Ann Thorac Surg 2009;87:1956-1958. doi:10.1016/j.athoracsur.2008.10.042
© 2009 The Society of Thoracic Surgeons
Case Reports
Use of CoSeal in a Patient With a Left Ventricular Assist Device
Aldo Cannata, MD*,
Corrado Taglieri, MD,
Claudio F. Russo, MD,
Giuseppe Bruschi, MD,
Luigi Martinelli, MD
"Angelo De Gasperis" Department of Cardiac Surgery, Niguarda Ca' Granda Hospital, Milan, Italy
Accepted for publication October 12, 2008.
* Address correspondence to Dr Cannata, "Angelo De Gasperis" Department of Cardiac Surgery, Niguarda Ca' Granda Hospital, Piazza Ospedale Maggiore, 3, Milan, 20162, Italy (Email: aldo.cannata{at}ospedaleniguarda.it).
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Abstract
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A 45-year-old man with end-stage idiopathic dilatated cardiomyopathy had previously undergone two left anterolateral thoracotomies for implantation and explantation of a left ventricular epicardial lead for biventricular pacing. Because of worsening heart failure and a predicted long delay to heart transplantation, a left-ventricular assist device was implanted, with application of CoSeal surgical sealant (Baxter Healthcare Corp, Fremont, CA) on the cardiac surface. At re-sternotomy for heart transplantation, surgical dissection of the left-ventricular assist device was greatly facilitated by the presence of avascular, very loose adhesions. CoSeal (Baxter Healthcare Corp) seems to be useful for the inhibition of adhesion formation after left-ventricular assist device implantation, although further clinical experience with this approach is required.
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Introduction
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The intracorporeal left ventricular assist device (LVAD) is an effective means to bridge-to-heart transplantation in patients affected by end-stage cardiomyopathy. However, the need to re-enter the chest and explant the LVAD poses further surgical challenges related to the formation of strong intrathoracic adhesions between the device, the heart, and the chest wall. Surgical dissection of adhesions may increase the perioperative risk, extending the overall operative time and the ischemic time for the donor heart, and increasing the risk of complications from both injury to the heart and lungs, and bleeding. To limit the formation of adhesions, we adopted an in situ-forming surgical sealant (CoSeal, Baxter Healthcare Corp, Fremont, CA) applied on the heart surface during LVAD implantation in bridge-to-heart transplantation patients.
Our patient was a 45-year-old man with end-stage idiopathic dilated cardiomyopathy (body surface area, 2.1 m2, blood group O+), who underwent two previous left anterolateral thoracotomies for implantation and explantation, respectively, of a left ventricular epicardial lead for biventricular pacing. The explantation of the lead was motivated by recurrent infections of the pacemaker. In June 2006, the patient was enlisted for heart transplantation. Ten days after the listing, he was admitted to our hospital for worsening of heart failure and required intravenous inotropes. Because of the prediction of a very long waiting time for a suitable donor, we elected to implant an intracorporeal LVAD (MicroMed DeBakey VAD, MicroMed Cardiovascular Inc, Houston, TX) through a median sternotomy. During the operation, strong adhesions inside the pericardium and between the left pleura and the left ventricle were encountered. The pump inflow was sutured on the left ventricular apex, whereas the outflow was attached to the ascending aorta. CoSeal surgical sealant (Baxter Healthcare Corp) (total volume, 8 mL) was sprayed on the left aspect of the pericardium and on the right atrium and ventricle. Before chest closure, a double sheet of polytetrafluoroethylene was used to wrap the device and the anterior surface of the heart, as previously described [1]. After LVAD implantation, the patient was discharged home on United Network for Organ Sharing status 2. In December 2007, a Proteus infection of the LVAD driveline exit was diagnosed. Although organism-directed antibiotic therapy was administered, the infection recurred. Therefore, in May 2008, the patient was placed on United Network for Organ Sharing status 1. On May 31, 2008, after 695 days of circulatory support, a suitable heart donor was identified, and the patient underwent heart transplantation. After re-sternotomy, surgical dissection of the device from the chest wall, the right atrium, and the ventricle was greatly facilitated by the presence of avascular, very loose adhesions. We observed strong adhesions only around the apex of the left ventricle. The subsequent postoperative course has been uneventful.
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Comment
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Heart transplantation in LVAD patients is a surgical challenge because of the technical issues related to surgical dissection and control of bleeding. Strong, vascularized adhesions can be expected in all patients, particularly after long periods of support [2]. Division of adhesions increases the operating time, making the surgical dissection from the early steps of the operation more difficult, and increasing the risk of inadvertent cardiac or device injury. Moreover, it may worsen the tendency to severe perioperative bleeding that is frequently observed after LVAD explantation [3].
CoSeal is a sprayable polymeric matrix composed of two synthetic polyethylene glycols, originally developed and adopted as a surgical sealant for the control of bleeding from cardiovascular anastomoses [4]. Contraindications to the clinical use of CoSeal are not described [5]. Marc Hendrikx [6] and colleagues, in an experimental model, observed a significant reduction of adhesions after sternotomy and pericardiotomy in CoSeal-treated rabbits as compared with controls. Initial experiences with CoSeal to prevent adhesions have also been very promising in pediatric cardiac surgery [7]. We believe that the clinical use of CoSeal in the field of circulatory mechanical support has not been reported to date. In our opinion, patients bridged to heart transplantation could significantly benefit from the application of the sealant on the cardiac surfaces at LVAD implantation. The inhibition of adhesion formation could reduce operative time and risks during surgical dissection at the transplantation. Moreover, by decreasing the tendency to perioperative bleeding from division of vascularized adhesions, this approach could be particularly useful in LVAD patients treated with both warfarin and antiplatelet drugs [8]. Our patient did benefit from the measures adopted to minimize adhesion at the transplantation: surgical dissection was straightforward and perioperative bleeding was less than moderate. We did not observe any adverse event related to the sealant.
We conclude that CoSeal could be a very useful product to inhibit the formation of adhesions in LVAD patients to facilitate the transplantation procedure and reduce the associated risk. Nevertheless, we need further experience to support such a conclusion.
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References
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- Vitali E, Russo C, Colombo T, Lanfranconi M, Bruschi G. Modified pericardial closure technique in patients with ventricular assist device Ann Thorac Surg 2000;69:1278-1279.[Abstract/Free Full Text]
- Leprince P, Rahmati M, Bonnet N, et al. Expanded polytetrafluoroethylene membranes to wrap surfaces of circulatory support devices in patients undergoing bridge to heart transplantation Eur J Cardiothorac Surg 2001;19:302-306.[Abstract/Free Full Text]
- Oz MC, Levin HR, Rose EA. Technique for removal of left ventricular assist devices Ann Thorac Surg 1994;58:257-258.[Medline]
- Glickman M, Gheissari A, Money S, Martin J, Ballard JL, CoSeal Multicenter Vascular Surgery Study Group A polymeric sealant inhibits anastomotic suture hole bleeding more rapidly than gelfoam/thrombin: results of a randomized controlled trial Arch Surg 2002;137:326-331discussion 332.[Abstract/Free Full Text]
- Baxter Healthcare Corporation CoSeal Surgical Sealant (package insert)http://www.baxter.com/products/biopharmaceuticals/downloads/CoSeal_PI.pdf 2002Accessed July 21, 2008.
- Marc Hendrikx M, Mees U, Hill AC, Egbert B, Coker GT, Estridge TD. Evaluation of a novel synthetic sealant for inhibition of cardiac adhesions and clinical experience in cardiac surgery procedures Heart Surg Forum 2001;4:204-209discussion 210.[Medline]
- Napoleone CP, Oppido G, Angeli E, Gargiulo G. Resternotomy in pediatric cardiac surgery: CoSeal initial experience Interact Cardiovasc Thorac Surg 2007;6:21-23.[Abstract/Free Full Text]
- Steenwyk BL, Kirklin JK, Gurley WQ, Nielsen VG. The hemostatic history of a 15-month-old child implanted with a Berlin heart left ventricular assist device Anesth Analg 2007;104:538-540.[Abstract/Free Full Text]
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Abstract
Introduction
