How organ care system saved the day during a donation after circulatory death heart transplant: a case of complicated sternal re-entry

Sternal re-entry during left ventricular assist device (LVAD) explant and heart transplantation risks damaging structures including the driveline, LVAD outflow tract, ascending aorta, or heart. Preoperative imaging is vital for planning re-entry. This report highlights a pitfall with CT imaging and an advantage of the Organ Care System (OCS) in minimising ischemic time during complex re-sternotomy. A 56-year-old male with ischemic cardiomyopathy and a LVAD underwent a donation after circulatory death (DCD) heart transplant. A CT scan immediately post-LVAD implantation suggested low re-entry risk. However, during re-sternotomy, a vascular injury occurred between the outflow graft and ascending aorta, causing catastrophic bleeding. Rapid chest proximation using pre-placed Ethibond sutures controlled bleeding whilst obtaining femoral access for cardiopulmonary bypass (CPB). Deep hypothermic circulatory arrest was required whilst the OCS optimally perfused the donor heart, extending preservation time (OCS perfusion time of 241 minutes). The transplant was performed, following which CPB was weaned. Postoperatively, the patient required a tracheostomy but recovered well, being discharged by day 40. This case illustrates the need to investigate anatomical changes post-LVAD implantation and implement measures to prevent re-entry injuries. CT imaging immediately post-implantation may not reflect evolving anatomy, hence serial imaging could enhance surgical planning. The OCS was vital in allowing extended preservation time to accommodate for unforeseen complications whilst the Ethibond sutures were essential in aiding control of the bleeding. Research in the LVAD subgroup to evaluate the extent of remodelling hence proximity of structures in relation to the sternum is essential to optimise surgical planning.