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Ann Thorac Surg 2002;74:234-235
© 2002 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, University of Rostock, Rostock, Germany
b Department of Pediatric Cardiology, University of Rostock, Rostock, Germany
c Department of Anesthesiology, Medical Faculty, University of Rostock, Rostock, Germany
Accepted for publication February 17, 2002.
* Address reprint requests to Prof Steinhoff, Klinik Herzchirurgie, Medizinische Fakultät, Universität Rostock, Schillingallee 35, 18057 Rostock, Germany
e-mail: gustav.steinhoff{at}med.uni-rostock.de
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Introduction |
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We describe the case of a patient with severe heart failure secondary to AM, who was successfully supported by a Thoratec left ventricular assist device [LVAD] (Thoratec Laboratories Corp, Pleasanton, CA). This allowed full recovery of myocardial function and weaning from the device.
A previously healthy 17-year-old girl weighing 55 kg was seen with cardiac decompensation after 10 days of flulike symptoms and bent to collapse. On admittance to our institution, she was hypotensive, systolic blood pressure was 80 mm Hg, and she had tachycardia. Echocardiography showed a pericardial effusion and poor left ventricular (LV) function. The chest roentgenogram demonstrated pleural effusion. After puncture, there was drainage of 2,000 mL of serous pericardial effusion and 1,800 mL of pleural effusion. Repeated transthoracic echocardiography revealed severely impaired LV systolic function, fractional shortening of 15%, and a nondilated ventricle, findings consistent with a diagnosis of acute myopericarditis.
Despite high-dose inotropic support with dobutamine hydrochloride (12 µg · kg-1 · min-1), epinephrine (0.12 µg · kg-1 · min-1), and norepinephrine (0.18 µg · kg-1 · min-1), the patient became progressively hypotensive and oliguric. Hemodynamic data included a right atrial pressure of 20 mm Hg, a pulmonary artery wedge pressure of 19 mm Hg, and a cardiac index of 1.8 L · min-1 · m-2.
Thirty-six hours after admission, the decision was made to implant a Thoratec LVAD because of severe low-output syndrome with hepatorenal failure. This was indicated by a strong rise in aminotransferase and bilirubin levels. After cardiopulmonary bypass was established, the outflow cannula was attached to the ascending aorta and the inflow cannula was placed into the apex of the left ventricle. The LVAD output was set at 4.6 L/min. Endomyocardial biopsy specimens showed parvovirus B19-associated myocarditis.
On the third postoperative day, the patient was mobilized. Twenty-five days later, when she was on a regimen of dopamine hydrochloride (2 µg · kg-1 · min-1), dobutamine (12 µg · kg-1 · min-1), and milrinone, lactate (0.25 µg · kg-1 · min-1) echocardiography showed markedly improved LV contractility and fractional shortening of 42%. Pharmacological treatment comprising propranolol hydrochloride (3 mg-1 · kg-1 · d-1) and enalapril maleate (5 mg/d) was initiated, and a weaning program was started. For this, the support frequency was reduced sequentially, and LV function was evaluated by echocardiography during short stops in 7-day intervals. After 46 days, the LVAD was removed successfully. Echocardiographic examination revealed a LV ejection fraction of 0.77, and the patient was discharged from the hospital. She has been well for 6 months, is in New York Heart Association class I, and has normal LV function.
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We are aware of only four reports [1–4] of patients with AM who were successfully supported by an LVAD with recovery of cardiac function without the subsequent need of transplantation. Patients seen with AM will recover fully without long-term sequelae if they are adequately supported [5]. This raises the question of the role of cardiac transplantation in this disease. A review of voluntary registries of the individual ventricular device companies in addition to a review of the literature reveals that more than 135 patients with myocarditis have been supported by mechanical devices [5]. Most of these patients received either extracorporeal devices (Abiomed, Inc, Danvers, MA; Thoratec, Pleasanton, CA) or extracorporeal membrane oxygenation (ECMO). Intracorporeal LVADs (Thermo Cardiosystems Inc Woburn, MA, Edwards Life Sciences, San Diego, CA) [Novacor] have been used to a lesser extent and are designed primarily as a long-term bridge or a destination therapy. Survival rates with the Abiomed and Thoratec ventricular assist devices (VADs) or ECMO should approach 50% to 70% [5].
At present, three mechanical support systems are available: intraaortic balloon pumping, ECMO, and VADs. Intraaortic balloon pumping is not adequate for the critical situation because the best approach to optimize end-organ function is to institute VAD support or ECMO early, before extended periods of low cardiac output, arrhythmia, or cardiac arrest. For children who require support for AM, Duncan and colleagues [6] prefer ECMO because of its ability to be instituted through peripheral cannulation, the presence of an oxygenator for use in patients with hypoxemia, and the unavailability of centrifugal VAD systems for extended periods of support in pediatric patients in the United States. For older children and adolescents, ECMO has disadvantages such as failure of LV decompression and impossibility of physical mobilization.
To reduce the potentially increased risks associated with biventricular assist device (BVAD) implantation, it is important to decide whether an LVAD or a BVAD is necessary to treat patients with AM. In a multicenter review of 213 Thoratec implants, Farrar and associates [7] demonstrated that severity of renal, hepatic, and respiratory dysfunction was predictive of the need of BVAD. They also suggested that the patient could be supported by an LVAD alone when it was implanted early. We prefer to support these patients with an LVAD alone whenever possible and to aggressively decompress the right ventricle pharmacologically with phosphodiesterase inhibitors and inotropic agents. We add a right VAD only when required. Therefore, either Thoratec or Abiomed devices should be used as bridges to recovery because of their versatility (LVAD, right VAD, BVAD) and ease of removal.
We agree with the conclusion of Levin and co-workers [8] that a process termed reversible remodeling by prolonged mechanical circulatory support can lead to ultimate recovery of ventricular function because of favorable influences on the neurohormonal cardiovascular milieu and unloading of the left ventricle resulting in normalization of ventricular geometry and function. For this reason, we prefer LV apical cannulation for the Thoratec LVADs. Left atrial cannulation is associated with inadequate LV decompression and an increased risk of LV thrombosis and stroke. The use of intravenous gamma globulin is of potential benefit in patients with AM. Steroid administration during the acute phase of the disease can impair viral clearance.
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This article has been cited by other articles:
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  S. G. Drakos, A. G. Kfoury, J. W. Long, J. C. Stringham, E. M. Gilbert, B. D. Horne, M.-B. E. Hagan, K. Nelson, and D. G. Renlund Similar transplantation outcomes in patients bridged with cardiac assist devices for acute cardiogenic shock versus chronic heart failure Eur J Heart Fail, August 1, 2007; 9(8): 845 - 849. [Abstract] [Full Text] [PDF]
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