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Interact CardioVasc Thorac Surg 2007;6:225-227. doi:10.1510/icvts.2006.143784 © 2007 European Association of Cardio-Thoracic Surgery
Successful implantation of Berlin Heart INCOR system after Bentall/De Bono operationDepartment of Cardiac Surgery, ‘St. Ekaterina’ University Hospital, 52a ‘P. Slaveikov’ Street, 1431 – Sofia, Bulgaria Received 12 November 2006; received in revised form 12 November 2006; accepted 14 November 2006
*Corresponding author. Tel.: +359 889 700 343; fax: +359 2 9159662.
Berlin Heart INCOR system is a novel left ventricle assist device (LVAD), which generates a laminar blood flow. Its cannulas are implanted in the heart apex and the ascending aorta. The present paper reports a case of successful implantation of the Berlin Heart INCOR system after a Bentall/De Bono operation. In this case the outflow cannula of the device was implanted in the Sorin Carbonart 27/30 conduit used in the previous operation. After the implantation no unusual events like thrombosis, anastomosis malfunction, and so forth, were observed. On the 100th day after the implantation the patient was discharged home in good condition.
Key Words: Aorta; Prosthesis; LVAD; Suture
Berlin Heart INCOR system [Berlin Heart AG, Berlin, Germany] is a left ventricle assist device (LVAD), which generates a laminar blood flow [1]. The device inflow cannula is implanted in the heart apex, while its outflow cannula is implanted in the ascending aorta [1, 2]. Here we report a case of implantation of the Berlin Heart INCOR system after a Bentall/De Bono operation. In this case the outflow cannula of the device was implanted in the conduit used in the previous operation.
A 26-year-old male Bulgarian patient (K.Z.P.) suffering from Marfan's syndrome was diagnosed to have an aortic root aneurysm. On February 7th, 2005 in The Heart Hospital, London, UK the patient underwent an emergency aortic root replacement. The ascending aorta and aortic valve were replaced with a 27/30 mm Sorin Carbonart conduit by the Bentall/De Bono technique. The operation was performed because of acute worsening of the patient's condition. Preoperative echo showed the following data: Aortic root diameter – 77 mm, LVEDD – 77 mm, LVESD – 70 mm, EF – 16%, FS – 8%. After the operation the condition of the patient did not improve significantly and on the 10th postoperative day an acute myocardial infarction developed. Because of discordant ventricular contraction (preoperative LBBB), low EF and a great possibility for life-threatening ventricular arrhythmias, a biventricular cardioverter defibrillator was implanted as resynchronization therapy. The patient did not qualify for heart transplantation in the UK, because he was not a UK resident and he was discharged home. The echo data on the day of discharge were: LVEDD – 79 mm, LVESD – 77 mm, EF – 10%, FS – 3%. On May 17th, 2005 the patient was admitted to our institution with severe LV dysfunction, NYHA class IV heart failure and the following echo data: IVS – 8 mm, LVPW – 9 mm, LVEDV – 275 ml, LVESV – 259 ml, EF – 15%, LA – 35/60 mm, mitral regurgitation – II degree, tricuspid regurgitation – I+ degree, left pleura effusion – 150 ml, right pleural effusion – 300 ml. An approach for conservative treatment of the heart failure was made, but without effect. On June 1st, 2005, because of the life-threatening progression of the disease – CI<1.8; hypotonia (blood pressure lower than 80/60 mmHg); tachycardia (heart rate over 150 bpm); CVP over 33 mm H2O and anuria (dieresis <1 ml/kg/h on continuous Dopamin, NTG and Furanthril infusion), an emergency implantation of the Berlin Heart INCOR system was performed (operation protocol No. 478/June 1st, 2005). The device inflow cannula was implanted in the heart apex, while the outflow cannula was implanted in the Sorin Carboart 27/30 conduit (Fig. 1). Six liters of effusions were evacuated – 5000 ml from the abdominal cavity, 700 ml from the left pleural cavity and 300 ml from the right one. The ECC duration was 166' and dopamin and adrenalin infusion was started in the operating theater. The clinical and echo examinations after the operation showed lack of radial pulse, lack of flow through the aortic valve and a significant reduction of the left ventricle dimensions: LVEDD – 60 mm, LVESD – 54 mm, LVEDV – 250 ml, LVESV – 210 ml, EF – 21%.
Immediately after the implantation, the anticoagulation protocol used in our clinic for VAD implanted patients was applied [3] – the Heparin infusion was started on the third postoperative day and it was continuously administered during the next 48 days (target APTT values 40–80 s), together with daily AT III infusions for 26 days, because of the low blood levels of the latter. Sintrome was started on the 48th postoperative day immediately after the extubation. Clopidogrel was given on the 50th postoperative day and aspirin (100 mg) – on the 59th postoperative day. The target INR values were 3.5–4.5. Either 5000 U heparin SC or two administrations of low-weight heparin were performed whenever the INR dropped under 2.5. In the early postoperative period the condition of the patient remained critical. He received adrenalin until the second postoperative day, dopamin until the sixth postoperative day, dobutamin from the 8th to 14th postoperative day. Immediately after the operation, because of the presence of oligo/anuria, a CVVF was started. During the next days a plasmaferesa was also performed. Nevertheless, the condition of the patient slowly improved (Fig. 2).
On September 8th, 2005 (100th postoperative day) the patient was discharged home in good condition with the following echo data: LVEDD – 62.5 mm, LVESD – 56.3 mm, EF – 25%, FS – 10%, RVD – 26.3%, mitral regurgitation – 0+ degree, tricuspid regurgitation – I-II degree. Without pleural or pericardial effusions. Until July 31st, 2006 (396th postoperative day) the patient is still alive and waiting for a heart.
Because of significant impairment of the patient's condition preoperatively and in spite of a meticulously performed operation, the postoperative period was toilsome. Nevertheless, the implanted LVAD contributed significantly to the recovery of secondary multiorgan failure and allowed the patient to be discharged home. There are several points that require discussion. The first is the lack of LV recovery after aortic root replacement. The explanation could be sought in the significant impairment of the preoperative LV function. The cause of myocardial infarction in this young patient is also an object of discussion. Unfortunately the cause remains unclear. Another important point is that the presence of the LVAD does not increase the thrombosis risk for the indwelling mechanical valve, because of the high target INR values (3.5–4.5). Because the implantation of VADs after previous cardiac surgery is a familiar situation for surgeons using them, we would not discuss this issue in detail. The feasibility of INCOR implantation in different clinical situations has already been demonstrated [4, 5]. Here we report a case of a successful implantation of INCOR outflow cannula in Sorin Carbonart 27/30 conduit, without significant device-related complications or anastomosis problems. According to our best knowledge such data are not yet reported. We hope that this report might be helpful in the decision-making process for implantation of ventricle assist devices in patients with end-stage heart failure as a bridge-to-recovery or bridge-to-transplantation.
The authors would like to express their special gratitude to D. Todorova for the magnificent drawing and to L. Venkova for her help during the preparation of the English version of the manuscript.
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Abstract
1. Introduction
