Interactive Cardiovascular and Thoracic Surgery 3:286-288(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Case report - Assisted circulation |
A safe, alternative technique for off-pump left ventricular assist device implantation in high-risk reoperative cases
Frédéric Collart*,
Horea Feier,
Dominique Metras and
Thierry G. Mesana
Department of Adult Cardiac Surgery, ‘La Timone’ University Hospital, Marseille, France
Received October 27, 2003;
received in revised form December 31, 2003;
accepted January 7, 2004
Supplementary data associated with this article can be found at doi: 10.1016/S1569-9293(04)00007-6.
* Corresponding author. Address: Service de chirurgie Cardiaque Adulte, Hopital La Timone, 264 Rue St Pierre, 13005 Marseille, France. Tel.: +33-04-91-38-57-17; fax: +33-491-38-49-26
fcollart{at}univ-aix.fr
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Abstract
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The implant of a ventricular assist device is a standardized procedure. However, it carries a high-risk in reoperations, especially if there are patent by-pass grafts. An isolated thoracotomy has been previously described as an alternative access route in these patients, but it offers a limited exposure should intraoperative right-heart failure occur. In the following, we describe an alternative, off-pump technique that combines a median sternotomy with limited dissection of the right-heart with a left anterolateral thoracotomy. In our experience, it proves to be a safe way for the LVAD insertion in these high-risk patients.
Key Words: Left ventricular assist device; Reoperation; Off-pump
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1. Introduction
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Left ventricular assist device (LVAD) implantation is a standardized procedure [1], but it carries a high risk in a redo setting. Median sternotomy with complete cardiac liberation in order to gain access to the left ventricular apex can be difficult and dangerous, especially in patients with patent by-pass grafts, and increases the risk of postoperative bleeding. An isolated left thoracotomy has been previously described [2,3] but offers limited access to the right cavities, should intraoperative right-heart failure occur. In the following, we report a modified method for the Thoratec® LVAD (Thoratec Laboratories Corp, Pleasanton, CA) implantation, combining a standard sternotomy, which provides good access to the ascending aorta and the right heart, with a short left anterior thoracotomy for the implantation of the left ventricular inflow cannula, without the use of cardio-pulmonary by-pass, in high-risk cases.
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2. Surgical technique
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The patient is placed supine with the left arm in extension. The median sternotomy is performed as usual, with dissection of the ascending aorta and a short portion of the right atrium, to provide cannulation sites should the need for cardio-pulmonary by-pass arise. A side-biting Satinsky clamp is placed on the anterior surface of the ascending aorta. The Dacron outflow graft is sewn at this level.
A short, left anterior lateral thoracotomy is performed, centered over the cardiac apex and the pericardium is incised. Teflon felt-reinforced mattress sutures of polypropylene 3–0 are placed around the apex, and then along the ring of the apical inflow conduit (Fig. 1). The left ventricle is incised, the incision controlled digitally and gradually dilated (Fig. 2). This can be done especially in a redo setting, since the pericardial adhesions keep the heart in position (Video 1). The inflow cannula is placed into the left ventricular cavity and secured by tying the previously placed sutures. Another row of polypropylene 3–0 continuous running suture is placed all along the ring of the inflow cannula for added buttressing. The conduit is brought out subcostally and both cannulas are connected to the paracorporeal pump.
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Fig. 1 Felt-reinforced sutures are passed in the myocardium and then along the ring of the inflow graft.
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Once the system has been deaired the pump work is established progressively. The right ventricle is supported by inotropic drugs and nitric oxide as in the standard procedure.
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3. Results
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We used this method of LVAD implantation in a 55-year-old patient, who had a patent left internal mammary artery to the left anterior descending by-pass graft. His medical history included four myocardial infarctions. He progressively developed an ischemic cardiomyopathy and had a biventricular pacemaker inserted 1 year previously. He was admitted in cardiogenic shock in our intensive care unit, with a cardiac index of 1.5 l/min per m2, a systolic pulmonary artery pressure (PAP) of 60 mmHg and a 15% ejection fraction. His biologic variables showed signs of renal malfunction (creatinine=1.9 mg/dl,) and hepatic dysfunction (ASAT=64 UI/l, bilirubin=58.4 mg/l, Quick index=52%).
Despite aggressive inotropic support (dobutamine 15 µg/kg per min) and the insertion of an intraaortic balloon pump his condition did not improve. The patient's size did not allow for the use of an implantable LVAD, so a Thoratec® LVAD assistance was decided.
The implant procedure was performed as described above. There was no need for an additional right-heart support. Upon arrival in the intensive care unit he was under inhaled nitric oxide and dobutamine (10 µg/kg3 per min). His systolic PAP fell from 65, preoperatively to 35 on a 4.5 l/min LVAD flow. The postoperative course was uneventful: total chest tube output at 48 h was 830 ml, the patient was detubated on day 2 and transplanted 45 days later.
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4. Comment
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LVAD systems have been used extensively in the last decade as a mechanical bridge to heart transplantation or bridge to recovery, with good results [4,5]. In most cases, a left ventricular assistance with complete unloading of the left ventricle and decrease of the right ventricular afterload provides a good right myocardial function recovery, however right ventricular assistance is sometimes necessary [6,7].
In reoperative patients, median sternotomy with complete cardiac liberation to gain access to the left ventricular apex can be difficult and dangerous, especially in patients with patent by-pass grafts, and may increase postoperative bleeding. An isolated left thoracotomy has been previously reported [2,3] but offers no access to the right heart should early right side failure occur. This is the more true in the case of a posterior lateral thoracotomy [2] or patent, anterior by-pass grafts such as was the case with our patient. This risk is non negligible, as it has been evaluated between 10 and 26% [6,7].
This combined approach provides good access to the ascending aorta and the right atrium without complete cardiac dissection. These sites can be used for establishing cardio-pulmonary by-pass in case of necessity. Furthermore, the pulmonary artery can be easily dissected if severe, acute right heart failure occurs, and the need for a BI-VAD arises.
The short left thoracotomy provides a good access to the left ventricle without elevating the apex while the pericardial adhesions allow for a digital control and gradual dilation of the ventricular apex incision thus being able to avoid the use of cardio-pulmonary by-pass. This method can also be used with an implantable LVAD by completing the median sternotomy with a median laparotomy as in the standard technique [1].
We feel that a combined approach, by median sternotomy and left anterior lateral thoracotomy, minimizes the risk of injuring patent grafts in patients with ischemic cardiomyopathy, reduces post-operative bleeding due to extensive dissection and provides a good access to the right-heart cavities, should the need for right assistance arise. In our limited experience, we found this to be a safe way for the implant of a LVAD device in a redo setting.
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References
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- Loisance D, Cooper GJ, Deleuze PH, Castanie JB, Mazzucotelli JP, Abe Y, Bajan G, Le Besnerais P. Bridge to transplantation with the wearable Novacor left ventricular assist system: operative technique. Eur J Cardiothorac Surg. 1995;9:95–98[Abstract]
- Piacentino V, Singhal AK, Macha M, McClurken JB, Fisher CB, Furukawa S. Off-pump technique for Thoratec left ventricular assist device insertion. Ann Thorac Surg. 2003;75:607–609[Abstract/Free Full Text]
- Tittle SL, Mandapati D, Kopf GS, Elefteriades JS. Alternate technique for implantation of left ventricular assist system: left thoracotomy for reoperative cases. Ann Thorac Surg. 2002;73:994–996[Abstract/Free Full Text]
- El-Banayosy A, Koerfer R, Arusoglu L, Kizner L, Morshuis M, Milting H, Tenderich G, Fey O, Minami K. Device and patient management in a bridge-to-transplant setting. Ann Thorac Surg. 2001;71:S98–102[Abstract/Free Full Text]
- Farrar DJ, Holman WR, McBride LR, Kormos RL, Icenogle TB, Hendry PJ, Moore CH, Loisance DY, El-Banayosy A, Frazier H. Long-term follow-up of Thoratec ventricular assist device bridge-to-recovery patients successfully removed from support after recovery of ventricular function. J Heart Lung Transplant. 2002;21:516–521[CrossRef][Medline]
- Ochiai Y, McCarthy PM, Smedira NG, Banbury MK, Navia JL, Feng J, Hsu AP, Yeager ML, Buda T, Hoercher KJ, Howard MW, Takagaki M, Doi K, Fukamachi K. Predictors of severe right ventricular failure after implantable left ventricular assist device insertion: analysis of 245 patients. Circulation. 2002;106:I198–I202[Medline]
- Van Meter C. Right heart failure: best treated by avoidance. Ann Thorac Surg. 2001;71:S220–S222[Abstract/Free Full Text]
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Abstract
1. Introduction