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Re-intervention for Superior Vena Cava Obstruction after Heart Transplant



Background:

Children undergoing orthotopic heart transplantation (OHT) may require complex reconstruction of superior vena cava (SVC) anomalies. SVC anatomy and mode of reconstruction are potential risk factors for SVC obstruction.


Methods:

Retrospective single-center review of patients undergoing initial OHT between 1/1/1990-7/1/2021. “Simple” SVC anatomy included a single right SVC to the right atrium or bilateral SVCs with a left SVC to an intact coronary sinus, without prior superior cavopulmonary connection. Presence of anomalous SVC anatomy, superior cavopulmonary connection, and/or previous atrial switch operation defined “complex” anatomy. Reconstructive strategies included atrial anastomosis, direct SVC-to-SVC anastomosis, and augmented SVC anastomosis using innominate vein, patch, cavopulmonary connection, or interposition graft. Primary outcome was re-intervention for SVC obstruction.


Results:

Of 288 patients, pre-transplant diagnoses included congenital heart disease (n=155, 54%), cardiomyopathy (n=125, 43%), and other (n=8, 3%). The majority (n=208, 72%) had simple SVC anatomy compared to complex SVC anatomy (80, 28%). Re-intervention for SVC obstruction occurred in 15/80 (19%) with complex anatomy, and 1/208 (0.5%) with simple anatomy (p=0.0001). Re-intervention was more common when innominate vein or a patch was used (9/25, 36%), compared to an interposition graft (1/7, 14%), or direct anastomosis (6/82, 7%) (χ2=13.1, p=0.001). Most re-interventions occurred within 30 days of OHT (14/16, 88%).


Conclusions:

Patients with complex SVC anatomy have a higher rate of re-intervention for SVC obstruction after OHT compared to those with simple SVC anatomy. In cases of complex SVC anatomy, interposition grafts may be associated with less re-intervention compared to complex reconstructions using donor tissue.



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