Cardiac MRI in the isolated porcine heart reveals possible etiology of sudden right heart failure following heart transplantation

Occurrence of immediate post-transplant heart failure in the cardiac transplant recipient is typically attributed to elevated pulmonary vascular resistance, however other etiologies may play a role. At the completion of the transplant, free air, which has collected in the donor heart, is vented via an aortotomy. Free air may rise into the right coronary artery and obstruct reperfusion of the right ventricle. Cardiac perfusion MRI may offer a method of non-invasively determining the presence of air embolus. The objectives in the pilot study were to identify steps in the donor process where free air could enter into the aortic root causing obstruction of perfusion of the coronary arteries. A change in surgical technique could then be used to eliminate a portal of entry and cardiac perfusion MRI could validate the technique. Standard cardiectomy was compared to a variation in technique in two animals. Pulmonary vein ligation was completed in the experimental model before completion of cardiectomy. Both hearts were isolated and imaged using T1-weighted FLASH sequence and gadolinium contrast via the aortic root. Cardiac perfusion MRI imaging of the heart with the unligated pulmonary vein revealed evidence of air embolus and no perfusion of the right coronary artery compared to the ligated heart. Anatomically, the right coronary artery is anterior in the mediastinum compared to the left coronary artery. Air emboli preferentially rise into the right coronary and can obstruct flow into the right heart. Cardiac perfusion MRI offers an effective method to evaluate the isolated pre-transplant heart for perfusion defects.