Ann Thorac Surg 2001;71:1719-1720
© 2001 The Society of Thoracic Surgeons
How to do it
A new off-pump technique for thoratec right ventricular assist device insertion
Vivek Rao, MD, PhDa,
Mehmet C. Oz, MDa,
Niloo M. Edwards, MDa,
Yoshifumi Naka, MD, PhDa
a Division of Cardiothoracic Surgery, New York Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, New York, USA
Accepted for publication December 18, 2000.
Address reprint requests to Dr Naka, New York Presbyterian Hospital, MHB 7-435, 177 Fort Washington Ave, New York, NY 10032
e-mail: yn33{at}columbia.edu
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Abstract
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The need for right ventricular support as an adjunct to left ventricular assistance is uncommon. When required, the insertion of a right ventricular assist device may be complicated by preexisting hepatic dysfunction, coagulation abnormalities, and renal failure, all of which are exacerbated by cardiopulmonary bypass. We report a technique for insertion of a right ventricular assist device without the need for cardiopulmonary bypass.
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Introduction
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The need for mechanical right ventricular support following implantation of a left ventricular assist device (LVAD) is low [1–3]. Right ventricular failure in these patients causes a myriad of abnormalities including hepatic congestion, renal dysfunction, and coagulation abnormalities. Prompt institution of right ventricular support may improve hemodynamic stability, but the use of cardiopulmonary bypass (CPB) may exacerbate preexisting coagulopathy and adversely affect renal function. We therefore developed a technique for insertion of a Thoratec (Pleasanton, CA) long-term right ventricular assist device (RVAD) without the need for CPB.
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Technique
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A 63-year-old man presented with idiopathic cardiomyopathy and intractable ventricular arrhythmias. After appropriate investigations, a TCI HeartMate VE LVAD (ThermoCardiosystems Inc, Woburn, MA) was inserted. The preoperative cardiac index while on 10 µg/kg per minute of dobutamine and renal dose dopamine was 1.97 L/min/m2 with a central venous pressure of 18 mm Hg and mean pulmonary and systemic pressures of 35 and 65 mm Hg, respectively. His initial postoperative course was uncomplicated and he was extubated on the fifth postoperative day and transferred out of the intensive care unit on the seventh day after the operation. Unfortunately, he had a self-limited bleed from his pocket site and was returned to the intensive care unit on the eighth postoperative day. Despite appropriate transfusion and antiarrhythmic therapy, the patient continued to have recurrent episodes of ventricular tachycardia/fibrillation requiring multiple attempts at cardioversion. The occurrence of ventricular arrhythmias resulted in a decrease in LVAD flows to between 3 and 3.5 L/min. Mean pulmonary pressures were 25 mm Hg with a central venous pressure of 22 to 25 mm Hg. Progressive right ventricular failure caused abnormalities in hepatic and renal function. In addition, the patient developed a suspected heparin-induced thrombocytopenia with platelet counts falling to 30,000/mL. The patient was taken to the operating room for insertion of an RVAD 13 days after his LVAD implant. Following insertion of right ventricular inflow and pulmonary outflow catheters, right ventricular support was established with a Thoratec system.
Postoperatively, the patient remained hemodynamically stable with excellent RVAD and LVAD flows with no further electrophysiologic abnormalities. Biochemical markers of hepatic and renal function normalized within 48 hours and his platelet count slowly improved. A suitable allograft became available on the 26th day following LVAD insertion and the patient underwent successful transplantation. At the time of transplantation, no thrombus was visible in either the right ventricle or pulmonary artery.
Operative procedure
The patient was transferred to the operating room, intubated and ventilated with central venous, pulmonary artery, and radial artery monitoring lines in situ. A transesophageal echocardiographic probe was inserted preoperatively and confirmed right ventricular distension with moderate-to-severe dysfunction.
The patient was placed supine on the operating room table and the midline sternotomy incision reopened to just below the xiphoid process, maintaining fascial closure over the LVAD pump. Two purse string sutures were placed on the anterior aspect of the right ventricular outflow tract using 3-0 Prolene sutures pledgetted with glutaraldehyde-preserved bovine pericardium (Fig 1) [4, 5]. Interrupted, horizontal mattress sutures were placed in a rosetta fashion on the acute margin of the right ventricle using 2-0 Tevdek sutures (Thoratec, Pleasanton, CA) buttressed with felt pledgets (Fig 1).
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Fig 1. Right ventricular cannulation for both inflow and outflow conduits of the Thoratec right ventricular assist device. A double purse-string suture is used to secure the outflow cannula. The inflow cannula is secured using interrupted 2-0 Tevdek mattress sutures in a rosetta fashion.
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The Thoratec angled right atrial inflow cannula was immersed in hot water and fashioned into a straight outflow cannula. A cruciate incision was made in the right ventricular outflow tract maintaining hemostasis with digital pressure. The outflow cannula was then inserted and advanced just proximal to the pulmonary artery bifurcation. The previously placed Tevdek sutures were then passed through the cuff of the right ventricular inflow cannula and another cruciate incision was fashioned on the acute margin of the right ventricle. The blunt tip Thoratec ventricular inflow cannula was then inserted and secured firmly in place.
The RVAD inflow and outflow cannulas were then brought out through separate stab wounds in the left upper abdominal quadrant and attached to the paracorporeal pump after appropriate removal of air. Right ventricular support was then initiated with immediate improvement in LVAD flows to more than 5.5 L/min.
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Comment
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The need for right ventricular mechanical support in patients who have received an LVAD has decreased significantly due to the increased use of inhaled nitric oxide and selective pulmonary vasodilators [1–3]. However, about 10% to 15% of LVAD recipients eventually require biventricular support. Unfortunately, the need for a right ventricular device frequently coincides with precipitous declines in hemodynamics accompanied by deterioration in hepatic and renal function. Not surprisingly, urgent operation in these difficult patients is often complicated by severe coagulopathy and persistent postoperative bleeding.
The deleterious effects of CPB on renal function and the coagulation cascade are well established [6, 7]. Therefore, modified techniques of device insertion that eliminate the need for CPB may be useful in preserving renal function and preventing heterologous blood transfusion. Although right atrial to pulmonary artery connections have been accomplished without the need for CPB (Thoratec Laboratories, personal communication), this report describes the off-pump insertion of right ventricular inflow and outflow cannulas [8, 9].
Previous studies have demonstrated that atrial and ventricular inflow cannulation both result in acceptable VAD flow rates [9–11]. However, ventricular cannulation results in greater right-sided decompression and is less sensitive to changes in preload [9]. Although the Thoratec outflow cannula was designed for pulmonary arterial cannulation, several authors have described alternative techniques for right-sided outflow cannula insertion because of concerns about pulmonary artery injury [4, 5]. For these reasons, we currently prefer right ventricular cannulation for both inflow and outflow conduits. We immerse the angled atrial inflow cannula in warm water until it is easily malleable and then cool it in a straightened orientation to form an RVAD outflow cannula. This technique facilitates insertion through the right ventricular outflow tract.
In this report, we have described off-pump ventricular cannulation of both inflow and outflow conduits. Although this patient was supported by a left-sided assist device, we believe that this technique is possible even in the rare patient who requires right-sided mechanical support in the absence of left ventricular failure. We find this technique safe and reproducible and the avoidance of CPB is especially beneficial in this high-risk cohort of patients.
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References
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Fukamachi K., McCarthy P.M., Smedira N.G., Vargo R.L., Starling R.C., Young J.B. Preoperative risk factors for right ventricular failure after implantable left ventricular device insertion. Ann Thorac Surg 1999;68:2181-2184.[Abstract/Free Full Text]
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Smedira N.G., Massad M.G., Navia J., et al. Pulmonary hypertension is not a risk factor for RVAD use and death after left ventricular assist system support. ASAIO J 1996;42:733-735.
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Chen J.M., Levin H.R., Rose E.A., et al. Experience with right ventricular assist devices for perioperative right-sided circulatory failure. Ann Thorac Surg 1996;61:305-310.[Abstract/Free Full Text]
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Dewey T.M., Chen J.M., Spanier T.B., Oz M.C. Alternative technique of right-sided outflow cannula insertion for right ventricular support. Ann Thorac Surg 1998;66:1829-1830.[Abstract/Free Full Text]
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Minami K., Bonkohara Y., Arusoglu L., El-Banayosy A., Korfer R. New technique for the outflow cannulation of right ventricular assist device. Ann Thorac Surg 1999;68:1092-1093.[Abstract/Free Full Text]
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Kestin A.S., Valeri C.R., Khuri S.F., et al. The platelet function defect of cardiopulmonary bypass. Blood 1993;82:107-112.[Abstract/Free Full Text]
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Utley J.R. Renal function and fluid balance with cardiopulmonary bypass. In: Gravlee G.P., Davis R.F., Utley J.R., eds. Cardiopulmonary bypass. Baltimore: Williams & Wilkins, 1993:488.
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Carpentier A., Brugger J.P., Brethier B., et al. Heterotopic artificial heart as bridge to cardiac transplantation. Lancet 1986;12:97-98.
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Arabia F.A., Paramesh V., Toporoff B., Arzouman D.A., Sethi G.K., Copeland J.G. Biventricular cannulation for the Thoratec ventricular assist device. Ann Thorac Surg 1998;66:2119-2120.[Abstract/Free Full Text]
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Holman W.L., Bourge R.C., Murrah C.P., et al. Left atrial or ventricular cannulation beyond 30 days for a Thoratec ventricular assist device. ASAIO J 1995;41:517-522.
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Lohmann D.P., Swartz M.T., Pennington D.G., McBride L.R., Reedy J.E., Miller L. Left ventricular versus left atrial cannulation for the Thoratec ventricular assist device. ASAIO Trans 1990;36:545-548.
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Abstract
Introduction
