Ann Thorac Surg 1999;67:246-248
© 1999 The Society of Thoracic Surgeons
Case Reports
Extracorporeal right to left atrial bypass to treat right ventricular failure
Giorgio Arpesella, MDa,
Pierluca Lombardi, MDa,
Sonia B. Albanese, MDa,
Piero M. Mikus, MDa,
Giuseppe Marinelli, MDa,
Angelo Pierangeli, MDa
a Department of Cardiovascular Surgery, University of Bologna, Bologna, Italy
Accepted for publication June 22, 1998.
Address reprint requests to Dr Arpesella, Cardiochirurgia, Policlinico S. Orsola, Via Massarenti, 9 40138 Bologna, Italy
 |
Abstract
|
|---|
Graft right ventricular failure after heart transplantation, secondary to preoperative functional pulmonary hypertension, was successfully managed in a 49-year-old patient using an extracorporeal right to left atrial bypass. We comment on the case and discuss the type of mechanical assistance used.
|
Introduction
|
|---|
Pulmonary hypertension secondary to dilative cardiomyopathy constitutes a risk factor for graft right ventricular failure after heart transplantation [1]. We report on a case of graft right ventricular failure after orthotopic heart transplantation secondary to preoperatively increased transpulmonary pressure gradient, treated with extracorporeal right to left atrial bypass (ECRLAB) [2, 3].
A white man, aged 49 years and weighing 64 kg, with postischemic dilative cardiomiopathy previously treated with coronary arterial bypass graft operation and left ventricular aneurysmal resection, underwent orthotopic heart transplantation. Donor to recipient weight matching was 0.9; graft ischemic time was 124 minutes. Transpulmonary pressure gradient and total pulmonary vascular resistance were, respectively, 12 mm Hg and 6 Wood units at preoperative cardiac catheterization. Weaning of cardiopulmonary bypass was attempted after 1 hour of myocardial reperfusion with a drug infusion of isoprenaline 0.5 µg · kg-1 · min-1, dobutamine 2 µg · kg-1 · min-1, and prostaglandin I2 8 ng · kg-1 · min-1. Progressive graft failure developed presenting ischemic changes on right precordial leads and an increase of transpulmonary pressure gradient up to 22 mm Hg with a pulmonary arterial pressure of 44 mm Hg systolic, 16 mm Hg diastolic, and 28 mm Hg mean versus a systemic arterial pressure of 94 mm Hg systolic, 47 mm Hg diastolic, and 63 mm Hg mean. A right ventricular (RV) assist device was used by performing an ECRLAB. A right atrial cannula (Jostra HKV46L90 26F Medlzintechulk AG Hirrlingen, Germany Jostra USA Inc, Austin, TX) drained the blood into a 3/8-inch polyvinyl chloride circuit (total length of the circuit, 2.7 m), connected to a Bio-Medicus centrifuge blood pump (Medtronic Inc, Eden Prairie, MN) and to an Avecor I-4500-2A membrane oxygenator (Avecor Cardiovascular Inc, Plymouth, MN). The blood was then reinfused into the left atrium through an identical Jostra cannula. The outflow cannula was positioned in the left atrium between the right pulmonary veins. The inflow cannula was positioned on the same side as the outflow cannula but in the right atrium. Both cannulas were passed through a double transcutaneous tunnel below the xiphoid process. The ECRLAB was maintained for the first 56 hours with a pump output of 3 L/min, using continuous heparin infusion (activated clotting time within 200 seconds). Mechanical ventilation was adjusted at the lowest FIO2 and minute volume possible to minimize barotrauma. Continuous thermodilution cardiac output (Vigilance, Baxter Healthcare Corp, Irvine, CA) and pulmonary Swan-Ganz pressure measurement were maintained (Table 1). During the first 56 hours, a pump output of 3 L/min corresponded to a relative pulmonary output of 0.9 L/min, keeping the RV preload to a mean right atrial pressure of 7 to 8 mm Hg. During the subsequent 26 hours, the weaning of the ECRLAB was carried out by reducing the pump output by 10% to 25% every 1 to 3 hours: a concomitant increase of the pulmonary output was observed up to 4.4 L/min with a 33% fall of transpulmonary gradient compared with before ECRLAB (Table 2). The ECRLAB was stopped and the atrial cannulas were removed by reopening the chest after an overall ECRLAB time of 82 hours. After removal of arterial cannulas, the cardiac output of the patient was 7 L/min with right atrial and left atrial pressures of 10 and 7 mm Hg, respectively. During the subsequent 48 hours the patient required one extracorporeal dialysis procedure because of transient renal failure. Forty-eight hours later the patient was weaned off the ventilator, extubated, and transferred to the ward. Immunosuppressive treatment during ECRLAB included rabbit antithymocyte globulin (1.5 mg/kg) and steroid administration. Subsequently, the patient was routinely managed with a three-drug immunosuppressive treatment (cyclosporine, azathioprine, prednisone). During the subsequent postoperative course, the patient underwent three cardiac catheterizations with myocardial biopsy to assess the hemodynamics and exclude acute rejection (Table 3).
|
Comment
|
|---|
Extracorporeal right to left atrial bypass is a new form of RV assist device that is very similar to the conventional extracorporeal membrane oxygenation from a technical point of view [4]. Its use appears advantageous for the treatment of both temporary graft RV failure and functional pulmonary hypertension. The rationale for choosing ECRLAB can be summarized as follows. (1) Right ventricular afterload and RV work load are reduced owing to the RV assist device working in parallel. (2) The RV assist device is easily managed. In fact, having defined a sufficient minimal flow and established a physiologic preload to the left ventricle (8 to 10 mm Hg), the pump output can be left unchanged until the beginning of weaning. The right atrial pressure should be kept around 7 to 8 mm Hg: if higher, a blood withdrawal is preferred to an increase of the blood output. In this way the pulmonary blood output can be physiologically self-regulated; an improvement of the RV contractility or a reduction of pulmonary resistance could lead to an increase in pulmonary blood output. Furthermore, a parallel configuration avoids the risk of pulmonary edema, which is always possible with in-series RV assist devices. (3) Blood oxygen content is not lung-dependent. As in conventional extracorporeal membrane oxygenation, patients with both low volumes and FIO2 undergoing ECRLAB can be ventilated; barotrauma is reduced and subsequent adult respiratory distress syndrome can be avoided. (4) Finally, ECRLAB is a low-pressure system with subsequent reduced trauma to blood cells and proteins of plasma.
Our single case experience suggests that ECRLAB can be effective in the treatment of graft RV failure secondary to preoperative functional pulmonary hypertension after heart transplantation. After further validation, ECRLAB might be routinely used during heart transplantation in patients with increased preoperative transpulmonary gradient to promote the functional adaptation of the graft and avoid graft RV failure.
|
References
|
|---|
-
Bourge R.C., Kirklin J.K., Naftal D.C., et al. Analysis and predictors of pulmonary vascular resistance after cardiac transplantation. J Thorac Cardiovasc Surg 1991;101:432-435.[Abstract]
-
Fanger J.D., Burtan A.M., Baumgartner W.A., Acitaff S.V., Augustine S., Reitz B.A. Acute right ventricular failure following heart transplantation: improvement with prostaglandin E and right ventricular assist. J Heart Transplant 1986;5:317-321.[Medline]
-
Nakakami T., Radovancevia B., Frasier O.H. Right heart assist for acute right ventricular failure after orthotopic heart transplantation. Trans Am Soc Artif Intern Organs 1987;33:695-698.
-
Whyte R.I., Deeb G.M., McCurry K.R., Anderson H.L., III, Belling S.F., Bartlett R.H. Extracorporeal life support after heart or lung transplantation. Ann Thorac Surg 1994;58:754-759.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
G. Arpesella, E. Mikus, A. Loforte, and P. M. Mikus
Right-left atrium by-pass as salvage treatment for graft failure after heart transplantation
Eur J Cardiothorac Surg,
October 1, 2007;
32(4):
671 - 673.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Taghavi, A. Zuckermann, J. Ankersmit, G. Wieselthaler, A. Rajek, G. Laufer, E. Wolner, and M. Grimm
Extracorporeal Membrane Oxygenation is Superior to Right Ventricular Assist Device for Acute Right Ventricular Failure After Heart Transplantation
Ann. Thorac. Surg.,
November 1, 2004;
78(5):
1644 - 1649.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
