Ann Thorac Surg 2007;84:301-302
© 2007 The Society of Thoracic Surgeons
How To Do It
Reinforcement of Left Ventricular Assist Device Outflow Grafts to Prevent Kinking
William E. Cohn, MDa,b,*,
Igor D. Gregoric, MDa,
O.H. Frazier, MDa,b
a Center for Cardiac Support, Texas Heart Institute at St. Luke’s Episcopal Hospital, Houston, Texas
b Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
Accepted for publication October 3, 2006.
* Address correspondence to Dr Cohn, Texas Heart Institute at St. Luke’s Episcopal Hospital, PO Box 20345, MC 2-114A, Houston, TX 77225-0345 (Email: wcohn{at}heart.thi.tmc.edu).
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Abstract
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Because of their small size, rotary left ventricular assist devices (LVADs) can be implanted through several alternative approaches, including transdiaphragmatic LVAD insertion through a left subcostal incision with anastomosis of the outflow graft to the retroperitoneal supra-celiac aorta and a left thoracotomy approach with anastomosis to the descending thoracic aorta. More recently we have added a counter-incision to allow the outflow graft of a transdiaphragmatic LVAD to be tunneled through the right chest and anastomosed to the ascending aorta. However, constructing a tension-free, nonkinking lie of the outflow graft can be challenging. We have found that placing a 10-cm to 15-cm length of polytetrafluoroethylene graft coaxially over the LVAD outflow graft ensures a smooth, kink-free lie. Thus far 12 patients have undergone reinforcement of the LVAD outflow graft prior to graft-to-aorta anastomosis. In all cases, graft lie was facilitated and kinking was eliminated.
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Introduction
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The field of mechanical left ventricular assist has expanded dramatically during the past 2 decades. The introduction of smaller, more reliable rotary blood pumps has allowed the development of several alternate approaches for implantation that avoid redo sternotomy in patients undergoing reoperation. These new approaches have the potential to be less invasive in appropriately selected patients and can often be performed without cardiopulmonary bypass. Examples include transdiaphragmatic left ventricular assist device (LVAD) insertion through a left subcostal incision with anastomosis of the outflow graft to the retroperitoneal supraceliac aorta in 8 patients and LVAD insertion through a left thoracotomy with anastomosis to the descending thoracic aorta in 6 patients. More recently we have added a second counter-incision in 3 patients to allow the outflow graft of a transdiaphragmatic LVAD to be tunneled through the right chest and anastomosed to the ascending thoracic aorta [1–3]. Although we have found each of these approaches valuable, unacceptable lie of the outflow graft may be problematic. Given the variability of anatomical and geometric relationships in some patients, constructing a tension-free, nonkinking lie of the outflow graft can be challenging. Early in our experience, 3 patients required reoperation for kinks that developed in the postoperative period. In this report we describe a method of reinforcing the outflow graft to minimize the chance of outflow graft kinking and obstruction.
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Technique
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Externally supported polytetrafluoroethylene (PTFE) comes in a variety of diameters and lengths. We have found that placing a 10-cm to 15-cm length of this material coaxially over the LVAD outflow graft before constructing the graft-to-aorta anastomosis ensures a smooth, kink-free lie of the graft. It is important that the internal diameter of the PTFE be only slightly greater than the external diameter of the outflow graft. For the Jarvik 2000 LVAS (Jarvik Heart Inc, New York, NY), a 20-mm externally supported graft fits the 16-mm outflow graft well. The semi-rigid rings in the graft wall prevent the outlet from kinking and decrease the chance of outflow kinking by the chest wall or abdominal viscera. The PTFE graft is tacked to the LVAD outlet to ensure coverage of the entire graft. The nontwisted lie of the outflow graft within the PTFE is confirmed by observing the orientation of the marking lines. Both grafts are divided after stretching the outflow graft to its pressurized length, and the anastomosis to the aorta is performed. Conversely the PTFE graft can be incised longitudinally and placed around the outflow graft after completion of the distal anastomosis.
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Comment
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We have used this technique to facilitate graft lie in 12 cases and have eliminated the occurrence of outflow graft kinking (Figs 1, 2A,
2B). We believe outflow graft reinforcement is an essential step in performing LVAD insertion when the descending thoracic or supraceliac aorta are used.
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Fig 2. Computed tomographic scans of a left ventricular assist device (LVAD) outflow graft showing (A) the kinked LVAD outflow graft before reoperation and revision, and (B) acceptable lie after the graft is reinforced with the coaxially placed PTFE graft.
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Acknowledgments
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The author would like to acknowledge Marianne Mallia, ELS, for her editorial assistance in the preparation of this article.
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References
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- Frazier OH, Shah NA, Myers TJ, Robertson KD, Gregoric ID, Delgado R. Use of the Flowmaker (Jarvik 2000) left ventricular assist device for destination therapy and bridging to transplantation Cardiology 2004;101:111-116.[Medline]
- Frazier OH. Implantation of the Jarvik 2000 left ventricular assist device without the use of cardiopulmonary bypass Ann Thorac Surg 2003;75:1028-1030.[Abstract/Free Full Text]
- Frazier OH, Gregoric ID, Cohn WE. Initial experience with non-thoracic, extraperitoneal, off-pump insertion of the Jarvik 2000 heart in patients with previous median sternotomies J Heart Lung Transplant 2006;25:499-503.[Medline]
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Abstract
Introduction
