Ann Thorac Surg 2006;82:1547-1548
© 2006 The Society of Thoracic Surgeons
How To Do It
Minimally Invasive Technique for Explantation of Right Ventricular Assist Devices
Saleem M. Haj-Yahia, MD, BSa,b,c,
Emma J. Birks, MRCP, PhDa,b,c,
James Hardy, MBBS, BSc,
Magdi H. Yacoub, FRSb,c,
Asghar Khaghani, FRCSa,b,*
a Royal Brompton & Harefield Hospital, Harefield, London, United Kingdom
b National Heart & Lung Institute, Imperial College, London, United Kingdom
c Magdi Yacoub Institute, Harefield Heart Science Centre, London, United Kingdom
Accepted for publication October 13, 2005.
* Address correspondence to Dr Khaghani, Director of Transplantation and Mechanical Circulatory Support Surgery, Harefield Hospital, Hill End Rd, Harefield, Middlesex, UB9 6JH United Kingdom (Email: a.khaghani{at}rbh.nthames.nhs.uk).
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Abstract
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In an attempt to reduce some or all of the complications resulting from the use of biventricular assist devices after mechanical circulatory support, we have developed and applied a minimally invasive technique for explantation of right ventricular assist devices.
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Introduction
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A significant number of patients undergoing mechanical circulatory support require biventricular assist device insertion for a variable period of time before the right ventricle recovers. This period can become extended for several weeks allowing firm healing of the skin and sternum as well as development of firm vascular adhesions. Explantation of the right ventricular assist device (RVAD) through a median sternotomy at this stage could be associated with increased morbidity and mortality due to excessive bleeding, hemodynamic instability, or infection at what could be considered a crucial stage of recovery.
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Technique
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To facilitate subsequent RVAD removal, should right heart recovery occur, the RVAD inflow and outflow cannulas are positioned in the right pleural space. The technique consists of a small (
6 cm) right anterior thoracotomy through the 4th intercostal space (Fig 1), dissecting and exposing the outflow and inflow cannulas of the RVAD (Fig 2a). After full heparinization the RVAD is switched off, the inflow cannula is removed from the right atrium (Fig 2b), followed by division of the Dacron (Thoratec Laboratories Corp, Pleasanton, CA) outflow graft leaving a stump of 4 cm on the pulmonary artery, which is oversewn (Figs 2c, 2d). The device inflow and outflow cannulas are then pulled (using sharp sustained tension on the tube as well as tugging), and are explanted without splitting the sternum. The minithoracotomy is closed in layers and the cannula exit sites are left open to drain (Fig 2e).
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Fig 1. Showing sites of minimally invasive incision (dashed line) and the position of the right ventricular assist device and inflow and outflow cannulas.
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Fig 2. (a) Dissection and identification of inflow and outflow cannulas through a single minimally invasive right anterior thoracotomy incision. (b) Removal of the inflow cannula after heparinization and switching off the right ventricular-assist device. (c) Clamping the outflow cannula proximal to the pulmonary artery. Dividing the Dacron (Thoratec Laboratories Corp, Pleasanton, CA) outflow graft, leaving a stump of 4 cm, which is oversewn. (d) Both cannulas are pulled out by traction. (e) The minithoracotomy is closed in layers and the cannula exit sites are left open to drain.
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Comment
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This technique was successfully used in 3 patients with Thoratec RVADs (Thoratec Laboratories Corp, Pleasanton, CA) and intraperitoneal Heartmate I LVADs in 2 patients, and a Thoratec biventricular assist device in the third patient. The interval between implantation and explantation was 58, 50, and 33 days, respectively. The operative and postoperative courses were uneventful in all patients. No perioperative blood products were needed in 1 patient, and 1 unit was needed in the second patient, and 5 units of blood were needed in the third patient, who also needed continuous anticoagulation for having a Thoratec LVAD. All patients had less than 3 days of intensive care unit stay and continued to improve and recover with LVAD support combined with pharmacologic therapy (the Harefield protocol [1]). Explantation of the LVAD in the first patient was achieved after 184 days, using another minimally invasive method previously described [2]. The second patient continues to be supported by the LVAD after 99 days of support, and the third patient was transplanted 340 days later.
We conclude that RVAD explantation can be accomplished by a simple and safe technique, which could contribute to improving the outcome in patients requiring biventricular assist device support.
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References
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- Yacoub MH. A novel strategy to maximize the efficacy of left ventricular assist devices as a bridge to recovery Eur Heart J 2001;22:534-540.[Free Full Text]
- Tansley P, Yacoub MH. Minimally invasive explantation of left ventricular assist devices J Thorac Cardiovasc Surg 2002;124:189-191.[Free Full Text]
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Abstract
Introduction
