Introduction: Sternal re-entry during left ventricular assist device (LVAD) explant and heart transplantation risks injuring structures such as the driveline, outflow tract, ascending aorta, or the heart. Preoperative CT imaging is vital for planning re-entry. This report highlights a pitfall with CT use and an advantage to the use of Organ Care System (OCS) in minimising ischemic time during complex re-sternotomy. 

Case Report: A 56-year-old male with ischemic cardiomyopathy and an LVAD underwent a DCD heart transplant. A CT scan immediately after LVAD implantation two years prior suggested low re entry risk. However, during re-sternotomy, a major vascular injury occurred between the outflow graft and ascending aorta, causing catastrophic bleeding. Rapid chest proximation was attained with Ethibond sutures pre-placed on the sternum (see Figure). This controlled bleeding whilst obtaining femoral access for cardiopulmonary bypass (CPB). Deep hypothermic circulatory arrest (26 min) was used, and the heart with LVAD was explanted. The donor heart was kept optimally perfused on the OCS, enabling extended preservation time (OCS perfusion time of 241 min and total warm ischaemic time of 96 min). After anastomosis of the donor heart, the patient was weaned from CPB. Postoperatively, he required a tracheostomy but made a good recovery and was discharged on day 40. 

Summary: The OCS enabled a positive outcome by extending preservation time, allowing more flexibility. The need for thorough preoperative planning and skilled intraoperative techniques are highlighted. The use of pre-placed Ethibond sutures aided swift control of bleeding, allowing time for femoral cannulation. The discrepancy between preoperative imaging and intraoperative findings suggests serial CT imaging could be a beneficial tool for planning, as evolving anatomical changes may not be appreciated on the initial post-LVAD implant scan. Research to assess the extent of remodelling and proximity of structures to the sternum is essential. 

Nika Majidi is a foundation doctor currently working at Croydon University Hospital. She graduated from St. George’s University of London with a medical degree, having received multiple academic prizes and achieved a First-Class Honours in a BSc in Anatomy. She has held clinical roles at King’s College Hospital and currently holds an Honorary Clinical Fellow role at Harefield Hospital, a leading centre for heart and lung transplantation. she has a strong academic interest in cardiothoracic surgery, with ongoing research in cardiac surgery and previous publications in the field. She has presented her work at national conferences and aims to continue contributing to evidence-based advancements in cardiovascular surgery. In addition to clinical and academic contributions, She is passionate about medical education. She is currently near completion of a PGCert in Medical Education and is actively involved in teaching medical students and junior colleagues. She is due to commence core surgical training at St. George’s Hospital in October 2025 where she aims to continue developing her interest both clinically and academically.