Interact CardioVasc Thorac Surg 2007;6:233-234. doi:10.1510/icvts.2006.145219
© 2007 European Association of Cardio-Thoracic Surgery
Negative results - Assisted circulation |
Splenic injury during biventricular assist device support as bridge to transplantation
Michel Kindo*,
Sébastien Gerelli,
Philippe Billaud,
Eric Epailly,
Jean-Philippe Mazzucotelli and
Bernard Eisenmann
Department of Cardiovascular Surgery, 1 Place de l'Hôpital, BP 426, 67091 Strasbourg Cedex, France
Received 19 September 2006;
received in revised form 8 December 2006;
accepted 12 December 2006
*Corresponding author. Tel.: +33-3/88/11/62/43; fax: +33-3/88/11/63/42.
E-mail address: michel.kindo{at}chru-strasbourg.fr (M. Kindo).
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Abstract
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Biventricular assist device (BVAD) has been shown to be effective for bridge to heart transplantation with an acceptability low incidence of adverse effects in critically ill heart failure patients. We report the case of a 44-year-old man with severe acute ischemic heart failure who was supported with the Thoratec paracorporeal biventricular assist system. After an initial uneventful postoperative course the patient experienced a splenic rupture which required a splenectomy. The pathological mechanism of this outcome remains unclear. Two months after discharge, the patient underwent heart transplantation and had no postsplenectomy sepsis or thrombotic complications at the last follow-up.
Key Words: Circulatory assist device; Heart failure; Ischemic heart disease; Myocardial infarction; Postoperative care; Transplantation heart
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1. Introduction
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Biventricular assist device (BVAD) support is a well-established method of bridging patients with end-stage heart failure to transplantation [1]. The adverse events most commonly associated with BVAD support are bleeding, infection, hepatic and renal dysfunctions and thromboembolism [1]. We report the unusual case of a patient with ischemic heart disease who presented with capsular tears and subcapsular splenic hematomas ten days after implantation of a paracorporeal biventricular assist system (Thoratec Corporation, Pleasanton, CA).
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2. Case report
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A 44-year-old man presented to an outside institution complaining of acute dyspnea and chest pain at rest and was admitted there eight hours later. The patient's medical history included smoking, dyslipidemia, and a familial history of myocardial infarction. The body size index and surface area were 25.8 kg/m2 and 1.9 m2, respectively. Cardiac evaluation revealed an acute anterior myocardial infarction and cardiogenic shock. Emergency coronary angiography revealed proximal occlusion of the left anterior descending coronary artery, which was successfully treated with angioplasty. Ventriculography showed anterolateroseptal akinesia with severe left ventricular dysfunction (i.e. an ejection fraction of 25%), which was treated by implanting an intraaortic balloon pump and starting intraaortic balloon counterpulsation. The patient remained in a state of cardiogenic shock despite optimal medical therapy and was transferred to our institution 24 h later.
The patient was refractory to medical therapy and met the criteria for BVAD implantation: cardiac index of 1.8 l/min/m2 while receiving inotropic and intra-aortic balloon counterpulsation support, pulmonary capillary wedge pressure of 26 mmHg and right atrial pressure of 21 mmHg. The patient underwent surgery to implant a Thoratec paracorporeal BVAD. The initial postoperative course was uneventful, the patient being extubated 16 h postoperatively and all of his inotropic support being stopped on postoperative day three. In addition to standard postoperative cardiac care, patient management consisted of anticoagulation by intravenous heparin administration. On postoperative day ten, however, the patient experienced acute abdominal pain and hypovolemic shock. Abdominal ultrasonography revealed a significant amount of free intraabdominal liquid. Nevertheless, the presence of the cannulas and the paracorporeal ventricles had limited the exploration of the abdominal cavity. Considering the hypovolemic shock and the peritoneal bleeding, the patient was transferred immediately to the operating room. Emergency median laparotomy and intraperitoneal exploration revealed capsular tears and subcapsular hematomas of the spleen but no signs of adhesion around the spleen or of injury to the left diaphragm. A splenectomy was performed. Pathological analysis revealed that the explanted spleen was of normal dimensions and histological appearance with no evidence of either hematologic or neoplastic disease.
The patient was discharged after an uneventful postoperative course and did not experience any late postsplenectomy sepsis or thrombotic complications. Two months after discharge, the patient underwent standard orthotopic heart transplantation by means of bicaval anastomosis. At one-year follow-up, the patient's post transplantation course has been favorable, and he has achieved New York Heart Association (NYHA) class I function.
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3. Discussion
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To our knowledge, this is the first published report of splenic injury requiring emergency splenectomy during BVAD support as a bridge to transplantation. Moreover, the patient's postsplenectomy course has been notably free of septic and thromboembolic complications.
Although many pathological conditions are associated with splenic rupture, the pathological mechanism in the present case remains unclear. It is possible that the spleen was traumatized by transcutaneous tunneling of the left inflow cannula, but the delay between such tunneling and the splenic injury in this case does not favor this etiology. Furthermore, the cannula was tunneled through the abdominal wall and, as revealed at the time of splenectomy, did not cause any injury to the left diaphragm. Another possibility is that the spleen ruptured spontaneously after the intravenous administration of heparin. Our patient had no evident history of infections, hematological diseases, or malignancies. Rupture of the spleen after heparin administration is exceedingly rare and occurs most commonly within one week after the start of heparanization [2].
A third possibility is that the movement of the left inflow cannula in the abdominal wall with each pump beat may have induced repeated microscopic traumatization of the spleen, especially in a thin patient receiving anticoagulants as in the present case. In order to prevent this adverse event, special care has to be taken into consideration in the placement of the left inflow cannula, particularly in a thin patient.
Consequently, as the present case suggests, splenic rupture, though rare, must be considered as part of the differential diagnosis in BVAD-supported patients who are receiving heparin therapy and who experience abdominal pain with hypovolemic shock.
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References
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- Farrar DJ. The thoratec ventricular assist device: a paracorporeal pump for treating acute and chronic heart failure. Semin Thorac Cardiovasc Surg July 2000; 12:243–250.[Medline]
- Ghobrial MW, Karim M, Mannam S. Spontaneous splenic rupture following the administration of intravenous heparin: case report and retrospective case review. Am J Hematol December 2002; 71:314–317.[CrossRef][Medline]
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Abstract
1. Introduction