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Successful Conversion of TandemHeart Left Ventricular Assist Device to Right Ventricular Assist Device After Implantation of a HeartMate XVE
Ann Thorac Surg 2008;86:1677–9
CASE REPORT TAKAGAKI ET AL RECONFIGURATION OF TANDEMHEART LVAD TO RVAD
1677
Fig 1. Coronary angiogram demonstrating the Vineberg implant (arrow) in (A) diastole and (B) systole.
Comment In 1945, Vineberg [1] experimented with the internal mammary artery (IMA) implantation in dogs by dissecting the IMA, ligating the distal end, creating artificial perforations in the ligated end, and inserting it into a tunnel created in the myocardium. He based this operation on the concept of the sinusoids [2, 3], and he hoped that these sinusoids would absorb the run-off from the perforated IMA. He further theorized that the sinusoids would fortify and develop collateral communications with the native coronary circulation [4]. After various modifications to his technique, Vineberg [5] took a bold step and operated on the first human in 1950. Although his first patient only survived 62 hours after surgery, his procedure was viewed as a potential success after postmortem examination revealed a patent IMA without evidence of infarction, hemorrhage, or hematoma. The case presented here stands as a testimony to the long-term success of VO, being, we believe, the only documented patent Vineberg implant more than 3 decades after the initial surgery. Although VO has become obsolete with the advent of coronary artery bypass grafting, the value of the IMA as an expendable artery, and its resistance © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
to thrombosis and atherosclerosis, were both recognized by early experimentation with VO on the path toward the current gold standard of myocardial revascularization.
References 1. Vineberg AM. Development of an anastamosis between the coronary vessels and a transplanted internal mammary artery. Can Med Assoc J 1946;55:117–9. 2. Wearn JT, Mettier SR, Klumpp TG, Zscthesche LJ. The nature of the vascular communications between the coronary arteries and the chambers of the heart. Am Heart J 1933;9:143– 64. 3. Truex RC, Angulo AW. Comparative study of the arterial and venous systems of the ventricular myocardium with special reference to the coronary sinus. Anat Record 1952;113:467–91. 4. Thomas JL. The Vineberg Legacy. Tex Heart Inst J 1999;26: 107–13. 5. Vineberg A. Coronary vascular anastomoses by internal mammary artery implantation. Can Med Assoc J 1958;78:871–9.
Successful Conversion of TandemHeart Left Ventricular Assist Device to Right Ventricular Assist Device After Implantation of a HeartMate XVE Masami Takagaki, MD, PhD, Chris Wurzer, CCP, Richard Wade, CCP, Richard Lee, MD, Sukit Chris Malaisrie, MD, Patrick M. McCarthy, MD, and Edwin C. McGee, Jr, MD Division of Cardiothoracic Surgery, Bluhm Cardiovascular Institute, Northwestern University’s Feinberg School of Medicine, Chicago, Illinois
A 60-year-old man with end-stage ischemic cardiomyopathy (ejection fraction, 10%) was admitted in cardiogenic shock, which was unresponsive to maximum inotropes and an intraaortic balloon pump. The TandemHeart (TH) Dr McGee discloses that he has a financial relationship with Cardiac Assist Inc.
Accepted for publication April 25, 2008. Address correspondence to Dr McGee, Heart Transplantation and Mechanical Assistance, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 201 East Huron St, Suite 11-140, Chicago, IL 60611; e-mail: [email protected].
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.04.101
FEATURE ARTICLES
tremity edema. Past medical history was significant for coronary artery disease with multiple cardiac interventions including initial coronary artery bypass grafting in 1970 with a saphenous vein graft to the right coronary artery and a VO with implant of the left internal mammary artery to the anterior left ventricular wall; and a redo coronary artery bypass grafting in 1995 with a right internal mammary artery graft to the left anterior descending coronary artery, a saphenous vein graft sequentially to the diagonal and ramus intermedius branches, and a free radial artery graft from the Vineberg implant to the posterior left ventricular branch of the left circumflex artery. Physical examination was unremarkable without evidence of fluid overload. Laboratory analysis revealed negative serial cardiac enzymes and normal brain natriuretic peptide. Electrocardiogram showed T-wave inversions in the inferolateral leads, which were unchanged from before, and an echocardiogram revealed preserved left ventricular function. Cardiac catheterization showed severe native coronary artery disease with occluded bypass grafts, except for the Vineberg implant, which was patent with good myocardial blush (Figs 1A and 1B).
1678
CASE REPORT TAKAGAKI ET AL RECONFIGURATION OF TANDEMHEART LVAD TO RVAD
Ann Thorac Surg 2008;86:1677–9
left ventricular assist device (Cardiac Assist Inc, Pittsburgh, PA) was placed in the standard percutaneous transseptal configuration with improved hemodynamics. The HeartMate XVE (Thoratec Corp, Pleasanton, CA) implantation was performed as a bridge to transplant 5 days after TandemHeart insertion. The TandemHeart was converted to a temporary right ventricular assist device during the HeartMate XVE (Thoratec Corp) implantation due to right ventricular failure. The right ventricular assist device was weaned 3 days later. This strategy was useful, technically easy, and cost effective. (Ann Thorac Surg 2008;86:1677–9) © 2008 by The Society of Thoracic Surgeons
left ventricular failure and respiratory distress. He had undergone coronary artery bypass grafting in 1987. Right heart catheterization revealed pulmonary hypertension (systolic pressure, 68 mm Hg) with high pulmonary vascular resistance (PVR) (417 dyn · s/cm5) with minimal reversibility. Despite inotropes and an intra-aortic balloon pump, his cardiac index remained low (1.8 L/min/ m2). The patient developed acute on chronic oliguric renal failure. A TH was placed to allow his condition to stabilize. He improved after TH support with increased cardiac index (2.4 L/min/m2), decreased Cr (2.2 mg/dL), and improved urine output. We believe that an isolated LVAD was his best option as that it could potentially lower his PVR to a level suitable for transplantation. To that end, we implanted the HeartMate XVE LVAD (Thoratec Corp, Pleasanton, CA) as a bridge to transplant 5 days after TH insertion. The HeartMate outflow graft (Thoratec Corp) was anastomosed to the ascending aorta with a partial occlusion clamp. The TH was turned off and the outflow of the TH was clamped distal to the 3/8 inch ⫻ 3/8 inch connector as cardiopulmonary bypass was instituted with aortic and bi-caval cannulation. The TH inflow cannula was pulled to the inferior vena cava. As we believe the patient was at high risk for RV failure, we wanted to keep the TH available for possible RV assistance post-LVAD implantation. To prevent stasis in the circuit, the TH pump was re-circulated, with inflow from the IVC cannula, and outflow to the reservoir of the cardiopulmonary bypass circuit, using a perfusion adaptor (1/4 inch ⫻ male luer) placed at the luer port on the TH outflow cannula (3/8 inch ⫻ 3/8 inch) connector. The TH outflow was then directed to the cardiotomy reservoir using vacuum assisted drain-
R
FEATURE ARTICLES
ight ventricular (RV) failure is a well-described complication of left ventricular assist device (LVAD) implantation [1]. Experience has shown that RV failure can be temporary and that the right ventricle can recover with temporary mechanical assistance. The TandemHeart (TH) LVAD (Cardiac Assist Inc, Pittsburgh, PA) is typically configured as an LVAD with transeptal left atrial inflow and femoral artery outflow. It can be deployed open or percutaneously. The TandemHeart (TH) LVAD (Cardiac Assist Inc) has been used for ventricular assistance during complicated interventional procedures [2], cardiogenic shock [3], and postcardiotomy cardiac failure [4]. It can also be configured to support the right ventricle as a right ventricular assist device (RVAD) [5]. We are currently using this device as a bridge to an implantable LVAD for patients in cardiogenic shock who do not improve with inotropes or an intra-aortic balloon pump. A 60-year-old man with end-stage ischemic cardiomyopathy (ejection fraction, 10%) was admitted due to severe
Fig 1. Recirculation circuit. The outflow graft to the femoral artery has been clamped distal to the 3/8 connector. Outflow is directed to the cardiotomy reservoir. Inflow is from the inferior vena cava. (CPB ⫽ cardiopulmonary bypass; FV ⫽ femoral vein; RA ⫽ right atrium.)
Ann Thorac Surg 2008;86:1677–9
CASE REPORT TAKAGAKI ET AL RECONFIGURATION OF TANDEMHEART LVAD TO RVAD
1679
age. The TH pump was not powered up, so a formal flow reading was not available; however, the pump head was visibly in motion and blood was flowing in both the inflow and outflow cannulas (Fig 1). The aorta was cross clamped, and the cavae were occluded. The right atrium was opened. The defect in the interatrial septum was closed followed by the right atrium. The HeartMate XVE LVAD (Thoratec Corp) was implanted in the standard configuration. RV function was extremely poor with low LVAD filling, and we were not able to wean from cardiopulmonary bypass, despite nitric oxide and inotropic support. We decided to use the TH as a temporary RVAD. A 10-mm Vascutek graft (Vascutek, a Terumo Company, Scotland, UK) was anastomosed to the main pulmonary artery. The recirculation of the TH was discontinued, and the outflow of the pump was directed into the graft using a 23-French aortic cannula. The graft had been secured about the cannula with multiple ligatures (Fig 2). Cardiopulmonary bypass was weaned and the TH RVAD and LVAD were initiated. With the TH flow of more than 4.0 L/min, LVAD flows of greater than 2 L/min/m2 were achieved. We kept the chest open on that day, and the patient went back to the intensive care unit with stable pump flows. Anticoagulation with heparin (partial thromboplastin time 50 to 60 seconds) was introduced at approximately 48 hours, when the patient was no longer bleeding. At 24 hours of RVAD support, the right ventricle began to recover as noted by a pulsatile pulmonary artery trace. The RVAD was successfully weaned on postoperative day 3. The inflow cannula was withdrawn from the femoral vein, which was repaired. The graft to the pulmonary artery was divided and ligated. The chest was closed with good pump flows (⬎ 2.2 L/min/m2). All inotropes were weaned and the patient was weaned from the ventilator, but he
required a tracheostomy for secretion management. His course was complicated by dialysis dependent renal failure. The patient eventually succumbed to necrotizing pneumonia 6 months after pump placement. Throughout his convalescence, he maintained pump flows in excess of 2.2 L/min/m2 while on no inotropic support, indicating acceptable RV function.
Comment We found the strategy of converting a pre-existing TH LVAD to a temporary RVAD useful, technically easy, and cost effective.
References 1. Ochiai Y, McCarthy PM, Smedira NG, et al. Predictors of severe right ventricular failure after implantable left ventricular assist device insertion: analysis of 245 patients. Circulation 2002;106(12 Suppl 1):I198 –202. 2. Kar B, Butkevich A, Civitello AB, et al. Hemodynamic support with a percutaneous left ventricular assist device during stenting of an unprotected left main coronary artery. Texas Heart Inst J 2004;31:84 – 6. 3. Thiele H, Sick P, Boudriot E, Diederich KW, Hambrecht R, Niebauer J, Schuler G. Randomized comparison of intraaortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J 2005;26:1276 – 83. 4. Pitsis AA, Dardas P, Mezilis N, Nikoloudakis N, Filippatos G, Burkhoff D. Temporary assist device for postcardiotomy cardiac failure. Ann Thorac Surg 2004;77:1431–3. 5. Rajdev S, Benza R, Misra V. Use of Tandem Heart as a temporary hemodynamic support option for severe pulmonary artery hypertension complicated by cardiogenic shock. J Invasive Cardiol 2007;19:E226 –9.
FEATURE ARTICLES
Fig 2. Right ventricular support using TandemHeart left ventricular assist device (Cardiac Assist Inc, Pittsburgh, PA). The inflow cannula has been placed in the right atrium. Outflow is directed into the main pulmonary artery to which a graft has been sewn. (CPB ⫽ cardiopulmonary bypass; FV ⫽ femoral vein; PA ⫽ pulmonary artery; RA ⫽ right atrium.)
CASE REPORT TAKAGAKI ET AL RECONFIGURATION OF TANDEMHEART LVAD TO RVAD
1677
Fig 1. Coronary angiogram demonstrating the Vineberg implant (arrow) in (A) diastole and (B) systole.
Comment In 1945, Vineberg [1] experimented with the internal mammary artery (IMA) implantation in dogs by dissecting the IMA, ligating the distal end, creating artificial perforations in the ligated end, and inserting it into a tunnel created in the myocardium. He based this operation on the concept of the sinusoids [2, 3], and he hoped that these sinusoids would absorb the run-off from the perforated IMA. He further theorized that the sinusoids would fortify and develop collateral communications with the native coronary circulation [4]. After various modifications to his technique, Vineberg [5] took a bold step and operated on the first human in 1950. Although his first patient only survived 62 hours after surgery, his procedure was viewed as a potential success after postmortem examination revealed a patent IMA without evidence of infarction, hemorrhage, or hematoma. The case presented here stands as a testimony to the long-term success of VO, being, we believe, the only documented patent Vineberg implant more than 3 decades after the initial surgery. Although VO has become obsolete with the advent of coronary artery bypass grafting, the value of the IMA as an expendable artery, and its resistance © 2008 by The Society of Thoracic Surgeons Published by Elsevier Inc
to thrombosis and atherosclerosis, were both recognized by early experimentation with VO on the path toward the current gold standard of myocardial revascularization.
References 1. Vineberg AM. Development of an anastamosis between the coronary vessels and a transplanted internal mammary artery. Can Med Assoc J 1946;55:117–9. 2. Wearn JT, Mettier SR, Klumpp TG, Zscthesche LJ. The nature of the vascular communications between the coronary arteries and the chambers of the heart. Am Heart J 1933;9:143– 64. 3. Truex RC, Angulo AW. Comparative study of the arterial and venous systems of the ventricular myocardium with special reference to the coronary sinus. Anat Record 1952;113:467–91. 4. Thomas JL. The Vineberg Legacy. Tex Heart Inst J 1999;26: 107–13. 5. Vineberg A. Coronary vascular anastomoses by internal mammary artery implantation. Can Med Assoc J 1958;78:871–9.
Successful Conversion of TandemHeart Left Ventricular Assist Device to Right Ventricular Assist Device After Implantation of a HeartMate XVE Masami Takagaki, MD, PhD, Chris Wurzer, CCP, Richard Wade, CCP, Richard Lee, MD, Sukit Chris Malaisrie, MD, Patrick M. McCarthy, MD, and Edwin C. McGee, Jr, MD Division of Cardiothoracic Surgery, Bluhm Cardiovascular Institute, Northwestern University’s Feinberg School of Medicine, Chicago, Illinois
A 60-year-old man with end-stage ischemic cardiomyopathy (ejection fraction, 10%) was admitted in cardiogenic shock, which was unresponsive to maximum inotropes and an intraaortic balloon pump. The TandemHeart (TH) Dr McGee discloses that he has a financial relationship with Cardiac Assist Inc.
Accepted for publication April 25, 2008. Address correspondence to Dr McGee, Heart Transplantation and Mechanical Assistance, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, 201 East Huron St, Suite 11-140, Chicago, IL 60611; e-mail: [email protected].
0003-4975/08/$34.00 doi:10.1016/j.athoracsur.2008.04.101
FEATURE ARTICLES
tremity edema. Past medical history was significant for coronary artery disease with multiple cardiac interventions including initial coronary artery bypass grafting in 1970 with a saphenous vein graft to the right coronary artery and a VO with implant of the left internal mammary artery to the anterior left ventricular wall; and a redo coronary artery bypass grafting in 1995 with a right internal mammary artery graft to the left anterior descending coronary artery, a saphenous vein graft sequentially to the diagonal and ramus intermedius branches, and a free radial artery graft from the Vineberg implant to the posterior left ventricular branch of the left circumflex artery. Physical examination was unremarkable without evidence of fluid overload. Laboratory analysis revealed negative serial cardiac enzymes and normal brain natriuretic peptide. Electrocardiogram showed T-wave inversions in the inferolateral leads, which were unchanged from before, and an echocardiogram revealed preserved left ventricular function. Cardiac catheterization showed severe native coronary artery disease with occluded bypass grafts, except for the Vineberg implant, which was patent with good myocardial blush (Figs 1A and 1B).
1678
CASE REPORT TAKAGAKI ET AL RECONFIGURATION OF TANDEMHEART LVAD TO RVAD
Ann Thorac Surg 2008;86:1677–9
left ventricular assist device (Cardiac Assist Inc, Pittsburgh, PA) was placed in the standard percutaneous transseptal configuration with improved hemodynamics. The HeartMate XVE (Thoratec Corp, Pleasanton, CA) implantation was performed as a bridge to transplant 5 days after TandemHeart insertion. The TandemHeart was converted to a temporary right ventricular assist device during the HeartMate XVE (Thoratec Corp) implantation due to right ventricular failure. The right ventricular assist device was weaned 3 days later. This strategy was useful, technically easy, and cost effective. (Ann Thorac Surg 2008;86:1677–9) © 2008 by The Society of Thoracic Surgeons
left ventricular failure and respiratory distress. He had undergone coronary artery bypass grafting in 1987. Right heart catheterization revealed pulmonary hypertension (systolic pressure, 68 mm Hg) with high pulmonary vascular resistance (PVR) (417 dyn · s/cm5) with minimal reversibility. Despite inotropes and an intra-aortic balloon pump, his cardiac index remained low (1.8 L/min/ m2). The patient developed acute on chronic oliguric renal failure. A TH was placed to allow his condition to stabilize. He improved after TH support with increased cardiac index (2.4 L/min/m2), decreased Cr (2.2 mg/dL), and improved urine output. We believe that an isolated LVAD was his best option as that it could potentially lower his PVR to a level suitable for transplantation. To that end, we implanted the HeartMate XVE LVAD (Thoratec Corp, Pleasanton, CA) as a bridge to transplant 5 days after TH insertion. The HeartMate outflow graft (Thoratec Corp) was anastomosed to the ascending aorta with a partial occlusion clamp. The TH was turned off and the outflow of the TH was clamped distal to the 3/8 inch ⫻ 3/8 inch connector as cardiopulmonary bypass was instituted with aortic and bi-caval cannulation. The TH inflow cannula was pulled to the inferior vena cava. As we believe the patient was at high risk for RV failure, we wanted to keep the TH available for possible RV assistance post-LVAD implantation. To prevent stasis in the circuit, the TH pump was re-circulated, with inflow from the IVC cannula, and outflow to the reservoir of the cardiopulmonary bypass circuit, using a perfusion adaptor (1/4 inch ⫻ male luer) placed at the luer port on the TH outflow cannula (3/8 inch ⫻ 3/8 inch) connector. The TH outflow was then directed to the cardiotomy reservoir using vacuum assisted drain-
R
FEATURE ARTICLES
ight ventricular (RV) failure is a well-described complication of left ventricular assist device (LVAD) implantation [1]. Experience has shown that RV failure can be temporary and that the right ventricle can recover with temporary mechanical assistance. The TandemHeart (TH) LVAD (Cardiac Assist Inc, Pittsburgh, PA) is typically configured as an LVAD with transeptal left atrial inflow and femoral artery outflow. It can be deployed open or percutaneously. The TandemHeart (TH) LVAD (Cardiac Assist Inc) has been used for ventricular assistance during complicated interventional procedures [2], cardiogenic shock [3], and postcardiotomy cardiac failure [4]. It can also be configured to support the right ventricle as a right ventricular assist device (RVAD) [5]. We are currently using this device as a bridge to an implantable LVAD for patients in cardiogenic shock who do not improve with inotropes or an intra-aortic balloon pump. A 60-year-old man with end-stage ischemic cardiomyopathy (ejection fraction, 10%) was admitted due to severe
Fig 1. Recirculation circuit. The outflow graft to the femoral artery has been clamped distal to the 3/8 connector. Outflow is directed to the cardiotomy reservoir. Inflow is from the inferior vena cava. (CPB ⫽ cardiopulmonary bypass; FV ⫽ femoral vein; RA ⫽ right atrium.)
Ann Thorac Surg 2008;86:1677–9
CASE REPORT TAKAGAKI ET AL RECONFIGURATION OF TANDEMHEART LVAD TO RVAD
1679
age. The TH pump was not powered up, so a formal flow reading was not available; however, the pump head was visibly in motion and blood was flowing in both the inflow and outflow cannulas (Fig 1). The aorta was cross clamped, and the cavae were occluded. The right atrium was opened. The defect in the interatrial septum was closed followed by the right atrium. The HeartMate XVE LVAD (Thoratec Corp) was implanted in the standard configuration. RV function was extremely poor with low LVAD filling, and we were not able to wean from cardiopulmonary bypass, despite nitric oxide and inotropic support. We decided to use the TH as a temporary RVAD. A 10-mm Vascutek graft (Vascutek, a Terumo Company, Scotland, UK) was anastomosed to the main pulmonary artery. The recirculation of the TH was discontinued, and the outflow of the pump was directed into the graft using a 23-French aortic cannula. The graft had been secured about the cannula with multiple ligatures (Fig 2). Cardiopulmonary bypass was weaned and the TH RVAD and LVAD were initiated. With the TH flow of more than 4.0 L/min, LVAD flows of greater than 2 L/min/m2 were achieved. We kept the chest open on that day, and the patient went back to the intensive care unit with stable pump flows. Anticoagulation with heparin (partial thromboplastin time 50 to 60 seconds) was introduced at approximately 48 hours, when the patient was no longer bleeding. At 24 hours of RVAD support, the right ventricle began to recover as noted by a pulsatile pulmonary artery trace. The RVAD was successfully weaned on postoperative day 3. The inflow cannula was withdrawn from the femoral vein, which was repaired. The graft to the pulmonary artery was divided and ligated. The chest was closed with good pump flows (⬎ 2.2 L/min/m2). All inotropes were weaned and the patient was weaned from the ventilator, but he
required a tracheostomy for secretion management. His course was complicated by dialysis dependent renal failure. The patient eventually succumbed to necrotizing pneumonia 6 months after pump placement. Throughout his convalescence, he maintained pump flows in excess of 2.2 L/min/m2 while on no inotropic support, indicating acceptable RV function.
Comment We found the strategy of converting a pre-existing TH LVAD to a temporary RVAD useful, technically easy, and cost effective.
References 1. Ochiai Y, McCarthy PM, Smedira NG, et al. Predictors of severe right ventricular failure after implantable left ventricular assist device insertion: analysis of 245 patients. Circulation 2002;106(12 Suppl 1):I198 –202. 2. Kar B, Butkevich A, Civitello AB, et al. Hemodynamic support with a percutaneous left ventricular assist device during stenting of an unprotected left main coronary artery. Texas Heart Inst J 2004;31:84 – 6. 3. Thiele H, Sick P, Boudriot E, Diederich KW, Hambrecht R, Niebauer J, Schuler G. Randomized comparison of intraaortic balloon support with a percutaneous left ventricular assist device in patients with revascularized acute myocardial infarction complicated by cardiogenic shock. Eur Heart J 2005;26:1276 – 83. 4. Pitsis AA, Dardas P, Mezilis N, Nikoloudakis N, Filippatos G, Burkhoff D. Temporary assist device for postcardiotomy cardiac failure. Ann Thorac Surg 2004;77:1431–3. 5. Rajdev S, Benza R, Misra V. Use of Tandem Heart as a temporary hemodynamic support option for severe pulmonary artery hypertension complicated by cardiogenic shock. J Invasive Cardiol 2007;19:E226 –9.
FEATURE ARTICLES
Fig 2. Right ventricular support using TandemHeart left ventricular assist device (Cardiac Assist Inc, Pittsburgh, PA). The inflow cannula has been placed in the right atrium. Outflow is directed into the main pulmonary artery to which a graft has been sewn. (CPB ⫽ cardiopulmonary bypass; FV ⫽ femoral vein; PA ⫽ pulmonary artery; RA ⫽ right atrium.)