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Ann Thorac Surg 1999;67:562-564
© 1999 The Society of Thoracic Surgeons

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How To Do It

Simplified technique for implantation of a left ventricular assist system after previous cardiac operations

^a Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Berlin, Germany

Accepted for publication July 6, 1998.

Address reprint requests to Dr Pasic, Klinik für Herz-, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
e-mail: pasic{at}dhzb.de

	Abstract

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Implantation of a left ventricular assist system through a left thoracotomy in patients with multiple previous heart operations avoids reopening the sternum and the possible consequent serious complications.

	Introduction

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Implantation of an assist device system is a straightforward procedure in most patients, but it represents a high-risk procedure for patients who have undergone multiple previous cardiac operations. The combination of the difficult redo procedure and a hemodynamically compromised patient with consequent hepatic dysfunction and coagulopathy greatly increases the risk of profuse postoperative hemorrhage [1]. Also, heart transplantation after assist device implantation is a highly demanding operative procedure which is accompanied by an increased risk of bleeding because of dense adhesions, inflammatory tissue reaction to cannulas, a poorly visualized anatomical field, and complex surgical preparation [2, 3]. We report on a modified method for the implantation of a paracorporeal left ventricular assist system after previous cardiac operations. Our method reduces or even avoids these problems and facilitates the procedure by implanting the system through a left thoracotomy using a left ventricular apex inflow cannula and an outflow cannula connected to the descending thoracic aorta.

	Surgical technique

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Arterial, central venous, and Swan-Ganz catheters are inserted in the standard manner. A double-lumen endotracheal tube is used to facilitate the intrathoracic part of the procedure. Cell-saver system and aprotinin administration are used for blood sparing, and routine perioperative prophylactic antibiotic therapy is given.

The patient is placed in the right lateral decubitus position with the left hip rolled back toward the surgeon so as to make the left groin easily accessible. A left anterolateral thoracotomy is made, and the thorax is entered through the left fifth intercostal space. After preparation of the left femoral artery and vein, the standard dose of heparin sodium (300 IU/kg of body weight) is given intravenously. The left common femoral vein is cannulated with a long 28F cannula and the left common femoral artery, with a short arterial cannula (20F to 24F depending on the size of the artery and the body surface area). Normothermic femoral-femoral partial cardiopulmonary bypass is established while the heart continues to beat. The left lung is deflated, the pulmonary ligament is divided between the two ligatures, and the left lung is mobilized cranially to ensure access to the aorta.

The parietal pleura over the distal part of the descending thoracic aorta is opened, and after limited dissection, the aorta is partially excluded using a long Satinsky clamp. A short longitudinal incision is made in the distal part of the descending thoracic aorta, and an outflow cannula with a 14- or 16-mm Dacron prosthesis is anastomosed end-to-side to the aorta with a continuous 4-0 polypropylene suture. (If such a cannula is not available, it can easily be constructed using a 14-mm gelatin-impregnated Dacron prosthesis and a straight venous [atrial] 40F cannula). The outflow cannula is brought out from the left pleural cavity either subcostally or through an intercostal space (usually the seventh intercostal space, but this depends on the patient’s body size and the proportions of the chest). It lies above the left hemi-diaphragm without angulation and exits the chest in the left anterior axillary line (Fig 1).

View larger version (21K): [in this window] [in a new window]   Fig 1. Paracorporeal left ventricular assist system implanted through a left thoracotomy. The paracorporeal pump is connected to a left ventricular apex inflow cannula and an outflow cannula anastomosed to the distal part of the descending thoracic aorta.

Both cannulas are connected to a paracorporeal pump with a pump volume of 80 to 95 mL. Once the air has been removed from the system, the pump work is established, and cardiopulmonary bypass is gradually discontinued with ongoing support of the right ventricle with inotropic agents, mostly epinephrine and norepinephrine, because peripheral vascular resistance is usually low after implantation of an assist device, and nitric oxide inhalation to lower pulmonary vascular resistance.

After femoral decannulation, the femoral vessels are reconstructed, and heparin is reversed with protamine sulfate. Closure of the thoracotomy wound is performed in the standard way after placing one chest tube. The patient is put in the supine position, and the double-lumen endotracheal tube is replaced by a standard endotracheal tube. If there is no bleeding, continuous heparin infusion is started 6 hours postoperatively to achieve an activated clotting time of between 160 and 180 seconds.

	Results

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We used this simplified method of left ventricular assist device implantation in 2 adult patients with multiple previous cardiac operations. Both patients experienced progressive deterioration of cardiac function despite aggressive medical therapy, ventilatory support, and implantation of temporary intraaortic balloon counterpulsation. Acute renal failure and progressive worsening of liver function had occurred in both patients. The surgical procedures were uneventful and resulted in quick recovery of the secondary organ dysfunction. The first patient, a 39-year-old man, was supported with a pump for 36 days and then received a donor heart. The postoperative course after heart transplantation was also uneventful. The second patient, a 64-year-old man, had good postoperative organ-function recovery, but an acute pulmonary infection developed. The patient died of consequent septic complications.

	Comment

Top Abstract Introduction Surgical technique Results Comment Acknowledgments References

 
Assist systems have been used extensively as a mechanical bridge to heart transplantation [3, 4]. After initial clinical success with biventricular pumps, it was noted that in most instances, only a left ventricular assist device was needed. Complete unloading of the left ventricle permits a dramatic reduction in right ventricular unloading, thus facilitating recovery of right myocardial function without the need for mechanical support of that side. However, implantation of an assist device by reopening the sternum after multiple previous cardiac surgical procedures poses a high risk in a hemodynamically compromised patient with consequent severe coagulopathy.

The technique described simplifies the procedure, requires only minimal preparation of the heart, avoids a risky redo operation, and allows the recovery of organ function without the serious complications that usually accompany implantation through reopening the sternum. We recommend implantation of a paracorporeal left ventricular assist system through a left thoracotomy. The paracorporeal pump is connected to a left ventricular apex inflow cannula and to an outflow conduit anastomosed to the descending thoracic aorta. The procedure is easy to perform, shortens the operating time substantially, and decreases the risk of immediate postoperative complications. It also allows a technically simpler subsequent heart transplantation than does the standard implantation of a paracorporeal left ventricular supporting pump through a median sternotomy.

All currently used types of paracorporeal pump (such as Berlin Heart, Thoratec, and ABIOMED) can be placed with this technique. With some modification, the technique could be used for placement of currently implantable devices (such as Novacor and TCI) in the standard or intrapleural positions (similar to heterotopic heart transplantation). At the time of heart transplantation, a portion of the inflow graft (the left ventricular apex cannula) is removed with the heart during cardiectomy. Access to the outflow cannula is usually through the pericardium or, if necessary, through a left anterior minithoracotomy. The Dacron prosthesis of the outflow conduit is simply ligated and divided, the outflow cannula is removed, and orthotopic heart transplantation is performed in the usual way. We have seen no problems with the material from the outflow graft, which is left in place at the time of heart transplantation. We believe that like the other prostheses used for vascular procedures, this one will cause no complications.

	Acknowledgments

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We are indebted to Mr Helge Haselbach for the illustration.

	References

Top Abstract Introduction Surgical technique Results Comment Acknowledgments References

 

1. Frazier O.H., Rose E.A., McCarthy P., et al. Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system. Ann Surg 1995;222:327-338.[Medline]
2. Oz M.C., Levin H.R., Rose E.A. Technique for removal of left ventricular assist devices. Ann Thorac Surg 1994;58:257-258.[Abstract]
3. Mehta S.M., Aufiero T.X., Pae W.E., Jr, Miller C.A., Pierce W.S. Combined registry for the clinical use of mechanical ventricular assist pumps and the total artificial heart in conjunction with heart transplantation: sixth official report—1994. J Heart Lung Transplant 1995;14:585-593.[Medline]
4. Pasic M., Loebe M., Hummel M., et al. Heart transplantation: a single-center experience. Ann Thorac Surg 1996;62:1685-1690.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Miralem Pasic Matthias Loebe Yuguo Weng Roland Hetzer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pasic, M. Articles by Hetzer, R. Search for Related Content PubMed PubMed Citation Articles by Pasic, M. Articles by Hetzer, R.