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Glenn Shunt Facilitated Weaning of Right Ventricular Mechanical Support
Glenn Shunt Facilitated Weaning of Right Ventricular Mechanical Support Jonathan P. Martin, BA, Jeremiah G. Allen, MD, Eric S. Weiss, MD, Luca A. Vricella, MD, Stuart D. Russell, MD, and John V. Conte, MD Division of Cardiac Surgery, Department of Surgery, and Division of Cardiology, Department of Medicine, Johns Hopkins University Medical Institutions, Baltimore, Maryland
Management of biventricular mechanical circulatory support patients can be complex and can require different systems for support of the right and left ventricles. We describe the use of a Glenn shunt to facilitate weaning from a right ventricular assist device in a patient with idiopathic dilated cardiomyopathy on biventricular mechanical circulatory support. (Ann Thorac Surg 2009;88:e16 –7) © 2009 by The Society of Thoracic Surgeons
L
eft ventricular assist device (LVAD) implantation for bridge-to-transplantation or destination therapy is complicated by the need for right ventricular assist device (RVAD) placement in 10% to 20% of patients [1, 2]. Most LVADs are intended for long-term left ventricular support alone [3, 4]. Biventricular support is often unplanned and can require a hybrid approach, using two different systems, each with their own energy sources, drivelines, and consoles. Multiple support devices increase management complexity, usually eliminating the possibility of discharge home and increasing devicerelated morbidity. Herein, we describe a biventricular support patient in whom a Glenn shunt facilitated RVAD removal. The patient was a 26-year-old man with inotropedependent class 4 congestive heart failure due to an idiopathic dilated cardiomyopathy. After failing medical management, he was referred for LVAD implantation as a bridge-to-transplant. His past medical history included substance abuse, mild renal insufficiency, and placement of an automated implantable cardioverter defibrillator. At the time of LVAD implantation, he was supported on 5.0 g/kg/min of milrinone and an intra-aortic balloon pump. Right heart catheterization demonstrated a central venous pressure of 24 mm Hg, pulmonary capillary wedge pressure of 28 mm Hg, and pulmonary arterial pressures of 52/40 mm Hg. In the operating room, the patient had significant four-chamber enlargement and severe tricuspid regurgitation. He underwent implantation of a HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD and tricuspid valve repair. Postoperative echocardiograms demonstrated effective unloading of the left ventricle and a dilated right ventricle with reduced systolic function. Despite this, he had LVAD flows of 6 L/minute to 7 L/minute, central venous pressures of 10 mm Hg to 12 mm Hg, and he was extubated. He required treatment
Accepted for publication June 19, 2009. Address correspondence to Dr Conte, Johns Hopkins Hospital, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287; e-mail: jconte@csurg. jhmi.jhu.edu.
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Patient with HeartMate II left ventricular assist device (Thoratec Corp, Pleasanton, CA) and ABIOMED AB 5000 RVAD (Abiomed Corp, Danvers, MA). Medical illustration by Tim Phelps.
with amiodarone for atrial fibrillation on postoperative day 2. On postoperative day 3, he had hemodynamically significant ventricular tachycardia develop that was initially treated successfully with boluses of amiodarone. However, these episodes increased in frequency and deteriorated into ventricular fibrillation, requiring both an automated implantable cardioverter defibrillator and external cardioversion on postoperative day 4. It was recognized that these episodes represented amiodaroneinduced Torsade de Pointes. During the next day, he had frequent ventricular tachycardia and ventricular fibrillation manifested by 30% to 50% reductions in LVAD flows and acute increases in central venous pressure and required hundreds of electrical cardioversions. Echocardiograms demonstrated further reduction in right ventricular function, and a percutaneous TandemHeart RVAD (Cardiac Assist Inc, Pittsburgh, PA) was placed on postoperative day 5 to support his right ventricular function; this failed, and an AB5000 (Abiomed Corp, Danvers, MA) RVAD was placed in the operating room on postoperative day 6 (Fig 1). During the next 3 weeks, as the amiodarone was cleared, his arrhythmias resolved and his hemodynamic measurements were stabilized with biventricular support. Multiple attempts to wean his RVAD were unsuccessful. Six weeks after RVAD placement, it was believed that the patient’s right heart would not recover. Given the inability to progress his care and discharge him home on two devices, he was taken to the operating room for a bidirectional Glenn shunt to facilitate RVAD removal. 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.06.086
Ann Thorac Surg 2009;88:e16 –7
CASE REPORT MARTIN ET AL GLENN SHUNT TO WEAN RVAD
e17
nosed degenerative neuromuscular disorder” that likely contributed to his dilated cardiomyopathy and arrhythmias (a feature of these disorders that has been previously described) [5].
Comment This case illustrates a novel use of the Glenn shunt to facilitate this patient’s transition from biventricular to single ventricular circulatory support. Traditionally, Glenn shunts have been used in the treatment of complex congenital heart disease in children (eg, tricuspid atresia). Outside of univentricular disease palliation, there have been few reports of Glenn shunts used in adult patients. Those that have been reported were for cases of acute right heart failure with ultimate recovery of systolic function [6, 7]. Although the final outcome for this patient was poor, related to his degenerative neuromuscular disorder, the bidirectional Glenn shunt was successful in liberating him from RVAD support. We believe this strategy, in patients with appropriately low pulmonary resistance, could be used for weaning from biventricular support or treatment of chronic right ventricular dysfunction, potentially enabling patients to be discharged home. Dr Allen is the Hugh R. Sharp cardiac surgery research fellow. Dr Weiss is the Irene Piccinini investigator in cardiac surgery. This work was supported in part by a Ruth L. Kirschstein National Research Service Award (NIH 2T32DK007713-12 ESW). Fig 2. Patient with HeartMate II left ventricular assist device (Thoratec Corp, Pleasanton, CA) after removal of ABIOMED AB 5000 RVAD (Abiomed Corp, Danvers, MA) and creation of bidirectional Glenn shunt. Medical illustration by Tim Phelps.
After establishing cardiopulmonary bypass through an aortic arch, innominate vein, and inferior vena caval, the superior vena cava was anastamosed to the right main pulmonary artery in an end-to-side fashion (Fig 2). After creation of this shunt, the patient was successfully weaned off RVAD support. Postoperatively, inotropes were weaned off, and with central venous pressures of 8 mm Hg to 12 mm Hg his LVAD flows stabilized at pre-shunt levels. His hemodynamic measurements and LVAD flows were stable throughout the remainder of his hospitalization. However, he had profound weakness of chronic illness develop, and he experienced multiple intensive care unit complications. The patient died 2 months postshunt from multi-drug resistant Acinetobacter sepsis. Postmortem examination revealed a “serious undiag-
References 1. Miller LW, Pagani FD, Russell SD, et al. Use of a continuousflow device in patients awaiting heart transplantation. N Engl J Med 2007;357:885–96. 2. Dang NC, Topkara VK, Mercando M, et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant 2006;25:1– 6. 3. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N Engl J Med 2001;345:1435– 43. 4. Dembitsky WP, Tector AJ, Park S, et al. Left ventricular assist device performance with long-term circulatory support: lessons from the REMATCH trial. Ann Thorac Surg 2004;78: 2123–30. 5. English KM, Gibbs JL. Cardiac monitoring and treatment for children and adolescents with neuromuscular disorders. Dev Med Child Neurol 2006;48:231–5. 6. Yie K, Sung S, Kim D, Woo J. Bidirectional cavopulmonary shunt as a rescue procedure for right ventricular endomyocardial fibrosis. Interact Cardiovasc Thorac Surg 2004;3:86 – 8. 7. Kunihara T, Dzindzibadze V, Aicher D, Schafers HJ. Bidirectional cavopulmonary shunt for acute right ventricular failure in an adult patient. Ann Thorac Surg 2004;78:1066 – 8.
Management of biventricular mechanical circulatory support patients can be complex and can require different systems for support of the right and left ventricles. We describe the use of a Glenn shunt to facilitate weaning from a right ventricular assist device in a patient with idiopathic dilated cardiomyopathy on biventricular mechanical circulatory support. (Ann Thorac Surg 2009;88:e16 –7) © 2009 by The Society of Thoracic Surgeons
L
eft ventricular assist device (LVAD) implantation for bridge-to-transplantation or destination therapy is complicated by the need for right ventricular assist device (RVAD) placement in 10% to 20% of patients [1, 2]. Most LVADs are intended for long-term left ventricular support alone [3, 4]. Biventricular support is often unplanned and can require a hybrid approach, using two different systems, each with their own energy sources, drivelines, and consoles. Multiple support devices increase management complexity, usually eliminating the possibility of discharge home and increasing devicerelated morbidity. Herein, we describe a biventricular support patient in whom a Glenn shunt facilitated RVAD removal. The patient was a 26-year-old man with inotropedependent class 4 congestive heart failure due to an idiopathic dilated cardiomyopathy. After failing medical management, he was referred for LVAD implantation as a bridge-to-transplant. His past medical history included substance abuse, mild renal insufficiency, and placement of an automated implantable cardioverter defibrillator. At the time of LVAD implantation, he was supported on 5.0 g/kg/min of milrinone and an intra-aortic balloon pump. Right heart catheterization demonstrated a central venous pressure of 24 mm Hg, pulmonary capillary wedge pressure of 28 mm Hg, and pulmonary arterial pressures of 52/40 mm Hg. In the operating room, the patient had significant four-chamber enlargement and severe tricuspid regurgitation. He underwent implantation of a HeartMate II (Thoratec Corp, Pleasanton, CA) LVAD and tricuspid valve repair. Postoperative echocardiograms demonstrated effective unloading of the left ventricle and a dilated right ventricle with reduced systolic function. Despite this, he had LVAD flows of 6 L/minute to 7 L/minute, central venous pressures of 10 mm Hg to 12 mm Hg, and he was extubated. He required treatment
Accepted for publication June 19, 2009. Address correspondence to Dr Conte, Johns Hopkins Hospital, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287; e-mail: jconte@csurg. jhmi.jhu.edu.
© 2009 by The Society of Thoracic Surgeons Published by Elsevier Inc
Fig 1. Patient with HeartMate II left ventricular assist device (Thoratec Corp, Pleasanton, CA) and ABIOMED AB 5000 RVAD (Abiomed Corp, Danvers, MA). Medical illustration by Tim Phelps.
with amiodarone for atrial fibrillation on postoperative day 2. On postoperative day 3, he had hemodynamically significant ventricular tachycardia develop that was initially treated successfully with boluses of amiodarone. However, these episodes increased in frequency and deteriorated into ventricular fibrillation, requiring both an automated implantable cardioverter defibrillator and external cardioversion on postoperative day 4. It was recognized that these episodes represented amiodaroneinduced Torsade de Pointes. During the next day, he had frequent ventricular tachycardia and ventricular fibrillation manifested by 30% to 50% reductions in LVAD flows and acute increases in central venous pressure and required hundreds of electrical cardioversions. Echocardiograms demonstrated further reduction in right ventricular function, and a percutaneous TandemHeart RVAD (Cardiac Assist Inc, Pittsburgh, PA) was placed on postoperative day 5 to support his right ventricular function; this failed, and an AB5000 (Abiomed Corp, Danvers, MA) RVAD was placed in the operating room on postoperative day 6 (Fig 1). During the next 3 weeks, as the amiodarone was cleared, his arrhythmias resolved and his hemodynamic measurements were stabilized with biventricular support. Multiple attempts to wean his RVAD were unsuccessful. Six weeks after RVAD placement, it was believed that the patient’s right heart would not recover. Given the inability to progress his care and discharge him home on two devices, he was taken to the operating room for a bidirectional Glenn shunt to facilitate RVAD removal. 0003-4975/09/$36.00 doi:10.1016/j.athoracsur.2009.06.086
Ann Thorac Surg 2009;88:e16 –7
CASE REPORT MARTIN ET AL GLENN SHUNT TO WEAN RVAD
e17
nosed degenerative neuromuscular disorder” that likely contributed to his dilated cardiomyopathy and arrhythmias (a feature of these disorders that has been previously described) [5].
Comment This case illustrates a novel use of the Glenn shunt to facilitate this patient’s transition from biventricular to single ventricular circulatory support. Traditionally, Glenn shunts have been used in the treatment of complex congenital heart disease in children (eg, tricuspid atresia). Outside of univentricular disease palliation, there have been few reports of Glenn shunts used in adult patients. Those that have been reported were for cases of acute right heart failure with ultimate recovery of systolic function [6, 7]. Although the final outcome for this patient was poor, related to his degenerative neuromuscular disorder, the bidirectional Glenn shunt was successful in liberating him from RVAD support. We believe this strategy, in patients with appropriately low pulmonary resistance, could be used for weaning from biventricular support or treatment of chronic right ventricular dysfunction, potentially enabling patients to be discharged home. Dr Allen is the Hugh R. Sharp cardiac surgery research fellow. Dr Weiss is the Irene Piccinini investigator in cardiac surgery. This work was supported in part by a Ruth L. Kirschstein National Research Service Award (NIH 2T32DK007713-12 ESW). Fig 2. Patient with HeartMate II left ventricular assist device (Thoratec Corp, Pleasanton, CA) after removal of ABIOMED AB 5000 RVAD (Abiomed Corp, Danvers, MA) and creation of bidirectional Glenn shunt. Medical illustration by Tim Phelps.
After establishing cardiopulmonary bypass through an aortic arch, innominate vein, and inferior vena caval, the superior vena cava was anastamosed to the right main pulmonary artery in an end-to-side fashion (Fig 2). After creation of this shunt, the patient was successfully weaned off RVAD support. Postoperatively, inotropes were weaned off, and with central venous pressures of 8 mm Hg to 12 mm Hg his LVAD flows stabilized at pre-shunt levels. His hemodynamic measurements and LVAD flows were stable throughout the remainder of his hospitalization. However, he had profound weakness of chronic illness develop, and he experienced multiple intensive care unit complications. The patient died 2 months postshunt from multi-drug resistant Acinetobacter sepsis. Postmortem examination revealed a “serious undiag-
References 1. Miller LW, Pagani FD, Russell SD, et al. Use of a continuousflow device in patients awaiting heart transplantation. N Engl J Med 2007;357:885–96. 2. Dang NC, Topkara VK, Mercando M, et al. Right heart failure after left ventricular assist device implantation in patients with chronic congestive heart failure. J Heart Lung Transplant 2006;25:1– 6. 3. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term mechanical left ventricular assistance for end-stage heart failure. N Engl J Med 2001;345:1435– 43. 4. Dembitsky WP, Tector AJ, Park S, et al. Left ventricular assist device performance with long-term circulatory support: lessons from the REMATCH trial. Ann Thorac Surg 2004;78: 2123–30. 5. English KM, Gibbs JL. Cardiac monitoring and treatment for children and adolescents with neuromuscular disorders. Dev Med Child Neurol 2006;48:231–5. 6. Yie K, Sung S, Kim D, Woo J. Bidirectional cavopulmonary shunt as a rescue procedure for right ventricular endomyocardial fibrosis. Interact Cardiovasc Thorac Surg 2004;3:86 – 8. 7. Kunihara T, Dzindzibadze V, Aicher D, Schafers HJ. Bidirectional cavopulmonary shunt for acute right ventricular failure in an adult patient. Ann Thorac Surg 2004;78:1066 – 8.