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Ann Thorac Surg 1997;63:1145-1146
© 1997 The Society of Thoracic Surgeons
Departments of Cardiovascular Surgery, Anesthesiology, and Cardiology, Albert-Ludwigs-University Medical Center, Freiburg, Germany
Accepted for publication November 5, 1996.
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Abstract |
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Introduction |
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Fulminant myocarditis can be the cause of rapid and irreversible cardiac decompensation resulting in death or requiring cardiac transplantation. Formerly steroids and other immunosuppressive drugs were the only therapy available to treat patients with acute myocarditis. However, the efficacy of these drugs has not been established, and the mortality of fulminant myocarditis remains high [1]. The availability of mechanical ventricular support might improve the prognosis of fulminant myocarditis. Few patients with myocarditis and severe left ventricular dysfunction can recover over weeks to months to have restored ventricular function without mechanical support, and cardiac transplantation in this group of patients with active myocarditis has a high mortality [2].
A 30-year-old woman, who was otherwise healthy had a 1-week history of flu-like symptoms. Because of tachycardia and dyspnea the patient was admitted to the hospital, where the diagnosis of an acute myocarditis was established. Despite maximal inotropic support she became progressively hypotensive and oliguric. An echocardiogram revealed normal chamber sizes of the heart with severe global hypokinesis and an ejection fraction of 0.15. On hospital day 2 the patient required intubation and a ventricular assist device (VAD) had to be inserted.
The MEDOS HIA-VAD (MEDOS Medizintechnik GmbH, Stollberg, Germany) is a pneumatically actuated blood pump [3]. The pump and the three-leaflet valves in the inflow and outflow tracts are made of polyurethane. Silicone cannulas and Dacron fabric grafts connect the ventricles to the left and right atria, to the aorta, and to the pulmonary artery (Fig 1
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The perioperative anticoagulation treatment was performed with regular heparinization for cardiopulmonary bypass. After cardiopulmonary bypass, heparin was antagonized partially and the activated coagulation time was kept between 120 and 200 seconds postoperatively. The partial thromboplastin time was maintained at a level of 60 to 80 seconds. Antithrombin III was substituted when the level decreased to less than 80%.
The VAD worked 17 days without any technical complications. Flow rates ranging from 5 to 6 L/min provided adequate hemodynamics without catecholamines. Postoperative blood loss 24 hours after the operation was 1,500 mL, and the patient received packed red blood cells and fresh frozen plasma. Five days after implantation of the device the number of platelets had decreased from 189 to 46/nL and substitution was necessary. After 6 and 9 days, examination of the ventricles showed clots on the interior blood-contacting surfaces of the right and left ventricular outflow tract, so the blood pumps had to be changed. On the 14th postoperative day surgical reintervention was necessary because of bleeding from the cannulation site of the pulmonary artery.
Seventeen days after implantation of the device the myocardial function had recovered and we could remove the assist system. Therefore, the electrocardiographic triggering mode of the device was reduced stepwise from 1:1 to 1:3, and then mechanical support was stopped. Echocardiographic examination revealed a left ventricular ejection fraction of 0.25 to 0.30 and a cardiac index of 2.6 L•min-1•m-2 without catecholamines. On the 10th day after device removal the ejection fraction had increased to 0.45 to 0.50 and the patient returned home.
Histologic examination of the right ventricular biopsy specimen and the acute and convalescent serum parameters failed to determine a cause of the acute cardiac failure. There was only a slight increase in titers of influenza B. After 7 months of follow-up, the patient is doing fine and has returned to work.
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Comment |
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The MEDOS HIA-VAD has been used in more than 100 patients so far. Guldner and coworkers [3] reported that it has no measurable activation of coagulation and excellent surface characteristics, which results in a low risk of thromboembolic complications. In contrast, bleeding and formation of thrombotic material were the main problems in our patient. Furthermore, the results of other investigators indicate that bleeding and thromboembolic complications remain a major threat during and after the use of VADs [8]. The main problem areas for thrombus formation in artificial heart blood pumps are the heart valves, connectors, and the native ventricles.
Complete transparency of the MEDOS HIA-VAD pulsatile blood pumps, however, enables early detection of clots. The exchange of the pumps is easy and can be performed within seconds. Consequent anticoagulation and early diagnosis of clots are important precautions to prevent thromboembolic complications.
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Address reprint requests to Dr Martin, Department of Cardiovascular Surgery, Albert-Ludwigs-University Freiburg, Hugstetter Str 55, D-79106 Freiburg, Germany.
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