Ann Thorac Surg 1998;66:2119-2120
© 1998 The Society of Thoracic Surgeons
How To Do It
Biventricular cannulation for the thoratec ventricular assist device
Francisco A. Arabía, MDa,
Venki Paramesh, MDa,
Bruce Toporoff, MDa,
David A. Arzouman, MDa,
Gulshan K. Sethi, MDa,
Jack G. Copeland, MDa
a Section of Cardiovascular and Thoracic Surgery, University of Arizona Health Science Center, Tucson, Arizona, USA
Accepted for publication June 17, 1998.
Address reprint requests to Dr Arabía, Cardiovascular and Thoracic Surgery, College of Medicine, University of Arizona Health Sciences Center, PO Box 245071, Tucson, AZ 85724-5071
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Abstract
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The Thoratec biventricular assist device has been used extensively as a bridge to heart transplantation. Right atrial cannulation has always been used during right ventricular support, however diminished filling and output of the right ventricular assist device have been noticed when compared with filling and output of the left ventricular assist device. We describe a technique to directly cannulate the right ventricle to maximize filling and output of the right ventricular assist device.
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Introduction
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The Thoratec (Berkeley, CA) ventricular assist device (VAD), is a pneumatically driven paracorporeal prosthetic ventricle. This system has been used successfully as a bridge to recovery or transplantation [1, 2]. Inflow to the device is obtained from atrial cannulae that are placed in either the left atrium, right atrium, or both, as dictated by the clinical condition of the patient. The outflow conduits are anastomosed to the ascending aorta, pulmonary artery, or both, via a Dacron graft. However, superior VAD filling and output are obtained if the left pump inflow cannula originates from the patient’s left ventricular apex. A special left apical cannula is available for this purpose. Inflow cannulation for the right VAD has always required the use of a right atrial cannula. Our experience has shown that usually the left VAD can provide adequate output in this configuration but that the right VAD sometimes demonstrates impaired filling and a compromised output. We describe a technique that uses an apical cannula in the right ventricle (RV) to maximize right VAD filling and output.
The Thoratec system can be installed in different configurations as a single VAD or as a biventricular assist device. The outflow cannulae are anastomosed to the great vessels, which sometimes can be accomplished without cardiopulmonary bypass. When the device is intended as a bridge to transplant, it is recommended that the inflow cannula to the device be anastomosed to the left ventricular apex. Cardiopulmonary bypass is required when the left ventricular apical cannula and right ventricular cannulation are used.
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Technique
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The ascending aorta is cannulated with a conventional canola and the right atrium is cannulated with a two-stage cannula. The left ventricle can be decompressed with a right superior pulmonary vent. The outflow conduits (aorta and pulmonary artery) are tunneled under the skin into the mediastinum and anastomosed to its respective great vessel by using 4-0 polypropylene. Cardiopulmonary bypass is then initiated and the apex of the heart is lifted. Six to eight interrupted pledgeted sutures (2-0 blue braided polyester fiber) are placed around the circumference of the apex. The apex is cored out. The diameter of the core is approximately 1 cm. The left ventricular beveled apical cannula is tunneled under the skin and brought into the pericardial space. The cannula is now inserted in the left ventricular apex, and the sutures are passed through the felt ring and tightened (Fig 1). The left ventricular cannula is now passed through the tunnel and clamped above the skin.
Transesophageal echocardiography can be helpful in determining the best location to place the right ventricular cannula. The cannula enters the right ventricle though the diaphragmatic wall, superior to the posterior descending artery. The beveled end of the cannula is placed facing the tricuspid valve to optimize inflow into the right VAD. Six to eight pledgeted sutures (2-0 blue braided polyester fiber) are placed on the diaphragmatic surface of the right ventricle (Fig 2). A purse-string suture can be placed through the peldgets to provide additional hemostasis, as the right ventricle is thin in this location. A small core of right ventricular wall is removed, and the cannula is placed in the area between the pledgets. In a similar fashion, the pledgeted sutures are placed through the felt ring and tightened. The purse-string suture that was placed through the pledgets is now tightened. Suture reinforcement of the right ventricular cannula might be required to secure hemostasis.
Once all the inflow and outflow cannulae are anastomosed to the heart and great vessels, they are connected to the VADs (Fig 3). Air is then removed from the system, the patient is placed in the Trendelenberg position. The patient is weaned from cardiopulmonary bypass by allowing the VAD or biventricular VADs to take over the circulation by increasing the its rate and decreasing the cardiopulmonary bypass flow rate.
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Comment
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This new arrangement of cannulae might provide superior flows for the Thoratec biventricular assist device. It could allow for faster postoperative recovery in the patients who have advanced manifestations of end-organ dysfunction.
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References
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Arabia F.A., Copeland J.G., Larson D.F., Smith R.G., Cleavinger M.R. Circulatory assist devices: applications for ventricular recovery or bridge to transplant. In: Gravlee G.P., Davis R.F., Utley J.R., eds. Cardiopulmonary bypass: principles and practice. Baltimore: Williams & Wilkins, 1993:693-712.
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Hill J.D., Farrar D.J. The Thoratec VAD system: patient selection and clinical results in bridging to transplantation. In: Lewis T., Graham T.R., eds. Mechanical circulatory support. London: Edward Arnold, 1995:169-175.
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Abstract
Introduction
