Ann Thorac Surg 2003;76:611-614
© 2003 The Society of Thoracic Surgeons
Case report
A strategy of hypothermic circulatory arrest for difficult heart transplant postventricular assist device
Eric Charbonneau, MDa,
Paul J. Hendry, MDa,
Fraser D. Rubens, MDa,
Frederic Collart, MDb,
Vlad Gariboldi, MDb,
Thierry G. Mesana, MD, PhD*a,b
a Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
b Unité de Chirurgie Cardiaque, Centre Hospitalier de la Timone, Marseille, France
Accepted for publication January 23, 2003.
* Address reprint requests to Dr Mesana, University of Ottawa Heart Institute, 40 Ruskin St, Room 213, Ottawa, Ontario K1Y 4W7, Canada
e-mail: tmesana{at}ottawaheart.ca
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Abstract
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Donor heart and ventricular assist device excision can be extremely difficult at the time of heart transplant. We present a strategy of hypothermic circulatory arrest established with ventricular assist device cannulas for difficult heart transplants. The device inlet or outlet cannulas already in place, or both, are used to complement the safe cannulation sites available. This approach permits controlled excision of the recipient heart and device, easy access to convert to standard ascending aorta and bicaval cannulation, and minimizes the donor graft anoxia time. Two case reports are presented.
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Introduction
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Ventricular assist devices are established therapeutic modalities as bridges to transplant [1] in selected patients [2]. Ventricular assist device (VAD) implantation, reopening for bleeding, and the severe intrinsic inflammatory response to implanted foreign surfaces can create a hostile anterior mediastinum at the time of heart transplant. The safely accessible central and peripheral cannulation sites may not offer acceptable flow for complete cardiopulmonary support. In these circumstances, the inlet or outlet cannulas, or both cannulas, of the ventricular assist device already in place may be easily used to complement or replace the initial cannulation sites. Hypothermic circulatory arrest then permits efficient and controlled recipient heart and device excision, and access for standard cannulation is easily gained. The donor heart is grafted while rewarming.
We aim to describe a surgical strategy permitting safer and faster heart transplant procedure in difficult circumstances. Two cases are presented.
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Case reports
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Patient 1
A 32-year-old man with idiopathic acute end-stage heart failure presented with fatal arrhythmias and was rapidly resuscitated with an extracorporeal membrane oxygenator. Subsequently, a Thoratec biventricular assist device (Thoratec Corporation, Pleasanton, CA) was inserted with cannulation through a standard right atrium to the pulmonary artery for the right VAD and left ventricular apex to the ascending aorta for the left VAD. His evolution was complicated by five reopenings for bleeding. The heart transplant was performed after a 2-month recovery from multiple organ dysfunctions. The right femoral artery and vein were cannulated before median resternotomy. A severe 2-cm thick inflammatory reaction of the anterior mediastinumresulted in inaccessibility to the right atrium and ascending aorta. The femoral cannulation allowed a maximal flow of only 2 liters per minute. The biventricular assist device support was stopped, the inlet cannula of the right VAD was cannulated to augment venous return and full flow (70 mL/kg/min) was established for cooling to 12° C. Hypothermic circulatory arrest was established and the patient exsanguinated. In a bloodless and motionless setting, the heart magma was entered at the level of the right atrium and right ventricle junction. The right atrium was opened and the two vena cava cuffs were tailored. The ascending aorta and pulmonary artery were retrieved, the atrial septum transected and the left atrial cuff prepared. The left ventricle was detached from the inflow cannula, and a clear posterior plane permitted rapid manual extraction of the right and left ventricles. The aorta was cross clamped, and cardiopulmonary bypass was reestablished after 17 minutes with double venous and the left VAD outlet cannula. The patient was rewarmed during the bicaval orthotopic heart transplant. Weaning from cardiopulmonary bypass required dobutamine (7.5 µg/kg/min), which was weaned on day 5. Total cardiopulmonary bypass time was 162 minutes, including 45 minutes of cooling, 17 minutes of hypothermic circulatory arrest, 48 minutes of rewarming, and 52 minutes of reperfusion. The hemostasis required packed red cells (9 U), platelets (18 U), fresh frozen plasma (12 U), and cryoprecipitates (10 U). The total operative time was 6 hours and 52 minutes. The postoperative bleeding was 900 mL. The recovery was complicated by staphylococcus pneumonia. The patient left the hospital 21 days after transplantation. He is presently living a normal life 3 years after transplantation.
Patient 2
A 12-year-old girl with idiopathic acute end-stage heart failure on Thoratec left VAD assistance for 1 month, complicated with two early reopenings for bleeding, underwent heart transplant. The femoral vessels were too small for cannulation. At repeat median sternotomy, severe inflammatory changes were encountered. Cardiopulmonary bypass was established with right atrial and distal aortic arch cannulation. Compromised cerebral flow was detected by transcranial Doppler echocardiography and electroencephalogram. The left VAD support was stopped, the arch was decannulated, and the left VAD outlet cannula was cannulated to establish cardiopulmonary bypass with proper full flow (80 mL/kg/min) and uncompromised cerebral perfusion for cooling to 20° C. A 21-minute hypothermic circulatory arrest permitted safe cardiectomy and device excision using a similar strategy as in patient 1. The ascending aorta was cross clamped below the left VAD outflow graft insertion site, and rewarming was performed through double venous and left VAD outflow cannula while grafting the donor heart.
Total cardiopulmonary bypass time was 194 minutes, including 40 minutes of cooling, 21 minutes of hypothermic circulatory arrest, 65 minutes of rewarming, and 68 minutes of reperfusion. The patient was easily weaned off cardiopulmonary bypass in normal sinus rhythm with milrinone (0.5 µg/kg/min) and dobutamine (7.5 µg/kg/min), which also were weaned after 48 and 96 hours, respectively. The intraoperative and postoperative hemostasis required packed red cells (7 U), platelets (15 U), fresh frozen plasma (9 U), and cryoprecipitates (10 U). The total operative time was approximately 7 hours, 30 minutes. The total amount of postoperative bleeding was 1,230 mL. The patient recovery was complicated by pseudomembranous colitis. She left the hospital on postoperative day 14. She is now 1 year posttransplantation and is leading a normal life (including the ability to resume ballet lessons) (Fig 1).
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Fig 1. Schematic representation of the precardiectomy and postcardiectomy cannulation strategy for patients 1 and 2. (CPB = cardiopulmonary bypass; LVAD = left ventricular assist device; RVAD = right ventricular assist device.)
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Comment
With the increasing use of VADs, the surgeons are commonly faced with difficult and risky recipient preparation at the time of heart transplant. Difficult cardiectomy exposes the patient to greater risk of bleeding, embolic events, hemodynamic instability, and longer graft anoxia. Access to the right atrium and the ascending aorta can be problematic, and femoral cannulation [3] can lead to suboptimal flow. Meticulous and lengthy dissection on the anticoagulated patient is often needed to gain access to the right atrium and ascending aorta. A significant amount of blood may have to be salvaged through a cell saver or through the cardiopulmonary bypass circuit leading to further coagulopathy. End-organ perfusion may be compromised in a bleeding and hypovolemic patient even if VAD supported. Alternatively, a strategy of short hypothermic circulatory arrest [4], established using VAD cannulas already in place to complement or replace the safe cannulation sites available, can be used for faster and safer recipient preparation. A bloodless, motionless, tension-free surgical field and a relatively adhesion-free posterior pericardium allow for efficient cardiectomy and device extraction. Standard ascending aorta and bicaval cannulation can then easily be established. Rewarming is performed while grafting the donor heart and does not prolong perfusion time. We believe this approach provides a safer, faster, and more controlled excision of the recipient heart and device, and we believe that our strategy should be considered in difficult circumstances.
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References
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- Farrar D.J. The Thoratec ventricular assist device: a paracorporeal pump for treating acute and chronic heart failure. Semin Thorac Cardiovasc Surg 2000;12:243-250.[Medline]
- El-Banayosy A., Arusoglu L., Kizner L., Tendrich G., Boethig D., Minami K. 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]
- Merin O., Silberman S., Brauner R., et al. Femoro-femoral bypass for repeat open-heart surgery. Perfusion 1998;13(6):455-459.[Abstract/Free Full Text]
- Kouchoukos N.T., Masetti P., Rokkas C.K., Murphy S.F., Blackstone E.H. Safety and efficacy of hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta. Ann Thorac Surg 2001;72:699-707.[Abstract/Free Full Text]
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Abstract
Introduction
