Ann Thorac Surg 2005;80:745-747
© 2005 The Society of Thoracic Surgeons
How to do it
Anterior Approach to Implant the Jarvik 2000 With Retroauricular Power Supply
Michael P. Siegenthaler, MD
a
,
*
,
Jürgen Martin, MD
a
,
Ralf Gutwald, MD, DMD
b
,
Roderich Bahr, MD
a
,
Stephen Westaby, MD
c
,
Rainer Schmelzeisen, MD, DMD
b
,
Friedhelm Beyersdorf, MD
a
a Department of Cardiovascular Surgery, University of Freiburg, Freiburg, Germany
b Department of Maxillofacial Surgery, University of Freiburg, Freiburg, Germany
c Department of Cardiac Surgery, John Radcliffe Hospital, Oxford Heart Centre, Oxford, United Kingdom
Accepted for publication February 17, 2004.
* Address reprint requests to Dr Siegenthaler, Department of Cardiovascular Surgery, University of Freiburg, Hugstetterstrasse 55, 79106 Freiburg, Germany; (Email: siegenth{at}ch11.ukl.uni-freiburg.de).
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Abstract
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The retroauricular power supply of the Jarvik 2000 (Jarvik Heart Inc, New York, NY) left ventricular assist device is suitable for permanent support, as it is associated with fewer infections than conventional drivelines. Implantation through a left-lateral thoracotomy limits the performance of additional cardiac procedures. We describe a technique that used a sternotomy for the implantation of the Jarvik 2000 with retroauricular power supply in two patients. The retroauricular power supply of the Jarvik 2000 can be provided with an anterior approach, allowing full surgical access to the heart. If the outflow graft to the ascending aorta indeed reduces aortic stasis and thromboembolic events, the anterior approach with retroauricular power delivery might evolve into a standard procedure.
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Introduction
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The permanent Jarvik 2000 (Jarvik Heart Inc., New York, NY) left ventricular assist device (LVAD) with retroauricular power supply has shown encouraging results in patients who need permanent ventricular support [1, 2]. It has a low incidence of infection [3] and unprecedented mechanical reliability without device failures to date. Some patients who need ventricular support require other cardiac procedures, such as closure of a patent foramen ovale, valve procedures, or coronary artery bypass grafting [4, 5]. As such combination procedures are impractical with the standard left-lateral thoracotomy for implantation [6], the option of an anterior approach can be important. We herein describe our surgical technique for the problem of gaining access and routing the power-cable to the retroauricular area by using a sternotomy approach to implant the Jarvik 2000 with retroauricular power connection.
A sternotomy approach for the Jarvik 2000 with retroauricular power supply was used in two patients ineligible for heart transplantation. The first was a 67-year-old man with insulin-dependent diabetes, chronic renal insufficiency, elevated pulmonary vascular resistance (3.8 Wood units), and dilated ischemic cardiomyopathy. He could no longer be cared for at home, despite maximal medical therapy. Coronary angiography showed a high-grade stenosis of his distal right coronary artery and an occluded circumflex coronary artery. Computed tomography showed severe calcifications of the ascending aorta. The decision was made to use a sternotomy for the implantation so that simultaneous bypass grafting to the posterior descending right coronary artery could be performed.
The second patient, a 65-year-old man with insulin-dependent diabetes, had ischemic cardiomyopathy and had undergone recent decortication and right lower lobectomy for an empyema and a destroyed lobe originating from an infected hematoma after pleural punctures. He had a large, residual right-sided effusion owing to incomplete expansion of the remaining lobes. With severe heart failure, he was barely compensated with ascites and tricuspid valve insufficiency grade 3 to 4 that was due to high pulmonary vascular resistance (5.6 Wood units). The decision was made to use a sternotomy to avoid a thoracotomy on the left side and to have surgical access to the tricuspid valve.
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Technique
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Patients are positioned in a 30-degree lateral position for a sternotomy with the left retroauricular area exposed (Fig 1). Because of limited neck mobility, the entire torso is turned with a roll placed under the left chest to gain access to the retroauricular area. The drapes are firmly secured to the skin. A sternotomy and an infraclavicular incision are made, and the retroauricular area for anchorage of the titanium pedestal is prepared. The surgical dissection between the subclavian vein and the clavicle is done under direct vision to reach the subcutaneous space in the lower neck. The subclavian incision is then extended down into the left chest cavity to bring up the power cable from the sternotomy (Fig 2). The curvilinear tunnel to the retroauricular area is fashioned in a strictly subcutaneous plane to allow head motion without strain to the cable and to avoid injury to the crossing accessory nerve. The titanium pedestal is mounted to the parietal bone as usual [6].
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Fig 1. Patient positioning for the anterior approach to implant the Jarvik 2000 (Jarvik Heart, Inc, New York, NY) is shown in a drawing (A) and in an intraoperative photograph (B). Because neck mobility is limited, the entire patient is turned about 30 degrees, with a roll placed under the left chest to gain access to the retroauricular area.
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Fig 2. A 40F chest tube is used to pull the power cable of the Jarvik 2000 (Jarvik Heart, Inc, New York, NY) device from the sternotomy through the second interspace into the infraclavicular incision.
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In the first patient, the anastomosis to the posterior descending coronary artery was performed on cardiopulmonary bypass with the heart resting using cold blood cardioplegia. Because of severe aortic calcification and thickening of the aortic wall, the outflow graft of the Jarvik 2000 was sewn to the ascending aorta using single-clamp technique with continuous Prolene (Ethicon, Somerville, NJ) sutures and felt strips. The aortic clamp was removed, and the insertion of the Jarvik 2000 LVAD into the left ventricular apex was performed on the beating heart, with a short period of ventricular fibrillation as previously described [6]. The proximal coronary bypass anastomosis was then based on the Dacron (DuPont, Wilmington, DE) outflow graft instead of the diseased aorta (Fig 3).
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Fig 3. The surgical view after implantation of the permanent Jarvik 2000 (Jarvik Heart, Inc, New York, NY) shows the Dacron (DuPont, Wilmington, DE) outflow graft from the left-ventricular apex (top left) to the ascending aorta (bottom), as well as the power cable from the retroauricular area (black arrow), which crosses the field from the left chest. Note: the proximal coronary bypass anastomosis (white arrow) to the posterior descending coronary was based on the Dacron outflow graft of the Jarvik 2000 because of calcifications in the ascending aorta.
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In the second patient, the implantation was performed on cardiopulmonary bypass with bicaval cannulation starting with the insertion of the device into the left ventricular apex followed by the outflow graft anastomosis to the ascending aorta by the use of a partial occlusion clamp. After cardiopulmonary bypass, the pulmonary vascular resistance could be lowered to 3.1 Wood units with 40 ppm of nitric oxide and mild hyperventilation. This lead to a reduction of tricuspid regurgitation to grade 1 to 2, and tricuspid valve repair was not required. Postoperatively, both patients had an uneventful surgical recovery.
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Comment
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The permanent Jarvik 2000 is potentially suitable for long-term ventricular support because of a low infection rate [3] and no device failures reported so far, despite support times of up to almost 4 years. Even though a similar power supply has been used in the United States for cochlear implants, to date the retroauricular power supply of this device has been released for clinical investigation only in Europe.
An anterior approach might be required for several reasons. In the first patient, we believed that the surgical revascularization of the right coronary artery was important for long-term right ventricular function. Access to the posterior descending artery through a left thoracotomy could only have been achieved with great technical difficulty, if at all. Implantation of the proximal coronary bypass anastomosis into the Dacron prosthesis was a suitable option, with a potentially better long-term prognosis than implantation into the thickened aorta. The long-term prognosis of saphenous vein grafts implanted into Dacron conduits for the Cabrol procedure have been excellent, even though inferior to the coronary button technique [7].
In the second patient, avoidance of a left thoracotomy in view of the already impaired right-sided lung function with simultaneous access to the tricuspid valve made a sternotomy preferable, even though no tricuspid valve repair was ultimately performed. Other cardiac procedures, such as the closure of a patent foramen ovale, are also more easily performed through a sternotomy and have to be addressed at the time of LVAD implantation [4].
The placement of the power cable under the clavicle deserves mention. In the early pacemaker experience, pacemaker leads were tunneled in a subcutaneous fashion over the clavicle to the external jugular vein, often leading to broken pacemaker wires because of mechanical strain. We strongly believe that the power cable has to be positioned under the clavicle to prevent late wire breaks. An infraclavicular incision with surgical exposure provides a safer approach for tunneling in the anatomically dense apex of the chest than uncontrolled blind maneuvers.
A left-lateral thoracotomy approach is normally used to implant the Jarvik 2000 LVAD with retroauricular power supply [6]. The Jarvik 2000 with abdominal power supply and other axial-flow pumps with similar power delivery, such as the MicroMed Debakey (MicroMed Technology, Houston, TX) and Berlin Heart Incor (Berlin Heart, Berlin, Germany), are commonly implanted through a sternotomy. Our anterior approach allowed the difficult exposure of the retroauricular area and tunneling of the cable for the skull-mounted power supply. This approach might have advantages even if no additional cardiac procedures are needed, as a better washout of the aortic root with an ascending aortic anastomosis, potentially leading to a reduction in thromboembolism, has been described in bridge-to-transplant Jarvik 2000 patients [8]. However, we observed no thromboembolism with a descending thoracic anastomosis in more than 1500 patient days, and such a difference will be difficult to illustrate.
In summary, our implantation technique of the Jarvik 2000 with retroauricular power supply by the use of a sternotomy approach may prove valuable for patients who are ineligible for transplantation and who require additional cardiac operations in addition to device implantation. This technique might evolve into a common procedure if the anastomosis of the Jarvik 2000 outflow graft to the ascending aorta indeed prevents thromboembolism.
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References
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- Westaby S, Banning AP, Saito S, et al. Circulatory support for long-term treatment of heart failureexperience with an intraventricular continuous flow pump. Circulation 2002;105:2588-2591.[Abstract/Free Full Text]
- Siegenthaler MP, Martin J, van de Loo A, Doenst T, Bothe W, Beyersdorf F. Implantation of the permanent Jarvik-2000 left ventricular assist devicea single-center experience. J Am Coll Cardiol 2002;39:1764-1772.[Abstract/Free Full Text]
- Siegenthaler MP, Martin J, Pernice K, et al. The Jarvik 2000 is associated with less infections than the HeartMate left ventricular assist device Eur J Cardiothorac Surg 2003;23:748-755.[Abstract/Free Full Text]
- Baldwin RT, Duncan JM, Frazier OH, Wilansky S. Patent foramen ovalea cause of hypoxemia in patients on left ventricular support. Ann Thorac Surg 1991;52:865-867.[Abstract]
- Potapov EV, Sodian R, Loebe M, Drews T, Dreysse S, Hetzer R. Revascularization of the occluded right coronary artery during left ventricular assist device implantation J Heart Lung Transplant 2001;20:918-922.[Medline]
- Siegenthaler MP, Martin J, Frazier OH, Beyersdorf F. Implantation of the permanent Jarvik-2000 left-ventricular-assist-devicesurgical technique. Eur J Cardiothorac Surg 2002;21:546-548.[Abstract/Free Full Text]
- Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Composite valve graft replacement of the proximal aortacomparison of techniques in 348 patients. Ann Thorac Surg 1992;54:427-437discussion 438–9.[Abstract]
- Frazier OH, Myers TJ, Westaby S, Gregoric ID. Clinical experience with an implantable, intracardiac, continuous flow circulatory support devicephysiologic implications and their relationship to patient selection. Ann Thorac Surg 2004;77:133-142.[Abstract/Free Full Text]
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Abstract
Introduction
