How I Do It: Maintaining Dextrocardia During Orthotopic Heart Transplantation
Lloyd McPherson Felmly, MD, Teimour Nasirov, MD, John Lamberti, MD, Olaf Reinhartz, MD, MD, Michael R. Ma, MD.
Stanford University School of Medicine, Palo Alto, CA, USA.
Objective(s): Orthothopic heart transplantation in the setting of dextrocardia is challenging due to the need to appropriately align a levocardic donor heart within a dextrocardic pericardial space. Additionally, venous abnormalities are common in situs inversus and heterotaxy, adding another layer of complexity. A modified implantation technique which rotates the donor heart addresses these issues.
Methods: A 13-year-old male with situs inversus, dextrocardia, unseptatable double outlet right ventricle, pulmonary atresia, and major aortopulmonary collaterals status post unifocalization and central shunt, then subsequent bidirectional cavopulmonary connection, presented in refractory heart failure and was listed for heart transplantation. A donor heart was implanted in a rotated fashion by oversewing the left pulmonary veins, enlarging the right pulmonary vein orifices, and directing the pulmonary artery and superior vena cava in a retro-aortic fashion. The implantation required no prosthetic baffles or extracardiac connections.
Results: This patient did well post-operatively, with good biventricular function and no significant obstruction at any anastomoses or intravascular pathways. A rotated implantation of the heart prevents compression of the heart due to malpositioning in a dextrocardic pericardial well.
Conclusions: Orthothopic heart transplantation in the setting of dextrocardia is challenging, but can be adequately addressed by a modified technique to allow rotation of the heart. In this way complex anatomy can be accommodated without prosthetic baffles or extracardiac connections. 
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