Ann Thorac Surg 2009;87:1623-1624. doi:10.1016/j.athoracsur.2008.09.024
© 2009 The Society of Thoracic Surgeons
How To Do It
Use of an Inexpensive Blue Band During Ventricular Assist Device and Total Artificial Heart Placement Facilitates and Expedites Explantation During Heart Transplant
Dawn E. Jaroszewski, MD, MBA*,
Jesse J. Lackey, FA,
Louis A. Lanza, MD,
Patrick A. DeValeria, MD,
Francisco A. Arabia, MD, MBA
Department of Cardiothoracic Surgery, Mayo Clinic, Phoenix, Arizona
Accepted for publication September 3, 2008.
* Address correspondence to Dr Jaroszewski, Department of Cardiothoracic Surgery Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ 85054 (Email: jaroszewski.dawn{at}mayo.edu).
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Abstract
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Ventricular assist devices and total artificial hearts are now being used routinely as a bridge to heart transplantation. Reoperation is often weeks to months from implantation. Difficulty dissecting mediastinal and cardiac structures is often encountered due to adhesion formation that prolongs operative time. A temporary, flexible, rectangular-shaped polyisoprene blue band is used to encircle major vascular structures. We have found that this facilitates identification, reduces adhesion formation, and expedites device removal at the time of heart transplantation.
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Introduction
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Univentricular and biventricular support devices (VAD) and total artificial hearts (TAH) are used successfully as bridges to transplantation [1–5]. These devices can be installed in different configurations; however, a uniform problem of a reoperative field at the time of transplant is encountered. When the devices are intended as a bridge to transplant, pericardial polytetrafluoroethylene (PTFE) sheets have been used to help prevent extensive formation of adhesions [6]. Despite this, difficulty dissecting out major vascular and mediastinal structures occurs.
As an alternative to the more costly PTFE or other surgical membranes, simple latex-free, 1-cm polyisoprene blue band strips, or blue band identifiers (BBI; Bioseal, Placentia, California), are inexpensive and easily sterilized for temporary use in the chest. The blue color facilitates identification of mediastinal vascular structures. This simple addition has greatly facilitated explantation and reduced the time required for reoperative dissection at time of transplant. No adhesions are formed at the sites where the BBIs are placed.
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Technique
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Nine patients underwent implantation of ventricular support devices: 5 had Syncardia TAH (Syncardia Systems Inc, Tucson, AZ), 2 had Heartmate II LVAD (Thoratec, Pleasanton, CA), 2 had Thoratec iVAD, and 1 had Heartmate I LVAD. The mean VAD/TAH support time and duration of implantation of the BBI was 31 days (range, 9 to 68 days).
After placement of the VAD/TAH support device has been completed, the patient is weaned from cardiopulmonary bypass by allowing the VAD/TAH to take over the circulation. The 1-cm strips of solid, latex-free polyisoprene blue bands are cut to 9 cm each for use. Three 1- x 9-cm bands are then placed into standard sterilization packaging and undergo gas sterilization (Sterrad 100S Sterilization System; Johnson & Johnson, Irvine, CA) for use during the procedure.
The superior vena cava, if not previously dissected free, is circumferentially freed of pericardial attachments and encircled with a BBI. Surgiclips (Autosuture Premium Surgiclip II M-9.75; US Surgical, Norwalk, CT) are then applied along the edge of the band to approximate the edges together. The inferior vena cava is also encircled. As a final step, the aorta is dissected free of the pulmonary artery posteriorly and encircled with the third BBI, which is clipped to approximate the edges (Fig 1). A Preclude Pericardial Membrane (W. L. Gore & Assoc, Flagstaff, AZ) is then placed to cover the VAD and cannulae to prevent adhesions to the device. Decannulation is performed, and the sternum and overlying tissues are closed in the standard fashion.
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Fig 1. Blue band identifiers are shown encircling the inferior vena cava (IVC), superior vena cava (SVC), and the aorta.
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At transplant, a redo sternotomy is performed and the BBIs are easily identified around the encircled vessels. The clips on the identifiers are removed, and a small hole is punched into one end. There are no adhesions between the encircled vessel and surrounding tissues. A single umbilical tape is then threaded and tied through the hole. (Fig 2). When the BBI is pulled out, the umbilical tape then surrounds the vessels and can be used as a tourniquet for bypass on the inferior and superior vena cavas. Similarly, an umbilical tape can be pulled around the aorta with the use of the BBI. No further aortic dissection is required because the BBI prevents adhesions between the aorta and pulmonary artery, facilitating cross clamping. Dissection of adhesions to the heart and remainder of the mediastinum can now be performed with control of the vessels and should emergency cannulation and bypass be required, the field is ready.
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Fig 2. Diagram demonstrates use of the blue band identifiers to place umbilical tapes for tourniquets. (IVC = inferior vena cava; SVC = superior vena cava; PA = pulmonary artery.)
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Comment
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The use of the BBIs has greatly facilitated safe and expeditious dissection. We have not had any infections related to their use in 9 patients. Furthermore, it provides easy identification of major vascular structures where control is required. No adhesions formed around the BBI and therefore reduced explantation time of VAD/TAH during the heart transplant procedure. There are other types of synthetic materials that can probably be used temporarily with equal result.
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References
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- Arabia FA, Copeland JG, Larson DF, Smith RG, Cleavinger MR. Circulatory assist devices: applications for ventricular recovery or bridge to transplantIn: Gravlee GP, Davis FG, Utley JR, editors. Cardiopulmonary bypass: principles and practice. Baltimore, MD: Williams & Wilkins; 1993. pp. 693-712.
- Hill JD, Farrar DJ. The Thoratec VAD system: patient selection and clinical results in bridging to transplantationIn: Lewis T, Graham TR, editors. Mechanical circulatory support. London, United Kingdom: Edward Arnold; 1995. pp. 169-175.
- Pagani FD, Lynch W, Swaniker Fresca, et al. Extracorporeal life support to left ventricular assist device bridge to heart transplant Circulation 1999;100II–206.
- Koul B, Solem J, Steen S, et al. Heartmate left ventricular assist device as bridge to heart transplantation Ann Thorac Surg 1998;65:1625-1630.[Abstract/Free Full Text]
- Copeland JG, Arabia FA, Tsau PH, et al. Total artificial hearts: bridge to transplantation Cardiol Clin 2003;21:101-113.[Medline]
- Copeland JG, Arabia FA, Smith RG, Covington D. Synthetic membrane neopericardium facilitates total artificial heart explantation J Heart Lung Transplant 2001;20:654-656.[Medline]
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Abstract
Introduction
