Ann Thorac Surg 1996;61:735-737
© 1996 The Society of Thoracic Surgeons
Case Report
Safe Application of Diagnostic Laparoscopy During Biventricular Assistance
Thomas W. Prendergast, MD,
Adrian E. Ortega, MD,
Vaughn A. Starnes, MD,
Thomas M. Klein, Ccp,
Mark L. Barr, MD
Divisions of Cardiothoracic and Minimally Invasive Surgery, Department of Surgery, University of Southern California, Los Angeles, California
Accepted for publication August 17, 1995.
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Abstract
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We performed diagnostic laparoscopy in a patient who was critically unstable while on an ABIOMED BVS 5000 biventricular assist system. A relatively unique feature of the ABIOMED is the venous return being dependent only on gravity and the drawing force of venous return being the height of the inflow cannula compared with the level of the ABIOMED blood pump assembly; this did not preclude the use of pneumoperitoneum necessary for laparoscopy. The safe application of diagnostic laparoscopy in patients on a ventricular assist device is of importance in an era of increasing use of these devices and the increased potential for intraabdominal complications in this population.
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Introduction
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A 44-year-old man with longstanding rheumatic mitral regurgitation underwent elective mitral valve replacement at an outlying community hospital. At the conclusion of the mitral valve replacement, the patient was in profound biventricular failure (left greater than right) and was able to be weaned from cardiopulmonary bypass only with high-dose epinephrine, norepinephrine, dopamine, and amrinone and intraaortic balloon counterpulsation. After 6 hours of marked hypotension, he was transferred to our hospital, arriving with a mean arterial pressure of 30 mm Hg, and was immediately placed on temporary percutaneous femoral vein to femoral artery cardiopulmonary support (Medtronic Bio-Medicus Portable Bypass System, Eden Prairie, MN) in the intensive care unit. He was then taken to the operating room for biventricular assist device implantation as a bridge to possible future cardiac transplantation.
Biventricular assist with an ABIOMED BVS 5000 system (Danvers, MA) was initiated while on percutaneous cardiopulmonary support as previously described [1], and the portable bypass system via the groin was discontinued. Total cardiopulmonary bypass time was 93 minutes. Central venous pressure improved from 35 to 20 mm Hg with right-sided flows of 4 to 5 L/min. Similarly, mean pulmonary artery pressures improved from 40 to 20 mm Hg and mean arterial pressures improved to a mean of 65 to 70 mm Hg with left-sided flows of 4 to 5 L/min. Initial inotropic support included epinephrine, norepinephrine, dobutamine, dopamine, and milrinone. A continuous infusion of heparin was administered to keep the activated coagulation time between 180 and 200 seconds. Continuous venovenous hemodialysis was initiated because of acute renal failure. His hepatic function as assessed by chemistry panels was consistent with shock liver. Except for the gradual weaning of norepinephrine, his hemodynamic picture remained essentially unchanged for the next 7 days. A picture of unexplained sepsis developed, with worsening leukocytosis, high fevers, increased vasoconstrictor requirements, worsening metabolic acidosis, and an abdomen that proved very difficult to evaluate. Intraabdominal catastrophe/mesenteric ischemia had to be ruled out, but the patient was too unstable at that time to be transported for abdominal computed tomographic scan or mesenteric angiography. We decided to perform bedside diagnostic laparoscopy.
In the intensive care unit, the patient was given intravenous sedation. An infraumbilical, semilunar incision was made through the linea alba, and a blunt-tipped trocar was inserted. Insufflation with carbon dioxide was initially done gradually to only 8 mm Hg. This did not appreciably affect the central venous pressure, pulmonary artery pressure, or mean arterial pressure at the aforementioned flow rates of 4 to 5 L/min. The insufflation was then increased gradually to 12 and eventually to 15 mm Hg over 5 to 10 minutes with no discernible change in hemodynamic parameters. A second 10-mm trocar was placed in the right lower quadrant to manipulate omentum and bowel. Excellent visualization was obtained and the exploration included gross inspection of free peritoneal fluid, liver, gallbladder, stomach, duodenum, jejunum, ileum, and colon. There were no focal abnormalities, and no evidence of mesenteric ischemia was seen. Pneumoperitoneum was decompressed after approximately 20 minutes and trocars were removed without any adverse effects.
The patient remained comatose, and an electroencephalogram and head computed tomographic scan revealed significant neurologic damage, consistent with the prior hypotensive low flow state, that was thought to be irreversible. As transplantation was no longer an option, at the family's request, hemodialysis was discontinued and he died within the next 48 hours.
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Comment
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The risk of general surgical complications from cardiopulmonary bypass is well documented: complications occur postoperatively in 0.3% to 3% of open heart surgical procedures [2–4]. This incidence may be even greater in patients in whom ventricular assist is implemented acutely because of cardiogenic shock where hypoperfusion is an etiologic factor in the development of gastrointestinal complications [5]. The mortality rate for gastrointestinal complications from cardiopulmonary bypass ranges from 15% to 63% and includes gastrointestinal hemorrhage, pancreatitis, cholecystitis, gastrointestinal perforations, and mesenteric ischemia [6, 7]. Clearly, early diagnosis and expeditious treatment are critical. After cardiopulmonary bypass and biventricular support, the initial recognition and diagnosis of these complications is difficult because of altered mental status and sedation [2, 3]. Furthermore, because of the instability of these patients and the extensive mechanical support required, it is often difficult to transport these patients for appropriate studies [3]. Thus the safe application of bedside diagnostic laparoscopy may represent the ideal modality to evaluate patients for intraabdominal catastrophe.
The ability to achieve flow rates of 4 to 5 L/min using the ABIOMED BVS 5000 system is dependent on the preload or venous return; venous return is most notably dependent on the pressure gradient generated by the difference in height between the venous cannulas and the ABIOMED blood pump assembly. We were concerned that insufflation of the peritoneal cavity to 15 mm Hg with carbon dioxide may impede venous return, as previously described [8], and result in reduced flow rates through the extracorporeal circuit. It has been demonstrated that venous return from the inferior vena cava may indeed be reduced by laparoscopic insufflation to the usual operating intraperitoneal pressure of 15 mm Hg with carbon dioxide [8], particularly in hypovolemic and normovolemic patients. It is hypothesized that venous return may be increased in hypervolemic patients [9]. Although we only gradually insufflated to 15 mm Hg, we found no significant hemodynamic pertubations on the ABIOMED circuit using this degree of insufflation. Safran and associates [10] have suggested that hypervolemia may help patients with poor cardiac reserve to better compensate for the increased afterload imposed by pneumoperitoneum. Furthermore, systemic exploration proceeded for 20 minutes without any problems, providing ample time to evaluate the abdomen thoroughly.
In a complex, multisystem failure patient with hemodynamic instability, diagnosis of mesenteric ischemia or other intraabdominal pathology can be made by laparoscopy earlier, and potentially with greater accuracy, than by computed tomography or angiography. Furthermore, the diagnostic capabilities of laparoscopy are far superior to those of a mini-laparotomy. Although we believe that the majority of therapeutic laparoscopic interventions should not be done at the bedside, especially in view of the increased risk of bleeding in the setting of anticoagulation, diagnostic laparoscopy can be considered as an option. We conclude that diagnostic laparoscopy, at the bedside or in the operating room, may be safely applied to a patient on the ABIOMED biventricular assist device without hemodynamic compromise. Laparoscopic exploration at the bedside may eventually be employed more liberally in patients who are relatively ``confined'' to the intensive care unit after open heart operations or ventricular assist support.
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Footnotes
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Address reprint requests to Dr Barr, Division of Cardiothoracic Surgery, University of Southern California, 1510 San Pablo St, Los Angeles, CA 90033-4612.
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References
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- Champsaur G, Ninet J, Vigneron M, et al. Use of the ABIOMED BVS System 5000 as a bridge to cardiac transplantation. J Thorac Cardiovasc Surg 1990;100:122–8.[Abstract]
- Wallwork J, Davidson KG. The acute abdomen following cardiopulmonary bypass surgery. Br J Surg 1980;67:410–2.[Medline]
- Pinson CW, Alberty RE. General surgical complications after cardiopulmonary bypass surgery. Am J Surg 1983;146:133–7.[Medline]
- Krasna MJ, Flancbaum L, Trooskin SZ, et al. Gastrointestinal complications after cardiac surgery. Surgery 1988;104: 173–80.
- Moneta GL, Misbach GA, Ivey TD. Hypoperfusion as a possible factor in the development of gastrointestinal complications after cardiac surgery. Am J Surg 1985;149:548–50.
- Ohri SK, Desai JB, Gaer JAR, et al. Intraabdominal complications after cardiopulmonary bypass. Ann Thorac Surg 1991;52:826–31.[Abstract/Free Full Text]
- Hanks JB, Curtis SE, Hanks BB, et al. Gastrointestinal complications after cardiopulmonary bypass. Surgery 1982;92:394–400.[Medline]
- Kelman GR, Swapp GH, Smith I, et al. Cardiac output and arterial blood-gas tension during laparoscopy. Br J Anesth 1972;44:1155–62.[Abstract/Free Full Text]
- Kashtan J, Green JF, Parsons EQ, et al. Hemodynamic effects of increased abdominal pressure. J Surg Res 1981;30:249–55.[Medline]
- Safran D, Sgambati S, Orlando R. Laparoscopy in high-risk cardiac patients. Surg Gynecol Obstet 1993;176:548–54.[Medline]
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Abstract
Introduction
