Ann Thorac Surg 2003;75:607-609
© 2003 The Society of Thoracic Surgeons
How to do it
Off-pump technique for Thoratec left ventricular assist device insertion
Valentino Piacentino, III, PhDa,
Arun K. Singhal, MD, PhDa,
Mahender Macha, MDa,
James B. McClurken, MDa,
Carol A. Fisher, BAa,
Satoshi Furukawa, MD*a
a Department of Surgery, Division of Cardiac and Thoracic Surgery, Temple University Hospital, Philadelphia, Pennsylvania, USA
Accepted for publication July 31, 2002.
* Address reprint requests to Dr Furukawa, Cardiopulmonary Transplantation, 3401 North Broad St, Philadelphia, PA19140, USA
e-mail: furukas{at}tuhs.temple.edu
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Abstract
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We present a case of left ventricular assist device (Thoratec; Thoratec Laboratories Corp, Pleasanton, CA) insertion performed through a left thoracotomy without cardiopulmonary bypass in a patient with severe end-stage congestive heart failure with renal and respiratory dysfunction and a history of multiple cardiac operations.
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Introduction
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Due to an aging population and a rise in the incidence of congestive heart failure, the number of patients awaiting heart transplantation has increased exponentially over the past 10 years [1]. Despite attempts to increase the donor pool, the number of available cardiac allografts remains unchanged [1]. Increased wait times may result in patients becoming refractory to medical therapy and requiring mechanical circulatory support. Indeed, in this country approximately 500 ventricular assist devices were implanted as a bridge to heart transplantation in the year 2000 (Thoratec "Heartbeat" Newsletter, November, 2001).
Insertion of a ventricular assist device normally requires access to the heart through a median sternotomy and circulatory support with cardiopulmonary bypass (CPB). Although a median sternotomy allows simultaneous access to the great vessels and cardiac chambers, this approach may be contraindicated in patients who have had previous cardiac operations. Furthermore, the well-established complications of CPB may exacerbate ongoing multiorgan failure in patients with severe end-stage heart failure awaiting heart transplantation [2]. We present a technique of Thoratec left ventricular assist device (LVAD) (Thoratec Laboratories Corp) insertion through a left thoracotomy without CPB support.
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Technique
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Patient history
A 63-year-old white male presented to Temple University Hospital with combined ischemic and valvular cardiomyopathy and was evaluated for orthotopic heart transplantation. The patient complained of fatigue and shortness of breath at rest. He had previous coronary artery bypass graft operations at 16 and 18 years prior. In addition, he had aortic stenosis and cachexia with a 27 kg weight loss over the past year. Physical examination revealed a 173 cm tall, 56 kg male with a significant systolic murmur and a liver edge that was palpable at the level of the umbilicus. Preoperative laboratory values revealed a creatinine of 1.5 mg/dL, and an alanine aminotransferase of 45 U/L, aspartate aminotransferase of 34 U/L, and alkaline phosphatase of 132 U/L. A transthoracic echocardiogram revealed biventricular dilatation with a left ventricular end-diastolic and left atrial dimension of 9.2 cm and 5.4 cm, respectively. The ejection fraction was approximately 10% to 15% with moderate mitral regurgitation. Preoperative right heart catheterization demonstrated a mean pulmonary artery pressure of 54 mm Hg with a systolic pressure of 76 mmHg. The cardiac index was 1.9 L/min/m2 using Fick’s method. Preoperative angiography revealed patent saphenous vein grafts and critical aortic stenosis (aortic valve area, 0.55 cm2). The decision was made to place an LVAD as a bridge to heart transplantation and allow for long-term circulatory support to decrease pulmonary vascular resistance and associated pulmonary hypertension, and improve nutritional status.
Operative technique
The patient was taken to the operating room for placement of the Thoratec LVAD (Thoratec Laboratories Corp). He was intubated in the supine position with a double-lumen endotracheal tube, and the left common femoral artery and vein were identified and isolated through a groin incision. The patient was then placed in the right lateral decubitus position with outward rotation of the hips. A posterior lateral thoracotomy incision was made, and the sixth intercostal space was entered. The left lung was blocked endobronchially. With single lung ventilation, the inferior pulmonary ligament was divided, and the left lung was retracted. The pericardium was identified, and the heart was remarkable for a globular shape. There was no definitive apex because of the spherical contour of the left ventricle. The area nearest to the apex, approximately 1 cm from the left anterior descending artery, was dissected and exposed. Next, the descending thoracic aorta was exposed, and a segment between the eighth and ninth rib was isolated. The activated clotting time was elevated to more than 1,000 seconds with 25,000 U of heparin sulfate. A 14 mm straight arterial outflow cannula (model #14126-2558-000; Thoratec Laboratories Corp) was placed through a separate left subcostal incision that penetrated just above the diaphragm, and the graft was cut to length. A side-biting clamp was placed on the descending thoracic aorta, and after aortotomy the graft was beveled and sewn with 4-0 Prolene (Ethicon, Somerville, NJ) in a running fashion with a pericardial pledget. The side-biting clamp was released, and air was removed from the entire cannula and graft. An atrial cannula (model #14121–2562–000; Thoratec Laboratories Corp) was used as the inflow cannula to the ventricular assist device. This inflow cannula was introduced through another left subcostal incision, medial to the aortic cannula, and brought into the operative field. A 24-mm hemashield graft was cut to approximately 3 cm and placed around the atrial cannula.
Next we prepared to insert the inflow cannula into the left ventricle. Two pledgeted 2-0 Prolene (Ethicon, Somerville, NJ) purse strings were placed in the previously mentioned left ventricular apical area. The patient was placed in the sharp Trendelenburg position. With a 30 mL balloon Foley catheter ready for occlusion, a stab wound was made into the left ventricle cavity through the middle of the purse strings. This was dilated using a Medtronic 10-mm Trocar (Medtronic, Minneapolis, MN). After complete dilatation, the inflow cannula was placed through the two purse strings into the left ventricle cavity. The purse strings were tightened and tied, and air was removed from the entire cannula. The hemashield graft previously placed around the inflow cannula was now brought down and sewn to the epicardial surface with 4-0 Prolene (Ethicon, Somerville, NJ) in a running fashion, and a silk tie was placed around the graft body onto the cannula. The atrial cannula was connected to the Thoratec LVAD (model # 14086-2550-000; Thoratec Laboratories Corp) inlet side and secured. A clamp on the atrial cannula was slowly released and the LVAD was allowed to fill. The aortic cannula was connected and air was removed by a small stab incision in the outflow graft, which was later closed primarily. After complete removal of air the VAD was started. Immediately the heart became less globular, and right ventricular function improved. Immediately the heart became less globular, and right ventricular function improved, as visualized through the left thoracotomy incision (Fig 1).
LVAD flows of 4.5 to 5 L per minute were observed. Surgical hemostasis was obtained, and protamine was administered. The left lung was reinflated, and the thoracotomy incision was closed in standard fashion (Fig 2). Intraoperative blood product requirements included 3 U of packed red blood cells and 6 U of fresh frozen plasma. Total chest tube output at 24 hours was 2,500 mL.
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Fig 1. Intraoperative view through the left thoracotomy demonstrating successful completion of the outflow graft anastomosis and the left ventricular assist device inflow cannula insertion through the left ventricular apex. Note that the Thoratec atrial cannula (Thoratec Laboratories Corp, Pleasanton, CA) is used as the inflow cannula, and the outflow cannula is the standard Thoratec aortic cannula.
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Fig 2. Postoperative photograph showing the exit and entry sites of the inflow and outflow cannulae, between the thoracic cavity and Thoratec left ventricular assist device (Thoratec Laboratories Corp, Pleasanton, CA).
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Comment
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Many end-stage heart failure patients present with multiple organ dysfunction and may not withstand the rigors of CPB. Implantation of a LVAD reverses low tissue perfusion, unloads the right ventricle, and allows rehabilitation of the deconditioned end-stage heart failure patient who is awaiting heart transplantation [3]. To avoid the adverse sequelae associated with a high risk redo median sternotomy, especially in a patient requiring one at the time of heart transplantation, we approached insertion through a left thoracotomy [4]. Moreover, we avoided manipulating the coronary artery bypass grafts that were patent in this patient. In this particular patient, access to the large globular left ventricle through the thoracotomy was technically simplified compared to either dissection of the apex through a median sternotomy or rotation of the dilated left ventricle for cannulation of the left atrium.
Our decision to implant the LVAD in the absence of CPB was based on literature documenting decreased morbidity and mortality of patients with pulmonary or renal dysfunction, or both, undergoing an off-pump versus on-pump CABG operation [5]. Patients with end-stage heart disease have a high prevalence of these comorbidities. Indeed our patient had significant hepatic and renal impairment and compromised respiratory function. Therefore avoidance of CPB may be especially prudent in the postoperative recovery of this patient cohort [6].
As an immediate result of the implantation, the patient had a mean pulmonary arterial pressure of 34 mm Hg with a systolic pressure of 43 mm Hg and was nourished by tube feedings to accelerate his physical rehabilitation. Extubation occurred on postoperative day 1 and postoperative laboratory values revealed a creatinine of 1.1 mg/dL, an alanine aminotransferase of 41 U/L, aspartate aminotransferase of 72 U/L, and alkaline phosphatase of 46 U/L. Our rehabilitation plan of advancing his diet and rigorous physical therapy was designed to optimize successful heart transplantation and postoperative recovery.
This article describes the implantation of a Thoratec LVAD (Thoratec Laboratories Corp) through a left thoracotomy without CPB in a patient with debilitating end-stage heart disease with previous multiple cardiac operations. This novel approach should be useful in selected patients who would benefit from minimal dissection and the avoidance of the adverse sequelae associated with CPB.
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References
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- Hosenpud J.D., Bennett L.E., Keck B.M., Boucek M.M., Novick R.J. The registry of the International Society for Heart and Lung Transplantation: eighteenth official report—2001. J Heart Lung Transpl 2001;20:805-815.[Medline]
- Hall R.I., Smith M.S., Rocker G. The systemic inflammatory response to cardiopulmonary bypass: pathophysiological, therapeutic, and pharmacological considerations. Anesth Analges 1997;805:766-782.
- Kasirajan V., McCarthy P.M., Hoercher K.J., et al. Clinical experience with long-term use of implantable left ventricular assist devices: indications, implantation, and outcomes. Sem Thorac Cardiovasc Surg 2000;12:229-237.[Medline]
- Pasic M., Bergs P., Hennig E., Loebe M., Weng Y., Hetzer R. Simplified technique for implantation of a left ventricular assist system after previous cardiac operations. Ann Thorac Surg 1999;67:562-564.[Abstract/Free Full Text]
- Cleveland J.C., Jr, Shroyer A.L., Chen A.Y., Peterson E., Grover F.L. Off-pump coronary artery bypass grafting decreases risk-adjusted mortality and morbidity. Ann Thorac Surg 2001;72:1282-1288.[Abstract/Free Full Text]
- Rao V., Oz M.C., Edwards N.M., Naka Y. A new off-pump technique for Thoratec right ventricular assist device insertion. Ann Thorac Surg 2001;71:1719-1720.[Abstract/Free Full Text]
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3(2):
286 - 288.
[Abstract]
[Full Text]
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Abstract
Introduction
