Ann Thorac Surg 2009;87:1934-1936. doi:10.1016/j.athoracsur.2008.10.034
© 2009 The Society of Thoracic Surgeons
Case Reports
Pulmonary Lobectomy in a Patient With a Left Ventricular Assist Device
Benjamin Wei, MDa,
Hiroo Takayama, MDa,b,
Matthew D. Bacchetta, MDa,b,*
a Department of Surgery, New York Presbyterian Hospital, Columbia College of Physicians of Surgeons, New York, New York
b Division of Cardiothoracic Surgery, New York Presbyterian Hospital, Columbia College of Physicians of Surgeons, New York, New York
Accepted for publication October 12, 2008.
* Address correspondence to Dr Bacchetta, New York Presbyterian Hospital, Irving Pavilion, Room 3, 161 Fort Washington Ave, New York, NY 10032 (Email: mb781{at}columbia.edu).
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Abstract
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Left ventricular assist devices (LVADs) are increasingly being used as both bridge-to-transplantation and destination therapy in patients with severe congestive heart failure. Performing noncardiac surgical procedures in patients with LVADs represents a unique challenge given the anatomic, hemodynamic, and hematologic considerations in these patients. We present the case of a man with an LVAD who successfully underwent right upper lobectomy for a pulmonary nodule. The literature on thoracic surgery procedures in LVAD patients and the intraoperative and postoperative management of these patients are also reviewed.
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Introduction
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As the number of patients with left ventricular assist devices (LVADs) for severe congestive heart failure grows, surgeons will be more likely to encounter the unique challenges of performing both elective and emergent operations on these patients. We present the case of a man with an LVAD who successfully underwent right upper lobectomy for a pulmonary nodule.
A 55-year-old man received a Heartmate XVE LVAD (Thoratec Corp, Pleasanton, CA) as a bridge-to-heart transplantation for severe nonischemic dilated cardiomyopathy. A computed tomographic (CT) scan of the chest, performed 6 months prior to LVAD insertion for wheezing, demonstrated a ground-glass appearing 12-mm right upper lobe nodule. Repeat CT scan showed a 15-mm nodule and a positron emission tomographic scan demonstrated no fluoro-deoxyglucose-acid uptake in the area of the nodule. The lesion was suspicious for possible bronchoalveolar carcinoma based on its appearance on CT scan (Fig 1). One potential approach to this lesion involved continuing to observe the lesion with serial CT scans at 6 month intervals. However, the transplant team was eager to list the patient for heart transplantation, given his deteriorating cardiac status, which could not occur unless the lesion was demonstrated to show that it was benign. The location of the lesion prevented transbronchial and CT-guided biopsy. Therefore, the patient was referred for surgical resection of the lesion 6 weeks after LVAD insertion. The patient had no obvious risk factors for lung cancer, such as smoking, occupational exposure to carcinogens, previous history of cancer, or family history of lung cancer, and had been recovering well from LVAD insertion with a flow of 5 L/minute. Pulmonary function test revealed a forced expiratory volume of 1 second of 1.84 L, 55% of predicted, and a diffusing capacity of the lung for carbon monoxide of 19.9 mL/mm Hg, 65% of predicted. Preoperative testing was significant for mild renal insufficiency (1.4 mg/dL).
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Fig 1. Computed tomographic scan of the chest showing 1.5-cm ground-glass opacity in the right upper lobe (marked by arrow).
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The operation was planned with the assistance of the cardiac anesthesia and perfusionist teams. Coumadin (warfarin; Bristol-Myers Squibb, New York, NY), which the patient was taking for his atrial fibrillation, had been discontinued more than a week prior; the patient's coagulation measurements were normal at the time of the operation. A double lumen endotracheal tube was placed, and the patient was placed in the left lateral decubitus position without impairment of LVAD flow. Single-lung ventilation was achieved without difficulty, and the right pleural cavity was first inspected with a thoracoscope. There were dense adhesions of the right upper lobe to the outflow graft of the LVAD. The hilum was significantly retracted. These features made the operation quite challenging, precluding video-assisted thoracic surgery, and therefore, thoracotomy was performed. The nodule was found deep in the right upper lobe, requiring lobectomy. The pulmonary artery and vein branches to the right upper lobe were dissected and divided with a 2.5-mm Endo-GIA (Covidien Inc, Mansfield, MA) stapler, and the bronchus was divided with a 4.8-mm Endo-GIA. The frozen section initially seemed to be consistent with granulomatous disease. The operative time was 3 hours. The estimated blood loss was 500 mL, and one unit of packed red blood cells was transfused. He was extubated and transferred out of the intensive care unit on postoperative day 1. He initially needed nocturnal bi-level positive airway pressure ventilation for mild hypercarbia. The chest tube was removed on postoperative day 9. Aspirin was resumed immediately, whereas Coumadin (warfarin) was re-started on postoperative day 7. Heparin infusion was not used or required in this patient. Pathologic analysis of the right upper lobe showed localized scarring with reactive pneumocyte hyperplasia and an artery with re-canalized lumen suggestive of infarct and no evidence of cancer. The lung parenchyma also demonstrated changes consistent with heart failure, including pulmonary venous and arterial thickening and hemosiderin deposition.
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Comment
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The largest series to date of noncardiac surgery performed in patients with LVADs included 14 patients who underwent a variety of general, thoracic, and vascular surgical procedures [1]. Complications occurred after 40% of the procedures, most of them re-explorations for postoperative bleeding. A wedge resection, empyema operation, pleural decortication, and lobectomy were performed, although the patient who received the lobectomy died from multi-system organ failure on postoperative day 57. Another series of 8 patients with LVADs included 1 patient who underwent thoracotomy and lung biopsy and experienced no postoperative complications [2]. Goldstein and colleagues [3] reported a pleural decortication and a right lower lobectomy performed for empyema in two different patients with no early postoperative morbidity or mortality.
In contrast to general surgical procedures, the location of the LVAD should not interfere with optimal placement of the incision in lung surgery. However, in our case, the dissection was more difficult because of adhesions of the lung to the LVAD outflow graft, which runs from the device to the ascending aorta through the right anterior mediastinum (Fig 2). Early resumption of full anticoagulation was not critical in our patient, as the Heartmate XVE (Thoratec Corp) does not require systemic anticoagulation. In patients with devices at a higher risk of thromboembolism, however, preoperative conversion of Coumadin (warfarin) to heparin with discontinuation of the infusion shortly before the operation, and early resumption of heparin in the postoperative period, is advised to minimize the length of time that the patient is exposed to increased risk of embolism. Some authors recommend the use of platelet inhibitors, such as aspirin instead of full anticoagulation in the immediate postoperative period, given the high risk of bleeding events [4]. Operations should be performed with bipolar electrocautery if possible, as it is less likely to interfere with the operation of the LVAD and the implanted cardioverters/defibrillators that these patients often have already. Drivelines should be excluded from the field with drapes, as entry of solutions used to sterilize the field into the driveline can lead to device malfunction. A perfusionist or nurse familiar with the LVAD should be available during the operation for technical support.
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Fig 2. Computed tomographic scan of the chest showing left ventricular assist device outflow tract (marked by asterisk) located in the anterior mediastinum.
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The LVAD patient undergoing major lung surgery should receive continuous blood pressure monitoring with an arterial catheter and possibly a central venous pressure monitor. Pulmonary artery catheter placement may be helpful in selected cases if right ventricular function is of concern. Hypovolemia from intravenous fluid restriction, although favorable from the perspective of postoperative pulmonary function, can decrease LVAD flows and cause hypotension by reducing preload. The lateral decubitus position may also result in hypotension by impairing flow from the apical conduit to the device, but the patient will generally respond to fluid resuscitation [3]. In our patient, the chest tube remained for 9 days due to persistently elevated chest tube output. Some patients with LVADs may be in state of volume overload in spite of their assist devices, and in these cases prolonged chest tube drainage and aggressive diuresis may be required. Vigorous attention to pulmonary toilet and early and intensive physical therapy are critical adjuncts in the postoperative period to prevent atelectasis, pneumonia, respiratory failure, and reintubation.
To summarize, attention to the following should be given when operating on patients with an LVAD:
- 1 Coordination with anesthesiology, nursing, and perfusion teams
- 2 Careful preoperative and postoperative management of anticoagulation depending on type of LVAD
- 3 Monitoring with arterial line, especially for continuous nonpulsatile flow devices
- 4 Careful positioning of the patient in relation to the device
- 5 Use of bipolar cautery as unipolar may interfere with the device operation
- 6 Exclusion of drivelines from the field
- 7 Expectation of encountering adhesions in the pleural space.
As our case demonstrates, pulmonary lobectomy can be safely performed on patients with LVADs in spite of its inherent challenges.
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References
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- Schmied C, Wilhem M, Dietl KH, et al. Noncardiac surgery in patients with left ventricular assist devices Surgery 2001;129:440-444.[Medline]
- Stone ME, Soong W, Krol M, Reich DL. The anesthetic considerations in patients with ventricular assist devices presenting for noncardiac surgery: a review of eight cases Anesth Analg 2002;95:42-49.[Abstract/Free Full Text]
- Goldstein DJ, Mullis SL, Delphin ES, et al. Noncardiac surgery in long-term implantable left ventricular assist device recipients Ann Surg 1995;222:203-207.[Medline]
- Schmid C, Wilhelm M, Rothenburger M, et al. Effect of high dose platelet inhibitor treatment on thromboembolism in Novacor patients Eur J Cardiothoracic Surg 2000;17:331-335.[Abstract/Free Full Text]
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Abstract
Introduction
