Ann Thorac Surg 2001;72:1403-1404
© 2001 The Society of Thoracic Surgeons
How to do it
Novel technique to repair type A acute aortic dissection in patients with a left ventricular assist device
Yoshifumi Naka, MDa,
Niloo M. Edwards, MDa,
Mehmet C. Oz, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, College of Physicians and Surgeons of Columbia University, New York, New York, USA
Accepted for publication May 16, 2001.
Address reprint requests to Dr Naka, 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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Acute type A aortic dissection is an uncommon complication with left ventricular assist device insertion, but is often fatal even if successfully repaired with conventional techniques including aortic valve repair. Residual aortic insufficiency is common because this valve is now subjected to systolic pressure. We present a novel technique for the repair of type A acute aortic dissection in patients with a left ventricular assist device with no chance of residual aortic insufficiency.
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Introduction
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Type A acute aortic dissection is a rare but usually fatal complication in patients with left ventricular assist devices (LVADs). These sick patients have a myriad of abnormalities including pulmonary dysfunction, hepatic congestion, renal dysfunction, and coagulation abnormalities. Type A acute aortic dissection requires prompt surgical intervention using deep hypothermia and circulatory arrest, which exacerbates preexisting abnormalities in LVAD patients. Key issues of the surgical intervention include secure hemostasis and avoidance of mechanical complications such as residual aortic insufficiency. We present a novel technique for the repair of type A acute aortic dissection in LVAD patients with no risk of residual aortic insufficiency and less chance for postoperative bleeding.
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Technique
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A 76-year-old female with ischemic cardiomyopathy and a left ventricular ejection fraction of 11% continued to have progressive shortness of breath and fatigue. A repeat examination revealed low cardiac output, pulmonary arterial pressure of 60/35 mm Hg, pulmonary capillary wedge pressure of 32 mm Hg, and cardiac output of 2.3 L/min. She was started on dobutamine at 10 µg · kg-1 · min-1, transferred to our institute, and underwent the HeartMate LVAD (Thoratec Corporation, Pleasonton, CA) implantation. Her postoperative course was significant for bleeding and renal failure, but steadily improved until postoperative day 8, when she had an acute onset of hypotension with LVAD flow decreasing to 1.9 L/min. Bedside transesophageal echocardiography showed a type A acute aortic dissection with a tear seen at the LVAD outflow anastomotic site. The patient returned to the operating room.
The ascending aorta had a rupture on its greater curvature laterally to the LVAD outflow graft anastomosis. Concomitantly, cardiopulmonary bypass was instituted through the groin. The ascending aorta was cross-clamped immediately before the inominate artery origin and the heart was arrested with retrograde cardioplegia. The ascending aorta was entirely excised, and the aortic valve was oversewn and a patch placed to ensure the closure of the aortic valve (Fig 1). Next, a Cabrol graft was constructed using an 8-mm Hemashield graft anastomosed in a single graft fashion to the coronary artery ostia with the end-to-side fashion (Fig 1) [1]. The LVAD outflow graft was then sewn in a side-to-side fashion to the Cabrol graft to reinstitute coronary perfusion (Fig 1). The LVAD outflow graft was then directly anastomosed to the aortic arch under circulatory arrest (Fig 1). Blood is now pumped by the right ventricle through the pulmonary circulation, returns to the left heart, then draws to the LVAD through the left ventricular apex, and is then ejected to the systemic circulation through the LVAD outflow graft. Coronary circulation was reconstructed as the Cabrol graft routes blood from the LVAD outflow graft to the coronary ostia. An attempt was made to perform this anastomosis before the removal of the cross-clamp, but proved impossible due to the fragile nature of the patient’s aorta. The patient was weaned from cardiopulmonary bypass with remarkable ease, and remained hemodynamically stable. She tolerated chest closure without difficulty and was transferred to the recovery room.
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Fig 1. Complete closure of the aortic valve and Dacron patch reinforcement were performed using 6-0 and 4-0 monofilament sutures, respectively. Coronary circulation was reconstructed by the Cabrol technique, sewing an 8-mm Hemashield graft to the coronary ostia in end-to-end fashion and performing graft-to-graft anastomosis in side-to-side fashion, using 5-0 monofilament sutures. Finally, the left ventricular assist device (LVAD) outflow graft was sewn to the ascending aorta reinforced with Teflon felt strips using a 3-0 monofilament suture under circulatory arrest.
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Her postoperative course was complicated by acute tubular necrosis requiring Continuous veno-venous hemodialysis (CVVHD), respiratory failure requiring a tracheostomy, critical illness neuropathy, and LVAD pocket infection with wound disruption requiring a rectus flap on postoperative day 37. She continued to make slow but steady recovery and was transferred to the in-patient rehabilitation on postoperative day 75. She is well at home more than 18 months after the initial surgery.
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Comment
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Type A acute aortic dissection in LVAD patients has not been reported previously, although reports address several problems with the outflow graft-aortic anastomosis, especially pseudoaneurysm [2]. Two cases were reported to have dissection of the native aorta after heterotopic heart transplantation [3]. We only experienced two cases in more than 200 cases of HeartMate LVAD implantation, and present the second case. However, in these sick patients, even if timely surgical intervention is performed, underlying hemodynamic instability could be worsened by residual aortic insufficiencies, and deteriorating hepatic and renal function. Moreover, LVAD patients are considered in a state of mild coagulopathy [4]. It is not surprising that emergent reparative surgery in these difficult patients is complicated by persistent postoperative bleeding.
The first patient was a 61-year-old female with history of dilated cardiomyopathy who presented with severe congestive heart failure and underwent implantation of LVAD. She suddenly became hemodynamically unstable on postoperative day 12, and was found to have a type A acute aortic dissection with an aorto-left-atrial fistula. We tried to repair the aorto-left-atrial fistula by obliterating the false lumen using a ring graft, but severe aortic insufficiency made separation from cardiopulmonary bypass impossible. The next attempt to create a similar extraanatomical repair failed and resulted in uncontrollable bleeding from a variety of sites because of severe damage of the patient aortic tissue by the manipulation at the first attempt, and the case was terminated.
The lesson learned led us to perform the repair technique used in the second case. Because the left ventricular assist device serves as an apico-aortic conduit, complete closure of the aortic valve is possible. In patients with aortic dissection, additional maneuvers to establish coronary circulation had to be performed in conjunction with elimination of the dissected aortic tissue and securing hemostasis. We believe that the minimized number of anastomosis between the artificial graft and the dissected aortic tissue minimizes the bleeding risk. In this report, we describe a technique to repair aortic dissection in LVAD patients that possibly minimizes postoperative bleeding and avoids aortic insufficiency. We believe that this technique is especially beneficial in this high-risk cohort of patients.
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References
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Cabrol C., Gandibakhc I., Pavie A. Surgical treatment of ascending aortic pathology. J Card Surg 1988;3:167-180.[Medline]
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Konsalla C., Weng Y., Buz S., Loebe M., Hetzer R. Pseudoaneurysm of the outflow graft in a patient with Novacor N100 LVAD system. Ann Thorac Surg 2000;69:1594-1596.[Abstract/Free Full Text]
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Vigano’ N., Rinaldi M., D’Armini A.M., Pederzolli C., Minzioni G., Grande A.M. The spectrum of aortic complications after heart transplantation. Ann Thorac Surg 1999;68:105-111.[Abstract/Free Full Text]
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Spanier T., Oz M., Levin H., et al. Activation of coagulation and fibrinolytic pathways in patients with left ventricular assist devices. J Thorac Cardiovasc Surg 1996;112:1090-1097.[Abstract/Free Full Text]
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Abstract
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