Ann Thorac Surg 2002;74:609-611
© 2002 The Society of Thoracic Surgeons
How to do it
Implantation of biventricular assist devices for chronic heart transplant rejection
Akira Sezai, MDa,
Latif Arusoglu, MDa,
Kazutomo Minami, MD, PhD*a,
Aly El-Banayosy, MDa,
Reiner Körfer, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Ruhr University of Bochum, Bad Oeynhausen, Germany
Accepted for publication March 20, 2002.
* Address reprint requests to Dr Minami, Georgstr, 11, 32545 Bad Oeynhausen, Germany
e-mail: akisez{at}eagle.ocn.ne.jp
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Abstract
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Mechanical circulatory support has been used to treat graft failure caused by rejection after heart transplantation, but the prognosis remains bleak. Organ failure induced by the addition of or an increase in immunosuppressive medication is known to be a cause of the poor outcomes. Thus we tried a new therapeutic technique that allows complete withdrawal of immunosuppressive medication, as the donor heart is removed and circulatory support is maintained with a biventricular assist device.
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Introduction
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In recent years, heart transplantation has provided a stable long-term outcome with the introduction of cyclosporine and OKT3 (murine monoclonal antibodies). A total of 1,122 heart and/or lung transplantations were performed at our institution from 1989 to 2000, with a 5-year survival rate of 69.4% and a 10-year survival rate of 51.7%. Although the number of heart transplantations has recently decreased because of a shortage of donor organs, heart transplantation is still considered the most effective surgical therapy for end-stage heart failure. On the other hand, rejection and infection are serious complications after heart transplantation; rejection-related problems have remained unsolved. Rejection is treated by the addition of or increases in immunosuppressive medications, and graft failure caused by rejection is usually treated with an intraaortic balloon pump and further with a ventricular assist device (VAD). However, many patients die if multiple-organ failure resulting from organ damage caused by immunosuppressive therapy, and the prognosis remains poor [1].
We describe the removal of an entire donor heart from a 21-year-old woman with graft failure caused by chronic rejection. The purpose was to allow complete withdrawal of immunosuppressive medication. The patient received a biventricular assist device for circulatory support. We have observed a good result with this new therapeutic technique, and our findings are reported here.
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Technique
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Heart transplantation was performed at our institution according to the method described by Lower and Shumway [2]. The transplanted heart was removed from the aorta, the pulmonary artery, bilateral atrial walls and the atrial septum to restore the pretransplantation state. The left and right atriums were formed with Hemashield grafts (Meadox Medicals Inc, Oakland, NJ) as compliance chambers. The Hemashield grafts were sutured to both atriums, and the inflow cannulas of the left and right VADs were inserted into each end of the graft and ligated with a silk suture. The outflow cannula of the left VAD and that of the right VAD were anastomosed end-to-end to the ascending aorta and the pulmonary artery, respectively (Fig 1).
For mechanical circulatory support, we used a Thoratec VAD (Thoratec Corporation, Pleasanton, CA) as a biventricular assist device. The Thoratec outflow conduit was wrapped with a Hemashield graft to prevent bleeding [3]. We do this because of the high porosity of Thoratec outflow’s conduit. The patient was followed up for 8 months postoperatively and received no immunosuppressive therapy.
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Fig 1. The left atrium (LA) and the right atrium (RA) were formed with Hemashield grafts as compliance chambers, and the inflow cannulas of the left and right ventricular assist devices were inserted into each end of the graft and ligated with a silk suture. The outflow cannulas of the left and right ventricular assist devices were anastomosed end-to-end to the ascending aorta and the pulmonary artery (Pulm. artery), respectively.
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Comment
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Rejection after heart transplantation is usually treated with an intraaortic balloon pump and mechanical circulatory support with a VAD if graft failure or right heart failure occurs. Circulatory support with a VAD can improve the state of the donor heart with graft failure in the early period after transplantation or can be useful as a bridge to retransplantation. However, donor hearts cannot be expected to recover in the presence of graft failure caused by chronic rejection because long-term immunosuppressive therapy causes organ damage [1]. Recovery from such chronic graft failure has not been reported.
There have been only a few review articles on mechanical circulatory support after heart transplantation. Marks and co-workers [4] used mechanical circulatory support in 10 patients in the early posttransplantation period. Patients were able to survive nonspecific graft failure, perioperative infarction, or bleeding, but none survived rejection. We [1] treated 25 similar patients (acute rejection, 9; primary graft failure, 7; acute right heart failure, 7; chronic rejection, 2) with mechanical circulatory support but observed no satisfactory outcomes. Although 5 patients were weaned from mechanical circulatory support and 2 underwent retransplantation, 18 patients (72%) died of multiple-organ failure. Only 1 patient with acute rejection survived; no patient with chronic rejection lived.
The patient discussed here had development of chronic rejection 5.5 years after heart transplantation. Despite additional immunosuppressive therapy with FK506 and rapamycin, she had acute renal failure, defined as blood urea nitrogen level of 148 mg/dL and a creatinine level of 6.15 mg/dL. The patient eventually required hemodialysis. Liver dysfunction, defined as a total bilirubin level of 2.0 mg/dL, a glutamic oxaloacetic transaminase level of 224 U/L, and a glutamic pyruvic transaminase level of 369 U/L, was also detected. Because graft failure and low output syndrome consecutively developed, circulatory support with a biventricular assist device was performed using a centrifugal pump (Bio-Medicus BP-80; Medtronic-BioMedicus, Inc, Eden Prairie, MN). Although her hemodynamic status could be maintained at a stable level, the donor heart showed no recovery, indicating the need of long-term mechanical circulatory support and use of immunosuppressive therapy. We decided to apply our new technique. Postoperatively, hemorrhage was controlled, and the drainage tube was removed on day 5. The patient was in hemodynamically stable condition, and central venous pressure was 6 to 8 mm Hg. Presently the flow in the left VAD is 5 to 6 L/min and that of the right VAD, 4 to 5 L/min. Hepatic and renal functions have recovered. Anticoagulation consists of warfarin sodium and clopidogrel bisulfate and is set at an international normalized ratio of 2.5 to 3.5. This is the same anticoagulant therapy as the protocol originally conducted at our institution for the Thoratec device. After implantation, there were no complications (thromboembolism, hemorrhage, infection, sucking of the Hemashield graft). The patient was discharged 3 months after implantation and has survival for more than 9 months since that procedure. She is waiting for heart transplantation.
Of the various VADs, we have used Novacor (Edwards Lifesciences, Irvine, CA), HeartMate (Thermo Cardiosystems Inc, Woburn, MA), and Thoratec devices as bridges to heart transplantation for patients who require long-term support [5]. Among these devices, the Thoratec system has proved to be effective for biventricular heart failure, and more than 60% of patients implanted with a Thoratec device eventually undergo heart transplantation [5–7].
We decided to remove the entire donor heart and to implant a biventricular assist device in our patient because we have observed deaths caused by multiple-organ failure resulting from continual administration of immunosuppressive therapy for chronic rejection, even when hemodynamics could be stabilized mechanically. Because the donor heart is completely removed in our technique, total withdrawal of immunosuppressive medication is a great advantage.
Recently, the AbioCor was implanted as a total artificial heart in humans for the first time, and various total artificial hearts have been developed for clinical use. At present, the CardioWest total artificial heart (CardioWest Technologies, Inc, Tucson, AZ) is applicable for clinical use. We did not choose it for our patient because at the time, we had not yet introduced it at our institution. A recent report by Copeland and associates [8] with long-term results for the CardioWest as a total artificial heart indicates it is an effective device as a bridge to transplantation. However, the console of the CardioWest is so large, that the patient cannot be discharged. On the other hand, use of a small sized Thoratec console (TLC-II) is considered superior in times of quality of life because the patient can be discharged under careful management. In that same report, Copeland and associates [8] presented a comparative study of the Novacor, CardioWest, and Thoratec systems as bridging devices to transplantation and concluded that the Novacor and CardioWest devices should be selected for patients with a body surface area of greater than 1.7 m2 and the Thoratec device for those with a body surface area of 1.7 m2 or less. We believe that our technique is beneficial for patients awaiting retransplantation because of therapy-refractory rejection.
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References
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- Tenderich G., Körner M.M., Stuettgen B., et al. Mechanical circulatory support after orthotopic heart transplantation. Int J Artif Organs 1998;21:414-416.[Medline]
- Lower R.R., Shumway N.E. Studies on orthotopic transplantation of the canine heart. Surg Forum 1960;11:18-20.[Medline]
- Minami K., Arusoglu L., Koyanagi T., El-Banayosy A., Körner M.M., Körfer R. Successful implantation of Thoratec assist device: wrapping of outflow conduit in Hemashield graft. Ann Thorac Surg 1997;64:861-862.[Abstract/Free Full Text]
- Marks J.D., Karwande S.V., Richenbacher W.E., et al. Perioperative mechanical circulatory support for transplantation. J Heart Lung Transplant 1992;11:117-128.[Medline]
- Minami K., El-Banayosy A., Sezai A., et al. Morbidity and outcome after mechanical ventricular support using Thoratec, Novacor, and HeartMate for bridging to heart transplantation. Artif Organs 2000;24:421-426.[Medline]
- El-Banayosy A., Arusoglu L., Kizner L., et al. Predictors of survival in patients bridged to transplantation with the Thoratec VAD device; a single-center retrospective study on more than 100 patients. J Heart Lung Transplant 2000;19:964-968.[Medline]
- Körfer R., El-Banayosy A., Arusoglu L., et al. Single-center experience with the Thoratec ventricular assist device. J Thorac Cardiovasc Surg 2000;119:596-600.[Abstract/Free Full Text]
- Copeland J.G., III, Smith R.G., Arabia F.A., et al. Comparison of the CardioWest total artificial heart, the Novacor left ventricular assist system and the Thoratec ventricular assist system in bridge to transplantation. Ann Thorac Surg 2001;71:S92-S97.[Abstract/Free Full Text]
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Abstract
Introduction
