Ann Thorac Surg 2008;85:1650. doi:10.1016/j.athoracsur.2008.02.061
© 2008 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Invited Commentary
Andrew J. Lodge, MD
Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Box 3340, Durham, NC 27710
(Email: andrew.lodge{at}duke.edu).
The use of left ventricular assist devices (LVADs) has become routine practice at many centers around the United States and abroad. This therapy has evolved fairly quickly and the development of new devices has outpaced the regulatory machinery that governs their use. Since the United States Food and Drug Administration approval of the Thoratec Heartmate XVE (Thoratec Corporation, Pleasanton, CA) for destination therapy, there has yet to be another device approved for this purpose. For this reason, as well as the fact that this device remains the only one on the market in which long-term anticoagulation can be avoided, it will continue to be implanted despite its limited durability.
Centers familiar with LVAD implantation for destination therapy have unfortunately also now become familiar with replacement of these devices. This can be a formidable operation. Techniques to simplify it are therefore very desirable and will be sought by many surgeons faced with this challenge. This article by Gregoric and colleagues [1] details their current strategy for replacing the failed Heartmate XVE with the Heartmate II (Thoratec Corporation). They have achieved excellent results using a subcostal approach, completely avoiding the redo median sternotomy in the last 7 patients in their series. This has translated into less blood loss and shorter intensive care unit stays, although it is possible that along with the change in operative approach, other refinements in care have contributed to these improvements.
We have attempted a limited approach in several patients requiring LVAD exchange, and we agree with the authors that avoiding the potential problems with redo sternotomy can be beneficial. The most important of these may be to avoid injury to the right ventricle, which is frequently still dilated and adherent to the sternum. Techniques that may be useful include cannulation of the axillary artery to avoid retrograde femoral perfusion and percutaneous cannulation of the femoral vein for venous drainage for cardiopulmonary bypass to avoid femoral cutdown. One significant concern that arises with more limited access to the heart is avoiding air embolism. Complete air removal during any LVAD implantation can be challenging. Lack of access to the outflow graft or aorta for venting may complicate this procedure. We have used carbon dioxide in the operative field to facilitate air removal in all LVAD procedures. Transesophageal echocardiography is critical in these cases to confirm the complete absence of air.
As with any less invasive approach, more attention to these precautions is necessary to avoid complications that could be associated with less exposure. Notwithstanding these concerns, the authors of this article should be congratulated for their efforts to advance the care of these complex patients.
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References
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- Gregoric ID, Bruckner BA, Jacob L, et al. Clinical experience with sternotomy versus subcostal approach for exchange of the HeartMate XVE to the HeartMate II ventricular assist device Ann Thorac Surg 2008;85:1646-1650.[Abstract/Free Full Text]
Related Article
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Clinical Experience With Sternotomy Versus Subcostal Approach for Exchange of the HeartMate XVE to the HeartMate II Ventricular Assist Device
- Igor D. Gregoric, Brian A. Bruckner, Leon Jacob, Biswajit Kar, William E. Cohn, Saverio La Francesca, and O.H. Frazier
Ann. Thorac. Surg. 2008 85: 1646-1649.
[Abstract]
[Full Text]
[PDF]
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