Ann Thorac Surg 2002;73:997-999
© 2002 The Society of Thoracic Surgeons
How to do it
Left ventricular assist device implantation via left thoracotomy: alternative to repeat sternotomy
Richard N. Pierson, III, MD*a,
Renee Howser, MSNb,
Terri Donaldson, MNb,
Walter H. Merrill, MDa,
Rebecca J. Dignan, MDa,
Davis C. Drinkwater, Jr, MDa,
Karla G. Christian, MDa,
Javed Butler, MDb,
Don Chomsky, MDb,
John R. Wilson, MDb,
Rick Clark, BSc,
Stacy F. Davis, MDb
a Department of Cardiothoracic Surgery, Vanderbilt University Medical Center and Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
b Department of Medicine (Division of Cardiology), Vanderbilt University Medical Center and Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
c Department of Biomedical Engineering, Vanderbilt University Medical Center, and Nashville Veterans Administration Medical Center, Nashville, Tennessee, USA
Accepted for publication October 20, 2001.
* Address reprint requests to Dr Pierson, Department of Cardiothoracic Surgery, Vanderbilt University Medical Center, Nashville, TN 37232-5734 USA
e-mail: robin.pierson{at}mcmail.vanderbilt.edu
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Abstract
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Repeat sternotomy for left ventricular assist device insertion may result in injury to the right heart or patent coronary grafts, complicating intraoperative and postoperative management. In 4 critically ill patients, left thoracotomy was used as an alternative to repeat sternotomy. Anastomosis of the outflow conduit to the descending thoracic aorta provided satisfactory hemodynamic support.
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Introduction
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Left ventricular assist devices (LVADs) provide lifesaving mechanical support as a bridge to transplant for patients with end-stage heart failure. Their role as an alternative to transplantation, as definitive or "destination" therapy, remains to be established [1, 2].
In some LVAD candidates, the consequences of prior cardiac operations present the surgeon with substantial technical challenges to safe device insertion through repeat sternotomy. The dilated right ventricle may be adherent to the back of the sternum, and injury to the heart, great vessels, or patent coronary bypass grafts may be associated with poor outcome [3], justifying consideration of alternate approaches.
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Technique
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The basic technique and sequence of device implantation is as described previously [4, 5]. Positioning is as for a thoracoabdominal aneurysm repair, exposing both groins for bypass access. External defibrillation pads are placed outside the surgical field. Transesophageal echocardiography is used to assess the descending thoracic aorta, positioning of a two-stage venous cannula from a femoral site, and adequate removal of air during initiation of device support. A double-lumen endotracheal tube facilitates exposure in the left chest. Vasopressin, nitric oxide, and aprotinin are used routinely.
The device pocket is created and a left anterolateral thoracotomy is performed, centered over the cardiac apex in the sixth or seventh intercostal space. The pump pocket and left chest cavities are joined internally by taking down the diaphragm, beginning several centimeters to the right of the xiphoid and extending to the left beyond the anterior axillary line. This method allows maximal flexibility in positioning the device and outflow conduit. Dissection of the right ventricle, acute margin, and apex of the heart away from the anterior chest wall can be minimized if dense adhesions are encountered. Cardiopulmonary bypass is instituted without active cooling. A left ventricular vent placed through the apex (Fig 1)
facilitates exposure to the descending thoracic aorta and prevents cardiac distention and tearing through of apical sewing ring sutures.
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Fig 1. Exposure for outflow conduit anastomosis. Pericardial sutures posterior to the phrenic nerve, left ventricular venting through the apex, and caudad retraction of the diaphragm through the abdominal incision facilitate exposure of the distal descending thoracic aorta for anastomosis (A).
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The inferior pulmonary ligament is divided, exposing the descending thoracic aorta. A large curved retractor with a broad tip (Harrington "Sweet Heart"), introduced and retracted through the abdominal incision, displaces the dome of the diaphragm and abdominal contents inferiorly. A deep, broad-based side-biting clamp (Satinsky or similar) provides vascular control during anastomosis of the outflow conduit to the aorta. If femoral artery cannulation is used, adequate cerebral perfusion should be assured during this step. Using a long length of outflow conduit (17.5 cm before distention, as supplied by Novacor/World Heart, Oakland, CA) facilitates removal of air, allows flexible positioning relative to the inflow conduit, and avoids conduit kinks and tension on the aortic suture line. The aortic anastomosis must be hemostatic, because subsequent access to this area is limited. The outflow conduit is either brought anterolateral relative to the apical inflow conduit (Fig 2),
or inferoposterior, along the diaphragm.
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Fig 2. Device configuration after implantation through left thoracotomy. The outflow conduit may be brought anterior and lateral to the inflow conduit (as shown), or medial and posterior. (Heavy dashed line indicate incisions.)
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As the patient is rewarmed, the sewing ring is affixed to the cardiac apex, bringing the left ventricle vent through the center of the ring to continue cardiac decompression. The pericardium over the cardiac apex is used to buttress the apical cannula insertion sutures, rather than dividing intrapericardial adhesions. After apical coring and securing the inflow conduit in the left ventricle, air is removed from the heart and device, as monitored by transesophageal echocardiography. Inotropic agents are calibrated for right heart support, and the patient weaned from bypass. Polytetrafluoroethylene wrapping of device components may facilitate LVAD explant.
At transplant we have divided and oversewn the outflow conduit at a convenient point in the anterior left hemithorax, and left the trunk of prosthetic material in continuity with the descending aorta.
Left thoracotomy was used as an alternative to repeat sternotomy in 4 patients. Three patients received a Novacor LVAS, and one a HeartMate pneumatic device (ThermoCardio Systems, Woburn, MA). Hemodynamic support was excellent in each instance. Two patients were successfully supported to transplant. One Novacor patient developed Ogilvie’s syndrome, and required right hemicolectomy and ileostomy on post-LVAD day 8. The HeartMate patient required prolonged ventilator support but recuperated fully over 10 months despite multiple TIAs and three console malfunctions.
Two deaths occurred shortly after Novacor insertion despite excellent device function. One patient with five recent ventricular fibrillation arrests despite having an intraaortic balloon pump, an automatic implantable cardioverter/defibrillator, and maximal inotropic support sustained a severe neurologic injury during the operation. A second patient experienced retroperitoneal bleeding associated with heparin-induced thrombocytopenia 4 days after operation, subsequently complicated by bowel infarction and sepsis.
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Comment
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Alternatives to repeat sternotomy have been advocated for reoperative mitral valve surgery, when left ventricular outlet obstruction is not amenable to anterior approaches [6, 7], and for paracorporeal or experimental device support [8–11]. Although we observed major morbidity and a high mortality rate in these high-risk reoperative patients, using the descending thoracic aorta approached through a left thoracotomy for LVAD outflow provided excellent hemodynamic support.
Significant potential drawbacks must be considered before selecting this approach. Arteriosclerosis or aneurysmal disease in the descending thoracic aorta poses obvious hazards for embolism of mural thrombus or atheromatous debris. Prior major lung resection, decortication, or inflammatory pleural disease in the left chest would pose formidable obstacles. If needed, right heart support might be instituted through the femoral vein and left pulmonary artery.
We do not believe that this approach reduces the risk of neurologic complication, as cerebral blood flow and distribution of emboli to the central nervous system are not likely to be significantly different than with ascending aortic outflow.
In conclusion, we believe that this LVAD outflow option should be considered when physiologic or anatomic considerations predict substantial risk for cardiac injury, bleeding, and other complications from repeat sternal incision.
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Acknowledgments
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Financial support was provided by Novacor/World Heart, Inc, Oakland, CA, for costs associated with preparation of the illustrations for this article.
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References
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Abstract
Introduction
