Ann Thorac Surg 1998;66:1817
© 1998 The Society of Thoracic Surgeons
Case Reports
ABIOMED BVS 5000 system: repair of venous cannulation site for excessive bleeding
Tyrone J. Krause, MDa
a Division of Cardiac Surgery, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
Accepted for publication May 2, 1998.
Address reprint requests to Dr Krause, Division of Cardiac Surgery, Robert Wood Johnson Medical School, One Robert Wood Johnson Pl, New Brunswick, NJ 08903
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Abstract
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The most common morbidity of the ABIOMED (Danvers, MA) left ventricular assist device is severe hemorrhage. Severe bleeding around the left atrial cannulation site can be repaired easily with the proper technique.
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Introduction
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Despite advances in ventricular assist devices, postoperative bleeding is still a significant risk factor for morbidity and death [1–3]. During the ABIOMED (Danvers, MA) Food and Drug Administration clinical trial, 76% of patients experienced bleeding (blood loss exceeding 1,500 mL in 12 hours) [4]. One of the most common areas of bleeding is the site of cannulation. We present a case of severe bleeding 2 hours postoperatively from the left atrial cannulation site.
A 58-year-old man underwent minimally invasive coronary bypass grafting using the left internal mammary artery to the left anterior descending artery. Six hours postoperatively, hypotension and severe ST elevations in lead V developed [1–4]. An emergency reoperation was performed with cardiopulmonary bypass. Although the left internal mammary artery appeared pulsatile (by Doppler echography), a reversed saphenous vein was anastomosed distal to our left internal mammary artery anastomoses to assure adequate blood flow. However, we were unable to wean the patient from the heart-lung machine. A left ventricular assist device was implanted (ABIOMED 5000 system). For venous access the left atrium was used in the interatrial groove. Specifically we used 3-0 Prolene (Ethicon, Somerville, NJ) with Teflon-pledgeted pursestrings (x2). The skin and subcutaneous tissue were closed and the patient was sent to the intensive care unit in stable condition. Two hours later, exsanguinating hemorrhage developed and he was sent back to the operating room. Severe bleeding developed at the left atrial cannulation site. We placed the patient on cardiopulmonary bypass via the left femoral artery to the vein. This site was used to facilitate exposure of all cardiac structures and to facilitate repair of the bleeding site. Once on bypass, the patient was placed in the Trendelberg position, the ABIOMED system was turned off, and the ABIOMED lines were immediately clamped. The left atrial cannula was removed and disconnected from the tubing. The left atrial site was repaired with 3-0 Prolene and Teflon pledgets. The cannula was then replaced into the left atrium, deaired and reconnected to the same ABIOMED system. The chest was closed (skin and subcutaneous tissue), and the patient was weaned from the ABIOMED 6 days later. He went home 14 days later.
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Comment
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This report describes the repair of the left atrial cannulation site for an ABIOMED assist device without replacing the entire pump system. Clamping of the ABIOMED tubing immediately after the machine is turned off prevents air trapping within the system.
Bleeding is a severe complication of ventricular assist devices and is the major cause of death postoperatively. Coagulopathy should be minimized by vigorously replenishing the body with platelets, fresh frozen plasma, and packed red blood cells. Occasionally, some surgical bleeding will occur at the cannulation sites. The left atrial cannulation site is particularly hazardous because any attempt at repair usually leads to further bleeding. The best method of repair is to place the patient back on cardiopulmonary bypass, remove the cannula, and reinforce the left atrial site with 3-0 Prolene and pledgets. In addition, the ABIOMED system already in use can be salvaged by preventing air entry. The entire repair should only take about 5 minutes and the entire operative time should be about 60 minutes. Although clamping of the device does lead to stasis in the tubing, if the repair can be done expeditiously, the heparinized blood in the tubing should be free of clot. A short cardiopulmonary bypass time under these dire circumstances is still warranted because the bleeding site can be fixed.
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References
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- Jett G.K. Postcardiotomy support with ventricular assist devices: selection of recipients. Semin Thorac Cardiovasc Surg 1994;6:136-139.[Medline]
- Chen J.M., Levin H.R., Catanese K.A., et al. Use of a pulsatile right ventricular assist device and continuous arteriovenous hemodialysis in a 57-year-old man with a pulsatile left ventricular assist device. J Heart Lung Transplant 1995;14:186-191.[Medline]
- Marelli D., Laks H., Amsel B., et al. Temporary mechanical support with the BVS 5000 assist device during treatment of acute myocarditis. J Card Surg 1997;12:55-59.[Medline]
- Pae W.E., Jr Ventricular assist devices and total artificial hearts: a combined registry experience. Ann Thorac Surg 1993;55:295-298.[Abstract/Free Full Text]
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Abstract
Introduction
