Orthotopic Heart Transplantation with Concurrent Coronary Artery Bypass Grafting Using In Situ Internal Thoracic Artery

Heart transplantation remains the definitive therapy for end-stage heart failure, but donor coronary artery disease (CAD) is a common reason for allograft refusal, limiting organ availability. We describe a case of orthotopic heart transplantation using a donor heart with isolated coronary artery disease managed with concurrent surgical revascularization. A 66-year-old male with end-stage non-ischemic cardiomyopathy requiring temporary mechanical circulatory support underwent heart transplantation using a donor allograft with a focal lesion in a large first diagonal artery. Following standard implantation, a left internal mammary artery-to-first diagonal artery bypass was performed prior to reperfusion. The patient was successfully weaned from cardiopulmonary bypass with improving left ventricular function and had an uncomplicated postoperative course aside from transient delirium and dysphagia. Echocardiography demonstrated recovery of normal left ventricular function, and the patient remained clinically well with preserved biventricular function at 7-month follow-up. This case demonstrates the feasibility of orthotopic heart transplantation with concurrent coronary artery bypass grafting using an arterial conduit and supports surgical optimization of select donor hearts, with focal coronary disease as a potential strategy to expand the donor pool without compromising short-term outcomes.