HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Johannes M. Albes Friedrich S. Eckstein Markus K. Heinemann Gerhard Ziemer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Albes, J. M. Articles by Ziemer, G. Search for Related Content PubMed PubMed Citation Articles by Albes, J. M. Articles by Ziemer, G.

Ann Thorac Surg 2000;70:277-278
© 2000 The Society of Thoracic Surgeons

---

Case report

Successful weaning of a transplanted heart from biventricular assist device

^a Department of Thoracic, Cardiac, and Vascular Surgery, Eberhard-Karls-University, Tübingen, Germany

Address reprint requests to Dr Albes, Division of Cardiac Surgery, University Hospital Jena, Bachstr 18, 07743 Jena, Germany
e-mail: johannes.albes{at}med.uni-jena.de

	Abstract

Top Abstract Introduction Comment References

 
Exceptionally few cases worldwide have survived weaning from a biventricular assist device following heart transplantation in contrast to those who underwent early retransplantation. We present a successful outcome after biventricular assist device implantation following initial biventricular failure after heart transplantation. Weaning could be performed after 1 week, although pulmonary vascular resistance remained markedly elevated.

	Introduction

Top Abstract Introduction Comment References

 
Primary allograft failure is the principal cause of operative mortality in cardiac transplantation. If the functional impairment cannot be overcome by means of catecholamine support as well as preload and afterload management, an assist device is required as a bridge to recovery or retransplantation [1]. In many patients, temporary univentricular or biventricular assist devices have been shown to save the life of the patient until retransplantation [2]. Only in very few cases, however, the transplanted heart recovered completely during mechanical support and could be weaned [3–7]. In the presented case, a biventricular assist device (Berlin Heart; Mediport, Berlin Heart GmbH, Berlin, Germany) was implanted directly after transplantation following biventricular failure as a consequence of a right ventricular insufficiency. The transplanted heart recovered and was weaned from mechanical support, resulting in a successful outcome for the patient.

A 23-year-old male patient suffered from end-stage cardiomyopathy due to cardiac sarcoidosis. Right heart catheterization performed 1 week prior to transplantation revealed a pulmonary vascular resistance of 232 dynes · sec · cm^-5. When an excellent matching male donor heart of the same size, blood type, and age was available, the patient underwent transplantation. The total ischemic time of the organ was 115 minutes. One thousand milligrams methylprednisolone were administered before release of the cross-clamp. During reperfusion, the transplanted heart gained initial sinus rhythm and appeared to be functionally unaltered while supported by cardiopulmonary bypass. However, in three consecutive weaning efforts from cardiopulmonary bypass, the right ventricle was unable to overcome a mean pulmonary pressure of 50 mm Hg. After the third attempt, the left ventricular function began to deteriorate as well with left atrial pressure rising from 8 mm Hg to 18 mm Hg. All pharmacological efforts to decrease the pulmonary vascular resistance with nitrates, prostacyclin, and nitric oxide, as well as all efforts to improve the inotropic support by means of catecholamines and phosphodiesterase-inhibitors failed. At that time, it was decided to implant a biventricular pulsatile assist device to save the life of the patient. A Berlin Heart (right chamber 60 cc; left chamber 80 cc) was implanted and adjusted to an output of 6.5 l/min. The chest was closed and the patient was transferred to the intensive care unit with intact pulmonary as well as renal function. Heparinization was adjusted to an activated clotting time of 150 seconds. Mediastinal reexploration was necessary 8 hours later because of bleeding from the pulmonary arterial cannulation site. Triple drug immunosuppression with antithymocyte globulin induction was initiated according to a standard protocol. Additionally, the patient was kept on a calculated antibiotic regimen throughout the period of ventricular assist device-support. The mean pulmonary artery pressure did not decrease substantially during the next few days, although nitric oxide and prostacyclin were continuously administered. Because of the fixed pulmonary vascular resistance, an acute retransplantation was not considered to be an option. Daily esophageal echocardiographies were performed showing a constant improvement of the biventricular function. The patient was therefore gradually weaned from the Berlin Heart over postoperative days 6 and 7. Pump output was eventually reduced from 6.5 to 1.5 l/min. Successful explantation of the assist device under extracorporeal circulation was performed at postoperative day 7, while the pulmonary vascular resistance was still substantially elevated (170 dynes · sec · cm^-5). During the following course, the patient developed a septic problem with consecutive renal failure requiring hemofiltration. Severe periods of atrial and ventricular arrhythmias were effectively treated either pharmacologically or with electrical cardioversions. Two weeks postoperatively, renal function had recovered. Four weeks postoperatively, a pacemaker was implanted due to intermittent atrioventricular dissociation. Twelve weeks postoperatively, the patient was discharged in good condition with excellent cardiac and sufficient renal function. Echocardiography showed a marked right ventricular hypertrophy accompanied by a mild tricuspid insufficiency, but excellent right and left ventricular function. Five months postoperatively, the patient is in good condition and followed as an outpatient. His explanted heart showed cardiomyopathy as a sequela of generalized cardiac sarcoidosis.

	Comment

Top Abstract Introduction Comment References

 
Many different assist devices have been used for temporary support of the failing heart following transplantation: intraaortic balloon pumps; right-, left-, or biventricular centrifugal pumps; as well as pulsatile biventricular devices such as the Novacor (Novacor, Edwards Lifesciences, Irvine, CA) or the Berlin Heart. Even implantable artificial hearts such as the Jarvik 7 (Jarvik, Louisville, KY) were utilized [3]. Right ventricular failure is most commonly observed as the indication for circulatory support. While mainly treated with right ventricular circulatory pumps, the outcome of these patients, however, is poor [8]. Although it can be due to an unnecessary prolongation of the onset of ventricular assist device support. Mild forms of the rather rare event of an initial biventricular failure are often treated with intraaortic balloon pumps and inotropic support [2]. The use of biventricular assist devices (BIVAD) for severe biventricular allograft dysfunction is recommended unequivocally [1]. However, a controversy exists regarding the adequate system. With respect to proper renal and hepatic function as well as potential cerebral complications, pulsatile devices which require only mild anticoagulation are preferred [2]. BIVAD implantation is mainly performed as a bridge to early retransplantation. The results of early retransplantation after BIVAD support are acceptable. About 50% of these patients leave the hospital [1, 2, 8]. Although it is recommended as a therapeutic option especially in the light of the increasing scarcity of donor organs, reports of a successful weaning of the transplanted heart following initial failure and temporary BIVAD support are surprisingly limited to only 7 patients [3–7]. In the particular case presented here, the preoperative resistance of the pulmonary vasculature was substantially elevated. Because of the rapid clinical deterioration of the patient, a heart transplantation appeared to be a more promising option than an unpredictable waiting period for an appropriate heart-lung donor. Considering the poor results of cardiac recovery of patients who were supported by right-ventricular assist device only, we chose a biventricular support in order to avoid further left ventricular impairment and the necessity of increasing catecholamine administration. Following transplantation, chances for a successful retransplantation were limited in our patient since the pulmonary vascular resistance remained elevated despite all pharmacological efforts. The only option for the patient was therefore to gain time for recovery of the right ventricle in order to deal with the fixed pulmonary hypertension. In such a scenario, the organ requires full immunosuppression. Management of the patient may therefore be more cumbersome. When primary weaning is achieved, the result, however, entirely justifies the effort.

Cardiomyopathy due to sarcoidosis is rare. In the review of the literature, not much is known about the outcome of these patients and potential contraindications for transplantation. Indications for transplantation in these patients have been made only on a very individual basis. Since the therapy of sarcoidosis requires steroids, a cardiac transplantation and consecutive immunosuppression was thought to be a reasonable therapeutic strategy [9].

We conclude from this case that in situations with fixed and untractable pulmonary vascular resistance after cardiac transplantation, the implantation of a pulsatile BIVAD offers a safe time frame for complete recovery of the right ventricle and weaning from the supporting device. We believe that the additional support of the already impaired left ventricle by means of the BIVAD played an important role in the successful outcome of the patient.

	References

Top Abstract Introduction Comment References

 

1. Hetzer R., Hennig E., Schiessler A., Friedel N., Warnecke H., Adt M. Mechanical circulatory support and heart transplantation. J Heart Lung Transplant 1992;11:175-181.
2. Hunt S.A., Frazier O.H., Myers T.J. Mechanical circulatory support and cardiac transplantation. Circulation 1998;97:2079-2090.[Free Full Text]
3. Emery R.W., Eales F., Joyce L.D., et al. Mechanical circulatory assistance after heart transplantation. Ann Thorac Surg 1991;51:43-47.[Abstract]
4. Obadia J.F., Boissonnat P., Bastien O., et al. Reversible graft dysfunction after cardiac transplantation. Arch Mal Coeur 1998;91:253-256.[Medline]
5. Jaggers J., Fullerton D.A., Campbell D.N., et al. Cardiac allograft failure. Ann Thorac Surg 1995;60:1406-1409.[Abstract/Free Full Text]
6. Marks J.D., Karwande S.V., Richenbacher W.E., et al. Perioperative mechanical circulatory support for transplantation. J Heart Lung Transplant 1992;11:117-128.[Medline]
7. Ott R.A., Mills T., Allen B., Eugene J., Gazzanija A. Successful treatment of acute allograft failure using pneumatic biventricular assistance. J Heart Lung Transplant 1992;11:117-128.
8. Tenderich G., Koerner M.M., Stuettgen B., et al. Mechanical circulatory support after orthotopic heart transplantation. Artif Organs 1998;21:414-416.
9. Oni A.A., Hershberger R.E., Norman D.J., et al. Recurrence of sarcoidosis in a cardiac allograft. J Heart Lung Transplant 1992;11:367-369.[Medline]

This article has been cited by other articles:

				J. M. Arribas, D. A. Pascual, F. Gutierrez, V. Ray, J. Garcia-Puente, M. Valdes, and R. Arcas Successful biventricular assistance after heart transplantation Ann. Thorac. Surg., February 1, 2004; 77(2): 720 - 721. [Abstract] [Full Text] [PDF]

				K. N. Fenton, S. A. Webber, D. A. Danford, S. K. Gandhi, J. Periera, and F. A. Pigula Long-term survival after pediatric cardiac transplantation and postoperative ECMO support Ann. Thorac. Surg., September 1, 2003; 76(3): 843 - 847. [Abstract] [Full Text] [PDF]

				A. L. Fernandez and A. Martinez Successful recovery of allograft failure with biventricular support Ann. Thorac. Surg., May 1, 2001; 71(5): 1753 - 1754. [Full Text] [PDF]

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): Johannes M. Albes Friedrich S. Eckstein Markus K. Heinemann Gerhard Ziemer Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Albes, J. M. Articles by Ziemer, G. Search for Related Content PubMed PubMed Citation Articles by Albes, J. M. Articles by Ziemer, G.