of
aorta to posterior descending artery (PDA) and other CABG
(arrowheads) from anterior aorta to left anterior descending
artery.
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Fig. 9B —52-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation with two coronary artery bypass grafts (CABG) was
performed 7 years earlier. Same patient is shown in Figures
7A and
7B. Curved multiplanar
reconstruction shows patent graft vessel from aorta of recipient heart to PDA
(arrow).
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The Lungs and Malignancy
Compression of the right middle and lower lung by the donor heart is an
early postoperative complication of heterotopic heart transplantation that can
result in impaired ventilation and in infection
[14]
(Fig. 10). In addition,
because most infections in patients who have undergone heterotopic heart
transplantation are pulmonary, regular chest radiography follow-up is
important for the early detection of pulmonary infection or conditions that
could predispose the patient to infection
[12]. Pulmonary edema,
atelectasis, consolidation, and pneumonia, as well as pleural effusion, can
also be depicted by CT (Fig.
11).
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Fig. 10 —45-year-old man with dilated cardiomyopathy. Heterotopic
heart transplantation was performed 4 months earlier. Axial CT image shows
compression of right middle lung by donor heart (arrows). dPA = main
pulmonary arteries of donor heart, rRV = right ventricle of recipient heart,
rAo = aorta of recipient heart.
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Fig. 11 —53-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 2 years earlier (same patient is shown in
Figs. 4A,
4B,
5, and
8). Axial CT image shows
bilateral pleural effusions with adjacent pulmonary atelectasis.
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Malignancy, such as lymphoma or skin neoplasm, will develop in 3.9% of
patients within 1 year of cardiac transplantation
[11]. This complication is a
recognized complication of long-term immunosuppression
[12]. Pulmonary masses
(Fig. 12), enlarged
mediastinal lymph nodes, and skin lesions on the chest wall can be detected on
cardiac CT.
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Fig. 12 —60-year-old man with ischemia and cardiomyopathy. Heterotopic
heart transplantation was performed 11 years earlier. Axial CT image shows
4-cm mass (arrow) in left upper lung with lymphadenopathy in
mediastinum (arrowhead). Non–small cell lung carcinoma was
proven by bronchoscopic biopsy.
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The Value of Cardiac CT in Heterotopic Heart Transplantation Patients
In recent years, ECG-gated dual-source CT and MDCT were accepted as
noninvasive tools for the diagnosis of ischemic heart disease. In a single
study, these imaging techniques can reveal a coronary artery stenosis and
provide a detailed assessment of cardiac anatomy and function, including
evaluation of coronary artery stenosis. In addition to annual cardiac
screening and postoperative heterotopic heart transplantation follow-up,
cardiac CT is also a useful tool for evaluation of the donor heart before
heart transplantation.
In our hospital, cardiac ECG-gated dual-source CT is performed in patients
who have undergone heterotopic heart transplantation without the
administration of any additional β-blocker regimen. The scanning delay is
determined according to a test-bolus method. A bolus of iodinated contrast
medium (iopamidol, Iopamiro 370 mg/mL, Bracco) is IV injected at a flow rate
of 5 mL/s via an 18-gauge catheter placed in an antecubital vein. After
acquisition of the raw helical CT data, retrospective ECG-synchronized slices
are reconstructed. The best reconstruction phase of cardiac CT may differ
between the donor and recipient hearts because each of the two hearts has its
own heart rate.
However, iodinated contrast material may be administered only to patients
with adequate renal function. Cardiac transplantation patients take an
immunosuppression agent, such as cyclosporine, that is nephrotoxic. The drug
may induce reversible renovascular ischemia and predispose the patient to
glomerular sclerosis [12].
Consequently, IV contrast studies—for example, ECG-gated dual-source
CT—are contraindicated in cardiac transplant recipients who have poor
renal function. Echocardiography or MRI may be used instead
[15].
In conclusion, with the improvement of cardiac transplantation technology,
pharmacology, and diagnostic imaging, there has been a significant increase in
the patient survival rate, which makes cardiac, pulmonary, and postoperative
evaluation using ECG-gated cardiac CT increasingly important. In addition,
heterotopic heart transplantation allows a broader range of acceptance
criteria for transplantation for both the donor and recipient hearts, which
has resulted in more transplantation procedures and the need for comprehensive
postoperative evaluation of the recipient and donor hearts in a single
study.
ECG-gated cardiac CT studies have proven to be particularly important in
evaluating the complex anatomy and anastomoses of the donor and recipient
hearts, as well as the postoperative follow-up status of the two hearts, the
cardiac arteries and great vessels, and the lungs, ultimately contributing to
the prolonged survival of heterotopic heart transplantation patients.
Acknowledgments
We thank Byron Feig for editing this manuscript.
References
- Barnard CN. The operation: a human cardiac transplant—an
interim report of a successful operation performed at Groote Schuur Hospital,
Cape Town. S Afr Med J 1967;41
: 1271-1274[Medline]
- Hunt SA. Taking heart: cardiac transplantation past, present, and
future. N Engl J Med 2006;355
: 231-235[Free Full Text]
- Hosenpud JD, Bennett LE, Keck BM, Boucek MM, Novick RJ. The
Registry of the International Society for Heart and Lung Transplantation:
seventeenth official report—2000. J Heart Lung
Transplant 2000; 19:909
-931[CrossRef][Medline]
- Bogot NR, Durst R, Shaham D, et al. Cardiac CT of the transplanted
heart: indications, technique, appearance, and complications.
RadioGraphics 2007;27
: 1297-1309[Abstract/Free Full Text]
- Chu SH, Tsai CH, Wang SS, et al. Heterotopic heart transplantation:
a life-saving procedure with a size-mismatched donor. Jpn Circ
J 1991; 55:1
-4[Medline]
- Chu SH, Chiu KM, Lin TY, Chu TW, Yeih DF, Li AH. Two donor hearts
beat in one chest. Tex Heart Inst J 2007;34
: 230-232[Medline]
- Barnard CN, Losman JG, Curcio CA, et al. The advantage of
heterotopic cardiac transplantation over orthotopic cardiac transplantation in
the management of severe acute rejection. J Thorac Cardiovasc
Surg 1977; 74:918
-924[Medline]
- Chu SH, Wang SS, Tsai CH, et al. Monitoring of two hearts in one
chest. J Cardiovasc Surg (Torino) 1995;36
: 449-454[Medline]
- Chiu KM, Lin TY, Li SJ, et al. Hybrid pulmonary artery conduit
angioplasty for heterotopic heart transplantation. Transplant
Proc 2006; 38:1538
-1540[Medline]
- Aranda JM Jr, Hill J. Cardiac transplant vasculopathy.
Chest 2000; 118:1792
-1800[CrossRef][Medline]
- Kouchoulos NT, Blackstone EH, Doty DB, Hanley FL, Karp RB, eds.
Kirklin/Barratt-Boyes cardiac surgery: morphology, diagnostic
criteria, natural history, techniques, results, and indications,
vols. 1 and 2, 3rd ed. Philadelphia, PA: Churchill
Livingstone, 2003: 1753-1761
- Valantine HA, Schroeder JS. Cardiac transplantation.
Intensive Care Med 1989;15
: 283-289[Medline]
- Halle AA 3rd, DiSciascio G, Massin EK, et al. Coronary angioplasty,
atherectomy and bypass surgery in cardiac transplant recipients. J
Am Coll Cardiol 1995; 26:120
-128[Abstract]
- Kadner A, Chen RH, Adams DH. Heterotopic heart transplantation:
experimental development and clinical experience. Eur J
Cardiothorac Surg 2000; 17:474
-481[Abstract/Free Full Text]
- Smart FW, Young JB, Weilbaecher D, et al. Magnetic resonance
imaging for assessment of tissue rejection after heterotopic heart
transplantation. J Heart Lung Transplant1993; 12:403
-410[Medline]
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Abstract
Introduction
