Ann Thorac Surg 1996;62:1192-1194
© 1996 The Society of Thoracic Surgeons
Case Report
Intraoperative Implantation of Percutaneous Left Ventricular Assist System
Hisashi Satoh, MD,
Yuji Miyamoto, MD,
Masahiro Koyama, MD
Cardiovascular Surgery, Yao Tokushyukai Hospital, Osaka, Japan
Accepted for publication April 12, 1996.
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Abstract
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The percutaneous left ventricular assist system, using modified Dennis technique, has been used successfully to treat patients experiencing severe cardiogenic shock in a variety of nonsurgical situations. Fluoroscopy is generally essential for implantation. Our experience with the implantation of the percutaneous left ventricular assist system during operations is described here. The percutaneous left ventricular assist system was applied using transesophageal echocardiographic imaging and by leading with the index finger through the right atrium without fluoroscopy.
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Introduction
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Dennis and associates [1] developed the left ventricular assist system without thoracotomy in 1962; however, early clinical experiences in desperate patients were unsuccessful [2]. Using improved catheter technology, we devised a percutaneous transseptal left atrial drainage cannula for the percutaneous left ventricular assist system (PLVAS) using modified Dennis technique. Recently the PLVAS was applied in 8 patients who had severe cardiogenic shock, and 1 patient survived [3, 4]. All patients were in nonsurgical situations and the PLVAS was implanted in the cardiac catheterization laboratory using a fluoroscopic imaging system and transesophageal echocardiographic guidance. This report describes 1 patient in whom the PLVAS was applied during a cardiac operation without fluoroscopy.
The PLVAS consists of a 21F transseptal left atrial drainage cannula (DLP, Grand Rapids, MI), a 17F femoral arterial perfusion cannula (DLP), and heparin-coated circuits for the centrifugal pump system (Carmeda BioActive surface; Medtronic-Biomedicus, Minneapolis, MN). This transseptal drainage cannula can be inserted with the usual transseptal catheterization technique using the Brockenbrough transseptal needle, Mullin transseptal catheter (7F), and a transseptal guide wire (Toray, Tokyo, Japan).
A 68-year-old man was referred to us with a diagnosis of unstable angina. Coronary angiography showed 99% stenosis at the proximal part of the left anterior descending artery, where intraluminal coronary balloon angioplasty and atherectomy had been performed three times during the past 1 year. Coronary artery bypass grafting to the left anterior descending artery using the left internal thoracic artery was performed. At first, the patient was easily weaned from cardiopulmonary bypass in sinus rhythm with a small dose of dopamine. The circulation, however, suddenly collapsed 5 minutes after weaning from cardiopulmonary bypass, which was reinstituted immediately. The ST segment of the electrocardiogram was abruptly elevated, and transesophageal echocardiography (TEE) revealed that the septum and anterior walls of the left ventricle were not contracting. We suspected that this event was due to severe vasospasm of the coronary artery or the internal thoracic artery. A saphenous vein graft was added to the distal site of the anastomosis of the internal thoracic artery under cardioplegic arrest. After intraaortic balloon pumping and intensive pharmacologic support with intravenous nitroglycerin, diltiazem, dopamine, dobutamine, and norepinephrine was started, cardiopulmonary bypass was terminated again. However, systolic arterial pressure was at most 80 to 90 mm Hg and severe low cardiac output with anuria persisted despite intraaortic balloon pumping and massive inotropic support.
We decided to apply PLVAS. A femoral vein was punctured with Seldinger technique and a Mullin transseptal catheter was inserted in the right atrium. We could detect the position and direction of the Mullin catheter by putting an index finger through the snare stitch on the right appendage. The tip of the Brockenbrough needle was guided to the fossa ovalis by the index finger. Septal puncture was performed and the Mullin catheter was inserted into the left atrium (Fig 1
). The TEE imaging revealed that the needle and catheter were inserted into the left atrium (Fig 2). After removal of the needle, the transseptal guidewire was properly inserted into the left atrium, and the Mullin catheter was then removed. A transseptal left atrial drainage cannula with an inner dilator was then passed across the atrial septum into the left atrium over the guidewire. The position of the left atrial cannula was confirmed by TEE imaging; the tip of the cannula was placed to the midportion of the left atrium. During these procedures, we continuously checked the position of the catheters, guidewire, and dilator at the atrial septum with the index finger and the TEE imaging. These procedures were performed by two cardiac surgeons. The perfusion cannula was placed into the femoral artery. These cannulas were connected to the PLVAS circuit and the left heart bypass was started.
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Fig 1. . (A) Septal puncture using the conventional Brockenbrough needle was undertaken with the index finger leading the needle through the right atrium, using transesophageal echocardiographic guidance. (B) The transseptal cannula was inserted through the Mullin transseptal catheter to the left atrium. (C) The transseptal cannula for the percutaneous left ventricular assist system was inserted and placed into the left atrium using a guidewire technique.
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Fig 2. . Transesophageal echocardiogram shows the transseptal catheter and guidewire across the atrial septum (arrow). (LA = left atrium; RA = right atrium.)
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The hemodynamic data and electrocardiographic changes were immediately improved with assist flow of 2.0 to 3.0 L/min. After protamine was administered, the sternum and chest wound were closed with the usual technique (Fig 3). Twenty hours after the beginning of PLVAS, the patient was successfully weaned from the PLVAS. The femoral cannulas were removed and hemostasis was done with a manual technique at the bedside in the intensive care unit. During PLVAS, no heparin was given and no major complications related to this device were experienced. The intraaortic balloon pump was required until the 6th postoperative day. The peak creatine kinase-MB fraction was 81 mIU/mL on the first operative day, and the electrocardiogram did not show significant changes postoperatively. Severe pneumonia with methicillin-resistant Staphylococcus aureus developed, however, and the patient died on the 18th postoperative day.
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Fig 3. . Chest roentgenogram shows the cannulation of the percutaneous left ventricular assist system (arrow) and intraaortic balloon pump on postoperative day 1.
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Comment
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Mechanical circulatory assist has been used with increasing frequency for the treatment of profound heart failure after cardiac operations and acute myocardial infarction [5, 6]. The conventional ventricular assist systems need a thoracotomy for application and removal. Even though the hemodynamic state is improved owing to the mechanical circulatory support, patients often do not survive due to serious complications, such as mediastinal bleeding or infection, associated with the implantation of the ventricular assist system.
In 1962 Dennis and associates [1] developed the left atrial–femoral artery bypass system by the jugular approach. Glassman and colleagues [2] developed a left atrial–femoral artery bypass system through the femoral vein. However, these early clinical experiences in desperate patients were unsuccessful. We devised PLVAS and applied it in 8 patients in whom severe heart failure developed after acute myocardial infarction and cardiomyopathy [3, 4]. In all patients PLAVS could be safely implanted in the cardiac catheterization laboratory using the fluoroscopic imaging system and TEE guidance, and the assist flow of PLVAS could be maintained at 3.0 to 4.0 L/min.
For postcardiotomy cardiogenic shock, the conventional ventricular assist system is usually implanted with direct cannulation technique. However, these assist systems have many complications due to the thoracotomy. In addition, they require rethoracotomy for removal of the devices. To avoid this cumbersome rethoracotomy, we developed a technique of implantation of PLVAS during the operation and applied PLVAS to our surgical patient. Under the TEE imaging and leading with the index finger through the right atrium, the puncture of the atrial septum with the femoral approach could be performed safely. When the tip of the Brockenbrough needle is positioned on the appropriate site of the atrial septum to be punctured, we can easily confirm the tip position by observing "tent formation" of the atrial septum with TEE [7].
The assist flow of 2.0 to 3.0 L/min was enough for circulatory support in this patient. The chest wound could be closed primarily, and no heparin was needed. Therefore, we did not worry about mediastinal bleeding and infection related to the implantation of the assist device. The removal of the PLVAS could be simply and easily performed at the bedside in the intensive care unit with a surgical procedure. In patients who cannot be weaned from cardiopulmonary bypass due to bleeding, PLVAS would be applied with this technique on partial bypass with single atrial cannulation.
The PLVAS is a simple, easy, and safe way to maintain systemic circulation in postcardiotomy patients with profound heart failure. On account of the easy removal, minimal complications, and sufficient assist flow, PLVAS may be widely applied to patients during cardiac operations.
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Footnotes
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Address reprint requests to Dr Satoh, Cardiovascular Surgery, Yao Tokushyukai Hospital, 3-15-38 Kyuhoji, Yao, Osaka 581, Japan.
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References
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- Dennis C, Hall DP, Moreno JR, Senning A. Left atrial cannulation without thoracotomy for total left heart bypass. Acta Chir Scand 1962;123:267–79.
- Glassman E, Engelman RM, Boyd AD, Lipson D, Ackerman B, Spencer FC. A method of closed-chest cannulation of the left atrium-femoral artery bypass. J Thorac Cardiovasc Surg 1975;69:283–90.[Abstract]
- Satoh H, Kobayashi T, Nakano S, Shimazaki Y, Kaneko M, Matsuda H. Clinical application of percutaneous left ventricular support with a centrifugal pump. ASAIO J 1993;39:153–5.[Medline]
- Satoh H, Kobayashi T, Nakano S, et al. Clinical experience with percutaneous left ventricular support using transseptal left atrial-femoral artery by pass. In: Akutsu T, Koyanagi H, eds. Artificial heart 4. Tokyo: Springer-Verlag, 1993:213–5.
- Pae WE Jr, Miller CA, Matthews Y, Pierce WS. Ventricular assist devices for postcardiotomy cardiogenic shock: a combined registry experience. J Thorac Cardiovasc Surg 1992;104:541–53.[Abstract]
- Matsuda H, Matsuwaka R, Kaneko M, et al. Analysis of clinical factors for survival after left and biventricular bypass using centrifugal pump following open heart surgery in infants and adults. Artif Organs 1990;14:382–6.[Medline]
- Kyo S, Motoyama T, Miyamoto N, Noda H, Dohi Y, Omoto R. Percutaneous introduction of left atrial cannula for left heart bypass: utility of biplane transesophageal echo guidance for transseptal puncture. Artif Organs 1992;16:386–91.[Medline]
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Abstract
Introduction
