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Ann Thorac Surg 2001;71:S82-S85
© 2001 The Society of Thoracic Surgeons
Presented at the Fifth International Conference on Circulatory Support Devices for Severe Cardiac Failure, New York, NY, Sept 15–17, 2000.
DR D. GLENN PENNINGTON (Johnson City, TN):
The first case is a 55-year-old woman undergoing mitral valve replacement who develops severe heart failure in spite of vasodilators, inotropic drugs, and balloon pump.
Dr. Nick Smedira, just tell us how you’d deal with this lady.
DR NICHOLAS J. SMEDIRA (Cleveland, OH):
When I asked my colleagues what they would do, their first response was: why do you have biventricular failure after a mitral valve replacement? I think that is a good question. When you start out, you have to step back and ask: What is the problem? What I would recommend initially is a transesophageal echocardiogram to assess the valve. Is the valve functioning? Do I have any regional wall motion abnormalities?
Now, here is an example of a patient who is having trouble. One view of the echocardiogram looked like the valve was working normally. But you can see here that only one leaflet is moving; in addition, there is thrombus forming on the frozen leaflet of the prosthesis. So in this situation, part of the reason you’re having biventricular failure is the fact that you have valve malfunction.
Now, the question is, what device would you use? The real issue here is trying to avoid valve and chamber thrombosis. This is a case in which we used extracarporeal membrane oxygenation (ECMO) in this setting, and you can see the large amount of thrombus that then developed within the left atrium, around the valve, and in the left ventricle, after support. So I think that is the key concern.
As Mike just mentioned, I think the ideal approach in this patient would be to use an ABIOMED device. Usually these rheumatic ladies are tiny. A 32F inflow cannula could easily be inserted in the left ventricular (LV) apex. You may or may not need biventricular support. But focusing on the left ventricle with drainage through the apex you would allow blood flow across the mitral valve. You’d obviously have to anticoagulate her, but you’d reduce the incidence of thromboemboli and complications of valve thrombosis as you anticipate or hope for recovery.
DR PENNINGTON:
Let’s see, any other of our panelists? How about Dr Pagani?
DR FRANCIS D. PAGANI (Ann Arbor, MI):
I similarly would choose an ABIOMED device with apical cannulation.
DR PENNINGTON:
Anybody disagree?
Jack, what about your centrifugal pumps, how would you apply that, or would you in this instance?
I should preface this by assuming we have already done the echo and the valve is not stuck but the ventricle is not working well so she needs a device.
Jack?
DR JACK J. CURTIS (Columbia, MO):
We do not have the luxury of having multiple devices, so we would use the centrifugal pump. But in the ideal world, I think I would have looked at this patient’s Wood units preoperatively. If she were a candidate for transplantation by preoperative pulmonary vascular resistance criteria, I would probably use a Thoratec or an ABIOMED. If she were not a transplant candidate, I would use the centrifugal pump.
DR PENNINGTON:
If you did use the centrifugal pump, how would you apply it?
DR CURTIS:
We have not had experience with apical cannulation with centrifugal pumps. I think the concepts that have been talked about are very good ones. But we have always used application by left atrial cannulation.
DR PENNINGTON:
Any other panelists want to address this case? Lou?
DR LOUIS E. SAMUELS (Philadelphia, PA):
I think Nick has the answer. I think you do the LV apical cannulation to allow flow across the mitral.
We had a similar case with both aortic and mitral St. Jude prostheses. That patient went on to transplantation. In the explanted heart, no matter how much heparin we used, those valve leaflets were just covered with thrombus. And that is a real problem for recovery. So unless you’ve got flow across that mitral prosthesis, no matter how much anticoagulant you use, those leaflets will freeze up.
DR PENNINGTON:
Any comments from the audience?
DR MICHAEL A. ACKER (Philadelphia, PA):
I have a short comment. I have done this one time, not in this situation, but with a TCI, and I have just removed the valve. The patient was supported without a mitral valve on an left ventricular assist device (LVAD) for 6 or 7 months and did very well and was transplanted. So if you have very good LV drainage and you are worried about thrombus, that’s something to consider.
DR SMEDIRA:
What device did you use?
DR ACKER:
TCI
DR SMEDIRA:
We had a similar experience with removal of a mitral valve and we had trouble. We had to take the patient back and we put in a left atrial (LA) monitor in. The mean left atrial pressure was about 35 to 37 mm Hg. So even though the ventricle was down, it was still generating enough squeeze and intermittently squeezing against a closed inflow valve such that the mean left atrial pressure remained elevated enough to cause pulmonary congestion, dyspnea, and it didn’t work. So we failed in one of those efforts.
DR PENNINGTON:
Let’s go on to the next case of acute myocardial infarction shock.
This 50-year-old man brought in to the catheterization laboratory obviously has a big anterior myocardial infarction and cardiogenic shock. I am going to ask Lou Samuels to kick that one off.
DR SAMUELS:
The main thing about this case is that the man is young, 50 years old, so there is clearly potential for him to be a transplant candidate.
The other thing is we had an acute infarct and the LAD territory got stented. There was severe reperfusion injury or some aspect of the infarct and cardiogenic shock. You want to be aggressive with this patient and insert an assist device that has the potential for recovery. You cannot predict, I do not think, whether this ventricle is going to go on to recover or not.
I would favor inserting an ABIOMED system in this patient and hope that recovery occurs but during the first few days, assessing for transplant in the event that recovery does not occur. And if he does not recover by a week’s time, convert him over to a long-term system and think about transplant. But this is somebody you want to be very, very aggressive with and you want to move very quickly on before irreversible damage occurs.
DR PENNINGTON:
Other panelists? Frank?
DR PAGANI:
Well, I agree with most of that with the exception that I would carefully assess the degree of hemodynamic instability and, depending on how unstable he is, would opt for ECMO if cardiac arrest appeared eminent.
DR PENNINGTON:
ECMO? What would you anticipate with ECMO in this patient? Would you put it in with the anticipation that he is going to recover pretty quickly?
DR PAGANI:
I would anticipate that there might be recovery. If the patient did not recover within 3 to 4 days, I would bridge him to a TCI device.
DR PENNINGTON:
We have a dissenter down here. Doctor Acker.
DR ACKER:
ECMO is just not great for the LV. Unless the patient is coming to you with them pumping on his chest and he has had significant down time, in which case I would use ECMO, because I want to know if the patient is going to wake up. But if the patient gets to the operating room and you have made the decision you need mechanical support and he still has a blood pressure, I would use something that is going to allow LV recovery to the optimal degree, if that is what you are really going to go for. If you feel this has been a massive myocardial infarction and recovery is not very likely, then I would consider a Thoratec or a TCI.
DR PAGANI:
Again, I would consider ECMO or an ABIOMED. I would consider what his hemodynamics were. The most important goal is to intervene in sufficient time to prevent a cardiac arrest.
DR SMEDIRA:
We really do not know though that ABIOMED or any other apically based cannulation system provides better myocardial recovery.
DR ACKER:
But I would use the Abiomed with LV cannulation.
DR PENNINGTON:
Would there be any concerns about this being an acute, fresh infarct and cannulating the LV and having tears or whatever problems?
DR SAMUELS:
I think that is a concern. I have not had a lot of experience with the fresh infarct in the LV, but it does concern me a little bit. And maybe Mike or Nick can comment. But I will say that there is a way to get into the LV through the LA across the mitral.
DR ACKER:
But then you cannot wean the patient.
DR SAMUELS:
Right, then you cannot wean. But if that is your concern and we have had one case in which the LV really looked bad, we just cannulate into the LV through the LA and just accept that.
DR PENNINGTON:
Anybody else have an opinion from the audience? Yes.
DR YOSHIFUMI NAKA (New York, NY):
We have done more than a couple of cases with the LV apex cannulation with TCI or ABIOMED devices.
DR PENNINGTON:
You used the TCI?
DR NAKA:
TCI or ABIOMED LVAD in this case. But it depends on how much you see creatine phosphokinase (CPK) or troponin release. In case of CPK release of more than 5,000 or troponin release of more than 500, you should never expect recovery. So I just avoid the ABIOMED. Because if you place the Abiomed followed by TCI, you have to perform two operations, and I think that is unnecessary.
But in this acute setting, we do not know the degree of CPK release after the operation. So I would put the ABIOMED in this patient with apical cannulation.
DR PENNINGTON:
You would use ABIOMED in the apex?
DR NAKA:
Yes. Which never resulted in tears or bleeding. Because you decompress the LV, in the very low pressure system, you never see the bleeding.
DR ACKER:
Well, I would not say never.
DR NAKA:
Very rarely.
DR ACKER:
Yes, right. Never at Columbia.
But the point is a good one. Despite poor tissue, there is no pressure being generated in the LV and you can get away with it generally.
DR HANS ZWART (Kettering, OH):
What do the panelists think of using the ECMO before heart catheterization? In other words, in the catheterization laboratory the cardiologist asks you to put an ECMO in before a heart catheterization.
DR PENNINGTON:
Good question. Lou?
DR SAMUELS:
I am not a big fan of that procedure. It gets complicated. It may or may not even be necessary to do it, so I would not just do it prophylactically unless it became necessary.
DR PENNINGTON:
How about our other ECMOs, Nick and Frank?
DR SMEDIRA:
Our cardiologists do not ask us anymore, they just do it; then they call us if there is a problem. But they put it in percutaneously themselves.
DR PENNINGTON:
The ECMO cannulas you mean.
DR SMEDIRA:
ECMO cannulas, put them on support for what they consider high risk, left main, some vein graft stuff. They do not really consult us.
DR PENNINGTON:
Frank, at your place?
DR PAGANI:
Similar. But we have a separate ECMO service, so they are consulted independent of us. We have had a number of patients who were placed on ECMO for acute myocardial infarctions complicated by cardiac arrest and then had some intervention done and then were weaned quickly off ECMO.
DR ROBERT L. KORMOS (Pittsburgh, PA):
The panelists have all brought up some important points in their discussion about acute postcardiotomy support, but in this case they are really not reminding us of the importance of those points.
DR PENNINGTON:
Are you talking about the previous case now?
DR KORMOS:
No, I’m talking about in general, what they have told us and taught us, they are not really applying to this case. And they are not making strong enough points.
One is LA cannulation is not only undesirable in a situation like this, I think it is dangerous, because you are going to get stagnant flow in an acutely infarcted LV, which is going to produce a higher thromboembolism rate than if you cannulate apically. We have done maybe 20 acute infarctions and I have not had a ventricle rupture, because of the points that were just bought out by the panel—you are decompressing the heart. So I think that is desirable.
Second of all, we discussed a little bit about recovery. And I know we are going to discuss that later, so I do not want to harp on it, but we do not know enough information about this case. We do not know what other zones of the heart are at risk here. We do not know whether there are other coronary targets. And I think this point is really important, because I think it is a big mistake to assume that this heart is necessarily a transplant heart. You do not know how much of this heart is going to recover if you give it the maximal chance to recover, and you can only do that if you decompress the LV to bring the end-diastolics down below 10 or so.
DR PENNINGTON:
What device do you recommend, Bob?
DR KORMOS:
In my estimation, you have to assess whether the coronary targets are there, then bypass the patient, put a Thoratec in him, and decompress him as much as possible.
DR EDWARD B. SAVAGE (Chicago, IL):
One question I have is when you have a patient who has a virgin chest, open the chest up, put in an Abiomed for a couple of days, and then you convert the patient to the HeartMate, does that create a situation in which the patient is at higher risk for infection of the HeartMate device? This is probably the biggest long-term problem with this device. I have not really heard any data on this. Do you have any data on this?
DR PAGANI:
Actually we looked at our experience with patients who have had prior bridge with other devices, or have had their sternum opened, and there seems to be an increase, in our hands, with superficial skin and wound infections, but there has been no increase in our mediastinal rate.
DR PENNINGTON:
I want to move on to the next case and take the 20-year-old professional soccer player, who I am sure no one ever has to deal with.
This guy is healthy but develops what we presume to be myocarditis. Mike, tell us what to do.
DR ACKER:
I think this is an illustrative case for the points I just discussed. His presentation is not quite fulminant. I am a little concerned that he lingered for a week and slowly deteriorated. So it is not your classic acute fulminant myocarditis, but we will assume it is in that category. In a 20-year-old guy, a transplant is committing him to a very shortened life. So I would do whatever possible to give him every chance for recovery.
Given this situation in which we might be on for more than just a week, I would use a Thoratec, with the chance of looking for recovery at 2, 3, or 4 weeks, and giving him maximum medical therapy during that time.
If our biopsy results or our apical core results came back as giant cell myocarditis, then I would just leave the Thoratec in and he would be transplanted. But other than that diagnosis, we would hope that he would recover with several weeks to a month or so of support.
DR PENNINGTON:
Now, would you use two devices or one?
DR ACKER:
Again, it depends on the hemodynamics at the time. My bias in myocarditis is biventricular support. But again, if his right ventricle looked fine, then I would not use it.
DR PENNINGTON:
Do any of the panelists differ from that opinion?
Jack, what about the centrifugal pumps in this guy?
DR CURTIS:
Well, I think they are suboptimal.
DR PENNINGTON:
Would you use one though?
DR CURTIS:
Yes, I would.
DR PENNINGTON:
And you have had recovery?
DR CURTIS:
Because of his young age, we would try to give this patient a chance to recover and hope that he would do it in a short period of time. My preference for him would be the HeartMate.
DR PENNINGTON:
Well, lest we swing the pendulum too far, let me say that you have this guy on a Thoratec device and he just has not recovered as you anticipated in 2 or 3 months, when are you going to consider transplanting this guy? Mike?
DR ACKER:
That is a great question. I do not know the right answer. I believe that patients with myocarditis, at least the ones I have seen, have recovered pretty much within 6 weeks. There are certainly reports in the literature of up to 50 days, 60 days, 3 months. But then we are getting into a different diagnosis. We are approaching that less fulminant type of indolent, already dilated myopathy. So I guess I would go for a transplant if by 2 months I had not seen significant recovery.
DR PENNINGTON:
Let us just poll the audience on it. Let us say this guy has been on a Thoratec device for 3 months and his heart has not recovered and you are offered a perfect heart, how many of you would transplant him? (Most of the audience and panel, with a few dissenters, would transplant him).
DR PENNINGTON:
This is a 75-year-old man who has had previous infarcts, has now undergone coronary bypass grafting, and is limping along in the operating room but has inadequate cardiac output. I find my anesthesiologists want to say, look, his cardiac index was only about 1.4 preoperatively, so he is not going to get much better than this. Let us juice him up with a little more epinephrine and send him to the ICU. Unfortunately, most of the time the patient dies. The written description does not include placement of an intraaortic balloon pump, but let us assume that was inserted. Jack, tell us what you would do.
DR CURTIS:
Well, we do not consider age a contraindication to the use of postcardiotomy mechanical support. In our database of 96 patients who have had postcardiotomy support with centrifugal pumps, age, ejection fraction, and even renal function do not predict the survivors and non-survivors. Once you have applied devices, these preoperative variables do not distinguish between those patients who will or will not survive.
The thing I do not like about this scenario is that I would not just treat the 1.4 number, because that 1.4 number can often be wrong. But if the SVO2 and everything else support low cardiac output, we would use an assist devce and we would use centrifugal pumps.
DR PENNINGTON:
Any of the other panelists?
DR SMEDIRA:
I think this highlights what Lou told us earlier. You have an older patient with borderline renal function to begin with, and then you start flogging him with multiple inotropes, you add the milrinone, you end up on vasopressin and Levophed and a balloon pump. And you are guaranteed that if you limp out, you will get by initially, but then he will develop multiorgan failure and die. So I think this is the case where you really should resort to more advanced support earlier and you’ll have a better likelihood of getting him through successfully.
DR PENNINGTON:
How many in the audience would definitely support this patient with a ventricular assist device?
(Most of the audience would.)
DR PENNINGTON:
I would. How many would definitely not support him?
(Show of Hands.) Some in the audience would not. Is the reason you’re not supporting him economic? Answer: No!
This article has been cited by other articles:
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  L. Samuels Reply to the Editor J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 1123 - 1124. [Full Text] [PDF]
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 P. Leprince, A. Combes, N. Bonnet, A. Ouattara, C. E. Luyt, P. Theodore, P. Leger, and A. Pavie Circulatory support for fulminant myocarditis: consideration for implantation, weaning and explantation Eur. J. Cardiothorac. Surg., September 1, 2003; 24(3): 399 - 403. [Abstract] [Full Text] [PDF]
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