Ann Thorac Surg 2003;75:297
© 2003 The Society of Thoracic Surgeons
How to do it
Stapled explant of the Jarvik 2000 left ventricular assist device
Michael K. Banbury, MDa*
a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
Accepted for publication July 22, 2002.
* Address reprint requests to Dr Banbury, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F24, Cleveland, OH 44195, USA
e-mail: banburm{at}ccf.org
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Abstract
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Currently the most common indication for placement of a left ventricular assist device is as a bridge to heart transplantation. One of the new generation axial flow left ventricular assist devices is the Jarvik 2000. This device is placed in the apex of the left ventricle and the outflow graft passes through the left pleural space and is anastomosed to the descending thoracic aorta. The course of the outflow graft presents technical challenges during explant for heart transplantation. Opening the posterior pericardium and use of a vascular stapler to control the outflow graft at the level of the descending thoracic aorta facilitates easy explantation.
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Introduction
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After years of research into mechanical circulatory support, many new left ventricular assist devices are now available for clinical trial. The Jarvik 2000 (Jarvik Heart Inc, New York, NY), a new generation axial flow pump, is implanted directly into the apex of the left ventricle.
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Technique
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This implant can be performed through a left thoracotomy using cardiopulmonary bypass. The apex of the left ventricle is cored and the Jarvik pump is placed directly inside the left ventricle. The outflow graft passes through the left chest and is attached to the descending thoracic aorta near the level of the diaphragm. An advantage of this method of implant is using a left thoracotomy in patients who have had prior median sternotomy.
The left thoracotomy implant does pose some disadvantages for explant during median sternotomy in patients for whom the Jarvik 2000 is used as a bridge to transplant. Management of the intrathoracic outflow graft requires careful attention. We have found that stapled closure of the outflow graft at the level of the descending thoracic aorta is a simple and effective way to manage this issue (Fig 1).
The patient is approached through a traditional median sternotomy, heparinized, cannulated, and placed on cardiopulmonary bypass. The apex of the left ventricle is freed up enough to place a clamp across the outflow graft. The outflow graft is then cut flush at the left apex leaving the clamp on the conduit in the chest. The heart is excised in the usual fashion leaving an empty pericardial well. At this point, a vertical incision is made in the posterior pericardium just lateral to the descending thoracic aorta, which is easily palpable. This exposes the area of anastomosis between the outflow graft and the descending thoracic aorta.
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Fig 1. The outflow graft is stapled flush with the aorta. The graft is then cut lateral to the staple line.
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Gentle circumferential dissection is then used to free up 2 cm of the outflow graft. A PI 30-V3 vascular stapler (US Surgical Corp, Norwalk, CT) is then passed aroundthe outflow graft and fired. The intrathoracic portion of the outflow graft is divided and the blood drained from the outflow graft. This leaves only a short stump of prosthetic material attached to the descending thoracic aorta with little residual blood in the outflow graft itself. If implantation is recent enough that the outflow graft is not firmly adherent to the intrathoracic structures, it can easily be pulled into the pericardium by drawing on the clamp attached to the graft at the apex of the pericardium. Orthotopic heart transplant is then carried out in standard fashion. Despite the small residual segment of outflow graft, no associated infectious complications have been identified.
Although still investigational, the Jarvik 2000 may become a standard left ventricular assist device bridge for heart failure. We have used the Jarvik 2000 as an investigational device in patients listed for transplantation and have found that this stapled excision is simple, easy, and effective.
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E. N. Sorensen, R. N. Pierson III, E. D. Feller, and B. P. Griffith
University of Maryland Surgical Experience With the Jarvik 2000 Axial Flow Ventricular Assist Device
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B. Hohlweg-Majert, R. Gutwald, M. P. Siegenthaler, and R. Schmelzeisen
Implantation of the Jarvik 2000 left-ventricular-assist-device: role of the maxillofacial surgeon
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337 - 339.
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Abstract
Introduction
